This Local Mental Health Startup Helps Kids Face Their Fears

Photo illustration: Getty Images/Bulat Silvia.

The ball bounces; the ball flies. Sometimes it sails through the net like a superhero; sometimes it thunks off the rim and hits a trash can. And isn’t that just like life? We have days of frictionless trajectories that land us exactly where we intended; we have days that push us wildly off course.

Ten-year-old Nadav Fel knows the most important thing: Keep taking your shots.

Coach Evan Hartley watches Nadav drive toward the basket in the driveway of his Providence home — less concerned about the fate of the ball than the state of Nadav’s emotions the night before a big math test.

“Remember, we have the anxious mind, which is ‘Timothy,’ and the rational mind, which is you. I want you to remind yourself, it doesn’t matter if I have chicken-scratching on the test as long as the answer is right,” says Hartley as he retrieves the ball. “OK, so along with preparing for tomorrow, I think even more important, is preparing for tonight.”

For nine years, Nadav, a sweet kid from a close, religious Jewish family, performed his bedtime routine without disruption. Then, one evening, “Timothy” — Nadav’s name for the sneaky little rat that was his anxiety — pounced. In the wake of witnessing his little brother in the throes of two severe allergic reactions in as many days, and Hamas’ October 2023 attack on Israel, the secure world that allowed Nadav to peacefully drift off to sleep vanished.  

“I had a tantrum every night. I was just screaming and the only answer would be my parents laying with me for the entire night,” Nadav recalls. “I just felt bad because my parents were trying really, really hard.” 

Shayna, a social worker by training, and Michael Fel, a rabbi, were professional comforters, but they could not settle their oldest son. As the bedtime battles wore on, the entire family of five was dragged under the nightly surge of Nadav’s anxiety.

“I don’t think we allowed ourselves to feel it,” recalls Shayna. “The state of the world was so complicated for us, and we were navigating so much. I didn’t realize how hard it was until I went out for dinner with two friends who saw that I wasn’t OK. They were like, ‘Tell me what’s going on.’ And as I told them, I realized how bad it had been — just draining and awful.”  

And, it just went on like that, says Nadav, “until Evan started to change things.”

Evan Hartley is one of eighteen coaches working for Braver, an outpatient exposure therapy program that treats children and adolescents with anxiety and obsessive-compulsive disorders. Founded two years ago by Dr. Brady Case and Abbe Garcia, Braver is the outgrowth of the research and practice the two clinicians had been doing for decades at Bradley Hospital, the state’s pediatric psychiatric facility.

The pair had successfully treated young patients terrified of germs, sleep or shots; beset by social anxiety at levels so high, they refused to go to school; or by a fear of vomiting so overwhelming, they refused to eat. But Case and Garcia wanted to expand their clinical reach by taking it completely out of the hospital setting and by using trained, bachelor-degree level “coaches” as a force multiplier to deliver the therapy under the guidance of staff psychologists and psychiatrists.

“Workforce development is the solution to access to high-quality care,” says Case. “That is the innovative part of Braver. Team-based care, in outpatient treatment settings. We see that as the most plausible solution to addressing the crisis of access to care.”

If it seems like every other teenager you know is struggling with anxiety, it’s partly because the stigma around it has lessened, but also because many of them are. Studies, such as the Centers for Disease Control’s August Youth Risk Behavior Survey, show a disturbing climb between 2013 and 2023 in high schoolers’ feelings of hopelessness and sadness, as well as suicidal thoughts.

“Young people are having a really difficult time right now, and it’s been a really rapid shift. Teens and young adults are spending about 70 percent less time in person with friends than they were just twenty years ago. And we know the COVID pandemic really affected young people. Global rates of childhood depression and anxiety doubled. But suicide rates were increasing for years before the pandemic,” says Dr. Laura Erickson-Schroth, chief medical officer for the Jed Foundation, a suicide prevention nonprofit. 

According to the 2024 Rhode Island Kids Count Factbook, one in four of the state’s children, ages three to seventeen, had a mental, emotional or behavioral health problem in 2022, but nearly 60 percent who needed treatment had a problem getting it. 

“We have this greater need and lower capacity than we’ve had in the past,” says Martha L. Wofford, president and CEO of Blue Cross & Blue Shield of Rhode Island. “To us — as an insurer, as a mother and as a member of the community — it feels like a crisis.” 

Conquering a fear by gradual exposure to it is a very old idea. In the ninth century, Persian scholar Abu Zayd Ahmed ibn Sahl Balkhi pioneered the first classifications of obsessive-compulsive disorder and anxiety as mental illnesses and is credited with identifying progressive exposure as the antidote. Its clinical roots lie in the work of experimental psychologists Ivan Pavlov and John Watson, who demonstrated that behavior can be learned or extinguished by association with another stimulus. Exposure as a formalized therapy began to take shape in the 1950s and ’60s as psychologists experimented with protocols to desensitize patients to their phobias. By the 1980s, it was accepted practice. 

