Post-Doctoral Fellow Kristy Cuthbert on Panic Disorder & Agoraphobia

An Interview with Post-Doctoral Fellow Kristy Cuthbert

Kristy Cuthbert, Ph.D. is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. She specializes in CBT and DBT for anxiety and related disorders, such as phobias.

Tori Steffen:  Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us today post-doctoral fellow Kristy Cuthbert. Dr. Cuthbert is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. Dr. Cuthbert specializes in CBT and DBT for anxiety and related disorders. She's also worked with individuals with post-traumatic stress disorder and borderline personality disorder. Her research focuses on alternative spectrum models of psychopathology and on treatment implementation in clinical settings. She has specialized training in working with veterans and has focused much of her clinical work on women's mental health and providing access to care for low-income populations. So before we get started today, Dr. Cuthbert, could you let us know a little bit more about yourself and what made you interested in studying, treating panic disorder and agoraphobia?

Kristy Cuthbert:  Sure. So thanks for the introduction. So I think my interest came about simply because I did my graduate training at Boston University, that's the home of the Center for Anxiety and Related Disorders. And they offer cognitive behavioral therapies for anxiety and related disorders of a fairly wide range as well as mood disorders. However, I found it to be both challenging and rewarding to work with individuals who have diagnoses of panic disorder and, or a agoraphobia. Because entering into that first exposure I think, and I can talk more about what that is and what that entails in a moment, but entering into that first exposure, I think people have a lot of fear. And then once they face that fear, it just kind of unlocks this ability to do more and more. And it's really great to see people succeed and to feel empowered at the end of the process.

Tori Steffen:  Yeah. And that must be really fulfilling work to do, to be able to help people and see the success rate.

Kristy Cuthbert:  Yeah.

Tori Steffen:  That's awesome. Well, getting down to the basics around our topic, can you explain for the audience what panic disorder and or agoraphobia are and how common they tend to be?

Kristy Cuthbert:  Sure. So I think this can be kind of complicated if you're not super familiar with all of this terminology, because there are panic attacks and then there's panic disorder and then there's a agoraphobia. And so the answer can be complicated. I'll say that panic disorder is specifically related to two or more panic attacks that meet a certain set of symptoms that we ask people about and that these attacks occur out of the blue. And that's a critical distinction. So some people will report having a panic attack in the middle of the night, and it just feels really surprising and sudden.

And then for agoraphobia, people taking this a step further feel fearful about going out in public because of those panic symptoms or fear that those panic symptoms will come up. Or this can also be related to other fears about embarrassing symptoms like having an upset stomach or having to urgently go to the restroom or having trouble escaping for whatever reason from very busy and crowded places. So in addition to the two disorders, panic disorder and agoraphobia, you can also have panic attacks, which can be related to any number of other anxiety disorders. So if you have a specific phobia and you're afraid of bees, you can have a panic attack if you see a bee. And so that would be specified as a part of the phobia. The key there being, that panic attack is triggered by the bee. Whereas in panic disorder, those attacks come on very suddenly and are not related to, "Oh, well I saw a bee." Right?

Tori Steffen:  Okay. That makes great sense. Thanks for making that distinction for us.

Kristy Cuthbert:  Yeah. And in terms of how common they tend to be, I'll say that the 12 month prevalence rate in the DSM-5-TR for that is 2 to 3%. And for agoraphobia, it's 1 to 1.7% as the 12 month prevalence. So panic disorder is not entirely uncommon, neither is agoraphobia. So it's not uncommon to see those. And that doesn't even include panic attacks, the ones that can occur with other anxiety disorders.

Tori Steffen:  Right. Have you seen any, or in the literature, are there any known causes for agoraphobia or panic disorder?

Kristy Cuthbert:  So I think in terms of causes, this can be wide-ranging. For both disorders, they tend to co-occur at very high rates. So one theory is, so for example, to think about panic disorder, panic disorder and agoraphobia can be preceded by anxiety disorders. So perhaps you start with social anxiety. And when you have social anxiety, you might have a panic attack or panic symptoms. And then you start to really focus on those symptoms and develop fear and anxiety about having those symptoms. So then you're more likely to have those symptoms come on unexpectedly or to have more fears about going out in public or in crowded spaces where you then might have those symptoms.

So sometimes it's just a matter of experiencing some of those discomforts and really keying into those physical cues. Because it's kind of like when you get an itch on your head. This always happens when I'm getting a haircut. So I want to scratch it, but I'm getting a haircut. And so because I can't, I focus on it and it feels more and more intense. So for whatever reason, a person might start to notice those physical sensations and then that feeling like, "How do I control this?" And not being able to fully control it can kind of start that cycle of panic and then lead to agoraphobia as well.

Tori Steffen:  Okay. Yeah, that makes good sense as in how it could potentially lead to agoraphobia. So thank you for breaking that down.

Kristy Cuthbert:  Sure.

Tori Steffen:  And as far as treating agoraphobia and panic disorder, what are some of the common treatments for the two?

Kristy Cuthbert:  Yeah, so I'll say the gold standard treatments for panic disorder and agoraphobia are exposure based therapies. And cognitive behavioral therapy more generally. So you can talk about what it means to have a racing heart, and from a cognitive perspective, you might think of other situations where you had a racing heart like when you were working out, and then it was okay. You might think about what it means to feel panic. It means, “I'm out of control.” And you might look for evidence that doesn't support that you're out of control.

For the most part though, we do focus on exposures. And for panic disorder, one of the key types of exposures that we do is called an interoceptive exposure. So these are exposures where we kind of mimic the symptoms of a panic attack. So if one of your main symptoms is hyperventilating, we have you breathe through a coffee stirrer to actually simulate that and to sit with that. I've had patients wear heavy coats and heaters to simulate warmth and sweating, and maybe we will run in place for a couple of minutes to get the heart racing to really try to bring on the simulated symptoms of a panic attack and then to sit with that discomfort until it passes.

Because another thing we know about panic disorder and agoraphobia is that people often have safeties or safety behaviors. So they might carry medications around in their pocket. They might do certain things like bringing friends along with them when they travel so that they don't feel discomfort. So we also ask that, say we're sitting with those panic symptoms, we ask people not to engage in those behaviors. So we're not going to keep an empty bottle of benzodiazepines. We're not going to... We're going to leave that at home, we're not going to take off the coat and crank up the fan to try to combat the symptoms. We're just going to say, what if we leave them alone? And we try not to react to them. And to learn that by not reacting to them, it kind dismantles that false alarm telling you that there's danger.

So for agoraphobia, taking that a step further, we also do what we call situational exposures. So if you're afraid of public transportation, because it gets really crowded here in Boston and because you want to make sure you can escape, whether because you have panic symptoms or for some other reason, we get on the train. We get on the train when it's busy, we ride the train, we resist that urge to escape, we watch for other safety behaviors. Like again, carrying a medication. We may start by doing an exposure together. And then the person I'm working with might start to ride the train or take the bus on their own.

And of course, in more severe cases, this is trying to get them out of the house. So we might start by having them go to a grocery store that's a mile away. And then when they get into the grocery store, making sure they're not using any safeties to try to distract from the discomfort. The idea is that if we face the discomfort, then we'll see that it passes on its own without us having to react and that breaks up that cycle of behavior, and eventually that fear starts to become extinct.

Tori Steffen:  Okay. So the goal is to reduce the fear that one would get?

Kristy Cuthbert:  Right. And another goal is to learn safety. To be able to say, "I'm in a grocery store and I noticed that I'm having these panic sensations. I noticed the urge to want to escape, and I know that this is a safe place. As far as the world is safe, this is a safe place. And I know that what I'm experiencing is not necessarily a medical emergency. I've had these symptoms before. I recognize them as panic. I'm going to trust what I have learned about these symptoms, which is that I am safe if I just let them pass." So that learning safety is also an important part of it.

Tori Steffen:  Okay. Okay. Well, great. And I know we spoke a little bit about how panic disorder and agoraphobia can co-occur pretty frequently. Is it likely for agoraphobia to be comorbid with any other mental health issues as well?

Kristy Cuthbert:  Sure. So I talked a little bit about potential precursors. We also see a lot of comorbidity and different disorders that might occur in addition to, or once someone has started to have panic symptoms or agoraphobia. Depending on the severity of agoraphobia, it can be incredibly isolating if people don't go out often, if they have a lot of restrictions about where they can go that they feel safe. So a lot of people with agoraphobia will often have a diagnosis of major depressive disorder and substance use disorders. Because benzodiazepines are often prescribed. And depending on the severity of panic, benzodiazepines can be misused and can be addicted. People also drink or use other substances to try to take the edge off of that anxiety, either when they're feeling panic or if they have to leave the house or go into an uncomfortable situation if they have agoraphobia. So those are two of the particularly important comorbidities that we know of.

Tori Steffen:  Okay, that's good to know. And have you worked with any other phobias out there, any that you can name for us?

Kristy Cuthbert:  Yes. So we also treat specific phobias at the clinic. So I've worked with phobias of vomiting and specific phobias of animals like dogs, blood, injury, and injection phobias, insect phobias, snake phobias. I don't particularly work with snake phobias, but we do treat those at the clinic. And spider phobias. So yeah, a pretty wide range of specific phobias.

Tori Steffen:  Yeah, there's definitely a lot out there.

Kristy Cuthbert:  Yeah.

Tori Steffen:  So yeah, that's very interesting. And how might somebody with a specific phobia typically present? Kind of what's their common experience, I guess?

Kristy Cuthbert:  So I would say that from the cognitive behavioral model, we look at everything from this model of our thoughts and our feelings influence our behaviors. So most of the time what we see is a pattern of, and I'll use a dog phobia as an example. Sometimes it comes from having had a negative experience when they were younger. Sometimes it doesn't. It might be that their parents didn't have dogs, didn't like dogs. It might just be that they never had them around so they're just an unknown entity. They can develop for a wide range of reasons.

What tends to happen to maintain it though is... Say I'm going to work, it's important for me to get to work on time, and at around eight o'clock when I'm supposed to be walking through the door every morning, there is a medium-sized dog across the street from me right there next to the door of my office. That thought, feeling and behavior pattern might go something like this. I feel physical sensations, I feel a little bit sweaty, my hands are shaking a little bit. I feel maybe some flip-flops in my stomach, like I'm nervous. And I know that's because I see this dog. So then I think, "That dog might bite me, I'm in danger. I need to get away." And then that leads to the behavior. I don't cross the street. If the dog crosses the street towards me, I walk the other way. I avoid or try to escape the situation.

So what that does though is that says, "Yes, it really is a dangerous situation because you had to get out of it." So it reinforces the fear. So that pattern is something that we see that sort of seeing the object, feeling uncomfortable, labeling it as dangerous and trying to avoid or escape, that's a pretty common pattern.

Tori Steffen:  Okay. And that fits so well with the cognitive behavioral therapy outlook. So that's really cool.

Kristy Cuthbert:  Exactly. Yep.

Tori Steffen:  And have you seen that any phobias are more common than others, in general?

Kristy Cuthbert:  You know, it's really tough to say. I know that we do treat a lot of blood, injury, and injection phobias. Having blood drawn, getting medical procedures. I don't know at our particular clinic if those are any more common. And I don't know the prevalence literature off the top of my head. I would say that we do see that a lot, probably because if I am scared of a snake, for example, that's really not impairing my day-to-day life because I don't have to regularly interact with them. Now, if I were a keeper at the zoo and it was my job to take care of the reptiles, then I might come in and say, "I have a snake phobia." Or if I was an avid hiker and I stopped going hiking and kind of lost this thing that I loved, that might warrant treatment for a phobia. Blood, injury, and injection phobias or phobias around medical procedures, these are things that most people need to have done at some point. So we will see those people come in to have those treated.

Tori Steffen:  Okay. Yeah, that's an interesting one. For the blood phobia, is it mainly seeing blood and having a fearful reaction to an open wound, is the common experience?

Kristy Cuthbert:  So this can be wide-ranging. For some people it is. For others, there's very specifically a fear of having blood drawn, that fear of passing out if they have blood drawn. Some people do have that experience. So that I would say is a little bit of a unique treatment because we often will teach them a technique of tensing and relaxing muscles to make sure the blood is flowing. It increases the blood pressure and can prevent passing out while having blood drawn. So that's something that people can learn and do.

And the rest of it is very, very similar to exposure for panic or agoraphobia. And that we say, "What is it that you're afraid of?" "Well, I'm afraid of having my blood drawn."` So we start wherever a person is ready to start. So it might be, "Watch this video of someone having their blood drawn. Let's go into our medical lab and I'll have you put on the tourniquet and we'll prepare and you can sit with that anxiety." Which is often anticipatory. We also have specific phobias of driving. So for those, we'll start with one stretch of road. And then we talk about trying to see how is that similar to other stretches of road that I might be afraid of? "If I can do this, can I do this highway as well?"

So it's sort of a buildup to eventually having your blood drawn, eventually taking the highway you're most afraid of.

Tori Steffen:  Right. Okay. Yeah, that definitely makes sense with gauging where they might be ready to start and starting there. So can all phobias be treated with exposure therapy?

Kristy Cuthbert:  So I would say for the most part, there's always something we can do in terms of an exposure. You can be pretty creative, like I said. You can find anything in this day and age on YouTube. There are YouTube videos of just dash cams of people driving on highways. That's an exposure for driving phobia, right? If it's a scenario that you don't often find yourself in, like interviewing for a job with a person in authority. We have what we call confederates come in. It might be our clinic director, it might be one of our professors who's cleared to work in the clinic. But we have them come in, they're doing the interview so that someone starts to get that experience.

And if the situation is one that you can't really recreate, like, "I'm scared of getting the flu and being sick," then we'll do an imaginable exposure. So that's where people write out a script of what is that scenario that you're afraid of? Write it out in as much detail as you can, engage all five senses about what you notice about the situation, and then sit with the discomfort and challenge any sorts of judgments that might be in your write up. So I think it is very versatile. Exposure therapy, I think, is the standard treatment for most phobias. Yes.

Tori Steffen:  Right. And how effective would you say that exposure therapy is in treating a wide range of phobias?

Kristy Cuthbert:  Yeah, so you can really generalize this concept. And there are trans diagnostic approaches like the unified protocol that treat a wide range of anxiety and mood disorders based on these same concepts. So much like we avoid driving or avoid dogs, we can sometimes avoid uncomfortable emotions. So sometimes exposure is exposure to an uncomfortable emotion and being able to tolerate that emotion. Sometimes if we're feeling depressed and we don't want to be up and active, the exposure is being active. Depression tends to make us feel like we don't get a lot of pleasure out of activities. The problem then is that we stop doing the activities that might make us happy.

So taking that same approach, it's entering into those situations and saying, "I might not cure my depression today by going for a walk, but if I do this every day it's going to be really hard to hang on to that inertia and that heaviness that can come with depression." Likewise, interoceptive exposures, the ones where you simulate the physical symptoms of panic, you can do that with depression. The heaviness of depression, for example. There are ankle weights and arm weights that you can put on to kind of simulate heaviness. So it really does touch on a wide range of anxiety and mood disorders.

Tori Steffen:  Wow, that's really interesting. Yeah, I'd never heard the examples for depression as well, so that's great to know that it can also help with that. Well, awesome. Well, while treatment options are best and ideally done under the guidance of the licensed mental health professional, are there any things that individuals can do on their own to potentially reduce the symptoms of panic or agoraphobia?

Kristy Cuthbert:  So I would say a starting point is to be willing to say, "What is my panic look like?" I think one of the scary things about panic is your body is physically reacting. And so it's really hard to know is this a medical emergency? Because it feels so uncomfortable. Obviously you're having a physical reaction. It's hard to know. I would say that over time, panic attacks though, you can get to know them. And you can say, “I know what this is,” and to approach it with a familiarity, which I think can prevent the urge to, for example, Google your symptoms or to say, "Should I go to the ER to get this checked out?" If you start to understand what your panic is, that's a first step. Of course. I always give the caveat, make sure you're aware of what your physical conditions really are so you do know what to look out for. And also really balance that with saying, "I also know what my panic feels like and it feels like this."

And I would say the other thing is to think about the story you tell yourself. So I say this a lot with patients, and this really gets at the cognitive piece. So two things about the story you tell yourself. First of all, if you're telling yourself that, "Yes, I'm scared of having my blood drawn and I did it today, but I was scared the whole time." Well that kind of discounts this big achievement, you did something that was important to do. And it also can create a bunch of fear around it. It's almost like the expectation is that I should be able to have my blood drawn with no fear or you know what, I should be able to drive over a really high bridge with no anxiety. That is a really high expectation. And I would say that sometimes I drive over bridges and I'm like, "Wow, this is a really high bridge."Or I have a pretty healthy level of anxiety in busy traffic, because you're watching a lot and you're vigilant.

So don't see anxiety as a thing you want to eradicate. Just kind of learn to get more comfortable with it and learn when it's kind of out of proportion to what you think you're experiencing and give yourself credit for victories that you do achieve. If you get across a bridge because you have somewhere to go, pat yourself on the back for that if you're afraid of driving across a bridge. And the other thing is to picture going into it. What do you tell yourself about that bridge? “I'm going to drive over this bridge, I'm going to lose control and drive the car off the bridge.” And then ask yourself, “What is making me think this? What evidence do I have for it?” Sometimes the one thing that gets in the way is the story that we tell ourselves. Even before an exposure, if you're telling yourself that story, it's going to amp up the fear. And part of the fear is going to come anyway. And the story we tell ourselves can make that fear feel stronger.

Tori Steffen:  Right. That makes a lot of sense, and that's great advice for just kind of starting off and getting introspective about what's really going on. Well, Dr. Cuthbert, do you have any final words of advice or anything else that you'd like to share with the listeners today?

Kristy Cuthbert:  Not that I can think of. I think other than to say above and beyond the things that people can do on their own, it's okay to ask for help, to see someone who specializes in different types of therapy. If you feel like you're afraid of something and you're not quite ready to do exposures, there are other types of therapy where you kind of explore the root causes or where you focus on approaches that have you live your life in spite of your fears. And eventually it might mean facing your fears. And it's all about looking at your values and living according to those values. If you feel like anything, any specific fear, panic symptoms or fear of certain situations, if you feel like that's getting in the way of living a life according to your values, it's okay to seek help from someone to help get you through it. Some of these treatments can be completed in as few as 12 to 16 sessions. So it is worth the investment and the time that it takes.

Tori Steffen:  Yeah, I would have to agree. That's great advice. So thanks so much for sharing that, and thanks for chatting today. It was really great speaking with you about this. And I hope you have a great rest of your day.

Kristy Cuthbert:  Thanks, you too.

Tori Steffen:  Thank you. And thank you everybody for joining.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Katherine Walukevich-Dienst on Substance Abuse & Social Anxiety

An Interview with Psychologist Katherine Walukevich-Dienst

Katherine Walukevich-Dienst, Ph.D. is a post-doctoral fellow at the University of Washington School of Medicine. She’s an expert in the field of substance abuse and social anxiety, particularly among young adults.

Tori Steffen:  Hi, everybody. Thanks for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us today psychologist Katherine Walukevich-Dienst. Dr. Walukevich-Dienst is a post-doctoral fellow at University of Washington School of Medicine. Dr. Walukevich-Dienst specializes in alcohol and cannabis use and co-occurring mental health problems among young adults. She's written several publications on the topic, including using substances to cope with social anxiety, associations with use and consequences and daily life, and hours high as a proxy for marijuana use, quantity and intensive longitudinal designs.

So before we get started today, could you please let us know a little bit more about yourself and what made you interested in studying substance abuse and social anxiety?

Katherine Walukevich-Dienst:  Absolutely. So thank you so much for having me. I could talk forever about this topic, so feel free to interrupt me if I go on and on. So I guess my journey kind of starts back when I worked at an anxiety lab at the University of Miami, and it was focused on anxiety across the lifespan. So we did a lot of work with kids and teenagers and young adults as well. And what I noticed, especially when studying people with social anxiety is that a lot of these individuals, teens and young adults in particular, mentioned using alcohol or cannabis to cope with their social anxiety. So that led to me to applying to grad school to work with my mentor, Dr. Buckner, who is kind of the queen of when it comes to research with social anxiety and substance use. Substance use doesn't occur in a vacuum, and it doesn't really ignore any type of person. So I was particularly interested what made these individuals, who are socially anxious, more vulnerable to using substances.

Tori Steffen:  Okay. Yeah, that's definitely a really interesting topic to study, so it's very cool that you found a great mentor for that.

Katherine Walukevich-Dienst:  Absolutely.

Tori Steffen:  Yeah. So I guess getting down to basics about our topic, could you explain for the listeners why social anxiety typically develops and how it tends to present itself?

Katherine Walukevich-Dienst:  For sure. So that's a really big question, especially with how it tends to develop, so we haven't narrowed down in research the one thing that tends to lead to social anxiety. And it's kind of a combination of a bunch of different things, including your genetics, your childhood history, experiences in adulthood, how you cope with things, among other susceptibility to other diagnoses among other things.

So people with social anxiety... Social anxiety is really common, and most people feel socially anxious in at least some situations. I know that I feel particularly socially anxious when I give a talk in front of a big group. And part of social anxiety is worried about fear or worry about what other people are thinking of you, and mainly that people might be judging you negatively, or that you might act in a way that's embarrassing, or that other people might see that you're anxious.

The important thing with that is that social anxiety, while we all experience that, people with social anxiety disorder experience that a lot of the time in a lot of different situations. So additionally, it is getting in the way of living the life that they want to lead. So while I am socially anxious in this one situation, people with social anxiety disorder might be anxious in a lot of different situations, and it's really getting in the way for them. They're really bothered by it, or it's causing problems in their life. For example, they really want to have a promotion at work, but find a really hard time speaking up in meetings, because they're so worried about being judged. So they end up getting passed over for a promotion over and over again, because they're not willing to speak up in those moments.

Tori Steffen:  Right. Okay, awesome. Yeah, thank you. That's a really... Paints a good picture for how social anxiety presents itself as a disorder, and then just in common. So that's really interesting. Well, in what ways are substance abuse and social anxiety connected?

Katherine Walukevich-Dienst:  So substance use and social anxiety have kind of a complicated and puzzling relationship, and this is part of the reason why these years later I'm still interested in this topic and I feel like we still have a lot to learn. So people with higher social anxiety don't actually tend to use substances more often than people with lower or no social anxiety. And in some cases, the research has shown, particularly with alcohol, like young adults with higher social anxiety drink less. However, what we do see pretty consistently in the literature is that people with elevated levels of social anxiety experience more problems or negative outcomes related to their use, even though they're not drinking more. So some of the research that I've done on this is trying to figure out, in particular context or situations, is it how people are drinking and when that are leading to these greater problems, even though they're not necessarily drinking more or more frequently than their non socially anxious peers?

Tori Steffen:  Okay. Yeah, that definitely makes sense. How would you say that alcohol use typically influences the way that one experiences social anxiety?

Katherine Walukevich-Dienst:  For both alcohol and cannabis, it tends to boil down to expectancies. And both alcohol and cannabis can reduce anxiety. So a lot of people expect that both what we call tension reduction expectancies. "If I drink, or if I use cannabis, I'll feel more relaxed, I'll be less stressed out, and that will make it easier for me to socialize with other people." There's also kind of that social facilitation expectancies. "I can only be in this situation when other people are drinking if I'm drinking too, and that will make it easier for me to have these conversations."

The thing with expectancies is that there's no kind of magical properties of alcohol or cannabis that makes you funnier or makes it easier to talk to people. It's really, a big part, the expectancies. There's been a lot of research done on that that is really interesting. So those are the two main reasons, or the two main expectations that people have is the social facilitation and the tension reduction as well.

Tori Steffen:  Okay. Yeah, that's really interesting about the expectancies. And your article about substance abuse and social anxiety compared alcohol-only days, cannabis-only days, and then co-use days, and then how that impacted social anxiety, or coping with it. So could you explain a little bit about your findings around that for us?

Katherine Walukevich-Dienst:  Absolutely. So I was lucky to work with this really large dataset from my post doc mentor, Dr. Christine Lee, where we measured 409 young adults, we measured them multiple times a day for two weeks at a time over a period of two years. So basically, we had a lot of data on these people.

Tori Steffen:  Yeah.

Katherine Walukevich-Dienst:  And while these people weren't selected particularly for social anxiety, there were high levels of social anxiety in the sample. Particularly, a pretty large number of individuals met the cutoff, clinical cutoff for social anxiety disorder. And what we looked at it was to see, on days people use substances to cope with social anxiety are those greater risk days for experiencing negative consequences, using more, and experiencing more positive consequences as well. So a lot of the literature has looked at negative outcomes or negative consequences, but we do know that people get positive things, or there's positive outcomes from drinking or using cannabis.

So what we found is that on days that people used substances to cope with social anxiety, they drank more, they experienced more negative consequences and positive consequences as well. So regardless of whether they were actually meeting criteria for social anxiety disorder or not, based on the measure that we had. So it was a high risk day for all people, regardless of social anxiety, which was kind of an interesting finding.

