CHAPTER ONE

Coming to Terms with Stress and Anxiety

I have good news. Actually, I have two pieces of really great news. First, stress and anxiety aren’t all bad. In fact, you can’t thrive without them. Understanding the difference between their healthy and unhealthy forms will change, for the better, how you help your daughter manage the tension she feels. Second, the field of psychology has a lot to say about how to alleviate stress and anxiety if they do reach toxic levels. Indeed, if I were to take an informal survey of my colleagues, the vast majority would agree that we have come to understand the root causes and inner workings of pathological stress and anxiety as well as we understand anything in our field. As a result, we have many ways to help people rein in psychological strain when it gets out of control.

Taken together, these two happy facts mean that you can already start to worry less about how stressed or anxious your daughter feels because, to a degree, these mental states are essential catalysts for human growth and development. And if you suspect that your daughter’s unease far exceeds the healthy mark, then I’m here to reassure you that you and your daughter do not need to feel helpless. We’re going to tackle unhealthy stress and anxiety, too.

Healthy Stress

Stress gets a bad rap. Though people don’t always enjoy being stretched to new limits, both common sense and scientific research tell us that the stress of operating beyond our comfort zones helps us grow. Healthy stress happens when we take on new challenges, such as giving a speech to a large audience, or do things that feel psychologically threatening, such as finally confronting a hostile peer. Pushing ourselves past familiar limits builds our capacities in the same way that runners prepare for marathons by gradually extending the distances at which they train.

Learning to brave stressful situations is also a skill that develops with practice. Researchers actually use the apt term stress inoculation to describe the well-documented finding that people who are able to weather difficult life experiences, such as riding out a serious illness, often go on to demonstrate higher-than-average resilience when faced with new hardships. I can speak for myself in saying that being middle-aged doesn’t seem to come with a lot of advantages, but it definitely has one particular benefit: problems don’t bother me as much as they used to. Like most of my agemates, I’ve got enough life experience under my belt that I now take in stride events—such as having a plane flight canceled—that would have put me on the ceiling when I was younger. While the saying “What doesn’t kill you makes you stronger” almost certainly overstates the point, it’s not all wrong.

As parents, we should think of stress the way Goldilocks thought about making herself comfortable while trespassing. We don’t want our daughter’s stress level to be consistently too low or too high. But we can embrace reasonable levels of stress as a nutrient for our daughter’s healthy development that will help her to grow into the strong and durable young woman we want her to be.

Much of what our girls learn about how to manage stress comes from observing how we manage it as parents. Our daughters watch us for cues about how alarmed they should be by life’s difficulties. When we let our own inner Chicken Little take over and panic in the face of manageable challenges, we set a bad example. When we accept that stress often leads to growth—and help our girls do the same—we create a self-fulfilling prophecy for ourselves and for our daughters.

Obstacles, however, only make us stronger when we can surmount them. Accordingly, Under Pressure will address in its coming chapters how you can help your daughter master the challenges she will face as she moves from childhood to adulthood. With your help and over time, your daughter can come to appreciate that stress is a positive and growth-giving part of life.

Except for when it’s not.

How Stress Becomes Unhealthy

Stress becomes unhealthy when it exceeds what a person can absorb or benefit from. There is no single yardstick for what constitutes unhealthy stress, because the volume of manageable hardship differs from person to person and can even differ for a single individual from day to day. Whether stress becomes unhealthy depends on two variables: the nature of the problem and the person upon whom the problem lands.

Psychologists consider stress to be unhealthy when it interferes with well-being in the short or long term. Whether or not a stressor harms well-being has surprisingly little to do with the source of the stress and much more to do with whether adequate resources—personal, emotional, social, or financial—are available to address the problem. For example, a broken arm could be a resilience-building hassle for a girl who writes with her other hand and has lots of friends to help carry her books. Or it could be a full-blown crisis for one who might lose a shot at a desperately needed athletics scholarship due to the injury. In the same way, if the primary breadwinner is laid off, that feels much worse for a family without a financial cushion than it does for one with a healthy savings account.

Knowing that stress becomes unhealthy only when its demands exceed our resources helps us to better support our girls. We can’t always prevent calamities, but we can often summon reserves to help our daughter manage the challenges life puts in her path.

A terrific example comes from my work as a consulting psychologist to Laurel School, a local all-girls’ school that runs from pre-kindergarten through twelfth grade. I’ve spent part of each week there for the past fifteen years, and in that time I’ve watched several high school girls and their families contend with the disease of mononucleosis, a particularly tenacious stressor. The course of the virus doesn’t differ much from girl to girl, as sufferers usually miss classes for a few weeks and also need to suspend their extracurricular activities. But the illness turns out to be much more stressful for some students than for others.

Under ideal conditions, a girl’s parents can surround their daughter with loving support to make the best of a bad situation. Her folks ensure that she gets lots of rest, they coordinate effectively with the Laurel faculty to keep their daughter reasonably up to date on her assignments, and they find ways for her friends to stop by for visits. One family of a dedicated soccer player happily drove their daughter to games so she could cheer on her beloved teammates from the bench. When parents have the wherewithal to marshal resources on their daughter’s behalf, I’ve seen a bout of mono amount to nothing more than a bothersome blip in a girl’s high school career.

