Ep. 128: Dr. Ron Rapee - Anxious No More

Sucheta Kamath: Welcome back to Full PreFrontal, we will dissect executive function into bite sized chunks. And we will discuss how to become more proficient, how to get gained knowledge about self and how do we strategize to lead a successful life where we have all the information we need about self. And maybe we can even take some time to understand why we do things the way we do. What are the roadblocks. And so today's episode is going to be another fantastic episode because I have somebody very special all the way from Australia. And his area of expertise is something every single person is going to find very, very useful, because he's going to talk about anxiety. So let's think a little bit about anxiety. I think all of us suffer from anxiety. And maybe some people I call it diagnosed versus undiagnosed. And so and and the question is anxiety, why does anxiety exist? And why some of alized by the fear or incredible stress that we experience every day, in everyday life? So with that, let me welcome Dr. Ron Rapee. He is a distinguished professor of psychology from mcquire University in Australia, and he is an Australian Research Council laureate fellow, and the founding director of the Center for emotional health. He has a background in clinical psychology, especially the understanding and development of mental disorders. His work specializes in developing treatment programs, and evaluating their efficacy through clinical trials. Foremost among these has been the cool kids suite of programs, which I'm so excited to talk to him about. And they have been introduced in 25 languages and used over in over 30 countries. His research interest or anxiety, depression related disorders across the lifespan, development of risk factors for internalizing distress, prevention of internalizing disorders and treatment for anxiety and related disorders. Welcome, welcome, Dr. Rapee to the program. How are you? 

Dr. Ron Rapee: I'm very well thank you. And thank you for having me. 

Sucheta Kamath: Well, it's it's my pleasure. And let me get started with I asked all this question of all of my guests is the topic is of executive function, insight, self management, and and having this metacognitive awareness of Who am I as a learner and thinker? And what are the obstacles that I face? That affects my being in the world? So since you specialize in anxiety, at what age or when did you become aware of your strengths and weaknesses? Do you struggle with anxiety? And what got you interested in the subject of anxiety? 

Dr. Ron Rapee: Wow, that's a lot of questions. When did I become aware of my, I guess, awareness, self awareness really begins very, very early in life. And so I'm sure I was like everyone else and probably started to become aware of myself really from infancy to in some simple way. And then self awareness would have increased after that. But of course, I can't remember I'd have no idea when I first became aware of myself as a as a thinking acting human being because it's such a subtle, slow process.  

Sucheta Kamath: What got you interested in anxiety? 

Dr. Ron Rapee: I partly it was serendipity. I mean, I'm, I guess people who know me would say I'm probably a shy, reserved sort of person. No, I'm not. I don't think I suffer particular anxiety disorders. But look, I'm on the, on the higher side of anxious personality style, perhaps. So no doubt it resonates with me. But my actual entry to anxiety as a researcher was purely accidental. I was actually interested when I finished my undergraduate studies and was going to do a PhD. There was a famous professor at our university at the time Syd Lovibond was his name and he was very well known. In the area of alcohol abuse, and in particular, in control the idea of using of getting people who are addicted to alcohol and teaching them to drink normally, what used to be called controlled drinking, and it was very popular back in the 70s 80s, very popular movements. And I was fascinated by that. And I really wanted to work in that field. And just at that time, they had accidentally there had been a case that I don't remember the details, but a very famous case where some behavioral people, I think, in America and Canada, had taken some very, very seriously ill alcoholics, and had supposedly taught them to drink normally. And this was this huge sort of breakthrough and this huge demonstration. And then there have been a famous incident, where a few years later researcher had gone back to their data had followed those people up and discovered that actually, all these people were in horrific states, and many of them had died. And it was just a shocking. And there was sort of all sorts of comments about potentially they made up their data and things like that. So it was it had just blown up. At the time when I walked in, this is fresh faced young kids does professors often say, hey, I want to do something on control drinking, he looked at me like I was an idiot, just said, Not a chance. And he just happened to have a paper on his on his desk on agraphobia. And he just picked it up. And he threw it at me and said he would do this. And that was I moved into anxiety. So it's purely accidental. But I think it does resonate. 

Sucheta Kamath: And I mean, you have a very now watched many of your videos and and you have a very calming presence. So I am suspecting I think your personal personal insights have influenced in a way that you don't look like you suffer from anxiety. So let's talk about anxiety. What is anxiety? How would you is a layman's understanding of worry, when unmanaged becoming anxiety is that fear and right way of describing anxiety? 