We also looked at the item level, which positive and which negative consequences people were more or less likely to experience. And what we found is that on the days that people used to cope with social anxiety, they experienced more likelihood of positive consequences, like feeling like they were more sociable, and not so much the negative consequences on those days. So it may be that they're saying, "Okay, this is great. I felt more sociable, I was able to express my feelings more easily." So they drink more, or used cannabis more often. And then it's using it kind of more often for those people in particular, or the way that they're doing that, that might be causing these problems.

Tori Steffen:  Right. Okay. Yeah, that's definitely interesting for the comparison of alcohol and cannabis use. So that's good to know. When measuring substance use, does the amount of alcoholic drinks per day or hours high have a significant impact on one's experience of social anxiety?

Katherine Walukevich-Dienst:  So I think that's a really good question as well. And I think it kind of boils down to how alcohol and cannabis work in the body. So for alcohol in particular, we know a lot more about alcohol and what the dosing looks like and what the response looks like for alcohol than we do cannabis. But we often think in young adults in particular that the more you drink, the better that is. So like, "If I have 10 shots, that's better than having just five over a longer period of time." But what we actually see is that there is this kind of we call it the biphasic effect, whereas people drink more, you get to this certain point where you're feeling the really good effects, but if you keep drinking, that actually gets worse and you start to experience some of those negative effects, like stumbling over your words, feeling dizzy or feeling nauseous, not remembering things. And that people tend to, in that moment, be like, "Oh, shoot, I need to drink more to feel good again." But once you hit that point, you can't.

And although we know less about cannabis, we do know that cannabis causes anxiety and can cause anxiety, especially in high THC or acute doses, which a lot of people use high THC products. So the more you use, even though it feels like the more you use, the less anxious you'll feel, sometimes the more you use, there's that sweet spot, and then you'll feel pretty anxious afterwards.

So I think the takeaway from that is more isn't always better, particularly with anxiety, and particularly with alcohol and cannabis.

Tori Steffen:  Right. Yeah. That's so interesting how your study looked at the nuances of people's experiences and exactly breaking it down, "Here's the positive effects, and then here are the negative effects." So yeah, that's all super interesting information. Have you found that socially anxious young adults are at a higher risk for substance abuse?

Katherine Walukevich-Dienst:  Again, that question is tricky, but it can be, yes. They're more likely to experience problems related to their use. And some people have done research finding that it's actually people with moderate levels of social anxiety, not necessarily clinical. Although, clinical levels are associated with worse outcomes. It's the people in that moderate range who might be going to the social situations, that might be putting themselves at risk, that are experiencing the most consequences and are the heaviest consumers of these substances. Because in some ways, social anxiety might be protective in that they might be avoiding situations where drinking or cannabis use is happening because of their social anxiety. Or we've also looked at finding that some people tend to use alone. So social anxiety is a big risk factor for using alone or by yourself.

Tori Steffen:  Yeah. That definitely makes sense as far as maybe keeping you from wanting to socialize.

Katherine Walukevich-Dienst:  One of the things about the study that we were talking about a little bit earlier that I found interesting is that the one negative consequence that came out significant for cannabis use days was on days people used to cope with social anxiety, they were more likely to feel antisocial or want to avoid other people. So even though they were using to cope with social anxiety and these other reasons, because of their cannabis use, they reported feeling more socially anxious and more avoidant-

Tori Steffen:  Yeah.

Katherine Walukevich-Dienst:  ... which is pretty unfortunate.

Tori Steffen:  Man, yeah, that's good to know though, that it can have those kinds of effects, especially if you're wanting to use cannabis to treat social anxiety, but it can have those reverse effects.

Katherine Walukevich-Dienst:  Absolutely.

Tori Steffen:  Yeah. Well, another article notes that smoking to manage anxiety can be targeted as a false safety behavior. Can you kind of explain that for our audience?

Katherine Walukevich-Dienst:  Yeah. So a false safety behavior is basically anything that we do that helps us feel, in the moment, less anxious or safe. So for example, non substance related false safety behaviors, particularly for people with social anxiety, can be only going places when you have a person with you or that you feel comfortable with. So this might look like only going to parties if you have that one friend who you know feel comfortable going with you, or only going places if you know that you'll have your medication with you. And if you have your medication, or if you have your safety emotional support water bottle or whatever thing, that makes it okay to go.

But when it comes to substance use as a false safety behavior, this can look like only going to social situations or being in situations where you are able to consume substances either before, during, or after to help manage social anxiety. And kind of targeting a false safety behavior means to first identify it and then try to fade it out. So try to go a longer period of time without using, or start to go maybe the first 20 minutes of the party you go and you don't use, and then you decide at that point, "Do I want to use and how much?" Or decreasing the amount that you use over time. So eventually, the idea is that you're not doing it anymore, this behavior anymore, to manage anxiety. So you may still use cannabis, you may still drink, but the goal is not to do so to manage anxiety.

Same with a safety behavior, like going somewhere with a friend. Right? Of course, you want to spend time with your friends, but if it's only to help you manage your anxiety, or in part to help you manage your anxiety, we want to reduce that part, so you're spending time with your friends because you want to and not to help you feel less anxious.

Tori Steffen:  Right. Okay, awesome. Yeah, that definitely breaks it down really well. Thank you. Well, other than engaging in substance abuse, how can young adults cope with negative symptoms related to their social anxiety?

Katherine Walukevich-Dienst:  So part of what alcohol and cannabis make tricky when it comes to social anxiety is that they do a really good job of making people feel less anxious in the moment, and pretty immediately too. But by... I keep using this example of being in a party setting, but by going into a party setting only while intoxicated, you're never really learning and your brain is never really learning like, "Oh, I'm actually okay here." Or, "Yeah, I said that something that was really embarrassing, or I couldn't figure out what to say, and that was okay." And that it's really not learning that these situations, while uncomfortable, you can survive them and you will be okay. And that the more that you do them, the more comfortable you feel. We call that habituation. So what substances do is they act as a way for us to avoid confronting that cycle and tolerating that discomfort that comes initially when you're in a new situation, or when you're in a social situation that makes you feel particularly anxious.

So with treatment, in part, what we argue for is, “Just do it,” which sounds really easy, but is really hard in practice. And instead of using substances to avoid, try to approach some of the things, little by little, that you feel produce anxiety or make you feel socially anxious. Start with something on your list that feels a little bit easier, and then maybe work your way up to some harder situations. But see what it's like to be in a situation without substances and try that a couple of times, get some more data on what that looks like, because for people who tend to do this, they haven't been in those situations very often without substances.

Tori Steffen:  Right. Yeah. It sounds almost like ERP a little bit.

Katherine Walukevich-Dienst:  Yeah.

Tori Steffen:  Are there any specific types of therapy like that that can be beneficial for treating social anxiety and substance use?

Katherine Walukevich-Dienst:  The good news is there is. So once you identify these things, one of the treatments is cognitive behavioral therapy for social anxiety, which includes exposure. So exposure is like what you're talking about with ERP. So coming up with a hierarchy of situations, that behavior piece is coming up with a hierarchy of situations that make you feel anxious, and working with a therapist to gain both cognitive skills and behavioral skills to experience and expose yourself to that anxiety.

So for example, if somebody says that they feel socially anxious about giving a presentation and the only way that they feel less anxious is by using cannabis before, the first exposure might be giving a presentation to your therapist, and the second without cannabis, and saying, "What's the worst thing that could happen here?" I'm telling myself I'm going to sound like an idiot, or I'm going to sound like I don't know what I'm talking about. What would be the worst thing about that? And coming up with a response like, "Even if these things happen, it will be okay," or, "I'll probably be embarrassed for a bit, but I'll get over it." Even having that more balanced way of thinking can be helpful. And it's not going into the situation saying, "I'm going to do amazing, and nothing's going to go wrong," because that's not necessarily helpful either if something does go wrong. It's finding a balance perspective, and then putting yourself in that situation.

So then what the therapist might assign for homework, an exposure homework, is then to do that in real life. So to set up a presentation, do it in real life without using substances. And if this sounds scary, it's because it is. And part of this is that you might feel really, really anxious at first. But I've done a lot of treatment with people with social anxiety and substance use, and it's pretty amazing how confidence grows in these different situations, and not necessarily their confidence in performing well in these situations, but their confidence in their ability to tolerate the anxiety and discomfort that might come from these things.

Tori Steffen:  Right. Yeah, that's amazing. That sounds so important to know the difference between that and treatment, so very cool. Well, do you have any final words of advice or anything else that you'd like to share with the listeners today?

Katherine Walukevich-Dienst:  I think final word of advice would be, if this is something that you're concerned about for yourself, start just paying attention to it and gathering some data, paying attention to, "What do I expect from using cannabis and alcohol in social situations? And am I actually obtaining those rewards?" So if I expect that using cannabis will make me funnier, or more enjoyable to be around in a social situation, does that actually happen? And does that happen every time, or just some of the time? And I think starting to gather that data can be really helpful in making different decisions potentially about using in those types of situations, or your need to.

Tori Steffen:  Yeah. Awesome. Well, thanks so much for sharing that advice, and thanks so much for sharing your knowledge with us today, Dr. Walukevich-Dienst. It was really great to talk with you.

Katherine Walukevich-Dienst:  All right. Thanks so much, Tori.

Tori Steffen:  Thank you. And thanks, everybody, for tuning in.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist David Rosmarin on Spirituality & Mental Health

An Interview with Psychologist David Rosmarin

David Rosmarin, Ph.D., ABPP is the founder of the Center for Anxiety (New York & Boston) a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin specializes in the relevance of spirituality in one’s mental health.

Tori Steffen:  Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us today psychologist, David Rosmarin. Dr. Rosmarin is the founder of Center for Anxiety, which has offices in both New York and Boston. He's also a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin's research at Harvard focuses on the relevance of spirituality to mental health. At Center for Anxiety, his team uses a combination of cognitive behavioral therapy (CBT) and dialectical behavior therapy, also known as DBT. These approaches are used to help patients struggling with moderate to severe symptoms of anxiety, depression, and other concerns.

Before we get started, could you please let us know a little bit more about yourself, Dr. Rosmarin, and it sounds like you have two different aspects of your career, the spirituality and then the anxiety piece. Are these related?

David Rosmarin:  Well, first, thanks very much for having me on your program and I'm really happy to be here. They can be related for some individuals. Spirituality is an interesting variable. It's the kind of thing that most people in mental health don't get a lot of training in, and my program of research seeks to remedy that, to give clinicians tools to be able to assess for and address aspects of spiritual and religious life when it's relevant, which is more often than you would think, but it's not for all individuals.

In terms of anxiety, sometimes it's relevant and sometimes it's not. Center for Anxiety doesn't practice spiritual psychotherapy per se, unless individuals need specific spiritual and religious supports. I would say it is somewhat unique about our practice that it's a domain that we're not uncomfortable to address, unlike a lot of others. But it's not the only unique thing about Center for Anxiety.

Tori Steffen:  Okay. Very interesting. Well, getting down to basics, could you explain for our audience what spirituality is?

David Rosmarin:  Sure. Spirituality is any way of relating to that which is perceived to be sacred or set apart from the physical world. These kinds of beliefs are pretty common. In the United States, 80 to 90% of the general population has some sort of spiritual beliefs, and more importantly, in mental health settings, there's data to suggest that more than 80% of patients, even in some of the least religious areas of the United States, utilize spiritual ways of coping when they are distressed by mental health concerns.

Tori Steffen:  Okay, perfect. Thank you for explaining that for us. What are some connections that you have found between spirituality and mental health?

David Rosmarin:  Sure. Like any domain of life, it can be positive or negative, and spirituality is no different. In many cases, people have spiritual resources, and they might think that their faith gives them a lift. It might help them to deal with depression. It might protect them against certain things like substance abuse or alcohol abuse or suicidality. There's some very strong research to suggest that completed suicide is substantially less among people who have certain types of faith. It might give them a sense that they can get through difficult periods of life. We've seen some evidence here at McLean and elsewhere that when individuals have spiritual and religious resources at the beginning of treatment, that can help them to reduce quicker through their treatments even if the treatment has nothing to do with spirituality, interestingly.

On the other hand, though, it can be a source of strain, I mentioned. It can definitely be negative, and a lot of individuals struggle with their faith. They might think, why am I dealing with depression again? What's God doing to punish me? What did I do wrong? They might feel guilty or estranged from a faith community. They might feel bad about certain feelings they have; they might have certain conflicts which are sometimes very serious. To be able to discuss all of these, the positive and the negative and all points in between is just part of being a good psychotherapist, frankly.

Tori Steffen:  Okay. Yeah, it seems important to know about the spirituality piece, especially when you're treating patients with suicidality and it's great to know that that can help too. Well, could you describe for us how the methods of both CBT and DBT work as those naturalistic treatments for anxiety?

David Rosmarin:  Sure. You mentioned my career has two parts to it, and I would say there is some connection and overlap, but a lot of it is really disparate. At Center for Anxiety, we use a combination of cognitive and dialectical behavior therapy, which is somewhat innovative in the treatment of anxiety disorders. Most individuals treating anxiety concerns would really stick more to cognitive behavior therapy. But these days, anxiety, as I'm sure you're seeing out in Seattle, a lot of individuals come in with some pretty severe symptoms. They might have self-injury, they might be debilitated by their anxiety or other symptoms that they have. There's also high levels of what we call comorbidity where people have co-occurring anxiety with other concerns, whether it's substance abuse or depression, as I mentioned before, or any number of issues, obsessive compulsive and related disorders and these concerns and the complexity and the severity that people have today, they really, we have found can benefit from a broader toolkit of strategies that we can provide in psychotherapy to them, and that's why it spans both cognitive and dialectical behavior therapy in the practice.

Tori Steffen:  Okay, great. That definitely helps introduce our topic today with CBT and DBT. How effective would you say are both approaches, CBT and DBT in treating those symptoms of anxiety, depression, suicidality?

David Rosmarin:  Yeah, that's a scientific question and fortunately we have research to study it. Center for Anxiety has a research protocol and all patients at all sessions are administered measures, and we track over time their progress. We a couple years ago did an evaluation of our IOP, our Intensive Outpatient Program, which are individuals who needed three or more sessions per week.

One of the things that's unique about Center for Anxiety as I mentioned before, is that we provide really a higher level of care than just standard once a week outpatient. Individuals coming in with a lot more severe concerns and symptoms, I'd say about 50% of our patients at this point, require IOP, Intensive Outpatient Program or treatment, IOP we call it, and our data was very positive. We saw substantial reductions and clinically significant reductions in anxiety and depression for substantial decreases in those symptoms over the course of treatment. In fact, none of the patients in that study had an increase in their anxiety or depression over the course of treatment, which I think was particularly encouraging given the severity that they had when they came in.

Tori Steffen:  Wow. Yeah, that's definitely good to hear that there's those treatments out there to be able to help with those symptoms. Have you seen any limitations that might prevent the treatment of anxiety, depression using those?

David Rosmarin:  Being in an outpatient setting, one limitation is the cost of treatment. Unfortunately, with the era of managed care, and I'm sure you have a similar situation out in Seattle, these are out-of-pocket services, and it does limit the people who can come, which is really truly unfortunate. One advantage though that I think we have, and one way of addressing this is we do have a training program and many of our trainees are learning these techniques and they are able to be accessible at lower fees. Also, some of them move on to different sites which can provide services to individuals using insurance or having no insurance at all. I do feel like we're having an impact on the field more broadly, but in terms of our actual caseloads, that's a very significant limitation.

Tori Steffen:  Okay. Definitely makes sense. Well, your research discusses the ways that CBT and DBT involve behavior activation and mindfulness. Could you describe how those might work for audience?

David Rosmarin:  Yeah, so DBT is a broad set of tools, principles, really, and tools to help individuals struggling with severe levels of distress, moderate to severe levels of distress. One of the core tools is called mindfulness, that was the word that you mentioned. Mindfulness means being attentive to the present moment and not being judgmental of oneself. One of the things that happens is not only do people feel depressed or anxious or have other symptoms, but they judge themselves for feeling anxious, depressed, and that judgment instead of simply being anxious or being depressed and allowing oneself to feel that way, that judgment of oneself and negative perception of that feeds in and actually creates more of a surge of adrenaline. It suppresses dopamine, serotonin, other neurotransmitters and individuals are more likely to struggle substantially when they judge themselves. Mindfulness is a training of simply allowing oneself to be in the moment and to experience whatever they're going through without that critical eye.

Tori Steffen:  Okay, great. Thank you for explaining that for us. Your research was also discussing how psychoeducation plays a role in the treatment. How might that work to address those symptoms for anxiety and depression?

David Rosmarin:  There are a lot of basic facts around anxiety and depression and other symptoms that people don't know. For example, if you're feeling depressed, you probably will not want to engage in this much activity because hey, you're feeling sad, you're not enjoying things as much. You're struggling to have the energy and your sleep might be dysregulated. However, to the extent that people simply keep a schedule, even if they're feeling depressed, their depression can and often does remit.

Scheduling an activity which is supposed to be so to speak, pleasurable, even if it isn't, can actually be a part of that. Going to an exercise class, simply going for a walk, lacing up one's shoes, getting out of bed, not sleeping during the day. This is what we call behavioral activation, which is actually in some ways invented in Seattle in your backyard over there and certainly came to be a tour de force in the world of behavioral psychology in Seattle. But in any event, this is a concept that we can just educate patients.

Another one is with anxiety, the more you avoid, the more anxious you will be. If you're afraid of something and you avoid it, you're going to become more anxious of it, not less, even though it feels better in the moment. These are basic concepts that have been clarified through the literature, through experimental science, through clinical science, and they're grounded in theory that patients and anybody just needs to know. So, sometimes just some basic info can go a long way.

Tori Steffen:  Okay. Yeah, that definitely makes sense how important psychoeducation can be. Are there any other approaches than CBT or DBT that individuals can utilize to combat those symptoms?

David Rosmarin:  Yeah, one of the DBT approaches that we really love is called distress tolerance. People often think that one of the goals of treatment is to reduce the amount of distress they're experiencing, and to some extent that's true, but to a larger extent, one of the goals, a better goal, I would say, is to increase the amount of distress that we can tolerate. There's a big difference between trying to reduce my distress versus trying to increase my capacity to withstand distress, and when we think about it the other way, the increasing our distress tolerance in of itself, we're not expected to never be distressed. It's not a surprise when we're having a really rough day and the goal then becomes to weather the storm as opposed to getting the weather to change. As we all know today, climate's very hard to predict and to control, not that we shouldn't try, but we can and certainly should learn to tolerate more with the situation that we have, especially when it comes to our emotions.

Tori Steffen:  Okay, awesome. Thank you for sharing that. While CBT and DBT are best and ideally done under the treatment and guidance of a licensed mental health professional, what are some things one can do on their own to potentially reduce or lessen some of those symptoms of anxiety or depression?

David Rosmarin:  I'm thinking about another DBT module called emotion regulation and simply the idea of being aware, for example, on a scale of 0 to 10, how stressed are you right now?

Tori Steffen:  Myself, I would say maybe a four. Not too bad.

David Rosmarin:  Four, not too bad for a mid-morning west coast kind of vibe. I get that, even though it's a Monday. That's great and you're aware of it right away, and maybe that's because you're involved in the field. Other people will fumble, I don't know, is it high? Is it low? I don't have a baseline. Simply being aware of how sad you are, how anxious you are, and throwing a number to it. If you don't want to throw a number to it, at least is it high, is it medium, is it low?

Being able to share that with someone, that's another factor in emotion regulation. Being able to just communicate how you feel to other individuals, whether it's a professional, as you mentioned, or a friend. Whether it's a post on Twitter, hey, feeling a little bit sad today, whatever it is. Then these kinds of things, it's important to maintain awareness and then to recognize also that we can shift our emotional states. Sometimes you might all of a sudden feel really dysphoric and sad and part of that we can't necessarily control, but we might be able to indirectly influence that. Listening to reggae music, right? Hard not to bop. Going for a walk, calling up an old friend, eating ice cream. But sometimes those can have negative effects, as well. Being aware of our emotional states and how what we do affects those, that's really the core of emotional regulation and that's something everybody can benefit from today.

Tori Steffen:  Okay, great. Awesome advice. Well, do you have any final words of advice or anything else that you'd like to share with our listeners today?

David Rosmarin:  I guess I'll share this, that we're living in very challenging times. People have higher levels of anxiety and depression than ever before in history for a variety of reasons. It's very real, these concerns, and they have very significant and real effects on people's lives. Our phones are ringing off the hook. The other day, I think they're 22 intakes that came in and that's very significant for a modest practice of our size.

I think it's important for people to know that they're not alone today, that if they're struggling, there's plenty of other people that are there. More importantly, that there are treatments that really are helpful, and in not a lot of time. I mean, our treatments will often see people 5, 6, 7 sessions and see a decrease. They might stay on longer to target other aspects of their mental health, but A) people are not alone and B) there is hope to be had and a lot of hope, so I think those are probably some important messages to get out there.

Tori Steffen:  Definitely important to keep a positive perspective on things, so that's very helpful. Thank you so much. Well, it's been really great talking to you today, Dr. Rosmarin, and thank you again for joining us and contributing to our interview series.

David Rosmarin:  Thanks for having me on your series.

Tori Steffen:  Thank you very much. Hope you have a great day.

David Rosmarin:  You too.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Julie Erickson on Aging & Anxiety

An Interview with Psychologist Julie Erickson

Julie Erickson, Ph.D., C.Psych is a Clinical Psychologist at the Forest Hill Centre for CBT in Toronto, Canada and adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto. She specializes in the treatment of anxiety disorders in older adults.

Tori Steffen:  Hi, everyone. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, a research intern at the Seattle Anxiety Specialists. We are a Seattle based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today Clinical Psychologist, Julie Erickson. Dr. Erickson is an adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto.

She practices at the Forest Hill Centre for CBT in Toronto, Canada. She's an expert in the field of anxiety disorders and has written several articles on the topic, including “Anxiety Disorders Late in Life: Considerations for Assessment and Cognitive Behavioral Treatment”. As well as “Associations Between Anxiety Disorders, Suicide Ideation, and Age in Nationally Representative Samples of Both Canadian and American Adults.” Dr. Erickson is also planning to publish a CBT workbook for older adults with New Harbinger in the fall of 2023.

Before we get started today, could you please let us know a bit about yourself and what made you interested in studying anxiety disorders in older adults?

Julie Erickson:  Yeah, absolutely. Thanks for having me. I live and practice in Toronto, and maintain a pretty steady clinical practice and I do some teaching as well. In terms of what got me interested in this area, so it actually started way back in one of my first jobs when I was a teenager. I worked in the recreation department of a nursing home. As part of that job, I was helping facilitate different recreation programs for residents, and noticed that it was the same group of people coming to recreation programs all the time.

It tended to be a group of people that were maybe more optimistic. They tended to be more social. They also tended to be the same group of residents that had more people visiting them. Relative to other residents, who were maybe a little bit more withdrawn or isolated, maybe a little bit more pessimistic or had fewer visitors. Just seeing the contrast made me curious. Why did some people tend to thrive and do quite well, as they got older and were in nursing home care, versus some people really have a more difficult time?

Ultimately, wanted to understand some of the psychological and social factors behind aging well. How to help people live better lives as they grow older and to be more fulfilled. As part of that, how to manage the anxiety and the stressors that can come up for people in late life. Ultimately, this led me to the field of clinical psychology and the intersection between that and gerontology.

Tori Steffen:  Okay, great. Thank you. Would you say that older individuals experience anxiety similarly to younger people?

Julie Erickson:  Yeah. I would say generally speaking, there's probably more similarities than differences. The similarities being maybe focusing on worst case scenarios, feeling agitated or restless, having difficulties relaxing, struggling with indecision or doubt, difficulties concentrating, so a whole host of similarities. Where some of the differences might be though, might be the types of symptoms that end up getting endorsed. Older adults can tend to report more physical symptoms of anxiety or at least report those predominantly.

One of the first things they might report to their family doctor, could be the physical symptoms like upset stomach, or having a racing heart or shortness of breath. As opposed to going to their family doctor and saying, "I'm worried about what people are thinking about me in social situations." That's one difference. The other difference might involve more of the content of the worries that older adults have. That's going to be a little bit different than younger adults. It's less focused on things like academic success, or career building or parenting.

It tends to be a little bit more focused on things like changes in your physical health or mobility, caregiving concerns, or even identity shifts that might be happening because of things like retirement. The surface nature of the worries will be a little different, as well as sometimes the types of symptoms that older adults report.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Would you say there are any limitations that you've found that might prevent the treatment of anxiety disorders in older adults?

Julie Erickson:  Yeah. There's several unfortunately, and several big ones that can get in the way of older adults getting treatment for anxiety disorders. The first one relates to something called mental health literacy. This relates to someone's ability to recognize the symptoms of a mental disorder. Knowing where to get information about mental health concerns, and knowing where and how to get help. Some research suggests that older adults tend to have lower rates of mental health literacy relative to younger adults.

That might be one of the things that prevents them from detecting that part of what I'm experiencing could be a psychological issue. It also might prevent them from knowing there're effective treatments out there and knowing where and how to get help. That's one of the first limitations. The second more has to do with a systems issue, so lack of access to qualified, geriatric mental health professionals. There's an undeniable shortage of us who specialize in treating older adults. That can certainly make it quite difficult to get qualified help.