In 1999, Rhode Island Hospital established the Pediatric Anxiety Research Center, which began to conduct rigorous, large-scale studies to determine the most effective treatments for pediatric OCD and, eventually, how to harness community support in the process. 

“There had been a fair amount of adult work over the years that had shown that there was a lot of efficacy, but it hadn’t really been done with children,” says Bradley President Dr. Henry Sachs III. “They came up with a clinical model of doing the exposure response, getting the family involved, and doing it — to the extent you can — in the environments where these targeted issues occurred. It was the groundbreaking research that established what was the best care for kids.”

PARC eventually moved to Bradley, where the staff could apply this research to treat patients in its partial hospital and outpatient programs. Similarly, the Braver program assesses the child’s barriers to normal functioning and then develops a plan to lessen the impact of that anxiety. Garcia, PARC’s former clinical director, and co-investigator with current PARC Director Jennifer Freeman on three National Institute of Mental Health-funded OCD treatment studies, says “anxiety is actually part of life.” 

“We’re not trying to make these kids not anxious. What we’re trying to do is get them to the point where their anxiety isn’t impacting their ability to go to school or hang out with their friends, find a job, do their homework, take a test. A lot of the kids come in thinking we’re going to erase their anxiety. And that’s part of the teaching — you’re still going to be anxious and that’s actually a good thing.”

Much of the therapy is delivered in real-world settings, like the Warwick Mall, which Hartley deems, “the best place for any sort of phobia.”

“You have a ton of germs for the germ kids. You have a lot of stores for social anxiety. The poor Target employees are bombarded by coaches asking where the bathroom is, but they’re good sports about it,” he says. “There’s food for our food kids, and tables with chairs for my shot kids. There’s a Claire’s, so we’ll go and watch kids get their ears pierced with a goal that someday, you’ll be up in that chair. We’ll pick out the earrings, and get excited about getting a needle through our skin.”

All coaches undergo rigorous training; some also bring valuable lived experience. Brooke McKay was once one of the kids she now treats. A germ phobia and extreme social anxiety left her friendless in childhood, and unable to eat, drink or use a restroom in public.

“I never got any help for it. There wasn’t really a lot of help back then,” she says. With therapy and her own personally driven exposure challenges, by high school she learned how to be “Brooke with anxiety and OCD and not Brooke who is anxiety and OCD,” she says. McKay understands the amazing accomplishment of ordinary days.

“They’ll say: ‘Brooke, I was really scared, but I went outside and I played by myself. I even rode my bike around the neighborhood and I’ve never been able to do that before, because I’m always too afraid.’”

From an insurer’s perspective, Braver
checks a lot of boxes: It expands the mental health workforce at a time when there is not enough clinical staff. It’s highly effective, evidence-based, hands-on treatment. Kids graduate from the program and open up appointments for others. And yet, getting insurers to pay for it was a challenge. While different health care provider re-imbursement models can cover an array of nonclinical staff, typically, psychological services delivered by unlicensed therapists aren’t billable. Blue Cross found a way to adjust the payment structure to reimburse the coaches as clinical claims. 

“I just am such a believer in getting to kids as early as possible with effective treatment, because I look around and just think of all these kids who are not going to realize their potential if we can’t step in and help them right now,” says Wofford.

Today, Braver is also covered by Aetna insurance, and that financial support has allowed Braver to expand beyond Rhode Island into Connecticut and Massachusetts. Case says they are in the early stages of bringing Braver to Ohio.

The Fels restored bedtime in thirty-second increments. The plan called for Nadav to spend thirty seconds alone in his room, after which Shayna or Michael would sit in a bedside chair until he went to sleep. Eventually, they added more seconds, and then more space — the chair got further away until it was out of the room, then down the hall and around the corner, until it wasn’t there at all.

“Shayna and I almost had a party on the landing of the stairs — silently — because we had worked hard to get there,” says Michael. “For us, bedtime became a conversation, and working together as a team.”

In six months, Nadav was back to sleeping on his own. He has the psychological tools to relax himself, and medication as a backup. Sleepaway camp and spending the night at a friend’s house are back on his schedule. All of those hours shooting hoops in the driveway with Evan revived Nadav’s confidence.  

“The way he does the sessions with me, I can play with him and be active, but also learn new things about myself and anxiety at the same time. It basically transformed the entire sleep process,” he says.

“Now everyone can get sleep and yeah, things are normal.”

__________________________________