Dr. Ron Rapee: Worry is one component of anxiety, definitely. And it would be what we would refer to as the cognitive component. So worry is about threshing over possible scenarios in your mind, looking for possible dangers. And then in a sense, one of the best descriptions I think of worry is a famous one many years ago of that it's failed problem solving. It's where people try to solve problems, but they but they fail, they don't manage to do it properly. And so they keep rehashing and rehashing and thinking about them in different ways. And that's definitely a major component of worry, of anxiety, sorry, but anxiety is more than that. And from a scientific but particularly from a clinical perspective, the component of word of anxiety that we often think about is actually avoidance behavior. Most anxiety involves a tendency to try to escape to try to get away from whatever it is that you're anxious about. And and so the core hallmarks, the core characteristic of anxiety is the desire to flee or to or to avoid altogether. And that's really a critical aspect, which I think any layperson would recognize and accept, but we as lay people, we don't normally talk about it in that way. 

Sucheta Kamath: So interesting. So bear with me as they formulate some thoughts here. So feeling anxious is normal, and everybody experiences at typically, I mean, anxiety is a uncomfortable or, or undesired emotion, or our response to something that's invoking this sense of bad outcome is that what we are trying to avoid? So what is it? Is it a conscious process? Is it a subconscious? 

Dr. Ron Rapee: It can be both so it it probably involves both conscious or I prefer to use aware and unaware process. Conscious always has a whole lot of connotations around it, which is unfortunate, but aware and unaware. So no doubt when we're anxious. There are a lot of unaware, urges and desires and motivations. But a lot of it is aware as well. We are aware of what it is we're anxious about and we're aware of what it is we want to do about that. I think the the hallmark definition of anxiety was the one pretty much what you said a minute ago, which is that anxiety is a response to a perceived threat or a perceived danger. And so that's really what it is it is just about it's it's an emotion that comes up in a person when they believe or not only a person so in pretty much any organism when that organism believes that it is in some imminent danger or threat. And it's, as you said, because it's that sense of protecting one or emotion in response to a danger, it is normal. And that is extremely important issue, that anxiety is very normal. And it's more than normal, it's necessary, you've got to feel anxious in order to survive. When you have, I don't know, a cockroach running across a room, and the light suddenly comes on and that cockroaches suddenly in the in the daylight or in the bright light, the cockroach becomes very anxious. And that anxiety motivates a cockroach to run and to run quickly and to find shelter. And that keeps the cockroach alive. Now, if it didn't do that it would set there, someone would come along and step on it. So it would die. So anxiety is critical, because it keeps us alive. 

Sucheta Kamath: That's so neat. Thank you for kind of explaining it that way. Because I think one, conventional wisdom commonly tells the term so loosely, and we use it intermeshed with stress and anxiety as if it's everyday affair. But what you're describing sounds to me there is a way to distinguish a clinical threshold where it becomes a bit smells mental well being. There's, I mean, so would you would you be idea of healthy anxiety and unhealthy anxiety? Or do we say essential anxiety and unessential anxiety? Or is there a different way to understand when does it become a problematic issue in somebody's life? 

Dr. Ron Rapee: I think what you've just said there is you've hit the nail right on the head, that it becomes a clinical problem. And I guess unhealthy or unnecessary anxiety, are great terms. So we tend not to use those. But that Yeah, that's are great terms. It's a clinical problem when it affects a person's life. So that is the difference. So anxiety is normal. Everyone experiences anxiety. And those people who don't experience anxiety, probably in a bit of difficulty in their lives, everyone has to experience some anxiety survive, as I said before, but where that anxiety becomes so persistent, and affects a person in so many ways that it actually starts affecting their life, and stopping them from reaching their potential, or stopping them from doing the things they want or need to do, then it becomes a clinical disorder. So of course, when it's an extreme case, that's easy to decide. So when you've got a person who's so anxious that they don't leave the house, they stay inside all the time, they can't make relationships with other people, they can't hold the job, then it's clearly a problem. And there's no question. However, when you have the gray areas where you have people who can do most of those things, but it's just those things are not up to their absolute maximum, it becomes a little harder to distinguish. But that is really the definition. 