Thirdly, also probably a societal or systemic issue, stigma. Some older adults may come from a generation or social or cultural background, where going to see a psychologist or a psychiatrist is only when someone is really sick. It still might be shrouded in a lot of their shame. That can be something that really gets in the way. Then finally, I would flag ageism as a potential issue that gets in the way of getting treatment. Sometimes symptoms of mental health conditions in late life can be missed by healthcare professionals.

They might be very well-intended, but maybe more inclined to look at some of the symptoms that older adults might be presenting with, as more attributed to a physical problem as opposed to a mental condition. It's not just maybe healthcare professionals, but also older adults themselves can hold some ageist types of beliefs. They might be inclined to see older adults as less capable of changing. If they hold that belief, which is an ageist stereotype, that can really defer them from seeking treatment as well. A whole host of different things that can get in the way of older people getting help.

Tori Steffen:  Right. Yeah. Those are some great points, as far as limitations go. Your research discusses the ways that CBT can defer among the younger and the older patients with anxiety disorders. Could you explain the differences for our audience?

Julie Erickson:   Absolutely. There's a few that I'll highlight. The first has to do with the pacing of treatment. It's important to know that with CBT, in particular with older adults, things might take a little bit longer for a number of reasons. It's longer to gather maybe a personal history from an older adult client. There's lots of background information to get. Depending on the client's experience with therapy, you may need to devote some extra time to socializing them to therapy. So they have more of a working understanding of what this is, what to expect as you engage in treatment.

There's also an issue of pacing if you're working with someone with cognitive impairment. Or even an individual with normal age-related changes in cognition, you might want to slow down the speed at which you're talking about interventions or introducing new things in session, or even consider having shorter sessions. I'm thinking for people who might have medical conditions that make sitting or sustaining their attention for full hour sessions more difficult. Pacing is one first thing to consider that would make treatment a little bit different with older adults.

The second issue relates to being more attuned to medical issues and how these might be likely to impact your conceptualization of a client and also treatment. Given that a sizable proportion of older adults are experiencing either chronic, physical health issues or more acute issues, there's likely going to be an interplay between some of those symptoms and the anxiety that they're reporting. For example, I had an older adult client diagnosed with tachycardia, and subsequently developed panic attacks every time she had an irregular heartbeat.

Doing a careful assessment and asking about physical health issues is particularly important, so you understand how this might be impacting an older adult in your treatment with them. Another potential difference and an issue to keep in mind, stems from cognitively how an older adult is doing. Cognitive issues require some assessment, even if it's just a brief screener at the outset of treatment. Just to take into consideration how that might impact treatment, and to consider how to best pace and deliver content.

Age-related, cognitive decline is pretty normal and primarily affects things like your short-term memory, your word finding, maybe speed of processing. This may or may not require any alteration in your treatment. But if you're seeing someone who's maybe got a cognitive impairment that's related to dementia, maybe they've got mild to moderate types of dementia. This is going to require some tailoring, in terms of your pacing, but also lots of use of memory aids, right?

Handouts, writing things down, even audio recording sessions, so clients can help retain what you're talking about in session.

Tori Steffen:  Okay.

Julie Erickson:  Then finally, what I'd flag in terms of how things look a little bit different with older adults, has to do with just the types of themes that might come up in treatments. There might be more themes to pay attention to around loss, right? Grief in a bunch of different forms, whether it's of people or of roles in your life.

Or grieving mobility, or functionality or independence. But also themes of isolation, identity changes, or even dealing with regrets. Being attuned to just some of the developmental concerns that can emerge in late life, I think is particularly important with older adults.

Tori Steffen:  Great. Thank you. Thank you for that. Then I know we spoke about it earlier, the somatic symptoms that older adults may experience. Can you explain what types of somatic symptoms that they typically experience and why that might be?

Julie Erickson:  Yeah. A lot of the somatic symptoms older adults experience, would be some of the typical ones we would see in early life as well, around whether it's upset stomach, or just feeling on edge, or restless or even elevated heart rate. Even things like feeling sweaty or short of breath, in cases like panic. Some of those somatic symptoms will look very similarly. As far as to why they might present more with some of those somatic symptoms. Well, we don't know for sure. There's a couple possible explanations.

One of which might be that there could be either biological or psychological, or social factors that influence how anxiety disorders are experienced or present, or seem more prominent in late life. It seems reasonable to expect that the types of symptoms that people might present with can change as one grows older. Due to things like different medical conditions or just age-related changes in things like sleep or emotion and how people experience it. It could just be that there are developmental changes in how anxiety disorders present.

But the other possible explanation relates back to something that I was talking about earlier around lower rates of mental health literacy in older adults. If older adults are less aware of what some of the different symptoms of anxiety disorders are, they may underrecognize some of the symptoms, for example, some of the cognitive symptoms. May be less likely report some of those symptoms, if they don't know that's in keeping with an anxiety disorder. If that's actually the case that this is more of a reflection of let's say a cohort effect, right?

That it's this generation of older adults who lack mental health literacy, we might expect to see that as younger generations of adults now as they get older, that they would be more aware of and more likely to endorse a greater array of anxiety symptoms. So we'll see, and probably research will have more to tell us in the coming decades about some of these age-related differences.

Tori Steffen:  Yeah. That'll be interesting to see the changes as time goes on and people grow older. Are there any other approaches than CBT, that older adults can utilize to combat the symptoms of anxiety disorder, maybe fear of aging?

Julie Erickson:  Yeah, it's a good question. The challenge is that there's probably relatively less therapy outcome research for older adults, compared to other age groups and most of it tends to focus on CBT. But if we look outside of this modality, there's some support for approaches like motivational interviewing or problem-solving therapy to have some success with older adults. One other approach that might be more useful and maybe more unique to late life.

Maybe more helpful too in dealing with issues like fear of growing older, or fear of aging or coming to terms with one's mortality, is the practice of reminiscence and life review, so reminiscing therapy. And while we all might reminisce about the past and recall the good, the bad, and the ugly of our lives, this is particularly important for older people as a developmental task. Older people use the process of reminiscing to help create meaning and integrate life's events.

Maybe even have a heightened awareness of things like the finiteness of life. And to work to create meaningful roles for themselves in their later years, which can be challenging given that society largely pushes older adults to the sidelines. This practice of reminiscence and life review has particular relevance to older adults, who might struggle with fears of growing older or come to terms with what that means for them.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Your article also mentions that the presence of cognitive impairments. We were talking earlier, dementia as an example, can make it more difficult for older adults to engage in CBT as a treatment for anxiety.

Would you mind just explaining this a bit more? Do you think CBT could ever be a suitable treatment option for an older adult with a cognitive impairment?

Julie Erickson:  Yeah. Yeah. Cognitive impairment can vary in late life. There's a certain degree of cognitive change that's normal as people get older, like declines in short-term memory, forgetting names of people or forgetting where you left an object, or walking into a room and not remembering why you walked in there for. That's all pretty normal, versus dementia is not considered a normal part of growing older.

Dementia's an umbrella term for a wide variety of different conditions that can include things like Alzheimer's disease or vascular dementia, or Lewy body dementia. They can come with more severe difficulties with memory, attention, speed of processing, language. It can be much harder for these folks to learn and retain new information, especially as the disease progresses. Now, it's not to say though that older adults with dementia can't benefit from CBT, but it really depends what stage of the disease that they're in.

There is research to suggest that if you're in the more mild to moderate severity range of dementia, that you can still benefit from this type of approach. But you want to ensure that your CBT protocol maybe is streamlined and simplified, in terms of the level of complexity. And to make sure there's ample use of memory aids. Things like handouts, keeping written notes of what's happening each session, and having the client keep their own notes as well, audio recording each session.

Things of that nature, as much as you can do to help the client remember and encode the information you're talking about in session, the better. You might be able consider involving significant others in the client's life to help assist with remembering information. I'm thinking of one client in particular, who after our sessions, she would often talk to her daughter. And would talk to her daughter about part of what she learned in her CBT session that day.

Then part of that was just to help her remember and consolidate what she's learning. But also, to bring her daughter into the loop so her daughter's more aware of what's going on in her treatment. Those are some of the things to keep in mind that might still help an older adults with dementia, let's say, benefit from CBT.

Tori Steffen:  Great. Yeah. It's good to know that it can still be helpful for older adults with those cognitive impairments. The case study outlined in your article, showed that older adults who experience regular panic attacks can improve such occurrences with the help of CBT tactics. Could you speak a little bit about this and what may help with that?

Julie Erickson:  Yeah. Yeah. Let's start with in its simplest form how we conceptualize something like panic disorder. Most simply, panic disorder is a fear of fear. Where individuals who might be experiencing normal or benign physical symptoms of anxiety, become quite fearful of these sensations because they start to assume that they mean more catastrophic things, like having a heart attack or being on the verge of fainting, going crazy or losing control.

When anxiety symptoms are viewed in that way, of course, it's very distressing and can typically result in avoidance of activities or situations, or things where people think that those physical symptoms might be activated. They might start to avoid things like cardiovascular exercise, caffeine, or even things like taking the stairs. With some of those avoidance behaviors, this can really reinforce and even magnify some of the fears that people have around those physical sensations of anxiety.

It can sometimes be the case that for older adults with panic disorder, the onset of those difficulties can go alongside other medical issues, like the tachycardia example I discussed earlier, or even GI conditions. The onset of these medical issues can make people more hypervigilant to changes in physical sensations, to be a bit more anxious or on edge about them. Now, when you're doing CBT for panic with older adults, the overarching goal is to help people learn that the physical sensations that occurred during panic are uncomfortable but not dangerous.

They don't actually need to try to actively control these sensations, that they'll dissipate on their own. Part of how we do this is by cognitive restructuring, so helping older adults to change their minds about what these sensations mean. With some older adults, they've had pretty longstanding beliefs about what these sensations mean, that they're crazy or they're unable to control themselves. Good psychoeducation is going to help people start to shift the perception of these symptoms.

Now, the other thing though that's really going to go a long way, is doing interoceptive exposures, which is basically making active, intentional efforts to try to mimic the sensations of panic. In doing so, is going to allow people to learn that these sensations aren't going to result in some catastrophic outcomes, like going crazy or having a heart attack. We'll often encourage people to do things like breathe through a straw for one minute and plug your nose. Run on the spot as quickly as you can or purposely hyperventilate for 30 seconds.

Doing that repeatedly is going to help people start to learn that these are at most, uncomfortable but not actually dangerous feelings for me. Now, the thing that's maybe more important if you're doing those interoceptive exposures with older adults, is to make sure that you inquire about any medical conditions that might contraindicate some of these exposures or require you to adapt them. For example, there's some cardiopulmonary conditions that you might want to avoid.

Certain forms of interoceptive exposures where you activate either cardiovascular symptoms or respiratory symptoms. Likewise, if you've got individuals with asthma or COPD, or renal disease or seizure disorders, some of those folks are advised not to do certain forms of exposures that involve breathing through a straw or inhaling more CO2. For this, don't work in isolation. Check with your older adult's primary care physician to get clearance to do some of these exercises.

Well, collectively, some of the cognitive work and the exposures in CBT for panic, can really go a long way into helping older adults reduce the frequency of those panic attacks, and ultimately, to feel more confident about their abilities to deal with anxiety.

Tori Steffen:  Great. That's great to hear that those tactics can help with panic disorder and definitely good. I know that CBT is best and ideally done under the treatment and guidance of a licensed mental health professional.

Are there anything things that older adults can do on their own to potentially reduce or lessen those symptoms of anxiety?

Julie Erickson:  Yeah, absolutely. There's a number of important things that they can be doing. One of the first things I'd encourage older adults to do, is to try to be a detective with their anxiety. By that, I mean trying to make note of a few things when they feel anxious. To make note of where and when they tend to feel more anxious. Is it before trips to the doctor, while driving, before traveling? To also identify what thoughts that they may be experiencing at the time that they feel anxious.

What if I get into an accident? What if my doctor gives me terrible news and the like? Also to make note of what behaviors that they engage in when they feel anxious, whether it's avoiding driving or researching physical symptoms online. Making note of those different things can help understand the full picture of your anxiety and how it shows up in your life. That can ultimately help you be better situated to interrupt some of those usual things that go on when we feel anxious.

The second thing I think older adults can do is to talk to themselves like they would talk to a loved one or a close friend who was feeling anxious. If we had a loved one who was worrying about an upcoming medical appointment, we'd probably try to understand, to empathize and even to comfort them. Oftentimes, if we can do that for ourselves, that just tends to feel better and helps us feel a little bit better situated to cope with feelings of anxiety that might be coming up.

The third thing and final thing I'll mention that might help older adults in dealing with anxiety, has to do with experimenting with doing the opposite to what your anxiety pushes you to do. If you notice that your anxiety tends to make you want to avoid things like socializing, exercising, or trying new things, try to attempt to gradually face and overcome some of these fears by doing the opposite. If you notice perhaps that your anxiety makes you overdo things.

So over-come it, over-prepare for things, over-research, experiment with scaling back on some of those things. And people can find that if they change their behavior when they feel anxious, many of their feelings of anxiety can reduce over time. Those are some of main things I would encourage older adults to do, who feel anxious.

Tori Steffen:  Great. Thank you for sharing that. I'm sure it's helpful information and definitely relates to mindfulness and exposure therapy as well.

Well, Dr. Erickson, do you have any final words of advice or anything else that you'd like to share with our listeners today?

Julie Erickson:  Yeah, sure. I always like to plug some optimism for growing older. As much as there can be some negative stereotypes of aging and fear surrounding the process of growing older, there's also a lot to look forward to. The later years of life can bring a lot of freedom from responsibilities that were present earlier in life, so like child rearing or building a career.

Older adults acquire a lot of wisdom and emotional maturity that tends to peak in later life. Alongside that, they tend to have more clarity about the people and the things that are most important to them and tend to spend their time accordingly. As much as there are considerable challenges to growing older, there are a lot of upsides and things to look forward to.

Tori Steffen:  That's great. I love the optimistic perspective on that. Well, thank you so much for joining us, Dr. Erickson. It's been really great speaking with you today. Thank you so much for contributing to our interview series.

Julie Erickson:  You're welcome. Thanks for having me.

Tori Steffen:  Thank you. Have a great one.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Therapist Claire Jack on Autism Spectrum Disorder

An Interview with Therapist Claire Jack

Claire Jack, Ph.D. is an Anthropologist and Therapist based in Scotland. Dr. Jack specializes in working with women with Autism Spectrum Disorder and has published “Women with Autism: Accepting and Embracing Autism Spectrum Disorder as You Move Towards an Authentic Life”.

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety specialists. We are a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us anthropologist and therapist, Claire Jack, who joins us from Scotland today. Dr. Jack received her Ph.D. in anthropology and has subsequently trained as a therapist over 10 years ago. In her late forties, she was diagnosed with autism spectrum disorder and has sought to help others understand more about this often challenging disorder. Before we get started today, can you let our listeners know a little bit more about you and what made you interested in becoming an anthropologist as well as a therapist?

Claire Jack:  Okay. Yeah, actually, I suppose for me the two things link up really quite a long time ago. When I was 18, I started to train as a psychologist, I started to do my degree in psychology. For various reasons, it just wasn't really the right course for me. I shifted to archeology, so I've had a long route to get here, which led on to anthropology and history because, obviously, anthropology and archeology are quite closely related. I think there was just always that interest in how people work, how they communicate, so very much was studying that within anthropology.

I really got into therapy from my own personal experience. I had a really bad driving phobia and I had had hypnotherapy a long time ago, which was reasonably successful, but not fully successful. I had an incredible hypnotherapy session for my driving phobia and that just made me want to train. I trained in that, I did counseling, I did life coaching. That's it, really, I've been working as a therapist now I think for probably nearly 15 years and I've had a training school for 10 years, so I combined the two.

Jennifer Ghahari:  Great. Can you explain to our listeners what autism spectrum disorder is?

Claire Jack:  Okay. Autism spectrum disorder is a developmental disorder, so that means that you're born with the condition. When we're thinking about it, we can really think about three levels of autism, we've got level one, level two, level three. I think it's really important to remember, it's a huge spectrum, so very big spectrum of experience.

People with level one autism, that's what I've been diagnosed with, that's equivalent to what used to be called Asperger's syndrome. I think in 2013, you no longer have an official diagnosis of Asperger's. That is roughly equivalent to level one autism. People with level one lead independent lives on the whole; average or above average intelligence. They have symptoms, I think it's important not to downplay how difficult level one autism is, but most people can lead a certain completely independent life.

Level two autism, we're talking about people that maybe need some kind of assistance, might struggle to be lead independent lives.

Level three is often associated with learning difficulties; it might include people who non-verbal.

It seems like it's such a big spectrum that you almost think what have people, say like me, who's leading a completely independent life, with someone who has special needs and a lot of help, what have we got in common? It's really thinking about the traits. People with autism, we have sensory issues, difficulties processing sensory stimuli, communication and social difficulties. We might have difficulties with restricted interests. Emotional regulation difficulties are really common as well. Across the spectrum, people have these traits that they share in common.

Actually, I don't have anything visual that I can show this on, but I think when we think of a spectrum, we often think of a linear spectrum, from good to bad or difficult to easy, but actually, if you think of it as a pie chart and think of the symptoms and think, well, somebody might be much more affected in terms of communication difficulties, but maybe less affected in terms of restricted interests, or they might have difficulties with eye contact, but less emotional regulation difficulties. Instead of thinking of it a spectrum, we can think that people have really diverse experiences within autism as a whole.

Jennifer Ghahari:  Wow, great. Thank you for explaining that and the different levels. Unfortunately, without more information known about autism among the general public, those without it can often feel frazzled or annoyed at some of the ways it may present in people. It's fairly common to hear notions like, "Why can't they stop doing that? Why don't they act normal?" Can you explain what it's actually like to experience autism? What does it feel like?

Claire Jack:  Yeah. I suppose, first of all, there's not a choice in it. You are experiencing the world differently and you're processing the world differently, so you can't think yourself out of autism. I think that's the first thing for other people to remember. Actually, although I'm autistic myself, I come into contact with autistic people and we don't all necessarily get on together, so I can see it from both sides. An example might be, I do a lot of teaching, I teach students, and sometimes my autistic students need me to really explain things in a huge amount of detail, I need to spend an awful lot more time going over things, they might take things that I say very literally so I have to go over that, and just I end up spending a lot more time with them. I can understand that they need that time, but I can see that that could be frustrating for somebody else.

Yeah, and to come back to your question, it's important to know that when something is happening for somebody autistic, it tends to be happening in a really extreme way and there is nothing that they can do about that. For instance, when I was a child, because I think a lot of people learn about autism because they've got maybe autistic children, when I was a child, I was very well behaved; never, ever misbehaved. That was what I wanted to be like, I just wanted to be a really well-behaved kid. But if I was triggered, I was a monster; absolutely, I was horrific.

One time in the hospital, I was there for an operation, I attacked all the nurses, I got all the medical equipment, I threw everything everywhere. I scratched my mum so badly that she still has the scars. I was five, but there was no controlling me. It wasn't a choice; I never would've attacked like that. I think that's just really important to think, because autistic people have to process things in a different way, you have to understand it is different. It's not the same, no matter how they might present most of the time to somebody.

Jennifer Ghahari:  Great. You mentioned triggers, could that be something like lights or smells or sounds?

Claire Jack:  Absolutely. I think when I'm thinking about triggers, I'm usually thinking about emotional triggers and sensory triggers. What you're talking about is more in terms of sensory processing. An example might be going to the supermarket and dumping your bags because you can't be there any longer, or a huge one for me is people scraping their plates. As a kid, I couldn't stand, especially if we had unglazed plates in the house, that noise, I just couldn't be in the room. Even as an adult, I've learned to cover it a bit, but that kind of thing, I experience it very, very deeply. It's like a physical, horrific pain. Both my sons have that sensory thing as well, they're exactly the same.

Emotional triggers can also be a huge thing as well. I think often, if you're not being understood or you're not being listened to, maybe somebody's given you too much information. I had a client recently, a student, and she was just getting too much information that she wasn't able to take in and had a complete meltdown. I think those are two really big triggering things for autistic people.

Jennifer Ghahari:  Great, thank you. On your website, you mentioned that males and females with autism actually present differently. Can you explain the differences?

Claire Jack:  Okay. Well, I think there are a lot of similarities, in terms of the traits, there are really big similarities, but women tend to camouflage or mask their autism. We know from a really early age, girls tend to be driven to be more social than boys. That goes from neurotypical girls and autistic girls, but there is this drive. They want to engage a bit more, little autistic girls than little autistic boys, so they find ways of trying to appear "normal" so that they pass. For that reason, girls tend to be awful lot better at making eye contact, at having conversations, at just blending in.

Also, in terms of things like interests, there seems to be a difference. The classic, what we might think of, collecting Star Wars toys or little trains or something that boys might do, collecting things, girls often become really obsessed with other people. It could be crushes, it could be bands, film stars, even a best friend.

Again, they tend to go under the radar because they're presenting very differently to boys. They still have the restricted interests, still have the social difficulties, still have all of it going on, but it tends to look really different in girls and boys.

Jennifer Ghahari:  In terms of comorbid mental health conditions, what do those with autism tend to experience? Is it anxiety, depression, things like that, or any other?

Claire Jack:  Yeah, absolutely. They tend to have really high levels of anxiety and depression. What the research shows is that that tends to be linked to the degree of camouflaging. It's not necessarily linked to how autistic you are, how severe your autism is, but how much you try and cover that. Again, women tend to maybe have worse mental health than men and that tends to be linked to how much they mask it, because when you're masking all the time, it's absolutely exhausting. It's a strange just doing anything because you're putting on such a constant act. That's a big reason for the certain mental health issues.

Suicidality is also a really big problem with autistic people, higher levels of suicidality and also more of a likelihood that it's followed through on as well. A lot of autistic, well, I don't know a lot, I'm possibly using the wrong term, but certainly some autistic people are misdiagnosed with things like bipolar disorder as well, because meltdowns can seem horrific, it can seem like a bipolar episode. Some of the extreme behavior that autistic people present with as well can sometimes be misdiagnosed as bipolar. Some people do have autism and bipolar, but the misdiagnosis is something that comes to light quite often as well.

Jennifer Ghahari:  When we diagnosis this, is it a psychiatrist, a therapist?

Claire Jack:  It's usually a psychiatrist, sometimes clinical psychologist will diagnose, for a full clinical diagnosis. Therapists, such as myself, might offer a nonclinical diagnosis. I suppose one of the reasons certainly that I offer that is just the problems that people have getting a full clinical diagnosis. The wait times can be huge, the expense can be really extreme, and so sometimes people might go to someone like myself, even as a stop-gap, so that they have something to work with whilst they're waiting a couple of years for a diagnosis.

Jennifer Ghahari:  Oh wow; years.

Claire Jack:  Yeah, absolutely. Yeah, I don't know about every country, and obviously in the UK we have the NHS, so it's a free diagnosis, but that can certainly be up to a couple of years waiting. It's a massive wait.

Jennifer Ghahari:  Which could lead, as you said, to the anxiety and depression.

Claire Jack:  Absolutely, yeah.

Jennifer Ghahari:  Wow. In terms of treatment, how would autism spectrum disorder typically be treated, from a therapeutic standpoint?

Claire Jack:  I think this is a really interesting question. The recognized treatment for autism is applied behavioral analysis, ABA. To be honest, it's not something that I've had and it's not something that I'm trained in, I'm no expert in ABA, but basically, it's... I'm trying to think of the best way to describe this. It's aimed towards people maybe having a more productive, and again, inverted commas, “normal” life. It's quite a rewards- and punishment-based therapy, as far as I know. It's not particularly popular within the autistic community, because the autistic community are of really working towards accepting autism and accepting yourself. But certainly, I think it's very common amongst autistic children, trying to almost train them to be less autistic. Like I say, it's not a very popular approach within the autistic community.

CBT can be effective, but I think what's really important is you need to go to somebody who understands autism. I've been trained in CBT and I do work with CBT, but it doesn't necessarily work with autistic people unless you really recognize the limitations, because trying to push yourself and change your beliefs and come up with new behaviors can be really impossible for people with autism. What I find is that a lot of people who have been down traditional therapy routes just haven't got the help that they need at all. A lot of them have talked about therapists, and actually I've had this experience looking for past trauma to explain what I'm experiencing, because it can present in a very similar way, and actually there's maybe nothing particular in the past that can explain what you're experiencing now.

There are autistic therapists out there. I think just having that level of understanding from a personal perspective and being able to educate your clients, I find with autistic clients, I'm educating them a lot more than I would with other clients and that's a hugely important part of therapy. But to me, therapy is all about accepting yourself, it's accepting you're autistic beginning to work to take the pressures off and work with, I don't like to call it limitations, differences. Just think, yeah, I'm different in this way, but this is a solution for it. It's all about acceptance.

Jennifer Ghahari:  Oh, that's fantastic, thank you. In terms of self-care tips, are there any that you can recommend that people can try at home or just on their own without any therapy?

Claire Jack:  Yeah. I think one of the big problems people with autism have is emotional regulation. The worst effect of that is when people have meltdowns, which can be absolutely horrific. It can involve leaving your house, putting yourself in danger, breaking things, putting other people in danger, they can be horrendous. But there are signs at some point that you are probably heading from meltdown, so it's really important to begin to recognize your own signs. They don't come out of nowhere.