Other families, especially those who may already be at the limit of the stressors they can manage, can provide only minimal support. A girl who spends long hours alone at home can be inclined to choose social media over sleep, thus causing the virus to drag on longer than it should. She might fall far behind on her schoolwork or be dragged down by sadness about missing her friends or the fun parts of school. When students in this situation eventually get better, I’ve heard them ruefully remark, “Thanks to mono, my entire semester was messed up.”

The Three Types of Stress

Of course, there are girls and families who do everything in their power to address the social and academic impact of mononucleosis yet still find themselves struggling to get back on track. We can better understand their challenges when we recognize that just as stress is not all bad, it is not all the same. When psychologists study stress and its impact on health, we sort it into three distinct domains, namely life events, daily hassles, and chronic stress.

Any life event that requires adaptation, such as a teenager catching mono, is inherently stressful. Even happy occasions, such as becoming a parent or starting a new job, come with the strain of adapting to abrupt change. There aren’t many cardinal rules in psychology, but here’s one: change equals stress. The more change a life event requires, the more taxing it will be.

Moreover, life events, both good and bad, often trigger daily hassles as well. For instance, parents who rearrange their schedules to care for an unhealthy teenager may have trouble getting around to their routine errands. Or they may not be able to clean up the sink full of dinner dishes that are usually loaded into the dishwasher by the teenager felled by mono. While daily hassles seem like they shouldn’t be a big deal, they do add up. Quite remarkably, one research study found that it was the number of daily hassles triggered by a major stressor, such as the death of a loved one, that actually determined how much emotional difficulty people faced down the line. In short, the pain of losing one’s wife is amplified by the stress of trying to figure out her system for paying the household bills.

Our instinctual understanding of the burden of daily hassles explains our impulse to cook for friends with new babies. We stock the fridges of those facing major life events to spare them the added nuisance of shopping and making meals. Appreciating that our own daily hassles really do compound stress can spur us to take steps to minimize them. Eating off paper plates for a few weeks won’t cure a teenager’s mono, but it can help to reduce the level of stress overall.

Apart from life events and daily hassles, there’s also chronic stress. This is the kind that results when basic life circumstances are persistently difficult. Enduring chronic stress—such as living in a dangerous neighborhood or caring for a relative with dementia—has been found to take a grinding toll on both physical and emotional health. Yet even in the worst circumstances, relief can sometimes be found. Studies of how young people cope with two grave and persistent sources of stress—ongoing cancer treatment or being raised by a severely depressed parent—have yielded valuable lessons that apply to a wide range of chronically stressful situations.

I found myself relying heavily on what we know about helping children and adolescents manage stress, even in the context of unrelentingly difficult conditions, when working with Courtney, a bright seventeen-year-old whose parents were in a drawn out and contentious separation. Courtney and I started meeting weekly in the fall of her junior year after she announced to her folks that she could not bear another day of their fighting. Though they disagreed about many things, Courtney’s parents both wanted to provide their daughter with some much-needed support.

Once we got to know each other, Courtney and I set our minds to figuring out how she could manage the problems at home. Our first step was to determine what she could and couldn’t change.

“Honestly,” she said, “I don’t think that they’ll ever get along.” With an air of exasperation she added, “They say that they won’t fight in front of me, but they can’t seem to help themselves.”

“I’m really sorry to hear that…and can only imagine how painful it must be to hear them go after each other.”

Courtney looked at her hands and then back at me before replying wearily, “Yeah, it sucks.”

I reflected a moment before saying, “With regard to the fighting, I think you’re stuck. Your folks are the only ones who can make it stop, and it doesn’t sound like they’re ready to do so.”

Courtney ruefully nodded her agreement.

“So, as much as I hate to say this, I think that you have to find a way to accept that reality for now.”

Indeed, for difficulties that cannot be changed, research shows that practicing acceptance is the critical first step. If your nose wrinkles at the new-age aroma wafting from the suggestion to “practice acceptance” (true confession: that was my own first reaction), consider it pragmatically. Why expend energy fighting an immutable reality? Once we find a way to digest a hard truth, we can get on with adapting to it.

Courtney, however, was having none of it.

Simultaneously incredulous and annoyed, she replied, “How can I possibly accept their fighting? It’s awful!”

“I hear you,” I responded as nondefensively as I could. “And if I thought you had the power to help your parents come to a truce, I’d be encouraging you all the way. I do, however, think that there are things you can control that will help your situation. Are you open to some ideas?”

Courtney reluctantly indicated her willingness to hear me out, so I proceeded with more of what we know from the research on chronic stress. Namely, that it’s helpful for young people to seek out happy distractions and enjoyable activities in order to take cover, even briefly, from their monsoon of stress.

“Are there things you enjoy that their fighting can’t disrupt?”

Courtney’s face relaxed as she thought about my question. “You know,” she ventured, “there is something I really like to do…”

I raised my eyebrows to let her know that I was eager for her to continue.

“I have a car…we say it’s my grandma’s, but it’s basically mine…and I love to drive it out on Chagrin River Road.” I smiled to indicate my familiarity with the wooded, hilly route that picks up about twenty minutes east of my office in the suburbs of Cleveland. “I roll down the windows, even when it’s cold outside, and play my music loud. Even after one song, I feel better.”

“Can you take that drive whenever you want?”

“Basically. Unless I have homework or something like that—but it doesn’t take me long to get there from my house.”