Sucheta Kamath: And so what's so interesting is I think, because it's such a common place, people are not likely to seek help, because they just think it's Oh, you're feeling anxious, calm down. And I bet that's like the worst advice you can give somebody is to calm down. Because it's it's a, an there's no better understanding of what this message of worry or threat that person is feeling. And in a supposedly talks about this, that in modern world, the threat is not the tiger or lion that's about to attack you. But these psychological threats of being misunderstood or being thought as incompetent or being perceived as a failure can be incredible threats, right? So how do we understand? So can you dive a little bit deeper into this perception of threat? what is causing? What do people fear about when they are fearing? Or that invokes fear response in them? 

Dr. Ron Rapee: Yeah, look, that's a good question. I guess the the list of possible threats is pretty much limitless in in terms of specific topics. But when we do factor analyses are fancy statistical techniques to divide things up into groups, when we try to group different types of fears. Interestingly, you do very, very broadly in a very broad level, you find that fears tend to fall into two sort of broad groups, and one group, what you might refer to as physical fears. So that is the lie and the tiger, you know, the, the fear of a burglar attacking you the fear of being raped, the fear of being hurt, physically hurt in some way. And the other sort of fear is the more social type of fear no social fears include the sorts of things you're talking about fear of failing, fear of being rejected, fear of not being understood fear of, not not succeeding. So there's more existential but more sort of interpersonal types. have fears. And if we think of all the different types of things in the world that can make us scared, very, very broadly at a very broad abstraction, those are the two sort of broad categories, things that can physically hurt us, or things that can emotionally or socially hurt us. 

Sucheta Kamath: So how does panic factor in this? Where is it on a spectrum? Is it? Is it a time related? emotional response? 

Dr. Ron Rapee: Yeah, that's a good question. It depends very much on whether you're talking panic in lay terms, or panic in a clinical scientific term. So what I mean, yeah, because when people when most of us use the term panic, we were talking about extreme anxiety. So we're talking about anxiety in a way that suddenly just makes us it's more than it was then then feeling anxious, it's a degree issue. And most of us just used the word panic to invoke that idea that it was very extreme. And in that sense, we can think of panic as being sort of like a time issue. That is, when I'm anxious, I'm worried about some danger or some threat, as we're saying before, but I'm worried about that danger or threat occurring at some point in the future. So if I'm anxious about losing my job, I'm not scared that I'm losing at this second, I'm scared that at some stage, I will lose it. When you get as that danger comes closer and closer in time, we start to get more and more and more anxious. And at some point, we start saying I'm panicking. And it's usually we're saying we're panicking when that danger is now. So when the lion is, is you can hear it roaring, the distance, you're anxious, as you hear the roar, and getting closer and closer, you get more and more and more scared. When you see the lion standing there right at you, you're panicking. And in that sense, that's the sort of like concept of the nature of that term, that emotion of panic. But we also, scientifically, there's another concept, which is panic attack or panic disorder. And that's a DSM disorder. And when we talk about panic disorder, we're talking about people who have very specific set of fears. And those fears are very much physical. So typically, people who have panic attacks and panic disorder are very worried their core fear is that they're going to die or have a heart attack or pass out. And so they're very much about physically related types of fears. And the fear is that my heart's pounding. And that because my heart is going to break through my chest, and I'm going to die, or something along those lines, or I can't breathe, I'm feeling dizzy, I'm going to faint. And and that's very much a physically focused type of disorder. 

Sucheta Kamath: And so I guess, when we talk about treatment, maybe you can shed some light, I wanted to take a look at some, you your work. And many researchers in this field, talk about three core features of anxiety, you know, avoidance, negative beliefs and physical symptoms. Can you talk about the second part is the negative beliefs kind of almost like a thought distortion? You would say? So, right, is that's also at the heart of anxiety. 