You might just recognize you're a bit tired, some people might stim, so it could be touching their face or rocking backwards and forwards or pacing, or even talking a bit loud, there will be something. If you can think about it as an emotional regulation timeline, you can begin to recognize that actually you need to stop and don't go to the supermarket. I'm mentioning supermarkets because I hate them, but don't go to the supermarket if you're starting to talk a bit quickly. At that point, you start to rest. I think that's a huge tip, start to think about a timeline and what you need.

Also, you need a recovery time. I think this is, again, autistic people are different. They take ages to recover from a meltdown. It might be hours, it could even be days. You need to think, “Do I need to rest here, do I need to avoid something?” There's a theory that lot of people use, called “spoons theory”, and it was actually developed by somebody with I think it was chronic fatigue, it was some kind of chronic illness. It's a great way to think about self-care. You need to think, “I have X amount of spoons this morning, so I've got 10 spoons. I'm not going to get anymore, when they're gone, they're gone.” I can think, “Right, I've got a meeting, that's two spoons, I've got the school run, that's going to be three, but I don't get any more at the end of the day.” You might actually only be starting with six. It's a real check in with yourself and thinking, I don't have limitless capacity, because fatigue is a huge thing as well.

I like to think of it in terms of pebbles, because I live by the coast. Literally, you have your pebbles. You can even take a pebble out with you, but you just don't get anymore. Again, without being negative or trying to think about limitations, it is a reality check, that you do need to look after yourself or you could end up being exhausted and frazzled and have a meltdown and all of these other things.

Jennifer Ghahari:  Yeah, I think you bring up a good point. I think a lot of people without autism don't realize how bad a meltdown can be, number one. Yes, people can witness it, but then, like you said, the recovery can be hours or days. Autistic people really need to do self-care. If they can't go to an event or if they're wearing noise-canceling headphones, it's not because they want to look stylish or interesting, it's because they actually need to do this for their own health.

Claire Jack:  Yep, yep, absolutely. I know a lot of my clients love noise canceling headphones and some will wear them in the house. I was talking to someone recently, big family, including stepchildren, and just the noise at dinner time was just too much to cope with, and she started to wear these. Her family thought it was amusing at first then they accepted it. It just made such a difference. Yeah, but yeah, it's not about trying to look for attention or anything else, it is about trying to keep yourself safe.

Jennifer Ghahari:  That's great. I'm glad that client found that way to do it.

Claire Jack:  Yeah, it's amazing. I think once you accept it, the solutions you come up with are really inventive.

Jennifer Ghahari:  This has gone by pretty quickly. I always think that's a good sign of a good interview. Usually, we wrap up our interviews by asking if you have any parting words of advice. I'm actually going to ask you that twice. First, do you have any parting words of advice that you'd like to offer for those diagnosed with autism disorder?

Claire Jack:  I think it's a really difficult thing at the beginning to come to terms with, particularly for adults. I think it's different if you've maybe known since you were younger, and certainly the way parents impart that knowledge to their children is really important. But I think just if you find out a bit later in life, as most of my clients have, you've got to be really patient with yourself. It can be scary, you can think, “My life's going to be limited, I can't have the career I want, can I have a family?” Yes, you can do all of these things, but you maybe need to just find different ways of managing it, but it really doesn't have to limit your life in any way.

To me, it's something that it can really open up doors and it can open up new ways of thinking and being once you've begun to accept it. I think that's the really important thing. If you keep battling against, it's always going to appear like this terrible thing that's going to hold you back, but if you can accept it... Autistic people tend to have different ways of viewing the world, they maybe have different talents, they might be particularly good in some areas, so once you can accept all of that, then you can lead this incredible, rich life. It might be slightly different or it might work in slightly different ways, and that's completely fine. I think it's accepting that that's completely fine.

Jennifer Ghahari:  Do you have any words of advice for those without autism that you want them to be aware and cognizant of?

Claire Jack:  Well, I think first of all, the client base that I work with, you wouldn't know they're autistic. I think some people think they're giving a compliment by saying that, “You don't look autistic at all,” which is actually really frustrating because they don't see what's happening in the background. When I went to my GP initially to ask for a referral to a psychiatrist, I was just completely knocked back on the basis that I can have a conversation, I can smile, I can look somebody in the eyes. I'd done tons of research and I really tried to explain why and what was going on for me, and it was, "You don't look autistic." I think it's terribly important, if you're not autistic, don't judge somebody, because you don't know how much effort they are putting into something.

It's also, I think, really important to recognize it's real. Most of the people that I work with tend to be really lucky in terms of their partners. I think autistic people are often drawn together anyway, but even if there is a non-autistic partner, most of my clients have had a lot of support, but I have had some clients who've had a really horrible experience from husbands and partners who will not believe that they're autistic and it doesn't seem to matter what they say. Even when they get a full diagnosis, they will not believe it.

I think if somebody has a diagnosis, even if they haven't, even if they're self-diagnosing and have done the research, what they're experiencing is very real. Just because you don't understand it doesn't mean it's not real. Again, just thinking about autistic people having to be inventive with some of their solutions is a great opportunity for partners, children, parents, to be inventive with the autistic person as well, be open to it. Accept if they don't want to do something, they don't have to do that thing. You can probably work around it, you can come up with a different solution. If they don't want to come to your family party, fine. Do they have to go? Probably not.

It's about, I guess, looking at societal norms, which very much are made to fit neurotypical people. This is where I'm going into my anthropology bit here, and I'm thinking, well, do we have to adhere to these norms, and why would we? I think, again, it's a great opportunity, but people have to be really open to accepting their loved one or colleagues or whoever has autism and thinking I can either treat this in a way that's going to stress this person or I can support them, because this is absolutely real for them.

Jennifer Ghahari:  That's really great. Thank you so much. Dr. Jack, it's been wonderful talking with you today and we really appreciate your contributions to our interview series.

Claire Jack:  Thank you.

Jennifer Ghahari:  Have a good day.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Social Worker Erin Maloney on the Innocent Lives Foundation

An Interview with Social Worker Erin Maloney

Erin Maloney, LCSW is the Director of Wellness for the Innocent Lives Foundation. She is a licensed clinical social worker specializing in trauma, addiction, ADHD, anxiety, depression, and other mood disorders.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us clinical social worker, Erin Maloney, who is the Director of Wellness for the Innocent Lives Foundation. Erin earned her Bachelor Degree of Science and Psychology from St. Joseph's University in Philadelphia, and a Master's Degree in Social Work from Widener University in Chester.

She is currently a licensed clinical social worker specializing in trauma, addiction, secondary trauma, ADHD, anxiety, depression, and other mood disorders. Thank you for joining us today, Erin.

Erin Maloney:  Thank you for having me.

Theresa Nair:  Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying clinical social work?

Erin Maloney:  Absolutely. I am a little bit about me. I am a mother of three. I also have a husband and a dog. I live in Scranton, Pennsylvania, like “The Office”. I have always been interested in mental health, actually since a very young age. I told my mom probably about five, six years old that I wanted to become a therapist and she just pushed me along to do whatever I wanted and follow my dreams.

I did, I entered into psychology and I loved it and I worked for quite a bit with my Bachelor's doing case management type work, but I realized I needed to further my education. While I was finished with my Bachelor's, I saw a plethora of therapists in the company that I worked for. It was a nonprofit behavioral health clinic and I saw everybody from LPCs to LSWs, LMFTs, every acronym in the book.

But my immediate supervisor was an LCSW and I found that she had the most, at the time for me, the most variety of opportunities. She could be a director of a program we might have had for behavioral health for children. Or, she could have actually done private practice type work, and I liked that because I could see a lot of settings.

That's when I decided to embark into Widener. I worked full time but got my Master's at night, and I really enjoyed finding that I wanted to keep pursuing from my Masters to license into the clinical license. That's how I got started in it. Always had an interest, always had an interest in people's minds and how it worked.

Theresa Nair:  That's great. It's wonderful when you feel like you're pursuing your purpose and even your calling.

Erin Maloney:  Yes, yes.

Theresa Nair:  For those who are not familiar with your organization, I'm wondering if you can tell us a little bit about the mission of the Innocent Lives Foundation and how it works to bring anonymous child predators to justice?

Erin Maloney:  Absolutely. I just want to say at this point, just a quick little trigger warning. My foundation does deal with trauma related to children and exploitation in any sort of assault. So just a little trigger if anybody is listening in to take care of yourself before or after. I don't think much will come up, but I always like to give that in advance.

Innocent Lives Foundation, what we do is our mission is to do that. We try to get the predators who are hiding online behind the scenes who are trying to exploit children or publish and/or share materials of, we call CSAM, Child Sexual Assault Material. That's our biggest mission is to bring to light the people hiding, to get them out of the dark and get them prosecuted properly.

Now, one of the things I always like to mention is we are non-vigilante. That is a very important part of our mission. We do not set ourselves up as young children. We do not try to entrap perpetrators. This is actually information we find on the open web. It's unbelievable what you would find on the open web, but we use what they call OSINT, which is open-source intelligence. It's basically anything any of us could find on the web, but they know where and how to look specifically for predators laying right within our children.

What we do at the ILF is we get leads and it could be come from, we have a form right on our website that people can enter. It could be a parent concerned about maybe who their children are chatting with. We might get law enforcement to say, "Hey, we could really use some good computer diving hacking skills to find out this case."

Or, it could actually come directly from somebody who might give it to us. Or, our researchers actually are doing the research and they can find a lead. Just be so maybe a username or somebody having an inappropriate photo up. We have, at ILF, different aspects that I wanted to go into because it sounds very confusing. What are you guys doing?

We have three distinct teams. We have what we call The PIT, which is Predator Identification Team, and they're our researchers and they are phenomenal hackers. We call them good guy hackers. They use their skills for good and they're all volunteers. But what they do is they are literally the ones behind the computer doing all the research for us finding this.

We have Education and Outreach Team, which those are our people who are more about putting out blogs, putting out educational materials, fundraising for us. They're really good for caregivers who might be struggling with anything like this.

Then lastly, we have a Development Team and what they do is they actually protect our PIT by developing tools that they can use to protect our PIT people from what they see. One of the big things we have is a blur tool so that our researchers are not seeing actual skin, they just see a blurred image and they can unblur it enough to maybe see a face if they need it, but it's to help them not be exposed to so much content in terms of that.

Those are our three distinct teams, and so what we do at ILF is we all work together in tandem to basically have that one common mission to help bring predators out of the light.

Theresa Nair:  That's great. I mean it's really interesting that you have the blur tool.

Erin Maloney:  Yes.

Theresa Nair:  Because I was wondering, how do you search for this without seeing all of it? So, that would be helpful.

Erin Maloney:  Yes, yes. We very much try to protect. Unfortunately, sometimes the text cases are some of the hardest because you're reading it and your mind goes there, but we still try to protect as much as can.

Theresa Nair:  Is that on the general internet or what's referred to as the dark web?

Erin Maloney:  Yes. Yeah. There is a whole dark web that we are aware of, but we actually try to leave that to law enforcement to do themselves because it is such a gray area. We keep everything above board. Like I said, we're trying to not be vigilantes, not get ourselves in trouble.

Everything people do, even our researchers do things on a device of ours so they're never caught with any sort of material or viewing. We would never want anybody be in trouble of any sort, so everything is done through a computer they have from us with tools and things like that to protect them.

Theresa Nair:  Okay, that's good. That helps to clarify how you even do something like this?

Erin Maloney:  Yes, yes, exactly.

Theresa Nair:  You spend a lot of your time working with volunteers within the organization, the people who are using their skills in order to help identify child predators. You're providing counseling services, I believe. Can you explain why it's important to provide this type of service to the volunteers, and what types of mental health impacts can result from this line of work?

Erin Maloney:  Absolutely. As this started, my CEO he realized quickly, he actually started Innocent Lives Foundation by accident. He is what they call a pen tester. His company does do security breaches for companies to help them learn how to improve the security of their companies.

In doing so, he accidentally stumbled upon child sexual assault material on somebody's device and was able to turn that into law enforcement. It was very validating and reassuring for him and he thought, "I did this so easily, why couldn't we do this as something like a nonprofit or a mission?" He started it from there, which really led to, but he knew the importance of the mental health piece. He said, "If we do this, we have to make sure we're not harming anybody in doing so."

That's how it's always been a proponent since day one. I'm part of every aspect from when they get onboarded. We have a very extensive onboarding. People go through various interviews, and one is a wellness assessment with me because again, we are trying not to damage anybody. If there's significant trauma that's maybe unprocessed or raw still, we're not going to want to have somebody in that capacity working right now with us.

By doing that now you had said, so there's the component of me meeting them early on and then I actually meet with them once a month if they are what we call The PIT, so at minimum they have to meet with me once a month. If you are in another aspect of our team like Education Outreach or Development, you only have to reach out with me once every three months because obviously they're not dealing with the content as much. Like I said, it's different timeframes for different people.

So, that's how I work with them. Now, if somebody has a already current mental health... Now remember, these people are coming voluntarily and not all of them have a psychological disorder. Not all of them have an Axis 1 diagnosis. However, some do and when they do, I make it very clear that I'm more of a wellness piece. If they need extensive work, if there's somebody that I sense needs almost weekly sessions or if they have an addiction they're struggling with or anything even more significant, then I definitely refer them out to a private therapist in their area and/or medication management or other resources.

Then I actually collaborate with any of the people they need me to collaborate with because it is such a unique setting situation. If a therapist needs a little bit of advice or what we do where we do, I'll consult with them as well. I'm involved with them quite a bit, at least once a month and I have a very good rapport with all the volunteers.

Theresa Nair:  Do you find that people may need more services the longer that they do this? Or maybe after particular incidents? Are there maybe something in particular that they find or is it steady?

Erin Maloney:  No, you know what it is? Actually, it's not the work that I notice, it's life changes that impact their volunteering with me. When I say that, we have new parents, for example. Let's say a volunteer has never been a parent, but suddenly they're a parent and they might be one of our researchers. They may not suddenly be able to stomach what they once stomached, and so they may very well say, "I cannot."

We actually have a pause program which is completely non punitive. It's something the volunteer can initiate, or myself if I really sense somebody's just not doing well, I'd encourage that. Really, up to 90 days they can just quietly stay with us. They can join meetings if they want, they can meet with me if they want, but they're not required to do any sort of minimal work for us to keep them active as a volunteer, which is nice.

Then the other option is we also have moving around. We had one PIT member who had a hard time, again with children, and almost sometimes people could actually put their child's face on a victim, which you'd never want to see happen. That is, we never want to damage anybody. So, that person actually still wanted to be with our mission so they stepped aside to Education Outreach and they write educational blogs, or they might speak publicly at a local community event for themselves.

It's really neat. You can still move around and help with that very same mission, but not damage yourself psychologically if you are struggling. I don't find the work... I feel like if people are already here in the mindset to do this type of work, then they've either been exposed to things or they're pretty prepared to compartmentalize their brain to step into this work and step out of this work.

Theresa Nair:  That's interesting because you would assume that maybe it was something that they saw. But it's interesting that it's more life changes that they might be going through.

Erin Maloney:  It truly is. Yep.

Theresa Nair:  And what they're able to view at different points in their life.

Erin Maloney:  We have a very strong level system, that when they start, they start at a very bare... it's more just finding leads. Maybe finding usernames that might be connected to something, and then there's levels. We're not going to have somebody brand new coming in exposed to something that might be very horrific.

I don't even, age is a big factor. Maybe younger children might be too difficult for them, so we're not going to do that. We're going to have them work up in levels and so that they're not really exposed to anything too much too fast because they could process with me the whole time they're doing it whether they're okay or not with that.

I'll check in on them with their case and how it's affecting them and generally fits good and they seem like they're confident with it, then they can move up in the level system, if you will.

Theresa Nair:  Sounds like there's a lot of options for volunteering.

Erin Maloney:  Yes, yes. We do not let it damage or harm anybody because they're helping us. They're volunteering for us, so we would never want to do anything that could hurt somebody.

Theresa Nair:  Okay. I know you've mentioned, and it says on the webpage as well, that you use cognitive behavioral therapy to assist your work with Innocent Lives Foundation.

Erin Maloney:  Yeah.

Theresa Nair:  Could you talk a little bit about how you use that, and then also if there's any other techniques that you find to be productive?

Erin Maloney:  Absolutely. Like I said before, my wellness sessions are typical check-ins. How are you doing, tell me what's going on in your life? But what I listen for and people know, all the volunteers know I use cognitive behavioral therapy because I'm listening for any sort of negative or illogical thoughts and they know that and they know when I can pinpoint that, what I might hear.

If I sense that somebody's really struggling with something, then we will start using cognitive behavioral techniques to see if we can figure out whether this is something more pressing, either a budding anxiety disorder. Or, if this is just something in their lives, maybe an adjustment to something that they're dealing with.

I do a lot of reframing. If I initially hear them say something negative, I might put it in a different reframe. If they're like, "Oh yeah, yeah, yeah" and they get that and I don't hear it again, then I realize they might have just been dealing with something. What I do a lot of with the volunteers is activity scheduling in terms of cognitive behavioral therapy. Because what we do is you would not be able to necessarily do this work in front of your family in the middle maybe of a work day. There's a lot of this content that cannot be exposed. We have to activity schedule, is it best to do this maybe an hour? But you don't want to do it right before bed either. Maybe there's an evening hour that this is best for. Or, perhaps you have a quiet hour in the day with nobody around you. We do that to find the best for a person to pick the time that they can do this type of work.

Role playing. If somebody's struggling with anything really in their lives, but in particular maybe wanting to switch gears in ILF, I might help role play with them. Maybe if they want to approach that with our COO and how they might be able to switch over into a different capacity.

So, I do a lot, now again, if I sense it's something more, then I will encourage them to seek out therapy on an ongoing basis so they can do real true weekly or even twice a week sessions if needed. But generally with some cognitive behavioral therapy, I could figure out if it's something more or not, and that's what I tend to do.

Theresa Nair:  Okay, and do you tend to see any increases in anxiety or depression from the volunteers when they work for maybe an extended period of time on this?

Erin Maloney:  Well, it's funny you said that. If I do sense that, then that's again where I will go into that pause option. "Hey, do you need to pause? Are things getting too much for you?" But it's funny you say that, I've actually seen it go both ways. Where I've seen it in the negative might be, again, if they have a, let's say they're starting a new job position and this is their volunteer position, they might have too much on their plate and so their anxiety's increasing and then they have guilt about not doing their volunteer work, then there's all that.

If I sense that, then we definitely encourage a pause and again, a pause could be 30 days. It doesn't have to be 90 days, but we just encourage that you take a little mental break, take a break from us and come back when you're refreshed and ready.

However, it goes on the other side where this work is very validating sometimes. Because a lot of our volunteers may either have been a survivor of assault in their past. They could have been groomed as a child themselves, or they have a family member who this maybe impacts. When they have a case that's a win, that is completely validating. It's a way to take power back from maybe where they've felt powerless in their past. It can actually be very, very good mentally as well.

The only struggle with that is the reality is we don't always get feedback from law enforcement of how our case is? We hand in a report to law enforcement, but it might not always be clear whether that case went to trial, whether that person was convicted.

We don't always get the information, and so I have to make sure the volunteer's okay with that, that we're not always going to know every win. Are you going to be able to stay motivated on cases you don't know the answer to? There's a lot of areas to poke around in there.

Theresa Nair:  That is interesting. There's that sense of empowerment, right?

Erin Maloney:  Yes, yes.

Theresa Nair:  When they're able to do something, but I'm sure it's a little frustrating when you just never know what happens?

Erin Maloney:  Yes. Exactly, exactly. But that's not our role. We don't want fame, we don't want to be associated with putting somebody away. We are really truly just totally behind the scenes trying to help. We have the computer skills to find a lot of people and we try to hand that over to law enforcement, and so we don't always get the answers.

Theresa Nair:  Do you think there's other areas of volunteer work, or perhaps other professions in general that would benefit from providing these types of mental health services to volunteers or to employees?

Erin Maloney:  Yes. It's funny you say that. We have some volunteers who are either currently or ex-military, or current or ex law enforcement. They have said many times that if they had somebody at their office to talk to, it could have made a major difference for them with some of the things that they endured or witnessed.

I know there's a lot of EAP programs for companies, but I think there is something at me being here every day for them that makes a very big difference. They just know. I get to know them very well. It's a stable, long-lasting relationship, and so they don't have to re-explain themselves to somebody new. I'm part of the team itself and employed there, so it makes a big difference I think in that consistency that they know I'm here and they could come to me at any time.

Theresa Nair:  It seems it might also be beneficial that you have a regular scheduled monthly meeting at least with everybody.

Erin Maloney:  Yes.

Theresa Nair:  Because I think sometimes in workplace mental health services, people are afraid to use them because they're afraid of being stigmatized even if somebody sees them going to talk to the person, or if the boss finds out that they're talking to the person. Do you think it's helpful just going ahead and scheduling appointments with everybody?

Erin Maloney:  Yeah, I really do. It's so funny you say that. Yeah, because I could definitely tell there's a resistance. Our team, for the most part, it is a lot of people who happen to be in cyber security type industry. When you're in that industry, you actually tend to be, not to stereotype an entire group, but sometimes you tend to be introverted and private.

Therefore, I do think this forces people a little bit out of their comfort zone and then they do realize, "Oh, this isn't so bad." Because I'm not deep diving way into their past, Freudian style. It is non-confrontational. I go at their pace and whatever they choose to talk about. Obviously, we talk about case work, but anything else they might need to address.

It gives them a huge shift if they already had a fear or resistance to therapy where it's not so bad for them after a while, once they get to know me better. Yeah, I agree. I think it's very good that it's almost forced upon them and I send out reminders and I reach out.

If they avoid me after a certain amount of time, then we have to do the whole, "Are you trying to pause? Is there something you need?" So, it's nice, but that's rare that I don't hear from somebody

Theresa Nair:  Then it's, "Well, I'm talking to her anyway. I may as well have a real conversation, right?"

Erin Maloney:  Exactly. The other thing to this is that again you mentioned, you asked about different fields. Well, law enforcement or some other heavy content type professions, they can't turn to their family or their loved ones and just spill what happened in their day, similar to this type of work. They're not going to turn and say, "Guess what this case is about?" You can't. You want to protect your own loved ones and family and friends.

A lot of our volunteers are anonymous, so this gives them a direct place to process what they need to process without feeling they're burdening anybody. Without feeling like they're going to hurt or harm anybody. It's just a safe space for them dedicated to them, and I feel like it gives them that open door.

Theresa Nair:  Then they can talk about that case work that they maybe couldn't discuss with other people.

Erin Maloney:  Exactly, exactly.

Theresa Nair:  I think that's a great model. I wish more places would do that.

Erin Maloney:  I do too. I do too. It's very nice, and I do feel like with law enforcement in particular, I think of that field and just the things that come home from, or anybody on the front lines really. After a really rough day of what you might witness or see or hear, and then you have to go home with that.

That's where I feel for people when they don't have any place to just unload that on, and making the time. That's the other thing you had mentioned. We all have a hard time making the time, and at least with this, it's mandatory so it's part of your volunteer. We ask people to volunteer if they're volunteering with us for about 10 hours a month if possible, but that includes a lot.

We have a team meeting, which is once a month. We have myself, would be an hour so that's already detracting right off their volunteer hours for us, so it helps that it's just built right in for them.

Theresa Nair:  Right, and then they don't have to take the initiative to seek out speaking to somebody. It's just a part of it.

Erin Maloney:  Exactly, exactly.

Theresa Nair:  Well, as someone who specializes in cognitive behavior techniques to support the mental health of those engaged in volunteer work, do you have any parting words of advice or anything else you'd like to share with our listeners?

Erin Maloney:  Sure. I mention this to volunteers all the time, and I would like for your listeners to know. I think balancing life is the key. You really have to balance your life, and volunteering is actually a very worthy and beneficial cause to you. This really helps fuel your soul. But if the plate's full and you just need to get rid of something, then that's generally, unfortunately some self-care things or things we do for ourselves might be some of the first things to go.

So, I just always say, "Stay balanced." But if you are realizing you can't manage everything, you can't problem solve, you're losing your focus, you don't want to burn out. Really, I always say we cannot, you do not want to burn out. Before you start, that's where, going back to the cognitive behavioral I therapy, I listen for the negative.

If I start hearing negative comments and negative thoughts that are just kind of untrue, I really try to help reframe. But if it's not possible, then we have to look at what they might have to cut out of their lives? What they might have to do to manage things? Balancing life, self-care is very important, but you need to know when you need to step back and maybe make some changes.

Theresa Nair:  That's great advice. Well, thank you so much for making the time to speak with us and participating in our interview series.

Erin Maloney:  Thank you. Thank you for having me. I just want to make sure I tell you guys that you can always go to our website, innocentlivesfoundation.com. There are great resources and tools on there. If anybody ever had to make a report of anything they were concerned with, again, it could be a parent, a caregiver, a teacher.

If somebody's concerned about maybe what a child's posting or who a child's speaking with or they're unsure of things that are online, you can always submit a report right there and we'll reach out and see what we can help investigate for you. Please use us as a resource as needed. Again, we have great blogs and articles on there and things that you might find very helpful.