“Then I think that should be part of our plan. You can’t stop your parents’ fighting, but it sounds like you have a reliable way to take a break from the stress of it.”

Courtney bit her lip, letting me know that she remained unconvinced.

“It’s definitely an imperfect solution,” I said gently, “but think of it this way: the arguments make you feel bad, and driving makes you feel better. Until your parents sort things out, taking a drive when you need to gives you some control of your mood.”

“That’s true,” she said slowly. She paused, then added, “I’ll try it and let you know.”

We can bring these lessons about coping with chronic stress home to our own girls by guiding them to think about what they can change and what they can’t when they are stuck in difficult circumstances. Should your daughter find herself in a class dogged by unrelenting interpersonal strife (hello, seventh grade), you might help her to focus on what she can actually do about the situation, such as keeping ties with low-drama neighborhood friends. Beyond that, you can support her as she finds ways to distract herself from the social tempest until it dies down (fingers crossed, eighth grade). Given that unhealthy stress cannot always be avoided, we should take comfort in what the scholarship tells us about how to reduce psychological strain. Taking a strategic approach—fixing what we can and finding a way to live with what remains—makes it possible to feel less helpless and more relaxed, even in the face of substantial adversity.

From Stress to Anxiety

Stress and anxiety are like fraternal twins. They have a lot in common, but they’re not the same. Stress and anxiety are alike in that they are both psychologically uncomfortable. But while stress usually refers to the feeling of emotional or mental strain or tension, anxiety usually refers to the feeling of fear, dread, or panic.

Though we can distinguish between stress and anxiety, in real life they often coil tightly around each other. For example, a girl who feels stressed by her academic workload may come to feel anxious about getting her assignments done. A girl who lives in a neighborhood where sporadic gun shots cause bursts of anxious panic will almost certainly suffer from chronic stress. We can’t always tease stress and anxiety apart, and most of the time we don’t need to. For practical purposes, we can treat the two concepts as nearly interchangeable (as this book will often do), focusing our efforts on helping our daughters to keep both their tension and their worries under control.

Stress and anxiety are also similar in that they can be good or bad. We’ve already taken a look at the difference between healthy and unhealthy stress. Now let’s do the same for anxiety.

Healthy Anxiety

Anxiety is a gift, handed down by evolution, to keep humans safe. Every one of us comes equipped with a sophisticated alarm system programmed deep in our brains. When we sense a threat, that alarm system triggers anxiety. And the discomfort of anxiety compels us to take steps to reduce or avoid the threat. To put it another way, our prehistoric ancestors who sprinted for the cave when they spotted a saber-toothed tiger survived to pass down their anxiety alarm genes to us. The caveperson who casually remarked, “Hey, check it out, that’s a really neat tiger” did not.

Our anxiety alarm now rings in response to a wide range of modern-day threats. It goes off when we nearly have an accident while driving, when we hear a strange noise while alone in the house, or when our boss calls an unexpected meeting in the midst of layoffs at work. In addition to warning us about the threats in our surroundings, anxiety also alerts us to dangers from within. You know that uncomfortable feeling that bubbles up right before we say something we later regret? That’s anxiety trying to warn us to zip it. And you know that nagging sense that arises when we’re binge-watching Netflix instead of doing our taxes? That’s anxiety trying to keep us from having to pay the fines for filing late.

In short, anxiety works to protect us from the world and from ourselves.

Unfortunately, anxiety, like stress, has gotten a bad rap. Somewhere along the line we got the idea that emotional discomfort is always a bad thing. This turns out to be a very unhelpful idea. Psychological distress, like physical pain, serves as a finely tuned feedback system that helps us to course correct. Just as physical pain prompts us to stop touching a hot burner, emotional distress alerts us to pay attention to our choices. For example, if you always feel nervous before having lunch with a particular friend because you never know how she’s going to treat you, it’s probably time to reconsider that relationship.

So here’s the first thing we can do to help our daughters take control of anxiety: we can teach them that anxiety is often their friend.

Several years ago I started working with a sixteen-year-old named Dana whose parents called me after she drank so much at a party that she landed herself in the emergency room. I had been practicing long enough to know not to come to any conclusions about Dana based on the single incident that brought us together, and indeed, when we met, my restraint was rewarded. In my waiting room I found a friendly teenage girl wearing jeans and a plaid flannel shirt. She stood up quickly and stuck out her hand as she introduced herself.

As we shook hands I said, “Hi, I’m Dr. Damour,” to which she replied sincerely, “Thank you for meeting with me.” I pointed the way to my office and followed her in as she walked, actually kind of bounced, ahead of me.

Once we were sitting down, I began. “Look, you don’t know me and I don’t know you,” I said in a welcoming tone, “but I know that something really scary happened.” Back in my early days as a psychologist, I used to make the rookie mistake of putting teenagers on the spot shortly after meeting them. In response, they usually clammed up. Experience has taught me that people (and teenagers are, of course, first and foremost people) feel much more comfortable broaching touchy topics when they’re not cornered into doing so.

“Do you want to start with what happened,” I continued, “or would you feel more comfortable if we just took some time to get to know each other?”