Dr. Ron Rapee: Very much. So. So yeah, there's that I guess we're talking a little bit before about the wiring component. So there's that cognitive or mental component of worry, which is, which is a very important part of it, which is all about those sort of negative types of thoughts about being unable to cope or being in some sort of danger, the distinction most mental disorders have some mental components. But the distinction for anxiety is that those beliefs are still about danger. So that might be about I am not going to succeed, or those people will laugh at me, or that walking there is going to kill me or getting in that car is going to I'm to get hurt or said something about I am in some sort of danger. And we know from a huge amount of research that people with anxiety disorders, that is people with clinical levels of anxiety, tend to hold those beliefs in unrealistic ways. That is what we would often refer to as being biased or out of proportion to reality. So they will often if you ask a person with a clinical anxiety disorder, for example, how likely is it that you will get hurt? How likely is it that something bad will happen? The estimate that they give you is usually much higher than someone who doesn't have clinical anxiety? In other words, they tend to overestimate the degree of danger.  

Sucheta Kamath: So and and that's measurable. I had the pleasure of interviewing Dr. David Burns, who has done a lot of work in cognitive behavioral therapy, in particular team approach. And so he talks about these 10 patterns of cognitive distortions. Is that a common understanding of these standard cognitive distortions that every person or some or many of these components that people experience when they're experiencing anxiety disorder? 

Dr. Ron Rapee: I think for most for certainly for many of the what we call internalizing disorders are those disorders, particularly anxiety and depression, which are about ourselves. There is a strong cognitive distortion aspect to it. And there's a huge amount of research regularly demonstrating the fact that people with those very emotional types of disorders tend to be more extreme in their thinking. So in the case of anxiety that people with anxiety have had to overestimate danger. In the case of depression, people tend to overestimate the negativity or how bad things are to focus on the negative. So there are clearly many distortions, dividing them into particular types and particular numbers of types is really more of an individual perspective. And I think that sort of thing is done much more for the ability to, to communicate with the public. And so David Burns comes up with the 10 types. Tim Beck, I can't remember how many types he had. But he had a number of different types as well, I think Albert Ellis had on them, they all have different numbers of types. But that's really those types are not necessarily scientifically demonstrated, it's more that they are a very, very useful way of helping people to understand the processes, and helping to communicate that to to patients, and to help people get a handle on it. When we when we look at it, in terms of research, you tend to again, find broadly to anxiety, at least I'm talking just anxiety, not depression, you tend to find two broad types of distortions. And so one, as I mentioned, is that overestimate of the probability of danger, that is you tend to think I'm much more likely to get hurt, or something bad is likely to happen much more so than it really does. The second type of distortion is a distortion of consequence. So anxious people tend to also overestimate how bad that bad thing will be. So to give you an example, if I'm a socially anxious person, and I'm having this interview, now, I might think it's extremely likely that I'm going to say something stupid. Now, of course, the real realistically, I could say something stupid, and maybe I already have earlier on in this interview, and that's realistic. But the chance that I'm very likely to say something stupid is probably an over estimate. So that's the difference between a clinically anxious person and not clinically anxious is that they might all say everyone might say, I might say something stupid. But the clinically anxious person overestimates how likely that is, but secondly, the clinically anxious person also estimates how bad that will be. So the non anxious people might say, yeah, look, I might say something stupid. But if I do, look, you know, probably no one will really notice. And if they do, they'll forget about it two minutes later, and it doesn't really matter. Where's the clinically anxious people would say if I say something stupid, it's going to be really terrible. It's the end of the world. My career is over, no one will ever take this seriously. Again, that's it I'm done for. So that's why we talk about the two broad types isn't over estimate of the likelihood that something will be bad, and also an over estimate of how bad that will be. 

Sucheta Kamath: So helpful, because I think one thought comes to my mind about children, as we are helping and particularly adults, if they don't, they're not psych-wise, if they don't have any psychological intuitions about how people think or behave, let alone deeper understanding of the clinical knowledge. A conventional wisdom, just say, has this tendency of using aggression towards them and saying snap out of it, or you're being completely irrational or to yell at somebody for why nobody's gonna make fun of you look, I'm wearing big clothes, nobody makes fun of me, you know. So there's like, like this, these often common sensical encouragement that people give are so ineffective. And and because it goes at the heart of this anxiety and even depression that people have this perceived notion of how one must overcome these problems. So what do you think what why is it so difficult for a clinically anxious or clinically depressed person to snap out of things or find meaning in advice that other people give? 