Theresa Nair:  That's great, and we will also link to that website underneath our interview so that people can find it easily.

Erin Maloney:  Wonderful. That sounds great.

Theresa Nair:  Okay. Thank you so much for joining us today.

Erin Maloney:  Of course. Thanks for having me.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Therapist Kate Willman on ACT & Writing Therapy

An Interview with Therapist Kate Willman

Kate Willman, LMHCA, MA, HCA is a Psychotherapist at Seattle Anxiety Specialists. She specializes in the use of ACT and the utilization of writing therapy in her practice.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Kate Willman. Kate is an associate therapist here at Seattle Anxiety Specialists. She is also a founder of Ben's Friends, a community support group for restaurant employees seeking recovery from alcohol and drug addiction. Kate has worked on numerous research projects regarding psycholinguistics and providing therapy for those suffering from addiction, traumatic brain injury, emotional experiences related to death, and military populations. Before we get started, Kate, can you please tell our listeners a little about yourself?

Kate Willman:  Sure. Thank you so much for having me. And about myself, you said it, in terms of therapy. I am a native of Texas. I spent many years also in New York City and then moved to Seattle almost five years ago. And working in mental health is my second career, definitely my most happy and fulfilling career, but I spent a lot of years doing hospitality and it's also very fulfilling. I actually still do some work with my partner in restaurants. And there's a lot of crossover, actually. And I think that's an important part of, I guess, why I'm here and who I am, in that I've always been interested in people's stories and always been interested in serving people.

Of course in hospitality, it's a very literal serving and in therapy it's a little bit different, but that's definitely a core part of me is like this continuing interaction with others, usually in some form of service to others. And not in a completely altruistic way either. Right? I get a lot out of that. I get a lot out of being in those really intimate situations with people and learning what they need and hopefully being able to help them get that. I also have two cats and two dogs, so I'm a very happy animal mama. I love animals. I have always loved animals. That's a big part of who I am too. And then, I live in Seattle with my partner and taking it one day at a time.

Amelia Worley:  What is it that got you interested in becoming a therapist?

Kate Willman:  Yeah. Like I said, I was always involved in one way or another, serving others. And the thing that got me very first interested in it was being a volunteer, they call it peer-to-peer counseling, and this was on the East Coast when I was living there several years ago. I guess, another giant part of me and this goes into Ben's Friends, is that I identify as a person in long-term recovery from drugs and alcohol. And I spent the better part of a decade, really not in the service of others, definitely in the service of myself. And that set of addictions really took over my life. And at 25, I found myself really, actually very close to death, and there's a lot of other stuff to that story.

And after that, I got sober January 30th of 2013. Part of my recovery and part of my success in recovery was speaking with other addicts and working with other addicts at various points in their recovery. So, this peer-to-peer counseling thing was happening in detoxes and hospitals, rehab centers out in New York, New Jersey. And I had done it at this one hospital, pretty regularly, weekly, basically, for a couple of years. I knew the nurses and the social workers and stuff who worked there and they were like, "You know Kate, this is a job. You are a volunteer, but you could really do this. It's a real thing."

And at that time, my career in hospitality was actually at its peak. I was working in really great, four-star, New York City restaurants. I had become a maitre d', which was my goal. And so, I was at an interesting crossroads too, of like, "Oh, shit, can I make a new career?" I had never even considered that. Getting sober and just living had been the really cool thing that had happened. And so, I sat with that for a while and decided to try my hand at school. I had gone to school when I was 18 and studied hospitality management.

So, I was 27 and just, "Oh, can I even do college? I don't know." And I decided to try community college. I took some psychology classes and I just fell in love, and it was such a great turning point for me to go back to school. I went to community college, then I went to a four year, got that degree in psychology. And at the beginning I was like, lots of addicts do this, "I'll just be a substance use counselor. I'll just go to school and get this certificate for substance use counseling." And no, the more psych classes I took, the more counseling professionals to whom I was exposed, the more I wanted to do more and more and more, and the more my interests really grew in this realm. So, I ended up moving to Seattle in 2017 and had tried on a couple different programs, local and national, and ended up doing Northwestern's online master's degree. I was really impressed with that program and that it was available online.

I am an advocate of telehealth. And even before COVID, I was very much an advocate of that because of the accessibility it allows for people. So, in terms of me becoming a counselor, taking those courses online and being able to say, "Hey, online is where we should be putting energy for counseling and for counseling education." That was really important to me too. The program was three years, as of course, you and everyone else knows, then COVID happens and everything happened online anyway.

So, now I find myself really, really full circle, able to be a counselor, be an advocate for folks in that substance use realm, the same way that I was nine-and-a-half years ago needing that counseling, needing that guidance. And a lot of other different folks that I get to see and really use my experience, not just as a counselor and someone who's educated in this way, but as a person who was really in many, many low places over the years, and who's experienced a lot of life transitions along the way. And in counseling, this is when a lot of people will come in, is for these life changes. And when things become different is when we find ourselves needing help. That was a lot of roundabout answer, but that's how I got here.

Amelia Worley:  What areas or disorders do you specialize in? I know you talked a little bit about the substance use.

Kate Willman:  Yeah, I definitely feel super at home with folks who are struggling in substance use, substance abuse, and then even to generalize it even more and zoom out even more, a lot of the discussions today are just about relationships to substances, alcohol, even lots of behavioral addictions, right? Shopping, gambling, sex, pornography, internet use. There are a lot of behavioral addictions that we consider as well. And again, having been absolutely enslaved by my addictions for many years, I feel really at home helping folks in those arenas.

I also developed a very clear interest and, hopefully one day specialty, in grief counseling. And I found that a lot of my experiences personally and then with these addicts and self-described alcoholics that I was working with over the years, a lot of people were dealing with various versions of grief. And some of them, it was like, "Oh yeah, I had this near-death experience." Or like me, I was so addicted, I almost died. Or, I have a couple suicide attempts, right? There's a lot of people who have considered suicide and who have really thought about suicide. And how does that affect a life? And we can use a lot of grief counseling in that area.

And then I mentioned, life transitions. A lot of grief being applicable in divorces or just changes, breakups, changing a job, losing a job. COVID was just a gigantic paradigm of lots of different layers and kinds of grief for people. So, I really find myself diving into more and more of the grief world, and all of the different applications of that. Certainly, within death, dying, bereavement. I volunteered in hospice for a while here in Seattle, too, for about a year, and really wanted to be in that world of death and how that affects us, the living.

And anyway, I could go on about that forever. I really like grief counseling and lots of different applications. And then, my time at SAS has really directly introduced me to the populations of folks who are aligning with symptoms of OCD, of ADHD, of these really specified types of anxiety, trichotillomania, excoriation, which is hair pulling and skin picking and stuff. And so, really, really niche, specified presentations of anxiety. These are things I was exposed to certainly in school and in my internships and some in my volunteer work for sure, but I've really gotten some great training and some great experience head on with these specific presentations as I've worked at SAS.

So, that's been a fun world to live into and to get exposure to doing exposure therapy and to just learning more about these struggles that folks go through in those areas and getting to see therapy, really nitty gritty therapy, and what real behavioral change can look like with a person. It's very, very exciting.

Amelia Worley:  Can you talk a little bit about your treatment approach?

Kate Willman:  Yeah. The easy, very general answer is that I'm eclectic. I think every grad student wants to believe that they're eclectic. And eclectic just meaning like, "Well, I'll do whatever the client needs, and I want to learn everything." And as we get more and more into the actual profession, it's quite impossible to be specialized in all of these approaches and get really good at them. It feels good to be good at something. Right?

So, I think there's a few that I come back to over and over again. Number one is ACT, acceptance and commitment therapy. This is such a beautiful iteration of cognitive behavioral therapy. It's so flexible, its main goal is flexibility, not for nothing, but it's so flexible in terms of its application, what presentations we find it helpful for people when we engage in ACT. And so, I really like that. It's nonlinear. It's not really focused on symptom reduction, right? It's focused on a meaningful life. The word acceptance is in the name. And so, I find it really, really helpful for, again, a lot of different presentations, but even as therapy goes on for people and maybe their symptoms have reduced a little bit, to go a little bit further in finding how to live a meaningful life, despite what's going on with anything that's happening, any life change, any type of grief or whatever, any sort of internal experience. There is always, always, always this universal need for a meaningful life, and getting to explore that with people via the ACT method has been really, really cool.

And then, I pull from certainly an evolutionary approach. I really found it helpful in my own journey to look at comparative animal behavior, to look at the lives and the struggles of early humans, as we understand it at least. And see how these different parts of our brain, having evolved the way that they have, why do we have something like a fight or flight mechanism? Right? And why are there these ancient, ancient mechanisms in our brain that we just rely on so primally. And when we can identify those, even in our 21st century modern life, with this big old frontal lobe, being logical all the time, there's so much acceptance that can happen for people when they realize, hey, this anxiety that you're feeling over X, Y, Z, is not just because you're a bad person. It's not just because you are defective in some way. Actually, early humans or the animal brain really relies on this function to keep us safe. Anxiety in most of its forms is really there to keep us safe. And so, we find that with this evolutionary lens, there can be quite a bit of just normalizing, I guess, and a deeper understanding of self, that all of these things, they're causing us trouble, but they're really there to help us. And that shift in relationship to our anxiety, it can be so, so powerful. So, I love that one as well.

I definitely do some existential stuff, which is on the other end of the spectrum from any kind of CBT. But when we talk about meaning making and what is my purpose in life? There can be some fun, especially in the realm of grief, there can be some fun discoveries of self when we are looking through this existential lens for ourselves. And then in terms of techniques, CBT has a whole host of really cool techniques from ACT, from DBT, that I will employ as needed. And then I also really enjoy narrative therapy. There's a lot more even coming out now, narrative therapy-wise. Here's that frontal lobe again, we were talking about the other parts of the brain before, but we have a lot of research that's showing the power of narrative therapy in engaging and re-engaging that frontal lobe part, the decision-making part.

And when we are able to look at our lives and our struggles and our relationships, or our questions in that narrative form, we're employing and re-employing all of these tools that are already there for us. And it's really a discovery of self. I think that I say that a lot actually, but I guess to wrap up treatment approach, I'm very much an advocate of helping people see they already have everything they need to be successful, everything they need to even define what success is. Some people have never been given that chance. What is success? What does a meaningful life look like to me? And then how do I get it? It's not going to be, because I give it to them, it's not going to be because they picked the right self-help book or YouTube channel to watch. All of those things might be useful in self-discovery, but it's really a matter good counseling, in my opinion. The best approach in my opinion, is being willing to try on all these different things with a client, with a person, and watch them and assist them in discovering for themselves, what is most meaningful and what is best for them and their life experiences. And for that meaning, defining that meaning and then approaching that meaning for them. That is the best approach all of the time, no matter what.

Amelia Worley:  That's great. Would you mind sharing your experience in using writing as a treatment approach? What are the benefits of writing therapy?

Kate Willman:  Yeah. Yeah. So, you can tell how much I love it, because I was already talking about it. And again, humans, we know a lot or we think we know a lot, we know it as best as we understand it, other animals, while definitely really advanced in a lot of their communication, as far as we know other animals do not have this writing thing. Right? So, we can guess from that, that it is a purely human function, purely human mechanism that we are able to write.

And so, when we look at that spectrum of evolution, of mammalian evolutions specifically, we are again, hypothesizing that this ability to write and the benefits to write, from the evolutionary perspective, the theory is we don't do anything that isn't of benefit to us in some way. Right? So, there are these surface level benefits of writing, right? Okay. Well, now I'm living in a society with other humans and the writing will enable us to communicate in a different way, in the here and now. We also know that writing of course, allows us to communicate with generations past and future.

So, it's really, really cool that writing as a mechanism, really came out of evolution in that way. So, those might be the external benefits of the writing for us as a species, as organisms, but internally there's got to be usually a benefit too. And so now, over the last 20, 30 years especially, our brain scans have gotten so much more advanced. And when they've looked at these brain scans and they've learned more about that internal function of writing and looked at the frontal lobe, what they realized was in its most simplest form, and I hope I'm not minimizing in any way or being a reductionist in any way, but it's really just very simply, I have to think about something, right? If I want to write about my experience in COVID, let's say, if I write about that, I have to think about it, to come up with the words and the language, then I have to involve all these other mechanisms with my body and my brain to write it down.

And then, the third time is if I'm going to reread it. And we know that reading involves some other areas of the brain, but the point is there's at least three times, usually much more, but at least three times when I'm involving my brain to go and review this thing that I wrote. And it's just like hearing a story from somewhere else, that I might learn if I'm hearing that story three different times or 10 different times. And then I hear someone else tell that same story, 10 different times, of course, logic says I'm going to get some different things from those stories.

So, in the case of writing and in narrative therapy, what we try to do is employ those different inherent lenses and perspectives, but all within here and in that person's writing just for themselves. So, the therapist's role is to provide provoking questions sometimes, right? That if I just go and write my story in COVID, okay, I'm liable to learn a bunch of different things because of, like I said, the brain is automatically reviewing it. And that means that even the next day, I might be subconsciously thinking about it, even if I'm not actually reading it or rereading it. Right? So, that's happening.

And then, if the therapist is like, "Okay, Kate, you wrote your story of COVID, here's some provoking questions." That's going to cause me to, “ooh, now I have to use my critical thinking, which is also up there. And my problem solving mechanisms are all activated in that frontal lobe.” And so, you see the infinite nature of narrative therapy in engaging and activating all of these different parts of our brain to allow us to see things from a different perspective and thereby, gain things from those different perspectives that we couldn't do if we were just sitting here trying to think about, "Well, what was my COVID experience like?" We get that really cliche, "I'm stuck in my head about it. I'm stuck in my head about it."

There's definitely a magic to putting it on paper or putting it on a computer, just as there's a magic to putting it in the universe, telling it to somebody else like your therapist or your friend, but we are taking that to the next level, writing it, rereading it, having these provoking questions that we didn't really come up with on our own. Well, shit, that gives me a lot of more perspectives, a lot of more answers that might come, that I'm just unable to retrieve from my brain alone.

The last piece, and this is my ACT brain coming in, ACT cheerleader maybe, not my ACT brain. ACT has this component of cognitive diffusion, right? That it behooves most of us and we have evolved to be fused to our thoughts and our feelings. So, when we defuse, that's that act of, we are not our thoughts, we are the thinkers, right? And we know when thoughts are so troublesome and we're dealing with OCD or anxiety or grief or whatever, by getting away from them for a moment, we are able to look at them a little bit differently and guide a little bit more, how much we want to connect to those thoughts, if we want to believe them or not.

And narrative therapy, in most of its forms, will also inherently engage in that cognitive diffusion, that I'm putting it out from me, again, in that same way when I tell someone, but it's on steroids, right? This ability to defuse and defuse and defuse. And we know that we just have much more autonomy and agency over those troublesome thoughts, while accepting them as there, and then deciding where we want to go forward. Yeah. That's narrative therapy.

Amelia Worley:  Do you have any words of advice or anything you want to say to our listeners?

Kate Willman:  Willingness is the key. We talk a lot and thankfully there's a lot of stuff out on the internet now, that's so accessible for people, maybe on social media, on TikTok or Instagram, people are getting help in ways that they have never been able to before. And so, I would want to say that I used to go to an AA meeting in New York City and it had on the wall, "There's no wrong way to get sober." And that used to piss people off. That used to make people really mad, like, "Oh, of course there's a right way to get sober." And I apply that now to therapy. There's no wrong way to try to feel better.

And that's a hot take, it's an unpopular opinion, right? Are there bad therapies out there? Yes. Are there bad therapists out there? Unfortunately, there are. There are people who might be more harmful than helpful, but I think the hardest step for most people is being willing to ask for help. And for some person that might be, I'm just willing to follow some accounts on Instagram and try to get some engagement from these people. And maybe I need help, being willing to say to ourselves, "I need help. I can't do this alone anymore."

And so, what I would say to people is, any level of willingness, wherever you are at in your mental health journey, in your becoming a counselor journey, on whatever journey you identify with, the willingness to keep going, the willingness to show up, the willingness to ask for help, the willingness to say, "I need a break today. I can't go any further right now. I'm not sure what to do." The willingness to say, "I don't know." Oh my gosh, what courage that takes.

So, willingness is the key to, so, so, so much in terms of success, in terms of meaning, in terms of contentedness and serenity. So, if you're feeling stuck and you can identify that, the next question might be, "What am I willing to do? How far am I willing to go?" And then, "Who or what am I willing to ask help from?" And just to love yourself, that's really one of the hardest parts too, huh? So, if you can find place for some love in your heart for yourself, I always recommend that too. No matter what.

Amelia Worley:  That's great. Well, thank you so much. It was really great interviewing you today.

Kate Willman:  Yeah. Thank you, Amelia.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Therapist and SAS ED Blake Thompson on Psychotherapy

An Interview with Therapist Blake Thompson

Blake Thompson, LMHC, MA is a Psychotherapist and Executive Director of Seattle Anxiety Specialists. He is a clinical supervisor and also provides both individual and group psychotherapy.

Nicole Izquierdo:  Hi, everyone. Thanks, Blake, for joining us today for this installment of the Seattle Psychiatrist Interview Series. This is a special one, it's called Meet the Team. I'm Nicole Izquierdo, I'm a research intern at Seattle Anxiety Specialists.

So Blake here, he is the practice's executive director. He serves as a clinical supervisor and he also provides individual and group psychotherapy. The first question for today is telling our listeners a little bit about yourself.

Blake Thompson:  Hey, thanks, Nicole. Yeah, that was a good introduction. Oh man, what to say about me? Well, I am married and I have a one-year-old daughter that keeps me up at night, but whom I love very much. I love reading. I find people really complicated and fascinating. A big part of what draws me to therapy still and to the field is that the more I learn, I feel like the more questions I still have. I feel like I haven't gotten bored yet. I still feel confused, so staying curious.

Nicole Izquierdo:  That's good. Let's start off with, what is it that got you interested in becoming a therapist?

Blake Thompson:  That's a good question. Well, one of my big inspirations for becoming a therapist was a comedy movie. I don't know if you've seen “I Heart Huckabees”. No? Yeah, older Dustin Hoffman, Lily Tomlin, Jude Law film. Great movie, very funny, but yeah, I think that put the idea in my head. I had been to therapy when I was younger and I think that experience really shaped me. Being a client, I think, was really impactful. But yeah I'd been really interested in philosophy in school and I don't think I ever really considered, you know, psychology. I think I took one psychology class in all of college. I was really not interested in psychology. The idea that I would do something professionally that was related to a subject that I just wasn't really interested in wasn't super appealing to me at the time, but as I went to graduate school in philosophy, more and more of the stuff that I was interested in philosophy started to bleed over into psychology and I got more and more interested.

In philosophy, a lot of what we're doing is conceptual analysis. We're thinking about not minds and brains, but the stuff that are the constituents of thoughts. We're really focused on ideas like justice and the good life and truth and causation and all of these ideas that are really central to the thoughts that we think on a day-to-day basis. I just got more and more interested in the machinery that realizes that and more and more aware of thinking processes as processes, and not just as like, you know, and less and less focused on abstract.

By the end of grad school, I think I was starting to think about a jump into psychology, away from philosophy. I was talking with people about just what there was in that professional space, and the idea of becoming a therapist hadn't yet coalesced, but I think talking with folks about what therapy was like as a profession, what was interesting in it, how it was different than other forms of healthcare, yeah that was definitely, those conversations really helped shape that direction.

While I was in grad school, I really didn't like teaching very much. That was not something that I found super rewarding, but I loved tutoring, doing one-on-one work with students. I think really reflecting on that process and how much more I liked tutoring than I liked teaching helped also solidify for me that I would like doing therapy, because it looks a lot like tutoring in a lot of ways.

Nicole Izquierdo:  With that extensive background in philosophy, how would you say it has impacted your therapy style and the way that you go about counseling?

Blake Thompson:  Yeah, cool. That's a good question. I think so much of what we do as therapists is we reframe things for clients. Clients come in with, something's happened, there's an event, a situation, or even just themselves presenting in a certain way, the various processes that make up our lives, and they've got a particular perspective on it. That perspective is part of what explains the way they feel, the way they're acting. We help clients to see different ways of looking at their lives, of looking at the situations that they're navigating. That helps them develop the psychological flexibility, helps them develop this ability to look at things from different perspectives and to free up the way they feel and free up the way they act to become less rigid, less stuck.

A lot of what philosophy is, is conceptualizing and re-conceptualizing things. It isn’t so much, it's not an empirical discipline, it's a discipline where we're thinking about, okay, well, what's a different way of looking at this, what's the right way of looking at something? It might not be contesting facts, it might be, it's often a question of what's the right frame to put on something.

So yeah, in terms of what philosophy looks like, there are a lot of similarities. It's less often a matter of what are the right facts and more often a matter of what's the right way to conceptualize a particular thing. So too for therapy, it's often not a matter of what are the right facts, like this person is just dead wrong about something, it's more a matter of like are they applying the right conceptual scheme to it?

Nicole Izquierdo:  Thank you. Are there any areas or disorders or age groups that you specialize in?

Blake Thompson:  I pretty much only work with adults, rarely see adolescents and I don't work at all with children. I don't work with couples. Yeah, I pretty much just work with adults. I work with a pretty broad range of people, but I really enjoy working with folks who've got cluster C personality disorders, like avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder (OCPD).

I really enjoy working with folks who've got high functioning or low support needs, autism adults that are like, especially folks who struggle with deficit in theory of mind, which is really pretty common for folks who've got high functioning autism. They might not necessarily lack social skills, which I think is often how that gets conceptualized, oftentimes they lack awareness of how social interactions work and how other people think. One thing that I find really rewarding about working with those folks is that a big part of the work is explaining how other minds work to them and working with them to help them see that. That project is, for me, really rewarding. It becomes a really interesting, like theoretical discussion about how to make sense of other people and how to understand interactions with them and how to navigate those interactions. Yeah, it ends up looking a lot like philosophy tutoring.

Nicole Izquierdo:  I know you've touched on this a little bit, but would you mind describing how your treatment approach is, to make it simplified for the viewers? Is it solution-focused, do you help them manage stress with CBT techniques, or do you have other ways to go about it?

Blake Thompson:  Yeah. I'm somebody who thinks that the different approaches to therapy are all valuable, for the most part. Maybe not all of them are valuable, there's certain things, like primal scream therapy, that maybe deserve to end up in the dust bin. But among the well-regarded extent approaches to therapy, those pretty much all have a place in my mind. First, second, third wave CBT I think is great, and that stuff is especially great for what used to be called axis one conditions: major depressive disorder, generalized anxiety disorder, social phobia, OCD.

I use exposure therapy, I use ACT, rely on DBT principles. You know, sort of like broad, everything that fits within that broad CBT umbrella I think is super valuable, all of these insights from behavioral psychology and cognitive psychology. That stuff, in some ways it can be really solution-focused, it can be really focused on symptoms, but yeah, at the end of the day, it's evidence-based and often it doesn't take a million years to see some positive impact in someone's life.

There are other people who come into therapy who have more characterological, what used to be called axis two, issues, like maybe they're struggling with narcissism or entitlement, maybe it's like they find it impossible to stand up for themselves, they're constantly subjugating their needs, maybe they're perfectionists or workaholics struggling with unrelenting standards, chronic sense of defectiveness that they can't shake, behaving in ways that kind of perplex them, like they find certain behaviors necessary or are driven to do certain things that in retrospect they can't really make sense of but in the moment feel like they have to do them.

A lot of that stuff is the stuff that when it's more intense, we would call it a personality disorder, but most people struggle with some of this stuff to some extent. We used to frame this stuff as just neuroticism. Neuroticism has taken on a technical meaning in personality psychology, but it's the kind of stuff that would make you a really great sitcom character. Depression doesn't really make you an interesting sitcom character, but an inability to stand up for yourself makes you a great sitcom character. Narcissism, entitlement, particularness, perfectionism, workaholism, all of these things make someone an interesting character. Yeah, I find working with these folks really endearing.

I think psychodynamic therapy is a really, really helpful approach for this kind of stuff. I think even the CBT world has really acknowledged this, that the best way to help folks deal with this stuff really is a more autobiographical approach to therapy, it's an approach to therapy that is focused on looking back and reprocessing the unmet emotional needs that were the foundation for these behaviors, that were the foundation for these, what at the time were adaptations, but are no longer adaptive.

There are still other reasons that people come to therapy. Sometimes it's not that somebody has a mental health disorder, it might be that they just have a lot of environmental stressors. There isn't something wrong with them, there's something wrong with their environment. If you're the director of an environmental nonprofit and the head of the EPA is cutting all of the funding to protect the wetlands or something, you're scrambling to figure out what to do, you're sweating bullets, something that you really care about is under threat, you might lose your job, whatever, therapy could be helpful for you, but probably it might not look like CBT and it might not look like psychodynamic therapy.

It might look more like supportive counseling, it might look more like Rogerian supportive counseling, where maybe the thing you need is not to explore your relationship with your parents, maybe the thing you need is not to identify cognitive distortions. Maybe you don't have any cognitive distortions, maybe the reason that you're so stressed out is that you're seeing things accurately, but you need to process that stress. You need some place, someone to be a sounding board and to help you think through what you could do that would be an adaptive coping response. That, I think, is a big part of the work too.