“I appreciate that,” said Dana, “but I’m okay with talking about what happened. I’m actually super bothered about it,” she began while tugging at a lock of her curly, shoulder-length hair. “A couple of weekends ago my friends and I went to a party at the house of a kid I’ve known for a long time, and that was fun. But then one of my friends heard about a party at another house, so for some reason we decided to go over there. I didn’t know the kid hosting the second party, but I knew a bunch of his friends. But there were also tons of kids I had never seen before, which was kinda weird.”

I nodded as she spoke but didn’t interrupt. Dana almost seemed as if she felt eager to unburden herself as quickly as possible. “I was really uncomfortable, just nervous. I drank one beer at the first party and I was totally fine, so I thought it would be okay if I had another beer at the second party.” She continued, “I just wanted to calm down a bit because my friends were having a good time so I figured we’d be there a while.

“While I was drinking that beer, someone offered me a shot, which I wouldn’t normally do, but I thought that would help me relax fast. So I drank it.” As she spoke, I found myself mentally cringing at two things: the free-flowing alcohol, which I hear about way too often, and Dana’s total certainty that she needed to find a way to quiet her nerves. “After that,” she said, “I don’t really remember. My friends said that I kept drinking. When I passed out, one of my friends got really scared and called her mom, who called my mom.”

“That’s a good friend,” I said, to which Dana nodded her solemn agreement. Then I asked, “Can you take me back to when you arrived at the second party?” She nodded again, so I continued, “Do you have a sense of what was making you feel so uncomfortable?”

“Oh, yeah,” she said quickly, “it was nuts. I couldn’t believe how many kids were there and some of them were definitely sketchy. Not to be unfair,” she said in the same offhanded tone teens use when they say “no offense” before expressing an unvarnished opinion, “but they were definitely way too old to be at a high school party.”

“Got it,” I said, “so let me run an idea by you. I’m wondering if part of what went wrong is that you treated your anxious feelings as your enemy, when I actually think they were acting as your ally.” Dana looked at me quizzically. I continued, “My hunch is that you felt really uncomfortable because you are smart enough to know that it was probably a risky party and you wanted to leave.”

“Definitely,” she replied emphatically, “it wasn’t a good scene. But I knew my friends wanted to stay, so I didn’t know what to do.” She paused, then added sheepishly, “Obviously, I shouldn’t have done what I did.”

“True,” I said. “And I’m sure you’re not surprised to hear that I think you should lay off drinking.” She tilted her head to acknowledge my perspective. “I also think that you’ll feel much better, and worry much less about something like this happening again, if you can get to know your anxiety.” Once more, Dana gave me a puzzled look. “Adults often talk about anxiety as if it were a bad thing, but it’s not,” I said. “It can get out of control, and we don’t want that. But most of the time it’s a really useful emotion.” I could see from Dana’s face that she now understood completely.

“Instead of trying to calm myself down with that shot,” she reflected out loud, “I probably should have paid attention to how nervous I felt and found an excuse to go home.”

“Yep,” I agreed, “you’ve got a sophisticated warning system that works well for you. Let’s put it to good use.”

Try this at home. The next time your daughter tells you that she’s feeling really nervous about a test for which she has yet to study, cheerily reply, “Good! I’m glad you’re worried. That’s the ideal reaction, because right now you know you’re not ready. As soon as you start studying, your nerves will calm down.” As she heads out with friends on a Friday night, you might say, “Have fun. Take good care of yourself, and if you find yourself in a situation that makes you uncomfortable, pay attention to that feeling! We’re always happy to spring you if things go south.”

In sum, when a girl gets anxious we want her to take that emotion seriously and wonder, “Why is my alarm going off? And what’s the best way to get it to quiet down?” Given that our culture has slapped a bad name on anxiety and all of the other uncomfortable feelings, we need to go out of our way to help girls attend to and appreciate anxiety as the protective mechanism it is.

The Mechanics of Anxiety

Fear is a powerful emotional experience that can feel alarmingly out of control. But psychologists have come to recognize that anxiety is, in fact, a highly predictable and systematic reaction that activates the cascading involvement of four different systems. First, stress hormones trigger a biological reaction known as the fight-or-flight response. Adrenaline and its chemical sidekicks crank up the heart rate, slow the digestive system, and widen the airways to the lungs in order to direct more oxygen to our punching and running muscles. In response to messages sent to our lungs from our central nervous system, breathing speeds up and becomes more shallow. Our pupils dilate so that we can see at greater distances. Once the perceived danger passes, an equally complex system resets the body to its pre-anxiety state. This is why moments of panic are often followed by an urgent trip to the restroom as the digestive system gets going again. Whatever else we might say about anxiety, it’s hard to deny that it puts on a pretty spectacular biological show.

Almost simultaneously, our emotions get in on the action. We tend to experience nervousness, fear, or dread, though some people also feel edgy or irritable when anxious. When our emotions are affected, our cognitive—or thought—system jumps in. Deep thinking goes out the window as we vigilantly scan our surroundings for information about the perceived threat. Upon hearing an unexpected noise while home alone, we prick up our ears while fretfully asking ourselves, “Did I remember to lock the door? Could someone be trying to break in?” At other times, anxiety simply causes the mind to go blank, or to have exaggerated, irrational thoughts such as, “An ax murderer is at the door!”

Last of all, our action system kicks in. Someone who feels truly frightened by a strange sound in the night might stiffen up so as not to make any noise, reach for the phone to dial 911, or stalk around household corners wielding a baseball bat.

