November 2022

This is such a useful question and I’m really glad that a listener submitted it. Now the poster didn’t say what they meant by “working” so I’m going to assume that their anxious child is still anxious even though they’re in therapy and that’s how I’m going to answer it. So. Why isn’t the therapy working? Why is your child still anxious?

There could be several reasons. Let’s walk through them.

First of all, it may be the wrong therapist for your child. The greatest predictor of therapeutic success, meaning the client makes progress towards their goals, is a good fit therapist and that means different things for different people. Same goes for kids. Think about all the teachers you had growing up. I’m sure you liked some of them more than others. Just being a teacher doesn’t make you the best teacher for every student. My very most favorite teacher, Mrs. Schwartz, made my third grade an absolute dream. Then when my little brother got her, his third grade didn’t go as well. She just wasn’t the same personality fit for him that she was for me.

If you’re not sure if the therapist is a good fit, ask your child and ask the therapist. How do they think things are going? Is the child participating? Are they sharing in session? Does the therapist feel like they have a handle on what’s going on? 

A wrong therapy fit may also be that the therapist doesn’t see things in the same way that the family does — whether that’s the parent or the child. Let’s pretend a therapist is working with the Ingall’s family, you know from Little House on the Prairie. Carrie was always kind of nervous in those books, right? So maybe the family brings Carrie to therapy and the therapist says, “Your family needs to quit moving around all of the time. This constant traveling around the country is a covered wagon is too disruptive for a child like Carrie.” And the family’s like, “Hey, listen, that’s how we do things. Telling us to just stop isn’t helpful or realistic.” See, that might be a poor fit. They might do better with a therapist who’s like, “Yeah, my dad moved us a lot, too, I get it. I know how it is. I can totally address this with Carrie in session.” 

It may be that therapy isn’t working because the therapist has a different conceptualization of what’s going on. So make sure you know what the treatment plan is — what are the goals? Maybe your child isn’t reaching them because you and the therapist have totally different ideas about what should be happening next. Maybe you’re hoping they deal with your child’s sleep problems and they’re working on test anxiety. Keep those lines of communication open so that  you’re sharing and collaborating.   

Sometimes, especially with younger children, the therapist isn’t offering developmentally appropriate interventions. Working with kids is a specialized skill that requires specialized training. I remember talking to one family who took their kindergartener to someone who said they worked with younger kids but had no toys in their office other than an antique tin ferris wheel that the child wasn’t allowed to touch. The younger the child is, the more therapy should be play-focused.

Another reason that your child’s therapy may not be working is because your child isn’t interesting in changing. Now there are ways to work on motivating an unmotivated child or teen for sure but ultimately we cannot force ANYONE to behave differently if they don’t want to. Some children resent being in therapy and won’t participate. Some children will perform well in therapy — doing what the therapist asks, answering questions — but it’s all surface-level and the child is unwilling or unable to bring that work out into the real world. 

Lots of times kids are coming to therapy not because they want to be there but because their parents have decided they need to be there. Or the child is willing to come but that doesn’t mean they’re ready to really participate. The anxious child might not be interested in learning new skills or facing their fears. They might not care whether or not their parents stop nagging because their fear is greater than their discomfort with their parents’ reactions.

I’ll tell you that my bias is not to send kids to therapy against their will. Especially if they’re anxious children. That’s because therapy is likely to be something they will want or need later on in their life and I think it’s important that they have a good feeling about it. I have a strong pro-therapy bias, obviously, and I don’t think anyone especially kids should be coerced into going because it’s likely to give them a bad feeling about counseling and make it more difficult for them to reach out when they’re ready.

Another reason therapy might not be working is that the parent isn’t doing their part in creating change. I’m not blaming the parent here. Sometimes this is because they don’t even know they’re supposed to be doing anything. If the therapist isn’t sharing that with them, how would they? 

Even if an anxious child is in therapy, if their environment isn’t shifting to supporting instead of accommodating their anxiety, then the anxiety will continue. And even if the child is making progress in session if they aren’t getting the opportunity to practice coping, to confront their anxiety, and deal with their discomfort then the progress will only exist in session.

In my own clinical practice a frequent challenge would be that I would work with a child on an anti-anxiety plan that was clear, that the child agreed to, and was committed to, and was ready to implement and then they would take that plan home with the parent and the parent would unintentionally undermine it. The child would be ready to do the difficult thing — whether that was to confront the challenge at school or socially — and the parent in an effort to be helpful would undo that child’s hard work and preparation by questioning them or reassuring them or interrupting the process.

This could look like a child about to step on stage and the parent says, “Are you sure you’re ready?”

Or the child is trying to sleep alone and becomes tearful and the parent says, “Do you just want to try tomorrow?”

Basically the child may be doing the prep work but still needs their parent to hold the boundaries and to remind them of their skills.

No matter how often I was telling the parent they needed to do this part, for some parents it was just really hard. They needed more direction and more encouragement which is why ultimately I shifted to working directly with parents. As I dug into the research, it became clear that the real key to change for anxious children and teens is their parents. If the parents can do their part, then the children — even without therapy — are able to do theirs. 

I personally think an ideal situation is the anxious child would be in therapy with a good fit therapist and the child’s parents would be working in or with a program like mine. That one-two punch is the best bet to learning to deal with child anxiety. If a therapist isn’t available for the child — and I know there’s a shortage right now — or the child is unwilling to go, that doesn’t have to stop the parents from doing their own learning and shifting the way they deal with anxiety in their home. 

I’m curious, if therapy hasn’t worked for your child, which of these issues do you think was contributing to that? Or was it something I didn’t mention here? Feel free to let me know and reach out if you have any questions or thoughts.