ERP

CEO RUTH STRONGE ON BUILDING RESILIENCE & REDUCING ANXIETY VIA DONKEY EXPOSURE THERAPY

An Interview with CEO Ruth Stronge

Ruth Stronge, MA is the CEO of Snowdonia Donkey Sanctuary. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. She specializes in helping children, teens and adults build resilience and mitigate various anxiety disorders at her farm sanctuary.

Jennifer Smith:  Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview series. I'm Dr. Jennifer Smith, 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 Ruth Stronge, CEO of Snowdonia Donkey Sanctuary, located in Bangor, Wales. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. Ruth was a primary school teacher by training, and with the founding and development of Snowdonia Donkeys, she has been able to combine her passions. Before we get started today, Ruth, can you tell our listeners a little bit more about yourself, and how the rescue organization got started?

Ruth Stronge:  Hi. Well, thank you for inviting me. Yeah, I would say I have a passion for donkeys, and I have always loved donkeys. Maybe about 12 years ago now, there came an opportunity for me to get two donkeys, and I got two little donkeys. I kept them with my daughter who had a pony, and my children were older, my daughter had a pony, and our son was at the village, so we never rode our donkeys. We always took them for walks. And for me, spending time with those donkeys before work and after work were just the best time of the day. I would do it before I'd go to school where I was teaching, so then I was ready for school. And then on the way home, that would be my downtime of reflection. It went on from there and people, our friends that we knew said, "Please, can we come and walk the donkeys with you?"

And then we would bump into people with our donkeys, and they would say, "Oh, it's been ages since we've seen a donkey." And then, people just wanting to come and spend time with our little donkeys. It grew from there in as much as I wanted a donkey to ride, so I got another donkey. And then a group of friends, when we were out walking the donkeys, we were talking and decided if we could help any local donkeys, we would do that. We set up a small charity, and that was just 10 years ago now, a small charity to help local donkeys, and that's how we began, really.

Jennifer Smith:  Wow. That's great. Your website has a large banner that states, "Rescuing donkeys and changing people's lives," and I think that's a pretty moving statement, and I'd like to talk about some of the work that you do there. One of the first courses that you developed was for vulnerable adult learners, so that they could help build confidence by working with the donkeys. Can you tell us a little bit about that? How can caring for donkeys help someone?

Ruth Stronge:  It was a chance meeting with another organization, and telling them about the looking after the donkeys we do, and how volunteers were coming to help us, and how we were working with just giving people opportunities and time to spend time with the donkeys. And it was an organization in the center of Bangor who worked with adults, providing them with opportunities for support if they had mental health difficulties. And I invited their manager to come out and see the site that we worked on, and go through some of the activities that we did of how we managed our donkeys, which was following a simple routine in a quiet place, and basically just really being quiet around the donkeys, and being around each other, explaining to people how some of our donkeys are not used to people, and how we have to approach them, and how we read their body language so that we can support them in the best way.

And it was that opportunity and those conversations that allowed us to run a small program of one afternoon a week for people to come spend time outside with the donkeys. Initially, our volunteers and staff had done all what we would class as the "donkey work", so they'd done all the cleaning out, and the working out, and the feeding. But then just giving people time to brush a donkey and learning which brushes to use, how you would approach a donkey, basically reading body language, as well, of an animal, and giving them the story of the animal, and finding their character was the start of all that then, really. And for some of the people engaged with us, they became more and more interested, wanting to come more often, be more involved with what the animals needed for their welfare needs. And one of the really important things that we took from it was that it was a conversation piece for people. They had something to talk about with other people, what they had done.

Jennifer Smith:  Wow. Oh, that's great. And just for our audience to know, I actually met Ruth when I went for a tour of Snowdonia Donkeys, and it was really fabulous just getting to spend time with the donkeys, and I have to say there is something very soothing about it. Just brushing them, like you said, just petting them, just having that quiet moment, it really is nice. And going for a walk, and seeing beautiful scenery with them is a wonderful thing. I think you've stumbled upon, and definitely have built, a beautiful organization.

Ruth Stronge:  Oh, well, thank you for that. But I would say it's how I want to spend time with my donkeys. I know it works for me. And sometimes when I'm talking to people, if we're explaining the kind of work we do, and with our young people as well, and I would have to say it isn't for everyone, and that's okay. If you are more interested in fast moving things, and you are boisterous, and you are running around, then we are actually not the right place for you to be, because you would frighten the donkeys. And it's a case of, okay, let's take a step back. And our donkeys and our organization is very good at supporting quiet, anxious people, because that's the way we look after our donkeys in a quiet way, building confidence, following routines. And partly that has just evolved, but also my training as a teacher, I was an early years teacher, so the routines and the structures that we put in place to take away too many decisions initially for people were simple things like which donkey you're going to work with.