A lot of people come to therapy not because they've got generalized anxiety disorder, but maybe because they just found out that their spouse is cheating on them or their kid just died or they lost their job or they just graduated from college and they don't know what they want to do with their life. There are these reasons that people come to therapy that don't have anything to do with having a disorder. All of that stuff might be causing stress, but it's not anxiety in a clinical sense. CBT and psychodynamic therapy might not really be well-suited to addressing those issues. I think that, what's often called the third wave in psychology, like Rogerian therapy, I think is really, really well suited to working with folks who are navigating normal life stressors and do want support with that stuff.

Yeah, and again, I think they're even more like what's the right theoretical orientation. It depends on the person, there's going to be for couples, Gottman approaches, EFT approaches. I think existential therapy is really helpful for folks who struggling with questions about meaning and purpose and identity. Those are things that CBT might not be able to tap into very well, psychodynamic therapy might not be able to tap into very well, Rogerian therapy might not be able to tap into very well, but having a working understanding of some sort might provide you with a leg up as a therapist to help you tackle these questions.

Nicole Izquierdo:  Yeah, I like that. There's not a one-size-fits-all approach, every client is unique with unique needs and unique environments and pasts. I like that, thank you.

How would you describe therapy to someone who's not familiar with it at all, or who's hesitant to start treatment, especially with the stigma on mental health treatment? Like you just said, I feel like there's a big misconception that people go to therapy because they have a mental health diagnosis disorder, but some people just go, like you said, when there's overwhelming environmental stressors and they need help with coping mechanisms. How would you describe it or reframe it to encourage those people that are hesitant?

Blake Thompson:  Yeah. I think people are hesitant for different reasons, and I think getting clear on our own hesitancy can be really helpful. We're often afraid of things that we don't know and afraid of things that have been stigmatized. A lot of men don't go to therapy because they find it hard to get help from other people. I mean, there's the cliché about men not asking for directions, not asking for help at the store. I think there's an extension of that for a lot of men around therapy, that they shouldn't open up, they shouldn't be vulnerable, they shouldn't share things. A lot of that is culturally normed. If that's what someone's struggling with, I think recognizing that is really the first step.

But there are other reasons why people don't come to therapy. In terms of OCD, for example, sometimes people have horrible intrusive thoughts, thoughts of like murdering people, for example, thoughts of deviant sexual acts. They might worry that if someone, if their therapist were to hear this from them, they might think that they intend to kill someone or kill themselves or what have you, and so they don't go. Suicidal people might not go to therapy because they're worried about getting committed to inpatient, or people struggling with substance abuse might not want to go because they're ambivalent and don't really want to stop drinking or using whatever product they're using.

Often when people are struggling with the question of whether or not to go to therapy, there's some ambivalence within them. There's some part of them that wants to go and some part of them that is repelled by the idea. I think that it might be the right decision. I mean, I'm really open to the idea that therapy is not for everyone. Therapy is not this perfect cure-all that is going to save us from ourselves. It is really helpful. I became a therapist and I'm still a therapist because I really do believe that it is really, really helpful, and for some people really profoundly helpful.

But I think really what we can do, what we ought to do, is identify that ambivalence, try to articulate it. What is that, what is this tension? What's this part of me that, A, wants to go, why is that, and what's the part of me that's telling me not to go? What is that? Where is that coming from? There's a little microphone in my brain and who's at the microphone? Who's like issuing the instructions? This fear, is that being put into me by my culture, is that put into me by like my parents, is that my bully from my youth speaking to me? Trying to get some clarity on where did I get this idea from that I need to be afraid of this thing, why am I hesitant about this, just spending some time investigating that for ourselves, sitting with that ambivalence, trying to unpack it. I think that's really productive.

Nicole Izquierdo:  Thank you. You're also executive director at the practice. Can you tell me a little bit more about what this role entails?

Blake Thompson:  Yeah. As a mental healthcare practice, we've got a number of administrative functions that are just important on a yearly basis. We have to renew our malpractice insurance every year, we've got to renew our lease with our landlord, we've got to make sure that we've got working internet, we've got to make sure we've got tea and coffee for our clients, we've got to make sure that staff are getting paid on time. Basically, it's all of this kind of behind-the-scenes stuff.

Our office manager, Jonathan, he focuses on really the day-to-day administrative functions of the practice. He's answering the phone, he's sending faxes, he's scheduling people, he's dealing with billing issues and all that kind of stuff. I deal with the longer-term administrative stuff, so I'm talking to our lawyers, I'm talking to our insurance companies, I'm talking to our landlord, I'm making sure all our contracts are in order, making sure paperwork for our clients gets updated as it needs to be. It's not like the most glamorous stuff, but it's important. It's all stuff that allows our therapists to just focus on being therapists and not have to worry about all of those questions and concerns that come up when you're in solo practice. Part of the benefit of being in a group practice is that, for most of the clinicians, not me, but most of them, they get to just focus on being a therapist, which is really nice for them.

Nicole Izquierdo:  This question is steering into the more personal direction, but how has becoming a parent impacted the way you view the world or the way you interact with your clients? Because it's this whole new identity, parenthood, that you're grappling with. If you don't mind.

Blake Thompson:  No, no, that's great. It's definitely opened my eyes to what parenthood is like. Obviously, not what parenthood is like for everyone, I have my own experience of parenthood. But I think being a parent is a lot more difficult and a lot more rewarding, both, than I sort of imagined it would be. I think it really does change the way that I look at, the way I think about my clients who are parents. It's helped me understand their perspective a lot better. It's also helped inform the way I interact with clients who are struggling with the question of whether to have kids. It's given me a lot of perspective there. I think in both of those areas, it's really had a positive impact on my work.

I think the area where it's had a negative impact is I get a lot less sleep sometimes now and that has unintended consequences. I think even during this interview, I'm probably rambling more than I would normally, but I'm running on like four hours of sleep. It is what it is.

Nicole Izquierdo:  Thank you. Thank you for sharing that. Again, another personal one, but where do you see yourself in five years?

Blake Thompson:  Oh, cool. Well, I'm really excited to continue to kind of grow SAS. I mean, I think that the one thing that we haven't done much of up to this point but that I'd like to see us do a lot more of is develop continuing education. I think that's an area that I'd like to have us devote more resources to, I think both in terms of providing good local, evidence-based therapy education, which is the thing that there's often not enough of, but also my particular background and my particular strengths as a therapist, I think having a background in philosophy, also having a background in psychology, I'm, I think, really well positioned to both provide existential therapy, but also to provide good instruction in it. I think over the next five years, I'm going to really work on developing curriculum so that I can provide really good continuing education in existential psychotherapy.

Nicole Izquierdo:  That's great. Last one, if you have any last words of advice for our listeners or anything else you'd like to add.

Blake Thompson:  Oh, well, if you watched, thanks for tuning in. The one thing that I'm really, I think, struck by, and that is, there are plenty of trainings in plenty of different kinds of psychotherapy, but one approach to therapy that I think doesn't get enough press time that I think is a really, really innovative and really, really helpful approach to therapy is ACT, A-C-T. I would encourage anyone who's a clinician or who's a client who's trying to figure out what else they can do to promote their own personal development, their own personal growth, either as a provider or as just a person in the world, I don't think ACT is everything, like I said before about approaches to psychotherapy, I don't think that any one approach can fully capture everything there is to being a person and address every sort of concern that we have, but I think ACT is uniquely helpful for how simple it is. I think it is remarkable how beneficial it is and how intuitive it is.

There's a great self-help book by Steven Hayes, who is one of the main developers of ACT, called “Get Out of Your Mind and Into Your Life.” There are millions of copies of this thing that have been printed, but I would encourage anyone who has any questions about how to apply therapeutic principles to their life, how to take the next steps. Sometimes therapy is too expensive, sometimes therapy is inaccessible, sometimes you feel like the therapists that you're finding aren't a good fit for you. There are really, really great therapeutic workbooks out there that are based on evidence-based psychology. This book by Steven Hayes, “Get Out of Your Mind and Into Your Life,” it's a phenomenal book and the ACT principles that it's based on are super, super helpful. I'd encourage anybody who's considering therapy, who's ambivalent about it, checking it out. Again, it might not be the thing for you, but it's about as close to a one-size-fit-all, helpful across the board approach to therapy that I've ever found. I really want to shout from the rooftops, everybody should know more about ACT than they probably already do.

Nicole Izquierdo:  Well, thank you so much for sharing that, and thank you so much for joining us, Blake. We really appreciate you taking the time to speak with us.

Blake Thompson:  Hey, thanks, Nicole.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Therapist Jim McDonnell on High-Stress Employment

An Interview with Therapist Jim McDonnell

Jim McDonnell, LMFT is a Psychotherapist at Seattle Anxiety Specialists. He specializes in working with clients in the tech industry and high-stress environments. Jim also has extensive training and experience providing couples therapy and family therapy.

Anna Kiesewetter:  Hi, thank you so much for joining us today on this installment of the Seattle Psychiatrist Interview Series. My name is Anna Kiesewetter and I'm a research intern at Seattle Anxiety Specialists. I'd like to welcome with us today our own Seattle Anxiety Specialist psychotherapist, Jim McDonnell. Before becoming a therapist, Jim had a successful career in technology across two decades. With his experience as a researcher at NASA's Ames Research Center, as a senior program manager at Microsoft, and also as a senior business intelligence analyst at T-Mobile, Jim is an excellent resource for clients working in high-stress careers. So before we get started, could you please just tell us a little bit more about yourself?

Jim McDonnell:  Sure. Hi, Anna. Nice to meet you and thanks for organizing and running this. A little about me. I grew up in New York. I was raised just north of New York City. I've spent years in the restaurant industry, and then I transitioned into technology. I worked in startup companies in Silicon Valley and then moved up to Seattle, worked in the tech industry in Seattle for a number of years. I'm an outdoor enthusiast. I like being outside in the woods. I love to exercise and keep my body in shape. It helps my mind stay clean and clear. I'm a father, my daughter's in college, and I don't know what else to say beyond that. Yeah.

Anna Kiesewetter:  Yeah. That's awesome. So you mentioned you worked in tech in Silicon Valley before you came up to Seattle. Could you tell us a little bit more about what got you interested in making that switch?

Jim McDonnell:  Sure. The switch from being in tech to a therapist?

Anna Kiesewetter:  Yeah.

Jim McDonnell:  I've always enjoyed helping people and making people feel better. When I was younger I used humor a lot to do that. I can make people laugh relatively easily, and if a friend had fallen down and hurt himself, or if something happened, I would sort of employ goofiness and jokes and physical comedy and stuff to bring someone out of their sadness into happiness and laughter and sort of lighten the mood. And I really leaned into that early in my life. I was a joker, a jokester, a prankster, and I just liked laughter.

I also loved gadgets and technology and loved programming and trying different... I was always sort of buying the latest gadgets when I was a kid. I had these electronic dictionaries in the early '80s when they were super rare and I loved them. I was a bartender and I was going to college. My undergrad is in industrial organizational psychology. I had a research methodology focus so when I graduated, I got a job at a startup company doing statistical analysis and database programming. I really loved that.

And so I sort of left the helping laughter stuff behind and really leaned into this, and the whole country and the world was sort of embracing this and I thought maybe I was going to be a gazillionaire and get all sorts of stock options and stuff like that. And I pursued that for many years, but in the background was always this desire to be a helper.

And I should point out that I originally wanted to be a therapist when I was in college. And I had an advisor who, for whatever reason, I'm assuming their reasons were sound, but they advised me against it. So I was in a bit of an existential crisis, like, “Who am I? What's my purpose in this world?” And so I leaned into the research methodology. I still wanted to be in the psychology domain, but I, for whatever reason, just accepted that fact that I couldn't be a therapist. So I went that route.

And so for many years I was leaning into that. I really enjoyed my time in technology, in the tech industry. I really loved the people that I was working with and the projects I was on. But there was this sort of transition in my mind where I was becoming a bit disillusioned with the industry. I wasn't finding deep meaning in it. And it wasn't really resonating with this core value of wanting to be helpful to the world and to reduce suffering.

And so, as I progressed through my career, I started getting closer to a point in my life where maybe some people have a midlife crisis or something like that, and I just was like, "I'm no longer satisfied. I'm not happy." I was actually super anxious. I was having panic attacks and anxiety attacks in the workplace. And then I decided to make a change. So I had some people in my life that were pushing me towards this. They recognized that I had particular skills and personality temperaments, and some gifts and traits that would be really, really helpful to people. I actually received formal training in being a therapist.

So I made the choice to just try. I applied to a couple of graduate programs. I was accepted and I kept saying, "Okay, I'm going to do this for a semester. If I don't like it, I can always just drop out and I still have..." I was working full time my first year in graduate school. So I was holding down a 50-hour-a-week job and I was going to classes and working in the classroom while I was learning. I just really liked it. It resonated with me. And so I've just stayed with it.

I think the question was what prompted the shift. It was sort of like this awakening. To be more specific, my father passed away when he was 46. I was 46 at the time, around the time that I wanted to be a therapist. I was maybe 44 when I finally decided to start applying to graduate schools. But it was sort of like, "What am I doing with my life?" If I was my dad, I would've been two years away from death. "Is this the legacy I want to leave for myself?" That really pushed me out of my comfort zone, as well.

So all of that is the reason why I shifted out. Looking for more meaning, finding something that was better aligned with my skills and my values and partially just sort of a life cycle change of like, "What do I want next for myself?"

Anna Kiesewetter:  Wow, that's really powerful. I think it's really inspiring that you pushed forward to doing that, making that change and showing what you value. Do you feel like you kind of fulfilled that, that kind of wanting to find more of your life's values in the change, the switch between careers?

Jim McDonnell:  Yes. When I first started off in graduate school, my vision was to be working more with youth and teens. And so I did that at a community mental health during my internship, and it turns out it wasn't a great fit for me. It wasn't really aligning with my passions and through, I would say, serendipity, maybe, what's the word, synchronicity. Some kind of, if you want to think more spiritually, woo-ish. I found Seattle Anxiety Specialists when I was looking for a group practice. And the more that I started thinking about the practice's mission and the focus area of specifically treating anxiety disorders, the more it just sort of was like, "Duh, you've been anxious your whole life."

So to be able to help people who are in the industry that I used to be in, learn how to recognize why they're anxious, to help interrupt feedback loops and disrupt patterns that reinforce their anxiety and to find more confidence in themselves, in their ability to experience distress, to reduce how long it lasts and how intense it is, and to just generally understand how their particular mind works and why it responds a certain way, is so fulfilling to me.

I go to sleep at night happy, knowing that I haven't helped every single person in the world, I'm never going to eradicate all of the distress on the planet, but every person that I interact with, from a client-therapist relationship, I feel like I'm doing the best job that I can to make the world closer to being in that state than it was before I started, if that makes sense.

Anna Kiesewetter:  That's amazing. How do you think that being in the tech industry yourself has helped you to help these people now that you're working with them? Especially people who have been working in tech industries?

Jim McDonnell:  Yeah. I mean, I don't know what it's like to work at every single company. I don't have a visceral understanding of every company culture. I've never worked at Amazon or Google or Facebook or Apple. So I don't know what it's like specifically to work at those companies. And I know what it's like to work, generally speaking, in the industry. I know the expectations that are put on people. I understand how software is created and managed. So project management perspectives and program management perspectives and different kinds of software development methodologies.

I understand those enough to be able to speak the language of the person. So when they come to me and they're trying to describe what's going on in their life, they don't have to explain the culture of the company. They don't have to explain why it's stressful. I get it and I am able to speak their language. I use metaphors a lot in the work that I do and I bridge kind of how we go from, this is the way the product is now and here's how we want the product to be in the next revision, and here's what we're doing to make that happen and here's our timeline and our plan and all of the schedules and milestones.

And I kind of use that same approach for mental health. So here's how you are right now, version, whatever, one, of you. And then you want a new version where you're not as anxious and you're not as stressed out and you have a more adaptive response to these stressors. What do we have to do to get you from here to there? How long is it going to take? How do we know we're making progress? How do we measure progress along the way?

So that sort of understanding, being able to speak the language. I know the different terminologies and review cycles and pressures and sort of the cultural contextual factors that are feeding and reinforcing the anxiety. I'm really rambling on a bit here, but it's helpful for me and I think my clients appreciate that I have been in similar spaces to them and understand, generally speaking, what it's like and why it's stressful. So I think that's probably the best way that I can answer that question. It's just like there's familiarity with the context and yeah, I'll leave it there.

Anna Kiesewetter:  Yeah. That makes a lot of sense. You mentioned anxiety is one of the things that you see a lot in people experiencing workplace stress and having to deal with these issues. What other kinds of areas or symptoms or disorders do you often see in your patients who are working in high-stress environments?

Jim McDonnell:  Other symptoms? Well, if we're thinking about this from an experiential perspective, like what are they experiencing? Obsessive, intrusive thoughts that are generating distress, physiological distress. So there's muscle tension and dysregulated breathing and fidgeting, elevated heart rate, perspiration, that sort of thing, racing thoughts. Really, there's a lot of what are we call cognitive distortions in cognitive behavioral therapy. So a lot of stories that people are telling themselves about what's happening now and what's going to happen in the future.

Anxiety's generally a future-oriented experience. We're thinking about the future and we're worried about it. And then the predictions that we make. Our mind is a model maker, modeling the future constantly, trying to figure out how to make sense of the world. And that model has some distortions in it. Maybe it's predicting a tragedy constantly. Like, "This is only going to turn out bad," or we can only see things either or, either good or bad. I think I've forgotten the question. I'm a little lost in my answer now. Can you restate that question so I can refine it?

Anna Kiesewetter:  Yeah, of course. Of course. I was asking what kinds of typical, or maybe not typical, but what kinds of different symptoms and disorders do you see in people who are experiencing high-stress work environments?

Jim McDonnell:  Right, yeah, so symptoms versus disorders. The disorders tend to be generalized anxiety disorder. There's a lot of obsessive-compulsive disorder, but maybe less on the traditional or the technical way of interpreting that diagnosis. I look for obsessional thought patterns and disturbing, intrusive thoughts, and then compulsive responses to that. Things that people are doing in response to those thoughts that try to protect themselves from it.

I see a lot of that OCD, generalized anxiety disorder, panic disorder, so people who, really, just there's runaway anxiety that leads to panic attacks, depression, as a result of that. So when you start to feel scared about your future over and over and over again, you can't figure out how to solve a problem, you end up becoming hopeless about the future. And so you can have people experiencing depression and anxiety simultaneously, which is a double whammy. That's not very fun.

I'm trying to think if there's other things. That is generally the areas that I focus on, things that I'm looking for or listening for. And then all of the physical symptoms that people are describing or experiencing, and the cognitive side of that as well. And the behavioral side of it. So what behavioral choices are people making? And again, it's typically in response to some sort of a trigger that's dysregulating a person, cognitively and physiologically, and then in response to that, they're making choices to protect themselves somehow. And sometimes it's just like fight, flight, freeze sorts of choices. Yeah.

Anna Kiesewetter:  I see. So when you're experiencing the patients with these different symptoms and disorders, can you talk a little bit about your treatment approach and how you approach therapy with these people?

Jim McDonnell:  Yeah. I'm generally using cognitive behavioral therapy as a therapeutic modality. I lead with a discussion around... How do I want to answer this question? My goal is to help people have an adaptive response to stressors. When you're in a state of constant anxiety, that's a maladaptive response to the stressor. So I want to help people get to that place where they can experience that stressor. They know how to process it, digest it, and instead of being stuck in an anxious feedback loop, they're able to resolve the thought, the feeling, the behaviors, and leave with confidence that they know what to do. Even if they don't know exactly what to do, they know generally what to do.

That sort of guides my approach. I want people to become consciously aware, explicitly aware of, what triggered me? I was doing fine and then suddenly I wasn't. What was it? Was it a thought that I had? Did I see somebody that reminded me of something? Did somebody say something to me? Was there an event that just happened, the anniversary of something that was traumatic? What is it? Because we're not just suddenly fine and then not fine.

So getting really clear on that and then getting really clear on what happens in your body when that happens. So that thought passed through your head and then your muscles tensed up and your breathing became shallow and quick and your heart rate elevated and you started sweating. Okay, great. So you understand the connection between why you're feeling this way in your body right now and what just happened. And then what stories do you tell yourself, your model-making machine, meaning-making machine? How do you make sense of this? Your prefrontal cortex has to tell you a story about, "Well, you don't feel good right now. Why? Oh, it must be because..."

And then that's where the cognitive distortions come in. "This is always going to be this way." I don't know. "I'm going to get fired. I'm going to get a bad review. My partner's going to leave me." Something. It's some tragedy. And then we feel hopeless about that. So getting really clear on the story, what's happening in our body, why, what the trigger was, being really clear on the behavioral choices we make as a result of that.

I want people to get bored with this because I'm going to keep asking them every session so it becomes rote so that when they feel something, they go... It sort of spurs a meta awareness. So like, "Oh yeah, I'm feeling anxious. Let me engage in this higher-level process to understand why." So then once they have that skill, how do we disrupt this pattern, this as-is experience?

There are physiological interventions, like learning how to regulate our breath and how to relax our muscles. There's cognitive interventions, like recognizing cognitive distortions and challenging them, coming up with ways to not lie to ourself about what the stressor is and why we're feeling this way. And also to feel confident that we know what to do in response to it. So appropriately sizing the stressor. So maybe I'm responding to it as though it's a 10 out of 10, but in reality, it's like a four out of 10.

So really right-sizing the way that we're thinking about problems, and then what can you do behaviorally that's different? So we're looking at this as a system and as a pattern, a template of a response to a stressor. And then we want to disrupt that pattern and template and replace it with a bunch of different choices along the way. And then if we score, how do I feel with version one versus version two? So long as we're feeling better with version two, then that's good. We're making progress.

So that's the approach I've taken. Lots of validation. There's no judgment in the process. What purpose does judgment have, right? We need to be able to just be honest about what we're telling ourselves and why. Positive regard. It's important for people, I think, to feel good about who they are, even if maybe they've made choices that they're not proud of, that at their core, they can feel as though they're good and they're seen as good. I think that's really important.

And I use humor along the way, as well, a little bit of levity. And then ultimately aligning all of this stuff with personal values. What's important to you? Who are you as a person? How does this map to your identity and how you see yourself? That's the best I can do in sort of summarizing. It feels complicated sometimes when I'm trying to describe it, but I try to keep it finite and relatively discreet so that it's not overwhelming, that a person kind of understands what we're doing. There's goals, there's structure, there's a plan, we're moving forward towards something. So that hopefully also communicates some confidence in the process, so that's how I do that.

Anna Kiesewetter:  That's amazing. Awesome. Yeah. Thank you so much for sharing that. Okay. We're approaching our final question: so, I'm just wondering if you have any other words of advice or anything else you'd like to say to our listeners before we wrap up.

Jim McDonnell:  I'm not sure exactly what to say other than perhaps we don't get to choose what happens to us in this world with 100% certainty, but we do get to choose how we respond to those things and suffering, while probably inevitable, is optional in many different ways. I didn't mention this before, but the core metrics that I communicate to clients is, how frequently am I triggered? When I am triggered, how intense is the response and how long does it last? So frequency, intensity, and duration.

We can't really always choose how frequently we're going to be triggered by something or how frequently the trigger is going to happen, but we do have agency on how intense the response is and how long that response lasts. So if people are experiencing a lot of anxiety, I think it's important for them to know it doesn't have to be that way. The world doesn't have to change in order for them to feel more at peace and they don't have to lie to themselves. It's not one of these toxic positivity sort of cycles where we just say, "It's all going to be great and everything's okay and stop worrying." I think that just actually reinforces the power of the stressor so we can't look at it with open eyes and accept things as they are.

So if a person is anxious and they've been anxious and they continue to experience anxiety, more often than not, it doesn't have to be that way. And there are people who can help transform the way that they're thinking and feeling in response to those stressors so that they just generally enjoy their life more. We don't get to live forever. We might as well learn how to use our brains to have a better time on the planet while we're here.

Anna Kiesewetter:  Awesome. Yeah, I like that a lot. All right. Well, okay. Thank you so much for your time and your insights coming on here today. I wish you the best and really hope to have you back for another interview in the future, if you're down for that. So this concludes this installment of the Seattle Psychiatrist Interview Series. Thank you so much for listening and we hope you'll tune in next time.

Jim McDonnell:  Thanks, Anna.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Norman Cotterell on utilizing CBT

An Interview with Psychologist Norman Cotterell

Dr. Cotterell is a Senior Clinician at the Beck Institute and specializes in the use of cognitive behavioral therapy (CBT).

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, Research Director at Seattle Anxiety Specialists. I'd like to welcome with us psychologist, Norman Cotterell. Dr. Cotterell is a Senior Clinician at the Beck Institute and specializes in the utilization of cognitive behavioral therapy. Before we get started, can you please let us know a little bit more about yourself and what made you interested in CBT?