Dr. Ron Rapee: I think that speaks to the nature of mental disorders, which is that they are not voluntary. They are very involuntary way they are. They are ways of thinking and ways of behaving but they are involuntary and they're ingrained. They're often steeped in a strong background of personality style. And the way the person deals with the world in general, combined with often a very, very long history of behaving in that way. So when you have someone who, for example, with anxiety has naturally has an anxious withdrawn personality style, and on top of that, has acted in a clinically anxious way for maybe 20, 30 or 40 years, to suddenly just say to them, well just snap out of it. And, of course, they can't do that. It's to say, it'd be the same as someone who's got a really sunny disposition is happy all the time to say, well just stop it stop being happy that it just doesn't make sense. You can't just change a personality like that you can change. And it takes a lot of hard work. And a lot of time, it's not something you step out of you You hit on it before a comment you made earlier also was about that you really need to have show some empathy towards the way people think. And the idea that anxiety is so normal, and that everyone gets anxious to some degree, I think it makes it very hard for people to empathize with extreme anxiety. Because most people say I get anxious, and I can deal with it. And so it's very hard for them to to really empathize with someone who can't handle it or can't get on top of it. But that's the that's the critically important thing. Of course, everyone wants to be understood. And everyone want doesn't want to be told to do something different or to step out of it. People want to have some recognition that what I'm experiencing is very real, and very difficult. And that I don't want to do it. I think that's the other thing. Often, as I said, for parents, but even for, for partners or others, there's a sense of, oh, you're just being weak, or you're being silly, and they're not they're not trying to do it, they can't help but it's the way that someone has learned to think and to behave. 

Sucheta Kamath: You know, I think I had another wonderful researcher, Tim Pychyl, who studies procrastination. And it was so interesting to me to, to follow that line of thinking, and I see, or the relationship between anxiety and procrastination as a as a behavior out outwardly observable behavior, particularly if they are not showing these distortions where somebody is having a panic attack. But if you just see them stalling and not initiating, so I see in my work, I see a lot of procrastination. And so what is how do you see the these two relate to each other? 

Dr. Ron Rapee: Well, they are very closely related. Procrastination is, as you said, is an is an in product behavior. It's an outward manifestation. And as a result, it's a complex behavior that could have a lot of different root causes. But in the majority of cases, anxiety will be one of the fundamental causes of procrastination, people tend to procrastinate, often, when they're feeling very socially anxious, that is a sense that I can't do it, I'm going to fail, I'm not going to be good enough, etc. Or when they're being very perfectionistic, the sense that it has to be done exactly. So and, and I'm not going to make it. And so procrastination is often underpinned by fundamental worries and fundamental anxieties, and in a way, in fact, in a very real way, you can think of procrastination as being a type of avoidance behavior. So again, what we're saying a anxiety involves worry components added involves avoidance, procrastination involves often involves a worry component, I won't make it I won't be good enough, etc. And then the result of that worry is often extreme avoidance, where you just say, Well, I'm going to go to the beach. 

Sucheta Kamath: So how young a child can be diagnosed with anxiety disorder? And how would that manifest in children? Does anxiety present itself differently at different ages, 

Dr. Ron Rapee: You could see anxiety, clinical levels and severe levels of anxiety occurring pretty much at any age. So really, from from 2, 3, 4 years of age, you can start to diagnose anxiety if you want. Now, I say if you want because when you're getting at that very young age to be putting labels on children can be controversial. Sometimes, in some cases, it can help if it gets them the help that they want. But they need but in many cases it you know, it's not necessarily something that people want to do, but certainly you can see clinical levels of anxiety at preschool level, from very young ages, as we say before anxiety or any disorder really is about a normal type of process that has gotten to such a point where it's interfering, whether it's or affecting your life, clearly the younger a child is, the harder it is to actually affect your life. Because younger children depend on their parents more. A two-year-old or a three-year-old doesn't really have to achieve a great deal. And so you don't, you don't tend to see anxiety interfering a huge amount at that young age. So you see much less examples of, of clinical anxiety. And then as kids get older, that those clinical levels of anxiety start to increase in frequency because there's more opportunity for interference and impact.  

Sucheta Kamath: You know... Sorry, go ahead. 