Even when anxiety serves a useful purpose—perhaps helping us discover an outside door flung open by the wind—it’s a biological, emotional, mental, and physical workout. If this elaborate alarm system malfunctions and spins out of control, we are run absolutely ragged. At these times, clinicians are likely to diagnose an anxiety disorder.

Anxiety Disorders and Their Treatments

The many different ways our alarm systems can become faulty is illustrated by the variety of anxiety disorders clinicians diagnose. When the alarm rings persistently—sometimes quietly, sometimes loudly—but far too much of the time, we apply the diagnosis of generalized anxiety disorder (GAD). Children (and adults) who suffer from GAD are beset by worries they cannot control, their minds racing from one concern to the next: Will I be picked last when we choose teams in gym? Will the teacher call on me unexpectedly? Will our car pool leave without me at the end of the day? This constant ringing of the anxiety bell can undermine sleep, concentration, and, of course, the ability to feel calm or happy.

In other disorders, the alarm is less indiscriminate, but rather blares at unreasonable decibels in response to particular threats. For example, separation anxiety disorder, social phobia, and specific phobia cause debilitating distress when their sufferers are, respectively, parted from caregivers, exposed to the possibility of social scrutiny, or faced with an object or situation of which they are mortally afraid. Given that young children often miss their parents when separated from them, and that most adolescents have moments of feeling uncomfortably “onstage,” and that all humans have fears, we diagnose an anxiety disorder only when a person’s worries are entirely out of proportion to the perceived threat or if they hamstring daily functioning. For example, it’s one thing to dislike spiders and quite another to skip an important meeting in a musty old building for fear of encountering one.

When anxiety comes on like a horrific siren that may blare for no clear reason at all, we call that a panic attack. These attacks are no joke. They are acute bursts of terror in which the physical symptoms of anxiety are so powerful that sufferers often think they might be losing their minds or about to die. Indeed, studies find that roughly a quarter of all visits to emergency rooms for chest pain are prompted by a panic attack, not a cardiac event. Panic attacks peak and recede quickly—often within twenty minutes. They can occur in the midst of an obviously stressful situation such as a high-stakes job interview, or can happen out of the blue.

Interestingly, panic attacks are common. At some point in our lifetimes, nearly 30 percent of us will be hit by a wave of anxiety so intense that it includes some combination of nausea, dizziness, numbness, tingling, a feeling of detachment from reality, chills, sweating, and, as already noted, fear that one is losing control or dying. Though having a panic attack is miserable, we diagnose panic disorder only when recurrent, unexpected attacks sow the constant fear of having another attack or cause people to rearrange their lives. Sometimes sufferers will start to avoid situations or places where they’ve had a panic attack—such as staying away from the gym or parties—in the hope of preventing another one.

A few summers ago, a friend whom I’ve known since childhood called me from the side of a highway somewhere in southern Colorado. She and her seventeen-year-old daughter were halfway into a six-hour road trip from our hometown of Denver to Santa Fe, New Mexico, where her daughter would be spending the summer in a long-coveted job with Santa Fe’s chamber music festival.

After filling me in on the background, my friend continued, “We were in the middle of this beautiful drive, and then out of nowhere, my daughter lost it. She started shaking, said she felt like she was suffocating, and explained that she’d never been more terrified in her life, but she didn’t know why. One minute she was completely fine, and the next she said she felt like she was losing her mind. She’s okay again now. But she’s really wigged out.”

After asking my friend a few more questions, I weighed in. “What you’re describing sounds like a classic panic attack. They feel completely awful,” I empathized, “but they’re basically harmless.” My friend was relieved to hear this but wanted to know what to do next.

“I’m wondering if we should tell her boss that she’ll have to start late and head back to Denver to get this checked out.”

“No,” I said, “I think that the best thing will be for you to get back on the road to Santa Fe. Panic attacks happen, but we don’t want to give a single attack more power than it deserves.” I then told my friend about the one panic attack I’ve had in my lifetime. It happened in graduate school when I found myself sharing intelligence test results with a shoot-the-messenger parent who was not at all happy to hear that his really quite charming son hadn’t tested stratospherically. I encouraged my friend to tell her daughter that I remembered the panic attack vividly. I felt terrified and couldn’t end the meeting and get out of the consulting room fast enough. Luckily, however, it has yet to happen again.

“Okay,” said my friend before adding tentatively, “you know, I think that my aunt used to have really bad anxiety. Are you sure we shouldn’t get it checked out?”

“Panic attacks can run in families,” I said, “but I still think it’s better to stay on the road to Santa Fe. If it happens again, call me and we’ll see about connecting her with a clinician in New Mexico.”

I didn’t hear from them again that summer. When I was recently back in Denver to visit my folks, I caught up with my friend and asked how things had turned out. She shared that her daughter had a great start to the summer, but then had another attack while out jogging in late August shortly before it was time to come home. “She got through it okay,” my friend explained, “because she knew what was happening. After that, she looked up some information about relaxation techniques but thankfully hasn’t had another attack since.”

When a girl’s nerves do interfere with her day-to-day life, it’s time to seek help from a clinician who specializes in treating anxiety. Cognitive-behavioral therapy (CBT) takes a tailored and systematic approach to treating the four components of anxiety we’ve addressed. CBT practitioners use advanced techniques to help clients manage their physiological reactions, cope with distressing emotions, challenge anxiety-provoking thoughts, and gradually confront their fears.

