what if therapy isn't helping? (and the thing nobody in the system will say out loud)

The question I have circled around for a while without quite landing on it directly, because it feels like something you're not supposed to ask — a betrayal of the professionals who are trying to help, or an excuse to stop doing something difficult, or evidence of the kind of magical thinking that tells you everything would be fine if you just stopped trying. So I want to be careful about how I say it.

But here it is: what if the constant focus on the anxiety — the appointments, the check-ins, the careful monitoring, the conversations about school and how school is going and what we're going to do about school — is making things worse rather than better? And what if taking a break, even a short one, might actually help?

It turns out there is research on this. More than I expected.

A 2025 paper published in Research on Child and Adolescent Psychopathology looked specifically at psychosocial interventions for anxious children and adolescents that may inadvertently prolong anxiety rather than reduce it. The term the researchers used is iatrogenic effects — which is clinical language for harm caused unintentionally by treatment. The paper found that certain interventions, particularly those that focus heavily on cognitive and relational components in isolation from exposure-based work, may actually maintain anxiety in the long run rather than resolving it. The mechanism is relatively straightforward: if the treatment keeps the focus on the anxiety without also doing the gradual exposure work that teaches the nervous system that the feared thing is survivable, the anxiety doesn't diminish. In some cases it strengthens, because the constant attention to it sends the message that the threat is real and serious and worth monitoring.

A separate analysis looked at what happens when teenagers are taught to talk extensively about their mental health — in schools, in group settings, in therapy that is primarily talk-based — and found that in some cases the outcomes were worse than for the control group. Not dramatically, not universally, but measurably. Researchers noted that those students had worse depression, worse anxiety, and worse relationships with their parents, and that those effects persisted over time rather than improving.

None of this means therapy doesn't work. The evidence base for CBT with adolescent anxiety is solid, and for the right child with the right therapist using the right approach, it makes a significant difference. What the research suggests is that not all therapy is the same, that more is not always better, and that the kind of therapy matters enormously — and that some well-meaning interventions may be quietly maintaining the problem they were designed to solve.

The specific mechanism worth understanding is something called accommodation — the way that anxious children and their families can get into patterns of managing around the anxiety rather than through it. The research on this is consistent: as the degree of family accommodation increases, so does the severity of the children's anxiety symptoms, with particular factors including providing verbal reassurance and modification of family routines. In other words, the more carefully everyone in a child's life organises around the anxiety — avoiding triggers, providing reassurance, adjusting routines — the more the anxiety tends to grow rather than shrink.

This is not a criticism of parents. It is a description of what happens when you love someone who is in pain and the only tools available feel like they are making things worse. Accommodation is instinctive and understandable and it is also, the research suggests, one of the mechanisms by which anxiety maintains itself.

The same principle applies, in a more complicated way, to some therapeutic approaches. A therapy that primarily validates and processes the anxiety without also doing the exposure work that reduces it may, over time, become its own form of accommodation — another thing that organises around the anxiety rather than through it.

What does this mean in practice, for a parent whose child is in therapy and not getting better, or whose child is refusing therapy and the school is demanding evidence of engagement?

It probably means asking some questions that feel uncomfortable to ask. Is the therapy being offered exposure-based, or primarily talk-based? Is your daughter being asked to gradually approach the things she's avoiding, or primarily to discuss how she feels about them? Is there a plan, with measurable steps, or is it open-ended? A good therapist will not be offended by these questions. If a therapist is offended by them, that is information.

It also means that the instinct to take a break — to stop talking about school for a while, to stop monitoring and processing and attending to the anxiety so closely, to just let her exist for a few weeks without the anxiety being the main subject of the household — may not be as wrongheaded as the school system's insistence on continuous engagement would suggest. The research on what is sometimes called worry time — deliberately limiting the time spent on anxious thoughts and conversations — suggests that reducing the attention paid to anxiety can reduce the anxiety itself, rather than letting it build in the absence of management.

This is genuinely difficult to hold alongside the school's requirements, which tend to assume that more intervention is always better and that any gap in therapeutic engagement represents a failure of parenting rather than a considered response to a child who is saturated. The system does not have good language for we are pausing because the constant focus is making things worse. It has very good language for you need to be doing more.

None of this is an argument for abandoning care, or for assuming that things will resolve without support, or for deciding that because some therapy can have iatrogenic effects, no therapy is better than any therapy. What it is, is permission to hold the question of whether what you are currently doing is working — really working, not just ticking the boxes the school needs ticked — and to ask for something different if the answer is no.

Your daughter's wellbeing is the point. The appointments are supposed to serve that, not the other way around.