Dr. Ron Rapee: Sorry, I was gonna add to the second part, but about you asking about different types of anxiety at different ages. So yeah, the nature of anxiety also tends to change across time. So early in life, you tend to see, for example, things like separation fears, separation, anxiety, being extra, of course, the most common form of anxiety, a fear of separating from parents. And just naturally with development that decreases and you get very, very little separation anxiety by about adolescence and onwards. On the other hand, social anxiety, you tend to find an increase in that across childhood, you can see a lot of social anxiety in young children, but it increases and you're more likely to find Social Anxiety Disorder beginning around about early adolescents, around 12-13 years of age. More broad based generalized types of anxiety, what we refer to as generalized anxiety disorder, you tend to find that increasing more across adolescence, and be much more likely later on. Whereas things like more physical fields like panic disorder, where people are worrying about heart attacks, you tend to find that occurring much more commonly after adolescence and into the early 20s. So those patterns of anxiety, different types of anxieties do occur quite quite different stages of life. 

Sucheta Kamath: I think, to me, also, what makes sense about what you just described the progression, more, you know, to fear, then your fear grows, you know, as you have more world experiences, you have more things to be afraid of, 

Dr. Ron Rapee: It certainly becomes more generalized as it becomes more 

Sucheta Kamath: All aspects of it 

Dr. Ron Rapee: More existential, perhaps as a way of thinking about it, that when you're younger, you get, for example, you get separation fears, but also phobias of dogs and the dark and go. So when you're younger, it's much more concrete things you're worried about. And as you get older, when you get into teenager courses, more social things, because teenagers are worried about their peers and social interactions. And then when you get older, still, it becomes perhaps more existential issues, death and taxes and various issues like that. And then, of course, the good news that I didn't touch on the great news is that after you get to about your 50s or so your anxiety disorders actually start to decrease. And we find a dramatic decrease of anxiety disorders in older age, you can still find anxiety disorders. So we still need treatments for older people. But they're much less common. And most people will say they get less anxious once they get into their older age. 

Sucheta Kamath: Is that because they have less expectations? Or they have less stakes, less things up stakes? 

Dr. Ron Rapee: We have no idea. We don't know. It's one of those really amazing questions. It's a fact. We know it's there. Epidemiological study after study shows that prevalence of anxiety disorders, and mood disorders, but anxiety disorders, decreases in older age. But the reasons for that people have looked at all sorts of possibilities, coping strategies, emotional reactivity, as you say, existential sorts of views of the world experience, all those things might be the case. But no one's come up with a good answer. It's a fascinating issue 

Sucheta Kamath: It's so funny, you said about patient teacher training. For two years, it's going to last for two years. I'm just in the beginning stages of it. And we have I mean, since everything after the pandemic has gone in the virtual world. They are we do follow up class like meditation practices and any questions you may have. And they're like 50 to 100 people on a call at a time and then when people are given opportunity to do a check in or describe what they're feeling 99% of people are anxious about dying in this with the Coronavirus and, and of course, um, maybe this is a more awkward on my part, but I have no fear about Coronavirus I mean, partly growing up in India with with lots of you know, cholera and, and all kinds of diseases, you know, plague and not plague maybe. But I think it's just so interesting that I was surprised with hearing so many people talking about their fears, and then not be able to process this sudden onset of new, something too intangible to worry about. So are you noticing? Or is your work? Are you inundated with more work in this pandemic? Has that shifted people's relationship to anticipated fears or outcomes? negative outcomes? 

Dr. Ron Rapee: Yeah, it's it's interesting. The short answer is no, we haven't I haven't seen anything partly because these days I work primarily with children and young people, and not with adults. And so that existential type fear of particularly fears of death, as much less in children anyway, children, don't worry as much as they shouldn't, about dying. But also, of course, coronavirus, doesn't affect them in the same way, at all. But I wonder if part of it is also a country difference. Australia very likely will likely and due to engineering. Perhaps we haven't really been affected by Corona very much. Currently. I think we, in my State of New South Wales, we're having about two or three new cases a day. So it's not something people... Yeah, that's what but it's very much top of the mind. But I think the reactions are much more to do with mood and depression. Because of the treatment, the cure, that is the lockdown. I see. I'm not sure how much of that you got. But I think, 

Sucheta Kamath: Say that again. Sorry. That part. 

Dr. Ron Rapee: Yes, I think the the issues in Australia are much more around boredom and depression and the mood effects because of the lockdowns and the effects of Corona because we have to stay home, isolated, we can't do those things. So those are the impacts. But anxiety is not an issue for people because we all know, the chances of getting sick with Corona is extremely tiny. And even if we did get it, we have almost no deaths. And so that's so that's not an issue. So there's probably country difference. But also, I think there's certainly age differences. 