Psychodynamic psychotherapy, which focuses on thoughts and feelings that may be outside of our awareness, can be especially helpful when there’s a reason for the ringing anxiety alarm that needs to be uncovered. That was the case for Simone, a high school sophomore whose mother found me through the counselor at her daughter’s school. On the phone, Simone’s mother explained that her daughter felt constantly on edge, but no one could figure out why. Things at home were good, Simone was doing well academically, she had a manageable schedule, and she had several close friends. When I asked how Simone felt about meeting with me, her mother replied that she was “really nervous about it and wants me to be there with her.” I explained that I was glad to do whatever was needed to ease Simone into therapy. We found a time when they both could come in.

In our first meeting, Simone and her mother sat beside each other on my couch so closely that their legs touched from hip to knee. It struck me as somewhat surprising that a fifteen-year-old would allow her mom to sit so near, but Simone had an unusual quality. She seemed at once to require the comfort of the physical contact with her mother, while also being utterly her own person. Our initial meeting was remarkably unremarkable. I learned that Simone was the oldest of three children, that her mom was a successful entrepreneur who traveled every few weeks for work, and that they had lived in the same home in Beachwood, a suburb near my practice, for nearly twenty years.

At our next session, Simone felt ready to come into my office alone. She sat at the far end of the couch, reached for a bowl of colorful magnetized toy rods and silver ball bearings that I keep on a small table, nestled the bowl into her lap, and constructed a pyramid that rose with a series of satisfying clicks as the rods and balls connected. As she worked, Simone comfortably answered my questions about her day (she had lots of homework waiting for her at home), her friendships (they were happy and reliable), and her current level of anxiety (heightened, thanks to her impending midterms). She talked about her close relationship with her mom, saying, “We get along well…not all the time but mostly. And even though I don’t tell her this, I really admire her,” and her dad, whom Simone described as “kinda hard to read—distant, I guess—but a really good dad, and a really good person.”

After our second session I found myself puzzling over why Simone was meeting with me at all. None of what I knew so far seemed to explain her constant edginess, nor did Simone seem to be in a rush to get to the bottom of what was causing it. But in our third session, the problem quickly came into focus. Simone entered my office quietly, returned to her pyramid-building, and worked silently for several minutes before asking, “How much do you tell my mom about what we talk about?” I assured her, as I had in our first meeting, that our conversations were private unless she gave me a reason to think that she, or someone else, might come to harm.

“My mom had an affair,” Simone said bluntly, “and she doesn’t know I know.” From there she went on to explain that, several months past, she had overheard her parents talking about the fact that Simone’s mother had used some of her work travel to arrange trysts with a former college boyfriend. She added, “From what I heard, I guess that my mom ended the affair and told my dad about it. I’m sure that was hard on my dad, but I think that they’re in therapy together and things seem to be okay at home. So I’m not sure what to do.”

“That’s a heavy secret to carry,” I said. Simone closed her eyes, perhaps to hold back tears, and bowed her head in agreement. We could both appreciate that harboring the secret of her mom’s affair helped explain Simone’s edginess. Together, we considered some of her options. She could tell her parents what she knew, or keep the news to herself for now and decide what to do later on. As she left, Simone seemed relieved. In fact, she seemed visibly lighter having shared the burden she had been shouldering alone.

“There’s something else,” said Simone, at the start of our next meeting. “I know that this affair doesn’t really involve me, but I’m not sure how I’m supposed to feel about my mom.” She explained how much she liked and counted on her mom, and how proud she was to have a mother who was the main breadwinner in the family. “I really respect her,” Simone continued gingerly, “so it’s hard to know what to think.”

I asked tentatively, “Is there any chance that you’re feeling sort of frustrated with her?” In truth, I suspected that Simone was far more than frustrated, but I’ve learned to tiptoe toward any feeling that is being kept at bay. Asking, “Are you enraged?” only shuts clients down, especially when they have built ramparts around their anger.

Tears, twin currents of them, suddenly streamed down both of Simone’s cheeks. We had hit an emotional jackpot, but we weren’t celebrating. “Listen,” I said warmly, “it’s really painful to be mad at someone you love and need so much.” After we sat together quietly for a long time I spoke again. “Your frustration makes a lot of sense,” I said, “and I think that it also helps explain some of your anxiety.” Simone now held me in her gaze. “Perhaps your edgy feelings are actually the third step in a hidden emotional sequence.

“Step one,” I explained, “might be that somewhere deep inside you feel very frustrated with your mom. Step two is that you don’t want to feel that way. And step three, the one that brought you here, was that you became filled with worry. Perhaps you worried that your angry feelings might damage your good relationship with your mom.”

Simone tightened her lips in concentration. “Maybe…I don’t know,” she said, “that could be it. But I’m not really sure.”

Over our next several sessions Simone’s worries started to ease as we weighed the possibility that her anxiety was actually fueled by anger. Our work was slow going, but at least we were headed down the right path.

Not all anxiety can be chalked up to a hidden cause, but we should bear in mind that anxiety works to alert us to threats both from without and from within. Sometimes a girl feels tense because she’s dealing with an external threat, such as being in trouble with a parent. And sometimes everything looks okay on the outside, but the girl faces a powerful internal threat, as was the case for Simone, who felt frightened of her anger toward her mom.