Norman Cotterell:  Oh, wow. I think it happened by accident because before my first day in graduate school, and this is like Beckian cognitive therapy, because really I went to college interested in geology and musical theater, and then I took the psychology class in freshman year where they showed... Remember that video where they showed Albert Ellis and Fritz Pearls and Carl Rogers seeing the same person?

Jennifer Ghahari:  Yes.

Norman Cotterell:  This is black and white movie. And that probably was my first introduction was, something in the CBT realm was seeing Albert Ellis in action with that individual. And then later on, I became a major in psychology and I was told you had to do that. And I was told early on, I was told back in 1978 in the psychology program, which had no clinical advisor until my junior year. In fact, my supervisor or advisor when I was an undergraduate, called psychotherapy, "Oh, you're interested in the talking cure." So it wasn't exactly pushing psychotherapy at that point.

They finally hired a clinical advisor, my junior year in college. And he told me basically the only version of therapy that he considered that had a future, was worthwhile, was in the CBT realm.

Jennifer Ghahari:  Wow.

Norman Cotterell:  Yeah. And that was in 1978. The guy was prescient, if anything else. And so I went to University of Delaware and I think right before my very first class, the weekend before classes started, I wandered into, I guess, Art Freeman giving an all day workshop in CBT.

Jennifer Ghahari:  Oh, wow.

Norman Cotterell:  He said, "Oh, come on, have a seat, come on in," and sat in. So before my very first class in graduate school, I sat in on a workshop on Beckian CBT.

Jennifer Ghahari:  Wow.

Norman Cotterell:  Cognitive therapy at that point. And so that was in the back of my mind ever since. And I got my chance to do my postdoctoral fellowship there in 1989 and I've been here ever since. It's been a 32-year postdoc. It's a pretty simple career trajectory, basically that was it.

Jennifer Ghahari:  It was the right fit. Yeah.

Norman Cotterell:  Yeah. It was absolutely the right fit. And even my last lecture in undergraduate was Viktor Frankl. It was standing-room only, I literally sat at his feet while he was talking about his experience at Auschwitz, where I remember him saying the two things enabled him to survive was what's intact. Number one, finding a reason for living. And at that point his only reason for living was to find a reason for living. The only thing gave him meaning was to search for meaning. The only thing gave him purpose was that search for purpose. And the other thing was maintaining a sense of humor. Said he's not going to let the Nazis take that away from him.

Jennifer Ghahari:  Oh, wow.

Norman Cotterell:  Yeah. That maintained him. So those experiences got me on this path and I've been with Beck’s since 1989 and that's basically my journey. And just in working on projects after that, I mean, I got thrown into a panic disorder study as soon as I got there. And then, there were protocol therapists for studies involving generalized anxiety disorder, refractory depression, bipolar crack cocaine addiction, later on a health psychology project involving camping out in primary care physician offices. So I saw people with positive HIV status or AIDS with end-stage diabetes, with chronic pain, cancer treatments and so forth. End-stage life issues - seeing people who were terminally ill. And I did that for a couple years before I transferred. It was back in '96 when I transferred in-house from the Center for Cognitive Therapy to the Beck Institute. But same folks because in '94, Beck took half the staff moved them to Bala Cynwyd when I stayed at Penn. And then two years later I traded places with a fellow who went back to Penn from the Beck Institute. And I went from Penn to the Beck Institute.

Jennifer Ghahari:  Nice.

Norman Cotterell:  But we're basically sister clinics.

Jennifer Ghahari:  Right. Yeah. That's great. So obviously, you know what you're talking about when it comes to CBT, which is...

Norman Cotterell:  I'm still learning here. (laughing) We're all students, you know?

Jennifer Ghahari:  Exactly.

Norman Cotterell:  Yeah.

Jennifer Ghahari:  So on that note, many of our clients reach out to us specifically requesting CBT because they've heard of it, they read a little bit about it, someone's recommended it to treat what they're experiencing... And so can you explain what is CBT and what type of issues can it used to treat? I know you just mentioned a few of them, but in general what's it used for?

Norman Cotterell:  Well, yeah. I mean, goes all the way back to Greek slave philosopher Epictetus. The idea that he had is that it's not the situations that make us feel the way we do, it's our beliefs about them. So it's the thoughts and beliefs that create or enable people to interpret situations that give rise to specific emotions. Probably the most important question he asked initially is, "When you experience said emotion triggered by said experience, what was running through your mind? What words, images and pictures are running through your mind?"

That gives a clue as far as your interpretations and your beliefs that may underlie those particular thoughts. As far as experiences, the experiences can be internal. They can be external, they can be interpersonal. You can have beliefs rising from physical sensations, beliefs rising from urges, beliefs being triggered by intrusive thoughts. I see as being the internal experiences can reflect body belief and behavior. Body is manifested in sensations. Belief is manifested in thoughts and behavior is manifested in urges.

So I'd say sensations, thoughts and urges can serve as triggers for activating beliefs, which can exacerbate those sensations, exacerbate those thoughts if they get triggered and exacerbate those urges as well. And then external triggers, things you see smell, taste, touch, or do, what people do with you, in front of you, circumstances that are external to you, interpersonal things that people say to you and your relationships with people can all trigger or activate particular beliefs, which can account for how we react to those situations. And of course it goes down in a circle because you can have beliefs about your reactions as well, so it can spiral up that way.

Jennifer Ghahari:  And so what type of issues can CBT treat?

Norman Cotterell:  Yeah. Well, Beck started off just really focusing on depression. I mean, you might know that oddly enough his version of CBT started with dream analysis. There's been pushback on this whether in fact that was the case, but really by his telling of it, he was doing a dream analysis to look at that theory of Freud, that depression was anger turned inward. Depression, what is depression? It's anger turned inward. So he looked at the dreams of depressed people to find that theme of anger turned inward and didn't find it. What he found instead, which was not only true in dream is also true in waking life is that people tended to have a negative view of three areas in their lives: a negative view of themselves, a negative view of their personal world, a negative view of their future.

And when they saw themselves at a negative light, it triggered a bit of a hibernation instinct or hibernation response. And with hibernation, motivation goes down. With hibernation, energy goes down. With hibernation, your interest in life goes down. And as your interest, energy and motivation drops, you feel worse about yourself. You feel more inadequate, which triggers more hibernation, which can affect how you see your personal world. It colors your world the way a drop of ink would color a glass of water. And your personal world takes on a more negative light, which causes a further drop in motivation, energy and interest, which in turn makes you feel worse about your future. What kind of future is this? I don't have a future or the future is nonexistent. The future is really horrible, which can make you feel even more inclined to hibernate.

So the insights that he had, this is in his evolutionary theory of depression was that depression it's like a hibernation instinct. Depression, if there's a purpose for it is to conserve energy rather than to waste it under fruitless and useless pursuit. And depression tells us that everything is fruitless. Everything is useless. So what's the point? For you to do anything to change your life is as fruitless as a bear looking for food under 12 feet of snow, give it up, forget about it, go to your cave, curl up in a fetal position, suck your thumb, wait for the day to end, because anything you do is doom to failure. Forget about it kid, go back to your cave and hibernate, hibernate, hibernate. And what fuels that is that classic depressive triad, negative view of self, negative view of personal world. Negative view of future, which triggers hibernation, makes feeling worse about themselves, their world and their future. So it spirals down that way.

And it was interesting design for that. I mean, and there are two points of intervention. The behavioral intervention is what depression does. It's a hibernation instinct, motivation, energy, interest goes down. And the insight that Beck wrote about in cognitive therapy depression is that you don't sit around and wait for motivation to come knocking at your door. Motivation is sleeping, but there's one thing that's going to wake up motivation and that's action. You take action. If you sit around waiting for motivation knocking at your door, it's not going to happen. It won’t spontaneously say, "Hey, I'm motivation." You'll be waiting forever. You take action in the absence of motivation. And people do that with depression. There’s not supposed to be any motivation whatsoever. It's sleeping - wake it up. And it’s taking action first without the necessity, without the belief let's say that, "I have to have motivation before I can move my left pinkie. I have to have motivation before I move my foot."

Well, we do things quite often without any motivation whatsoever. We go through the motions and with depression going through the motions is brilliant. Going through the motions is a great achievement. Why? Because it is so bloody difficult. And so giving one credit for everything that you do with depression, because doing anything with depression is a sign of strength. By doing anything with depression is a sign of strength and to acknowledge that strength, give yourself credit for it. And that's a behavioral aspect and that’s our first intervention. In fact, one time I remember seeing Aaron Beck, Tim, as we called him, ATB, as we used in communication, passed away recently.

Jennifer Ghahari:  I’m so sorry for your loss.

Norman Cotterell:  And he's like one of my few remaining father figures. He was my academic father for the past 32 years.

Jennifer Ghahari:  Oh wow.

Norman Cotterell:  Yeah. It's a long time. But I saw him working with an individual who wanted to delve deep into beliefs, wanted to delve deep in terms of schema, wanted to delve deep in terms of his thoughts. And Dr. Beck told him, "You're not ready for that yet." That they were not ready for that. We need to do the behavioral work first. We need to take you off the ledge first and work behaviorally before you even touch. And that was from the father of cognitive therapy. Who's telling this guy, "We need to work on behavioral activation first." Yeah, but that is often first line of attack, do nothing-ism, behavioral activation. Really that first thing.

And then the cognitive aspect is what depression tells us. Depression is your worst best friend telling you, "Look, kid, you're crap. Your world is crap. Your future is crap. So give up." And it's a propagandist. And it's like, somebody who's printing up signs, printing up propaganda left and right. "You're crap, the world is crap. The future is crap and you're crap. The world..." And that's what it does. That's what it does for a living. That's depression doing its job. But you don't have to buy into those thoughts. You don't have to base your actions on those thoughts. In some ways there's a story from Kierkegaard where he's walking down the street, seen a sign on the shop window. Sign says, "Clothes pressed here." So he goes home, gets his clothing, plops it down the counter.

The shopkeeper says, "What are you doing that for?" Well, he said, "I saw the sign on windows says, 'clothes pressed here." And the shopkeeper says, "I don't press clothes, man. I make signs." Well, basing your actions on what depression tells you is like getting your clothes pressed at a sign making store. Depression is in the business of printing up signs. "Look, kid, you're crap. The world is crap. The future is crap. Give up. You're crap. The world is crap. Your future is crap. Give up." That's what it does. It's doing its job. But you don't have to buy into it. You don't have to base your actions on it. And as Steve Hayes, often said, "Don't believe a thing your mind tells you."

Jennifer Ghahari:  Yeah, exactly.

Norman Cotterell:  That would be the case where Steve Hayes council would be absolutely 100% on target, "Don't believe a thing your mind tells you." Especially when it's providing those depressive messages, where you base your behavior on, you base your actions, what's truly important in life. And if you're sitting around saying, "What's my motivation? What's my motivation?" Like a method actor. "What's my motivation? What's my motivation? Well, I can't move a finger until I know what my..." Well, far often people are depressed. Only motivation is they hate depression.

Jennifer Ghahari:  That'll work.

Norman Cotterell:  Yeah. That's it. But they don't even need that. They just need to move the muscles first. So that was really what cognitive therapy was designed for. What Beck designed it for was really depression and his great perspective being the depressive triad, leading to loss of motivation, energy and interest, which kind of led up back to that depressive triad negative view of self, versus the world and the future. And then they applied it to anxiety disorders. And initially it was hard to apply to anxiety because oftentimes people didn't have thoughts.

They did not have automatic thoughts with anxiety. They had strategies, they had behaviors and really they had to adapt some of the techniques of Beckian CBT to deal with people who... What's going through your mind?

Nothing. And dealing with the absence of that, which really meant that a lot of behavioral work with anxiety disorders involved identifying and eliminating people's reliance on safety behaviors and also dealing with beliefs about anxiety. As you know, very much the current wisdom is which we replicated the study from David M. Clark's group at Oxford University when I first got to Penn in 1989. Replicating the study at Oxford on panic disorder. I got thrown into that. Saw nothing but people with panic disorder when I first came to Penn. And the model that we used really had to do with individuals with panic, having a catastrophic misinterpretation of anxiety itself.

Yeah. In fact, David M. Clark, who was one of the first people I met at Penn, he was actually in resident. He was visiting there when I came, saying that was the one case where the DSM actually had a cognitive interpretation built into the guidelines for diagnosis. That is a catastrophic misinterpretation of untriggered anxiety. Only for a panic attack is having an unexpected sensation, which you catastrophically misinterpret and that gets the ball rolling. "I'm dying. I'm losing control." Either loss of physical control, loss of psychological control, either way it's catastrophic, it's immediate. And he also described the continuum between let's say panic and hypochondriasis or health anxiety as we call it now, in which with panic, you're dying now, you're losing control now, it is happening right now at this minute. Health anxiety: sometime in the future.

It's just a matter of timing. That I will eventually die, that I will eventually lose control. I will eventually... And he saw the continuum between panic and health anxiety, both involved, having misinterpretations of internal phenomena, specifically physical sensation. So we replicated the study. And so I saw people for whom their primary issue was having a catastrophic misinterpretation of physical sensations that were unexpected. And what we did was make them a bit more expected by doing panic inductions. I did panic inductions every week, with all the people I was seeing for the panic disorder study and really therapy started with the panic induction. Because that point we triggered it in-session the sensations, not really the panic attack because I was present there.

My mere presence and the fact that we did it, the fact it gave him a sense of control that there's something I did that triggered it meant that it wasn't unexpected. If you take the unexpected nature out of panic, it just doesn't have the same enthusiasm as it otherwise would have. Panic needs the element of surprise, surprise, surprise. There's no surprise that we're doing it. So as much as I did panic induction, they never really triggered panic, because we were doing something deliberately, took away the element of surprise. But what it did do, it gave them a chance to experience those very same sensations with a different interpretation of those sensations. It enabled them to have those sensations and realize and test it out that they weren't going to die.

They weren't going to lose control. They weren't going to faint for example, and that they could experience those sensations and flow through them.

Jennifer Ghahari:  Wow.

Norman Cotterell:  Yeah. So I got there when they were applying Beckian CBT for anxiety disorder. And then after that, we had a bipolar study in which people like Cory Newman and Mary Anne Layden and I think Susan Byers applied it to bipolar and borderline personality. They would book on that one. Cory wrote a book on bipolar and applying it to drug abuse. I worked in the project applying it to crack cocaine addiction. For a while we didn't see people with OCD, anybody with OCD we referred to Foa. She had a cognitive way of looking at it, but her procedure was very behavioral even though her conceptualization to my way of thinking was quite cognitive, but then we started seeing people with OCD. David M. Clark came up with a model for treating OCDs similar to Foa's but a tad more cognitive, I suppose, in perspective didn't necessarily involve that.

And didn't necessarily involve purely behavioral means, really Paul Salkovskis was one of the first people that I saw present on OCD, which is title of the talk was, “Why don't we all jump out of 10 story windows?” His point, being that for us, asking somebody with OCD to do exposure and response prevention, is like asking somebody to leap out a 10 story window and expect to fly. Just like doing anything constructively with depression is a sign of strength and you got to honor that, doing anything constructively with anxiety is a sign of courage. You have to acknowledge their courage. For them to do anything towards exposure response prevention and I would regularly first off ask, "What are the disadvantages of doing exposure response prevention? What are the benefits of OCD?"

Someone had an affection for OCD. There's some person I regard as being an old friend. Old worst, best friend. When I saw a presentation from a person yesterday who likened OCD to being with a lumbering dog, that gets in the way of things. But you might have some degree of affection for that dog. And there's some people, not everybody, some people that I knew also despised OCD, but some people thought they might miss it and they... I heard one person say, "Just give me a social alcoholic, you'd be a social drinker. Don't want to give up drinking entirely. Can I be a social OCD person? I do just enough to take the edge off things, but not so much that it controls my life."

I look at the benefits of OCD and look at the cost of OCD and then the benefits of exposure response prevention, because sometimes people have some ambivalence about it and so you got lay those cards on the table. And that's capturing their beliefs about the process of therapy, because you got to acknowledge the courage and the product of therapy that they might miss an old friend if they regard OCD as being a little bit of an old friend, especially since they've had it since childhood, they wonder how life could exist without it. You got to expose those beliefs as well. So we saw people with OCD and then the final frontier, where Beck thought that CBT would not apply was with psychosis. But then Kingdon and Tarkington in the UK applied it to psychosis.

They had their model, normalizing delusions, normalizing hallucinations. We all got them, basically, and agreed upon hallucination, it's called reality. And delusions, one person's belief system, can be held as delusional by another. A Protestant might regard a Catholic’s belief in transubstantiation as being a fixed delusion. By saying, "Okay, so every week you turn wine into blood and bread into flesh. Okay." And for me that was Sunday. I had 12 years Catholic education. So that was just the way that it was. But from the perspective of a Protestant, that would be a fixed delusion that Catholics have that they performed this miracle every Sunday and transubstantiation, but it does not interfere in our lives whatsoever.

And I think what they had was that people can have said beliefs and not have it interfere with their lives whatsoever. That's really the issue. And that got extended with the latest work, which Beck was working on two days before he passed away at the age of 100 and Paul Grant, Ellen Inverso, Aaron Brinen on recovery oriented cognitive therapy, CTR, which is... Really, what Beck was most enthused at in working with severe chronic mental illness, in inpatient settings, working within the milieu, working such that people can identify their aspirations and find ways to achieve and experience those aspirations, either in hospital or out of hospital.

And that's the latest. So I think he described it, every time he thought that there was a place where it'd not apply, he'd applied it to. Now granted, I saw people occasionally who were referred to me for cognitive therapy who were struggling with dementia; CBT does not cure dementia.

Jennifer Ghahari:  Right. Yeah.

Norman Cotterell:  That it does not. But I worked with their family members.

Jennifer Ghahari:  Nice.

Norman Cotterell:  I had experience in geriatrics prior to coming to the Center for Cognitive Therapy, I worked with Philadelphia Geriatric Center where I was actually working with sociologists. I interviewed people who were caregiving spouses with dementia as part of a sociology research project. I interviewed people who had put their parents, loved ones in nursing homes. And for a third study, I was starting to interview people who experienced the death of a loved one, a death study.

And I was snatched from that to work on my dissertation and then also to go to the Center for Cognitive Therapy. Yeah, so I wouldn't say that CBT is appropriate for somebody with dementia, but it certainly is appropriate for caregiver stress.

Jennifer Ghahari:  Definitely makes sense, yeah.

Norman Cotterell:  Although on the other hand, there may be people who are finding ways to use CBT for people with dementia. The wild thing is... Oh, I forget who was visiting us. I forget. He's a neuroscientist. (*Joseph E. LeDoux of NYU) You'll probably look him up. He has a rock band called the Amygdaloids. He's a rock musician and neuroscientist. He opened for Roseanne Cash, I think. But anyways, he's a neuroscientist primarily, rockstar by night and he was visiting us. And he was basically saying that the notion that memory is just hippocampus is not true.

He says there's memory in every single cell of the body. He says, "I could teach planaria how to do tricks. I could teach single celled creatures how to do tricks. It's not just in the hippocampus." And that was reiterated in work that was cited by Charles Duhigg's book on habits, showing that even people with dementia can learn new habits. So they’ll forget that they learned them, but they could still learn them through muscle memory.

Jennifer Ghahari:  Oh, okay.

Norman Cotterell:  Yeah. Or even just things that they don't forget. I remember there was one person I was interviewing and some stuff remains and maybe some stuff can also be taught, but they gave demonstration to people even with dementia being taught specific habits. So maybe the B of CBT might even find some for people's dementia. When I was interviewing a caregiving spouse one time, I thought he had the radio on because I heard music playing and music stopped and his wife came out obviously in dementia and she was playing piano purely for memory.

Jennifer Ghahari:  Oh, wow, okay.

Norman Cotterell:  And he said she's been playing piano since she was five years old. Everything else was gone that remained, the muscle memory remained intact and it gave her great pleasure. In fact, there was a Ted Talk about a woman whose preparation for dementia was to learn how to knit, because she had observed that there were people with dementia who had muscle memory for activities that gave him a great pleasure. Since it ran in her family, her method of preparing for dementia was to learn a skill, put it in muscle memory, so if per chance that she came with dementia, that she'd have a pleasure to engage in.

Jennifer Ghahari:  It was something that she can to create. It sounds like whether it's music or knitting or something…

Norman Cotterell:  Yeah. And that's assuming that the portion of the brain would not be the portion of the brain that enables her to knit because actually I interviewed another caregiving spouse, but in that case the first thing that went for that individual was her painting ability, everything else... So it depends which part of the brain is being affected by the dementia as far as whether or not you maintain or lose specific capabilities. But with the cases of the woman with piano… that remained intact.

So maybe the B of the CBT might be a frontier for even working with dementia. But Tim Beck said the anytime he thought that CBT would not apply to a certain area, some expert, some person who knows that backwards and forwards would find a way. There were people who were expert in autism, spectrum conditions who found a way to adapt CBT to work with people on the spectrum.

Jennifer Ghahari:  Oh!

Norman Cotterell:  Okay. That's it. There are people who specialize in addictions who found a way to adapt CBT to work with addictions. So what happens is you get people and it might be more matter of the individual rather than the techniques. Find people who work well with that population, and they may find a way. They find a way to adapt the tools from CBT into the modality they work in. So we'll see. Well actually, can you think of an area that CBT has not touched yet?

Jennifer Ghahari:  No, not at this point.

Norman Cotterell:  Yeah. It'll probably come to us after the interview.

Jennifer Ghahari:  Exactly.

Norman Cotterell:  Yeah. I'd say it's a matter of the personality of the therapist and their expertise in that particular area. Like I stay away from kids, I don't see kids under the age of 17. No, do not. But there are people who are really, really good with children. I saw one of my colleagues working with a three or four year old and I regarded that as being amazing, but that was his field of expertise. That was his comfort zone. That's what he knew as far as working with children. And he applied the tools and techniques and strategies that were geared and tailored for that population in CBT to work with children. But I say that has more to do with the characteristics of the therapist than anything else.

Jennifer Ghahari:  Right.

Norman Cotterell:  Yeah.

Jennifer Ghahari:  So when someone goes to a therapist for CBT, what can they typically expect to happen? I know you mentioned exposure ERP for example, as one method, but what else can someone expect?

Norman Cotterell:  Well, I think the first thing I do ask them about what they want to see happen from therapy. I mean, this is before I even do the diagnostic interview. Really the purpose is to give them tools, so they can be on the road to changing their life. So really I start off, the most important thing is goal setting, which is defining a direction they want their life to head into. A goal is like a terminal point, direction is like heading Northeast in the direction of health towards that direction you want to go in. And whether it's a small step or a large step, you're still heading in the right direction. So I asked him to get a sense of that. I asked them the old question from Alfred Adler.

He had the magic wand question. David Burns reframes it as a magic button question. They might regard a magic wand as being a tad in infantilizing. So now I use a magic button, that way they have control over pushing it. And so if they push that magic button and they're healed, depression is gone. You feel great about yourself. Feel great about your personal world. You feel great about your future, your energy, your motivation, your drive for life, your zest for life is back and full force. And on top of that, anxiety's not a problem. The current wisdom is that anxiety's not the problem, fear of anxiety is the problem. Well, your fear of anxiety is gone and anxiety is nothing but booster jets to get the job done. Anxiety goes from being a liability to being an asset. Anxiety goes from being a foe to being a friend, goes from being enemy troops to reinforcement and anxiety is just energy to get the job done.

You push that button. You feel great about yourself, your world, your future, your energy, your motivation is back in full force. Anxiety is just energy and whatever goals you have, they're there. If you push that button and you're totally healed, external circumstances are the same. Externals are the same, but you push that button you have a change internally. What would you do? What would change in your life? And write that down. And then I ask a second way, same question. You push that button. You feel great about yourself, your world, your future, energy, motivation back in full force. Anxiety is just energy to get the job done. What would you do in the next seven days? Next seven days what would you do?

Jennifer Ghahari:  Yeah.

Norman Cotterell:  Yeah. To make it more specific and sometimes might say, "Yeah, do the same thing." Well, more pep in your step, more glide in your stride." Yeah. Okay. Put that down. More energy in doing what you're already doing. Or some people might say, "Well, nothing would change. I'd just be doing the same thing I did before." And some people might say, "Well, everything would change. Everything would change." I want to know whether they say nothing would change, everything will change or somewhere in between. And then I ask it a third way. You push that button. You feel great about yourself, your world, your future energy is back and full force. Anxiety is an asset rather than a liability. What would you do for the rest of day, this afternoon, this evening, tomorrow morning, tomorrow afternoon, tomorrow night what would you do if you are totally, thoroughly and permanently healed?

And I write that down to get a sense of what their life would be like if they were not plagued with these symptoms. And then I also ask, just a matter to ask, what kind of hobbies and interest do you have? What kind of things do they enjoy? What things, give them pleasure in life? And again, aspect of what interest they have, what things they would do. What interests they have had in the past and might have in the future again, if depression or fear or anxiety were gone. And I asked them the old Steve Hayes question, "If you could be in a world of your own making what would you want your life be about? What is really, really important for you?" I want to get a sense of their values.