Sucheta Kamath: Well, we can't I know we we have been talking a lot. But let's talk about your wonderful book, and all the research you have done. But those who haven't had a chance yet, but I want I highly encourage all of you to get this book, Helping Your Anxious Child. It's step by step guide for parents. And Dr. Rapee, is main author, his co written this with many others. Tell us about you bring message of hope. So I'm so excited to know that there's something we can do. So talk about cool kids, and particularly this approach to managing anxiety. 

Dr. Ron Rapee: Right? Well, yes, look, I think conversation has been fabulous so far, but it's been very much focused on on adults, I guess, and the bigger picture. And so that just to say that anxiety disorders, clinical levels of anxiety can occur in children. And it affects around about 5% or so of people of young people, between about 7 and 17 increases slightly in adolescence. And so many young people do have clinical levels of anxiety. And the treatments we offer are actually very similar to the treatments we offer to adults. It's really what you might refer to as a cognitive behavioral approach, which is that we teach children, young people how to think differently about their fears and worries how to approach their they feared outcome, say in a different way. And we teach them the critical issues, we teach them to gradually not avoid, to gradually face their fears to get out and to do the things they're afraid of their parents have a critical role in this. And I think that's clearly the difference between working with children and working with them with older people is that with the children, we have the parents involved. And so the parents have a key role to play, where they really act in some ways as the sort of co-therapist and the parent helps the child along the way with the process. The parent helps the child engage in activities, the parent provides rewards for the child. And we also teach the parents way different ways of interacting with their child. So they're not getting quite as caught up with their child's problem, but they're able to take a step back and in that way, provide more help for the child begin having a slightly more dispassionate approach. And so we find and we find that it works incredibly well. We get At the end of treatment, I usually treatment goes for about three months. And at the end of that time, we find about 60% of young people are free of their main presenting problem. And over the next sort of three to six months, we find that number goes up to about 75%. So once we finished the Cool Kids program, we found that find about three out of four kids are completely free of their main anxiety disorder, which which is a pretty good outcome. 

Sucheta Kamath: That's phenomenal. So can you walk us through some of the what would that might look like for a parent working with a child? What's so interesting, I was in preparation for your this interview, I was reading some research about parents and anxiety. And there was a one particular group that studied math anxiety of parents, and parents who themselves had math anxiety. And if they were helping their children, their children had negative outcomes. But if the parents had math anxiety, but did not help with the homework, the children were actually safe. There's a way to influence because that emotional contagion, you can feel extremely anxious, if the person is anxious that you are with right. So what you're talking about this dis compare dispassionate? Is that a sense of equanimity? Is that taking control of your own emotions? How does that look like? 

Dr. Ron Rapee: Yeah, we that first of all, we know that anxiety runs in families, there's no question, there is a strong genetic component. And that relates back to the personality style I was talking about earlier, there is no doubt that there is something that is passed on. And so we do find that anxious children tend to have slightly more anxious parents, doesn't mean the parents have a clinical disorder at all, they might be very, very high functioning fabulous bear not a not a problem, but they're more likely to be at that anxious end of the spectrum. And so what we do tend to find in a lot of our work is that the parents when you have a child who is highly, temperamentally anxious and a withdrawn nervous type of child are often going way back to the day they're born. They get it the parents and the child that can often get into a sort of a cycle, a pattern where the child gets anxious, a lot cries a lot gets distressed a lot. So of course, there's a loving, caring parent, what do you do, you go and you help them. And then you very quickly learned that my child is going to get upset, so I better help them. And you start getting into the cycle, where you're leaping in more and more quickly to the child's defense. So what happens then? Well, a child is not learning to cope, a child is not learning to deal with life themselves, because every time they try and do something, the parent is there helping them. And so you have this cycle, it's not the parents fault. But it's a habit or a pattern that they've gotten into as a couple, where the child gets upset, the parent leaps in and helps, and then the child doesn't learn that I can do it and gets more upset in future. And so part of what we do in the program is teaching parents to take that step back, to start to tell themselves, my child can do this. They're perfectly capable, and I don't need to help my child here. And giving the child a chance to make their own mistakes is the type of lesson we try to get them to learn. 