When therapy doesn’t provide sufficient relief, or work quickly enough, anxious feelings can also be managed with medical help. It’s important to note that being female may increase the biological vulnerability to anxiety. Beginning in childhood and for the duration of adulthood, girls and women are at least twice as likely as boys and men to be diagnosed with an anxiety disorder. Overwhelmingly, we attribute this massive gender disparity to nonbiological factors that we’ll be tackling in the rest of this book, but there are nonetheless a few physiological forces at work that fray girls’ nerves more than boys’.

You’re probably not surprised to hear that premenstrual hormonal shifts routinely leave many girls and women feeling more tense, irritable, or uneasy than usual. Furthermore, for those who suffer from panic attacks, some research indicates that the premenstrual drop in estrogen and progesterone levels can temporarily ramp up the frequency and intensity of panic attacks for girls and women who have them. Several experts suggest that the emotional ups and downs of the menstrual cycle may contribute to the development of anxiety disorders or help to sustain or exacerbate disorders that are already under way. Studies show that anxiety can also be conferred genetically, but the jury is still out regarding whether it is more likely to be passed down to daughters than to sons.

Whether anxiety results from a genetic predisposition or not, prescription drugs can help to muffle it. Though I rarely suggest medication as a first line of approach, I don’t hesitate to recommend a consultation with a psychiatrist when psychotherapy isn’t putting a dent in persistent anxiety, or to clients who are paralyzed by unrelenting panic attacks. Indeed, antidepressants often provide fast relief to individuals with panic disorder—the diagnosis we give when overwhelming fears of having a panic attack undermine everyday living. The symptoms of anxiety are usually warded off so long as the medication is in use, which allows clients to capitalize on the anxiety cease-fire to explore hidden, difficult feelings in therapy or to learn relaxation techniques, thinking strategies, and routines that may give them the option of ultimately managing their distress without medication.

In recent years, mindfulness practices have emerged as a highly effective way to counter anxious emotions and ideas. Mindfulness, an approach rooted in ancient Buddhist meditation techniques, involves learning to observe—but not judge—one’s own feelings and thoughts. Anxiety stirs up trouble when it convinces our daughters that they’re facing insurmountable threats and then prompts them to imagine dreadful outcomes. Mindfulness addresses anxiety by teaching its practitioners to carefully observe their emotions, ideas, and sensations, but not to get carried away by them.

Mindfulness practices aren’t necessarily a substitute for psychotherapy, but they share key principles with established Western approaches to managing difficult feelings. Indeed, early on in my career, one of my favorite colleagues pointed out to me that psychologists have a very strange job. On the one hand, we aim to help people learn precisely what they are feeling and what they are thinking. We want our clients to become intimately familiar with the landscape of their inner lives. Then, once the people we care for are in close touch with their own painful, upsetting, or frightening internal worlds, we step back to reassuringly point out that what they have discovered is only a thought or only a feeling—and that they have options for how they might respond to their ideas and emotions.

If you suspect that your daughter is very high on the anxiety continuum but remain unsure about whether a visit to a specialist makes sense, there’s a half step to consider. Alongside the guidance provided in Under Pressure, you and your daughter might explore one of the many excellent workbooks and guides available on how to regulate the anxiety response system or those on how to practice mindfulness. Several suggestions can be found in the list of Recommended Resources at the back of this book.

Dealing with Ordinary Anxiety

While there’s no definitive line that separates “normal” anxiety from its unhealthy extremes, clinicians usually feel that a diagnosis becomes warranted only when a person’s anxiety becomes so pervasive or potent as to spoil daily life. Unfortunately, many young people (and sometimes, their parents) now treat even the slightest whiff of anxiety as grounds for concern. Indeed, it is not at all unusual for a girl to say to me, “I have anxiety,” as if she were describing a grave and permanent congenital defect.

Given that anxiety is an adaptive factory setting provided to all humans, you can imagine that I sometimes have to stop myself from responding enthusiastically, “Well, of course you do! That’s how you are able to cross streets safely and not get hit by cars!” Instead, I usually ask a lot of questions about the situations that trigger her anxiety. More often than not, I find myself making the point that anxiety is usually a good thing, as I did regarding the worries that arose for Dana when she found herself at a strange party.

Put another way, informed adults can help girls and young women feel far less worried about the fact that they feel any anxiety at all. To do this, we can teach girls that their nerves may occur on a continuum that ranges from the usefully protective to annoyingly disruptive. And even when a girl finds herself on the miserable end of that continuum, there’s a great deal that can be done to return her worries and fears to healthy levels.

To help girls manage their jitters, we address the same four response systems that serve as a safeguard in healthy anxiety and misfire when anxiety is out of control: physical reactions, emotional responses, thought patterns, and behavioral impulses. A few years ago I found myself coaching one of my favorite colleagues through these steps over lunch at Laurel School. We were chatting in the cafeteria line when she asked, “Can I get your help on something we’re dealing with at home?”

“Sure,” I said, “what’s up?”

“My eleven-year-old has herself completely tied up in knots about an upcoming sleepover at her cousin’s house. She’s dying to go because she loves her cousin and the other two girls who will be there, but she’s terrified that she won’t be able to fall asleep. When she thinks about going to the sleepover, she practically starts hyperventilating.”