Now, when we first came to Penn, I got thrust in another study on values in 1989, where they just had two, sociotrophy, autonomy were the two values that you're looking at Penn back in 1989. It's been expanded since then, I mean, Russ Harris has a quick look at your values, which I think I have 63, which are a good deal more than two that we're looking at Penn. But there can be values or needs or desires based on sociotrophy connections with people or based on autonomy. Things that can be done more individually. Either way, I want to know what's really, really important to them. What is really, really key for them. Sometimes if they are students I ask if success was guaranteed and whatever you touched turned to gold - what would you do for a career? If that is an issue for them, if they still try to decide what they want to do with their lives. I think if success was absolutely guaranteed what would you do for a career or for a livelihood? If that's relevant.

That's where I start off. And then with that, we review the goals in the first session, have them add detail to that. And I asked to tell also, what do you know about cognitive therapy? And how do you think it can help you with these issues to get you where you want to be or head in the direction you want to head? And then that's where we start in using the tools, in order to focus on the specific goals that they have in life, the direction they want to head towards in life and how we can take those initial steps in that direction. And sometimes it may be depression, which is telling them, "Forget about a kid, go to your cave, curl up in a fetal position." Depression telling them that they're a bear and it's time to hibernate. Or else the impediment could be fear of anxiety, fear of anxious sensations, fear of anxious thoughts, fear of anxious urges that can get them stuck in which the cure, seemingly for anxiety it can be avoidance. For everything just avoid, but then they avoid everything.

And what happens, the byproduct of avoidance, it reduces anxiety temporarily if they avoid things that really, really matter. And then anxiety, the fear goes up. And then on top of that, if they get addicted to avoidance, it can trigger another side effect called depression. So we basically see what's getting in the way of them doing that. And so what they can expect is that I'll ask them what they want to put on the agenda or what they want to accomplish in session today. What's their goal for today's session.

And I ask them how the week went? I'm using the matter of course to capture people's aspects of the week. I'm taking from Marty Seligman on this one, on his PERMA mnemonic. Are you familiar with that one?

Jennifer Ghahari:  I'm not. No.

Norman Cotterell:  Yeah. It's his recipe or formula for well-being, if not happiness. First homework assignment, the first action plan I give people after the intake evaluation, after we look at the goals is... I define happiness like Oprah defines love: as behavior. It's what you do. Ok. So it can be what you do for pleasure. What you see, smell, taste, touch, hear that's pleasurable. What you do for others what other people do for you, what you enjoy vicariously that provides pleasure. And then I asked them, "What was the most enjoyable thing that you did in the past couple weeks? And what gave you pleasure?" For example, if I ask you, what was the most pleasurable thing you did in the past couple of weeks?

Jennifer Ghahari:  I actually traveled. I just got back from Europe and it was amazing.

Norman Cotterell:  Okay. So I write under pleasure: traveling. And then I say, there might be some things which might not create pleasure, but they engage your mind. They turn you on intellectually. So looking back in the past couple weeks, what interested you? What engaged your mind in the past couple weeks the most relatively speak?

Jennifer Ghahari:  It might sound funny, but the first thing that just popped into my head was decorating for Christmas.

Norman Cotterell:  Decorating for Christmas. Okay so for pleasure, it was travel, for engagement, decorate for Christmas, and there might be some things which might not create pleasure, they might not engage your mind, but they build relationships. The people you care about, the things that you do for love, either to give love, receive love, express love, anything that you did to build relations with people you care about in the past couple of weeks.

Jennifer Ghahari:  Actually both of those things, the traveling and decorating for Christmas, I think.

Norman Cotterell:  Yeah. Doing it for others, it could be service. And that could include words of affirmation, that could include gifts that you give to people. It could include just simple quality time you spend with people. It could include, physical touch and affection, could include acts of service. Anything like that can be those languages of love, which I just cited that people do to build relationships with people they care about and love. And then finally I say, or actually second to last, I say, there might be some things though that might not create pleasure. They might not engage your mind. They might not build relationships, but they give you a sense of meaning and purpose. And sometimes I go back to what do you want your life to be about for that one?

What do you want your life to be about for that one? And I ask, if there's anything that you did in the past week or two that gave you a sense of meaning and purpose? And sometimes it's a tough one for people. So it's really a matter of saying and identifying what they're already doing that gives them that sense of meaning and purpose. And that could be things they do for security and stability. If that's important to them, things they do for stimulation or adventure or variety in life, that's important for them. Things they do to build connections with people they care about, things they do to contribute to themselves. Things they do where they can experience, intellectual, spiritual, or growth or things that they do that provide them a sense of accomplishment or significance for that matter, feeling important, feeling valued in some ways.

Though that's a categorization of values or needs that I found in two places, one was with Cloe Madanes, she divides needs into those categories and found something similar in the works of Norman Epstein and Don Baucom in their couple's therapy book which also has lists of needs. Lists of needs, probably in those categories as well between, sociotropic needs, autonomous needs in those categories. But, it's a short step between needs and values. And Tim Beck didn't like the word needs, so he changed that word to desires. Because he said, "We’ll always need food and water." But these are more like desires than needs.

So Epstein and Baucom called them needs, I can call them the desires. If you don't like the word needs, it seems needy. So he said desires. So short step between desires and values. So we can go for that. And so that's what I capture what gives them a sense of meaning and purpose is what valued action they engage in. They're already engaging in. And so when you think about that in the past couple of weeks, what did you do in the past week or two that gave you a sense of meaning and purpose?

Jennifer Ghahari:  For me, I've been learning to cook a little bit healthier. And so I think that's... And sharing that with family and that I think gives me a little bit more meaning and purpose. And speaking with you as well for this series.

Norman Cotterell:  And according to that categorization provides a little spice as the variety of the spice of life. And so you add a little spice into your foods and it provides contribution because you're giving the food to others, the sense of contribution to them and it maybe even connection for that matter. And also if they complement your food, you can feel, "Oh God, that's great." And also growth in terms of your learning a new skill, learning a new ability. So it might capture a variety of desires or values that you might have. And so when I come to meaning, it's almost like having them discover what they're already doing, that they're already doing that satisfies those desires, what they're already doing that is in line with their deeper, deeper values.

And then finally back to Seligman, again, finally, there might be some things which might not create pleasure, they might not engage your mind. They might not build relationships, might not give you a sense of meaning and purpose, but they provide you a sense of accomplishment. And looking back over the past week or two, what gave you a sense of accomplishment?

Jennifer Ghahari:  Ooh, honestly, I made some really good recipes.

Norman Cotterell:  Okay. Okay. Yes.

Jennifer Ghahari:  They came out so much better than I expected.

Norman Cotterell:  Okay. So that's what I write down. For the first I say, "I write down for pleasure." Okay, let's say it can be travel, for engagement, it was learning how to cook, for relationship, the same thing. For meaning, being able to learn new things and for accomplishment, sharing the food with your family. Yeah, for meaning sharing the food with your family, learning new skills as far as what to cook and for accomplishment, the same thing. And then I asked them, at the end of the day, this is straight from Seligman as well, "at the end of the day write three things that went well." Things that you did that either provided pleasure or engaged your mind or built relationships with people you cared about or gave you a sense of meaning and purpose, or gave you a sense of accomplishment. Not three of each, please that would be 15. That's pleasure or engagement or relationships or meaning or accomplishment.

And together they spell the word PERMA, stands for pleasure, engagement, relationships, meaning, accomplishment. And that's the first thing I do. So before every session, I'm in the habit of asking, in the past week, what did you do for pleasure? What did you do that engaged your mind? What did you do for relationships? What did you do for meaning? What did you do for accomplishment?" And if they say, "I can't really think of it." That's fine, but be on the lookout. And oftentimes people might say “Nothing provided pleasure.” And if I think that's an important one, I ask, "Was there anything you saw? Come to your senses. Was there anything that you saw that gave you pleasure?"

Jennifer Ghahari:  Yeah.

Norman Cotterell:  "Anything that you heard that gave you pleasure. Anything you smelled." The most primitive sense, before we could do anything else, we could smell. Anything, you smell, any aromas, direct beeline to the brain. Any aromas that provided pleasure for you? Anything that you tasted that provided pleasure. Anything that you felt that provided... And usually when you come down to sensory experiences, even people who said, "Nothing was enjoyable. No pleasure whatsoever." When you break it down to the senses, nine times out of 10 they can pick out something that provided pleasure.

They could find something that provided that measure of pleasure for them. So that's what I lead off with. And then I ask, what do you want to work on problematically that you dealt with in week? Or look on the list of goals, which are these goals you want to work on first? And then just use the tools to do that. But I really start off with asking what went well, because our brains are really built to focus on what's wrong, not what's right.

We focus on what's wrong. It could eat us for lunch as if our lives depended upon that. And really what we do for growth perhaps is to update the software a little bit by having people focus on what's right. Not on the tile that is broken, but the tiles that are intact: the broken tile syndrome. We have a tendency to focus on that one tile that is broken to the exclusion all the ones that are intact. And so by doing that, I'm having them focus on the ones that are intact. That's John Kabat-Zinn’s notion that as long as you're breathing, there's something right with you. So focus on what's right, because we're really, really good at focusing what's wrong. And so just them giving equal time.

Jennifer Ghahari:  Fantastic. So as a therapist specializing in CBT, would you have any other advice or recommendations for our listeners? This is the last question I always like to end with.

Norman Cotterell:  Advice?

Jennifer Ghahari:  Any words of wisdom or…

Norman Cotterell:  Yeah, be nice, have fun. I mean, at this point I wasn't prepared for that because I'll probably say something that's going to be really, really, really trite like that. But sometimes trite things carry some weight for me. And I'll probably know exactly what it was. I'll probably email you, "This is what I should said." Words of wisdom!

Jennifer Ghahari:  (laughing) We’ll put a “Part Two.”

Norman Cotterell:  Well, I'm thinking of... I had an uncle who was born in the 1870s. He died of 1980s. He was a son of person who had been enslaved. And before I went to college, my uncle Willie said, "I got one word for you son, one word.” He said, “Strive. strive." So I think of my uncle Willie, as far as that word strive. But he had fun in the process, he had a lot of fun in the process of his long, long life. I mean, he lived way over 100 and went in long walks around Manhattan, read the New York Times every day and maintained that curiosity. So I think probably the other thing that I think that's really important is maintaining that spirit of curiosity. Maintain it.

Jennifer Ghahari:  As you said too, also just looking for the little positives in every day, whether it's a smell or if it's something more significant.

Norman Cotterell:  Yeah. And growth. My father's an amazing man. My father, he grew up with a drunken, gun toting, carousing gynecologist as a father. My grandfather immigrated this country with $7 in his pocket, worked construction when he was in divinity school, pastored a church when he was in medical school and later taught medical school at Meharry (Medical College). And then drank himself to death in 1941. My father was serving in World War II. So I regard the first Dr. Cotterell as being a cautionary tale, but his son, my father: amazing. My father barely graduated from high school, volunteered, was part of the CC camps where he built the national park system in the Pacific Northwest and Northern California and volunteered for the Navy and his first experience was Pearl Harbor. He survived that.

And I didn't find out about his heroics until after he had passed away about what he did there that he was cited for. But he hated the story told about African American soldiers being cowardly. So he made a point to put himself as many dangerous life-threatening situations as possible. He was in World War II. He was in Korea. He was a civil rights actor. He marched with Martin Luther King. Martin Luther King actually marched with him in Los Angeles with his group, Congress of Racial Equality. He was the firefighter where his job was to run into burning buildings. And my dad was a wild swimmer, take a raft in the middle of the Pacific Ocean and swim laps around it in the middle of the Pacific Ocean as well.

Amazing, amazing swimmer. I have none of his gifts in that area. And also built an addition to the house, single handedly, mad, mad, mad skills, mad skills. But at the age of 85, when he was no longer going to break any records, because he was the guy who would do twice as many pushups as guys for half his age when he was a firefighter. The one-arm’d push up, it would be my dad. And at the age of 85, he wasn't going to break any physical records, but yeah, he took piano lessons. And had a piano recital the age of 86.

Jennifer Ghahari:  Oh, that's amazing.

Norman Cotterell:  And so I think that is my role model really for maintaining curiosity and maintaining growth even into your 80s. And my other role model for that of course is Aaron Beck.

Yeah. Working and writing and maintaining that undying curiosity to the very, very end. Both he and my father were active, up until shortly, case of Aaron Beck two days before he passed away. Case of my father, like a month, maybe less, because my father went into the hospital thinking he would survive the surgery and got plane ticket. And this is at the age of 91, despite his best effort to lead a short and a rough life, he still lived to be 91. And at 91 he was thought to be fit enough to survive the surgery for a benign tumor. He wasn't. But he had plane tickets. He was going to have the surgery, hop on a plane, go to my niece's wedding at the age of 91, but he did not survive the surgery.

So he kept that spirit up until the end. So really when I think of my words of advice, I say seek inspiration from those people you admire the most. We all have people that we admire and they serve as role models. And we all have people who are more problematic. They're cautionary tales. And those might be people where we do the opposite of what they did. Whatever they did, the first Dr. Cotterell, he taught me about the importance of fidelity and sobriety. So that's just a good role model as far as what not to do in those areas.

And also nonviolence too. He was not exactly a peaceful guy. My father, on the other hand, absolutely a role model of what to do. So I'd say what I do is I find the people who I admire the most. I find the people who inspire me. And as much as possible I model all their actions, I learn from them. And I put into practice what they taught me. That's how I honor their memory by putting into practice what I learned from my uncle, Willie. Putting in practice, what I learned from my father and putting into practice, what I learned from Aaron Beck.

Jennifer Ghahari:  That's wonderful. Thank you so much. I'm probably going to watch this interview myself about 40 more times just because I feel like I got so much out of it personally, so I'm sure our listeners will also have an amazing time listening to it. Dr. Cotterell from the Beck Institute, thank you so much for spending this time with us.

Norman Cotterell:  It's certainly my pleasure.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Kevin Chapman on Panic & Social Anxiety

An Interview with Psychologist Kevin Chapman

Dr. Kevin Chapman is the Founder and Director of the Kentucky Center for Anxiety and Related Disorders (KY-CARDS), and specializes in the treatment of anxiety, panic disorder and social phobia using CBT.

Jennifer Ghahari: Hey, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I'd like to welcome with us licensed clinical psychologist Kevin Chapman, who is certified by the Academy of Cognitive and Behavioral Therapies. Dr. Chapman is the founder and director of the Kentucky Center for Anxiety and Related Disorders, KY-CARDS. He specializes in treating anxiety, panic disorder, and social phobia, and has written a multitude of books, book chapters, and peer reviewed journal articles, including “Minority Inclusion in Randomized Clinic Trials with Panic Disorder” and “Clinical Behavioral Treatment of Social Anxiety among Ethnic Minority Patients.” Before we get started, can you please let our listeners know a little bit more about yourself and what made you interested in cognitive behavioral therapy?

Kevin Chapman: Thank you. I appreciate that. Well again, I’m Kevin Chapman, licensed psychologist. I'm originally from Louisville, Kentucky, and again, run the Kentucky Center for Anxiety and Related Disorders. And I've always been fascinated, honestly, with anxiety-related disorders and CBT in particular, because I was also a college athlete, and when I took my first psychology course, it kind of spilled into the abnormal psychology. And once I took that, I learned something in the literature that was pretty perplexing to me; it was “Wait a minute, more people have anxiety than anything else.” It's widespread, yet it's treatable.

So immediately I was like, “Oh, sign me up!” That's something that's not only challenging, but something where we can plug some holes. So as I matriculated throughout that process, I learned about the different modalities and types of therapy, and cognitive behavioral therapy not only was rational and logical, it just made a great deal of sense. And I think that the practical application of CBT that we know today is really attractive to me because it gives you the ability to not only be flexible, but also creative. So it was just a really fun approach, but also something where you actually saw what I call the “before- and after-shot” when you're working with clients who struggle with anxiety. So it just made a lot of sense.

Jennifer Ghahari: Great. We've had several clients reach out to us for help specifically for panic attacks. And can you explain what a panic attack actually is and what someone with this disorder might experience when they're having one?

Kevin Chapman:  Yeah, sure. So I mean, I guess we define panic as a discrete experience, like a concrete experience of the fear response, essentially, where you have intense fear and discomfort. Ultimately what we've learned about panic over the years is that panic is what we call a false alarm. It's essentially a fear response out of context. And I think for many people, when they realize that a panic attack and fear are actually the exact same process, it's just that I'm having the fear response out of context, that in and of itself can be really helpful in helping a lot of clients manage.

So in many ways, when we see the experience of panic, it's very discrete. So ultimately, we have the fight or flight response, right? Our body's flooded with adrenaline and noradrenaline. And ultimately, it's preparing us for perceived danger. So we have heart palpitations, shortness of breath, lightheadedness, smothering sensations, sweating, tingling sensations in our body, and essentially it's fight or flight. And the good thing, as you know, is that if I'm in actual danger, that's super adaptive and helpful. It's that when people have those recurrent panic attacks when there is no threat, that's a problem.

I always tell people that it's like saying, “I'm pulling a fire alarm in a movie theater when there's no fire.” And ultimately, that's very scary for people who experience it. And then they start pairing that with situations. And all of a sudden we develop agoraphobia, so I start fearing places and situations in which those panic attacks occur. And now I have two problems. I have that panic cycle, but then I have situations in which the cycle occurs, and therefore I'm really distressed when I go out and about.

Jennifer Ghahari: Wow. And what will be the best and most effective treatment for something like that?

Kevin Chapman: Yeah, that's a great question. And we often talk about the most effective treatments in that regard, and the first line treatment, of course, is medication, and medication certainly seems very helpful in that regard. And it certainly helps a client dampen some of the depression symptoms that come about, also the anxiety that's associated with it. So it decreases that negative affect, if you will.

But the gold standard treatment is cognitive behavioral therapy. And that's something that I certainly implement with my clients. So CBT, and of course CBT is the gold standard where we're teaching clients to not only recognize that, psycho-educate them about what's the difference between anxiety and fear and panic, but also teaching them the importance of the role that their cognitions or thoughts about having panic attacks and the sensations themselves, and in some people, the situations in which they occur, teaching them that their thoughts influence the physiological arousal, the feelings in their body, and that leads to subsequent action, which in many cases, of course, is avoidance of things that trigger panic. So teaching them how to engage in cognitive restructuring and engage in exposure-based therapy is really the best way to treat panic.

Jennifer Ghahari: And anxiety, particularly social anxiety, is another disorder that clients often reach out to us about. What is social anxiety, and can you describe what someone feels when they're experiencing that?

Kevin Chapman: Yeah, doc, I think that when we think about social anxiety, I think that the seductive part about social anxiety is that social anxiety is a normal part of life, right? And when we talk to clients about social anxiety, we normalize it, because it's saying, when we think about being in a situation that's unfamiliar to us or that's uncomfortable, that involves people, certainly anxiety to a degree is super helpful. So on the one hand, we all experience anxiety, but social anxiety when it becomes a disorder, is essentially me having this persistent fear, not just occasional, but a persistent fear of social or performance situations where negative evaluation may occur.

You'll appreciate this, but I'll often tell the clients, so think about that. Any social situation you find yourself in, like for example, Chick-fil-A, the nicest people on earth, you technically could be made fun of in the drive-through. Now granted, that's unlikely, but ultimately, any situation that involves a person has the potential of negative evaluation. So therefore, I have this persistent fear of making a fool of myself, being negatively evaluated, humiliating myself.

And that tends to include things like initiating or maintaining conversations, group discussions, the number one fear in the United States: public speaking, meeting new people, speaking to a figure of authority. And that creates significant distress, I'm bothered by it, and also impairment in my day-to-day functioning. So that's what we talk about when we say the disorder or the diagnosis of social anxiety.

Jennifer Ghahari: Wow. You had an article on the KY-CARDS site, on your site, which discusses how wearing a face mask ironically may impact someone's social anxiety. And can you explain the correlation that some people are experiencing with that?

Kevin Chapman: Yeah. You know, it's interesting, because if we had our druthers as fellow scientists, of course, we would want to study that and see how that comes out empirically. But anecdotally what we find, I think, that one of two things can happen because of the pandemic with the COVID, of course, pandemic. And I think that what we find is number one, for people who have social anxiety, I've found quite a few clients, when they wear a mask, it's somewhat of a buffer to their social anxiety. In other words, they feel less anxious, because you can't really see my facial expressions, and therefore I have an illusion of control. So on the one hand, you can see it as a good protector.

However, from a cognitive-behavioral standpoint, we could call that a safety signal, too. And that could be problematic, because once you're able to resume normal, as we know normal life at this point, and interact with people socially, that kind of essentially prevents you from navigating those situations the way that we would want you to in treatment. In other words, that buffer is temporary. Just like having a bottle of Xanax in my pocket or having some essential oils or my safe person, or whatever it might be to make me feel better temporarily. So on the one hand, it can be a buffer. On the other hand, it can backfire and perpetuate vicious cycles of social anxiety, because after all, we communicate often non-verbally with our facial expressions, and that's what many people are very sensitive to, is “how I appear to other people.”

Jennifer Ghahari: Wow. Okay. It's a lot going on. Yeah, it's interesting that it's almost like a Band-Aid, but like you said, once that Band-Aid gets removed, the wound is essentially still there. Wow.

Speaking of COVID, the pandemic has led to an increase in anxiety for so many reasons, like health, financial, isolation, fear of the unknown, et cetera, et cetera. And you've come up with an acronym on your website to help people find ease during the crisis. Can you explain to our listeners what that is?

Kevin Chapman: Yeah. And I think, you know, doc, that I love CBT. So any time I do any sort of media, my whole purpose behind that is to disseminate the science and psychology to help people on a day-to-day basis. That's why I like media platforms. It's for dissemination. So with that being said, the acronym that I came up with is steeped in CBT, and people have really resonated with it, because it's very practical and easy to understand, and we call it FIGHT. And in this case, we talk about “Fight COVID.”

So FIGHT is an acronym. The F is focus on what I can control. So ultimately, I can't control what will happen in three hours or what happened two hours ago. But what I can control is what's happening in this present moment. So kind of borrowing from mindfulness-based literature, I can focus on this moment in time. I can regulate my emotions. I can regulate my breathing. I can see how this couch feels on my body, things like that. And focusing on what I can actually accomplish in the moment is critical to regulating emotions as it relates to things like COVID and such.

The I is identify negative thoughts, and identifying of thoughts ultimately is super important for regulation because thoughts, particularly catastrophic thoughts or negative prediction type thoughts, tend to fuel the fire, of course, to strong symptoms of anxiety. And that's something that when we identify the thoughts that are leading to the emotional experience itself, that gives us a knowledge base to be able to alter that to some degree.

G is my favorite, it really is. And that's generating alternative thoughts. That's the heart and soul of cognitive therapy, is coming up with not necessarily positive thoughts, because there's a lot of things happening right now in our society that's just simply not good. However, we can be flexible in how we think about situations. And that's what's key to emotional regulation, is that if I'm flexible in how I think about things, coming up with different alternatives, that can lead to different emotional experiences, which is so important.

Which leads to the H, which is highlighting adaptive behaviors. What can I do behaviorally to alter my emotional experience? What can I do to help my neighbor? What can I do that's something that's an action step that will alter my entire emotional experience? You know, as well as I do, like with depression, if I can engage in behavioral activation, just walk down the road, that in essence creates endorphins. And then even if I didn't feel like doing it, it makes many people feel better. So engaging in adaptive behaviors.

And then finally it's something that we really nerd-out about, and that's T, and that's teaching somebody else the same principle. So CBT is not a selfish treatment modality. It's something where it's like, if I learn how to do it, then I'm becoming my own therapist, and therefore, I can teach somebody else the same exact thing. So that's the FIGHT acronym, and it seems to be pretty practical.

Jennifer Ghahari: Awesome. Thank you. And so as a psychologist and a therapist specializing in CBT, do you have any other advice or recommendations for our listeners if they're suffering from panic attacks and/or social anxiety?

Kevin Chapman: Yeah. Well, number one, I would say for sure, “You're not alone.” And I think in many ways, many people we encounter who experience anxiety and related symptoms, because it feels so bad and they have such low distress tolerance, I think that they often feel isolated and like nobody can ever understand how I feel. And I just want to say to listeners that, number one, it's normal to experience anxiety. Many people who don't have disorders experience panic attacks. The bottom line are these are all things that we experience on a semi-regular basis, especially social anxiety. So number one, normalizing your experience.

Number two, you can be helped. And I think that is so encouraging, because CBT is the gold standard for a reason. If you're motivated, there are people, capable therapists out there, who have the expertise to be able to help you navigate these situations. And I love this. This is one of my quotes. I call it the emotional law of gravity. Always remember that what goes up must come down, and that's true for emotions, too. So in many ways, when we think about experiencing distress, know that though it's uncomfortable, it's not threatening, and this too shall pass.

Jennifer Ghahari: That's wonderful. Thank you so much. I really appreciate it. And thank you for being part of this installment of The Seattle Psychiatrist. Again, a lot of our clients reach out for help on these topics, so we appreciate your expertise in helping out.

Kevin Chapman: Well, thank you. It's a pleasure. Thank you.

Jennifer Ghahari: Thank you.

For more information, click here to access our article in “The Seattle Psychiatrist” Magazine: The Impact of Nervous System Attunement on Social Anxiety.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.