Sucheta Kamath: And, you know, one very important component of that, is that incredible tolerance for somebody's mistakes, you know, because another spectrum that I see that the the, the parents desire to help or step in, is to really not offer respite to the child from the already hit their anxiety, but their own expectation of perfection from their children, or unending expectations of excellence, which is just not possible by definition child is learning, you know. So, sounds like a do you do any? Do you see any difference in affluent versus non affluent communities in terms of the level of anxiety? I had had an opportunity to interview, Suniya Luthar. She's a researcher here, social psychologist, and she found in affluent communities, they were more stresses about this invisible kind of wall that they have to all climb and parents were doing, going above and beyond trying to get their children market ready, so to speak, you know, and and so there is like a generalized anxiety in the communities not just a family. So the kind of school you belong to everybody wants to yell or fail kind of mindset, you know. So do you see any difference that way? 

Dr. Ron Rapee: Not really. One of the really interesting things about anxiety clinical anxiety disorders, is that it is really non discriminatory. It affects all races, it affects all levels of society. It affects all different types of people. And pretty much equivalently. Mental health problems in general are more common in the lower socio economic groups. And so people who are struggling with life's stresses are slightly more likely to have anxiety problems, but it's really much, much less of a difference, much less of a difference, then problems like depression, for example, which is much more strongly linked to socio economic level, anxiety affects all levels of society pretty much the same. And that's one of the fascinating things about it, it's very hard for us to find, causes or define predictors, because it's pretty much universal. 

Sucheta Kamath: You know, I've been thinking about now I'm forgetting his name, but there was one wonderful author and a comedian, and an actor who, about his childhood, and he described his whole family was a little neurotic, you know, they had, and, and a little bit, as you said, you know, shy, nervous, awkward, weird, but the parents were so nurturing, they kind of identified and recognize this child's quirky behaviors. And what they did is they converted his bedroom, entire bedroom, into this amazing theater, and with drop down curtains, and and this very odd kid kid who would perform plays and had have, you know, shows on his bed, and the only audience member would be his aunt, you know, something like that. But eventually, he became this very celebrated now, I can't think of his name, I was trying to look for the name of his book. But what was so beautiful about that, to me is the kid the parents never tried to do anything to change him. They actually created a workaround, and, and empowered him to, to find a true meaning in his awkwardness. And I think that's such a wonderful way to live a life where we can't be perfect. And particularly, we can't be some ways that other people want us to be and, and anxiety can really do a number on us, because it's all other kind of expectations, the world and we ourselves have. So as we come too close, do you have any parting thoughts? What's the most inspiring thing you have learned about anxiety? 

Dr. Ron Rapee: I think the most The main thing to remember is is that anxiety is normal. That anxiety can be really important. It can motivate us to great things. We need some level of anxiety to get us to get out of bed in the morning and get going. It's about keeping it under control and not letting it dominate your life. 

Sucheta Kamath: Well, thank you, Dr. Rapee for being here with us and for your wisdom and your knowledge. As we part away, do you recommend any books? Any your favorite all time favorite books that you might recommend to our audience? 

Dr. Ron Rapee: No. I'm thinking for some reason the Kite Runner jumps into my mind. That was fabulous. I love that book. But yes, there are many many, Johnathan friends and I loved a lot of those books. Look, 

Sucheta Kamath: Any anxiety researcher that you admire?  

Dr. Ron Rapee: Axienty? Um, my colleagues will shoot me now. But I must say I never I very rarely, if ever read anxiety books because I read scientific papers. I don't tend to read the sort of the whole book type aspect. 

Sucheta Kamath: Did you ever read Joseph Ledoux's book on anxiety? 

Dr. Ron Rapee: I didn't know I should. I should because people talk about. I read his papers. I read scientific papers. I tend not to read books. I have to probably put a plug in for my old mentor and supervisor David Barlow. Of course he's written the volume on anxiety disorders, Anxiety and it's Disorders, it's called. 

Sucheta Kamath: Perfect. Well, we will plug that into our show notes. And thank you once again for being here. Everyone, please stay tuned for our next episode. And if you love what you heard recommended to your friends. I bet you know a lot of anxious people who will benefit from this conversation. So remember, be brave, be bold and know more about yourself. So thank you Dr. Rapee for being with us today. 

Dr. Ron Rapee: It's been my absolute pleasure, thanks Sucheta.