“I’m so glad you asked,” I replied, “because there’s a lot that you can do to help her manage the sleepover.” We got some silverware and carried our plates to a relatively quiet corner of the lunchroom.

“For starters,” I said, “you should help her understand that her body goes into overdrive when she gets nervous—that’s why she’s hyperventilating.”

My friend cocked her head.

“Explain to her that her brain is telling her heart and breathing to speed up so that she can get ready to deal with danger. Her job—which she can do—is to let her brain know that nothing’s really wrong.”

“How?”

“Well…you know how everyone talks about taking deep breaths to calm down?”

“Yeah,” my friend said gamely.

“It really does work, but I’ve found that it’s most effective when girls know why it works.”

I shared with my colleague that, just as nerves run from the brain to the lungs to tell the body to speed respiration, nerves also run from the lungs back to the central nervous system to tell the brain to calm down. The brain is particularly interested in dispatches arriving from the respiratory system because, if a person is suffocating, the brain needs to tell the body to start freaking out. When we deliberately deepen and slow our breathing, stretch receptors in the lungs pick up the message that all is well and send that high-speed, high-priority, and highly reassuring dispatch back to the brain.

“Tell your daughter that she can use her breathing to hack her own nervous system and calm it down when she starts to tense up about the sleepover. You guys can look up different breathing techniques online to see what the options are. My favorite is called square breathing.”

“Explain,” she said between bites.

I told my friend that she could coach her daughter to inhale slowly for a count of three, hold that breath for a count of three, exhale slowly for another count of three, and then pause for a final count of three before repeating that cycle a few more times.

“That sounds easy enough,” said my friend as a gaggle of third graders entered the lunchroom.

“It is,” I agreed, “and it’s most effective when girls practice it before they need it. Any time I teach it to one of the girls here at Laurel I offer the analogy of tennis players who smash dozens of lobs in practice to find a rhythm they can count on in the middle of a game. Using a breathing technique to relax works the same way. Square breathing is easy to do, but it’s most effective if it’s a well-worn groove that a girl can slip into when she’s feeling afraid.”

“So,” my friend said, “I can help her get her body to settle down, which is good, but I still think she’ll be upset.”

“Then find out about her fears. In general, anxiety happens when we overestimate how bad something is going to be and underestimate our ability to deal with it.”

“Well, she’s totally terrified that she’ll be awake all night.”

I paused a moment to think of a suggestion. “You might say to her, ‘It’s true that it will probably be harder for you to fall asleep at your aunt and uncle’s house than at home, but I’m guessing that you’ll get tired enough that you zonk out before too long.’ Or something like that. You’ll want to validate her concerns while helping her see that they’re probably exaggerated.”

“Right,” she said, “but then I know that she’ll tell me she’s worried that if she doesn’t get enough sleep, she’ll be a total mess the next day.”

“We call that catastrophizing—imagining the worst possible outcome.”

“Oh, yes,” my friend replied with a smile, “she can be very good at that.”

“Let her know that, even if she stays awake all night, she’ll just be tired the next day and can go to bed early. Be matter-of-fact about it so that she can tell you don’t think it’s a big deal.”

“Honestly, I’m not sure that she’ll buy that, but I’ll give it a try.”

“Fair enough,” I said.

“I’ve got one more question…I know that when she gets there, she’ll want to call me a lot so that I can tell her that she’ll be okay. Should we do that?”

“No,” I replied quickly, “that’s not a great idea.”

I explained that anxiety can get us to do things that provide immediate relief—such as seeking reassurance or compulsively checking on something we’re worried about—but these nervous habits don’t help in the long run because they only reinforce the idea that something’s really wrong.

“Tell her that she can call you at bedtime if she wants to say good night but, other than that, you’re going to count on her to use her square breathing to help herself relax if she’s feeling upset.”

The look on my colleague’s face darkened. “She’s probably not ready to bite that bullet, but I know how badly she wants to go.”

“Not to worry,” I said. “If she doesn’t make it to this sleepover, there will be others. In the meantime, she’ll stop feeling at the mercy of her anxiety if you teach her how to calm herself down and question her own worries and anxious ideas.”

Stemming the Worrisome Tide

When we allow girls to view all stress and anxiety as harmful, they feel stressed about getting stressed and anxious about getting anxious. Instead, we can help our daughters take control of stress and anxiety by teaching them that both serve as normal and healthy parts of life. And if stress and anxiety do grow out of control, we can draw on our large body of knowledge about how to put them in check.

It’s important to remember that stress and anxiety can accumulate, and that their overall volume in our lives rises and falls like a water level. Even under the best conditions, every one of us sloshes around in at least a shallow puddle. We wade through our typical daily hassles and have moments when the waters rise quickly, such as when we receive an unexpected call from the school nurse, and lower again almost as fast, such as when we learn that she was phoning simply to alert us that our daughter bumped heads with a classmate in gym class but has no signs of a concussion, only a goose egg, to show for it.

For too many girls the floodwaters of anxiety have risen from their ankles up to their necks. Under Pressure is about the sources of that deluge and how we can bail our daughters out or keep them from becoming swamped in the first place. The chapters that follow consider five different wellsprings of stress for girls: their interactions at home, with other girls, with boys, at school, and with the broader culture. Tributary by tributary, we’ll address what we can do as loving adults to ease the feelings of stress and anxiety that sometimes threaten to drown our daughters.