Well, if you've got a pink brush in your hand, then you are going to be brushing the donkey that's wearing a pink head color. The one in the picture behind me is wearing a pink head color. So you would know, she would have pink brushes, a pink bucket for her feed, and if you were going for a walk with her, she would have a pink lead rope. It sounds simple things, but it takes away anxiety from people if they don't have to ask questions. Some things are just pointed out for them, and next time they come, that routine is built upon.

Jennifer Smith:  Wow, that's wonderful. Through a partnership with Adult Learning Wales, you run an accredited course on animal care, which focuses on supporting young adults. Can you speak about what that entails, and how can young adults psychologically, emotionally, and socially benefit from that course?

Ruth Stronge:  Again, you realize as you do these other, things happen by meeting and talking to people. Behind the scenes, the young people that we work with, or the adults, for them, they don't always know where the funding comes from as enablers to deliver sessions for them. So behind the scenes, it's a bit like a jigsaw puzzle so that they can have the best opportunities. And if they are interested, they can stay as long as they can if we can afford them to stay, and to progress their development. So Adult Learning Wales are a national organization here in Wales that fund accredited and non-accredited courses for people over 16, and we had been delivering some courses that it called engagement courses, which were non-accredited. But working with some of our other young people who had come through us from another grant program which allowed them to do one-to-one sessions with an adult and a donkey, basically just being in a nice quiet environment, having someone to talk to if they wanted to, or just spending time with a donkey.

We were looking for a next step for some of these young people when we identified that for a vast majority of them, they hadn't engaged with the education system at all. They had, whether it be anxiety built on after COVID, or for whatever reason that they had, not been in the education system, so there were no exams, and there was nothing on paper for them to take their next steps. With the program that we had delivering one-to-one sessions, we then built on that, offering them some small group sessions, which for us would be no more than four or five at the most for a few weeks. And then Adult Learning Wales, because myself as a trained teacher, I can be a tutor for them, I approached them and said, "I have this group of young people, who some would like to go to formal college in the future, but I want to be able to acknowledge the progress they've made. And also once the summer holidays comes for some of our other young people, what do they do for six weeks?"

And I wanted them to be able to come and work with us, but we didn't have any funding to enable that to happen. So Adult Learning Wales helped me find a couple of, we would call them entry level modules, so not too high, but requiring some academic input on animal care. We would do things like how to muck out, and how to brush an equine. And the young people that we had focused on having come for one time, one session a week as an individual, and then as a small group, were then asked to apply, we knowing that they would always get on the course, but to give them a formal leading to it, to apply us for a fortnight, coming every day to take part in practical activities and record those activities using photographs and written work so that they could then submit it for an accreditation from one of our organizations, Agored Cymru which accredits their work and then they can build on that.

That was a journey. We've been plotting a journey for some of those young people, and they themselves wouldn't know who had funded their journey, but behind the scenes, we were able to do that. And for our funders, that's interesting as well, because they like to see that it has an impact, which it certainly does.

Jennifer Smith:  Oh, that's really fantastic that you help people to transition in that way.

Ruth Stronge:  And one of the things you asked was about their anxiety and their social skills, so that because they had had those small steps before they got to something that we called education, but we often didn't use that term, then we were trying to look at adding one new thing every time they came. If they were all familiar with the setting, then one-to-one was their first step, be familiar with the setting. The next change would be to work with a small group of people, and then to come every day for a longer period, so trying to increase that confidence, and reduce the anxiety as they took on new things, then.

Jennifer Smith:  Oh, wow. Yeah, that's similar to exposure therapy, correct? And like you said, to lessen their anxiety, the social anxiety and such, that's wonderful.

Ruth Stronge: By the time they got to the accredited side, brushing a donkey was what they would do automatically, so it wasn't the new thing. The new thing may have been recording or talking about what you'd done. So yeah, it's those small steps, and just building on that was really important.

Jennifer Smith:  Ah, fantastic. You also offer one-on-one sessions for those with additional learning needs. What types of conditions is this specifically geared for, and who can benefit the most from these sessions? Would it be people with social anxiety like you mentioned, or general anxiety, or anything else?

Ruth Stronge:  A lot of people with either social anxiety or general anxiety, and we do quite a bit with people with autism as well, who have communication difficulties. Communication difficulties on the side of struggling to verbalize their needs, or anxiety, or shyness, or selective mutism. And again, through following those routines and building that confidence, we've worked with quite a number of young people in that way to increase their confidence. And again, hopefully moving from one-to-one sessions onto small groups. For some of the people that we work with, it isn't always appropriate to do that, but if we can, we can do that, or we would then change or build on the activities that they're doing, so they are being more engaged in different activities. Some of our work, we also work with young people who may have learning disabilities, and may have reduced cognitive abilities, and again, we would match the donkey to their needs.

Some of the autistic people we have worked with are very sensory, some of them like to throw things around, so sawdust moving around the place obviously isn't appropriate for all our donkeys. And so, we've got some donkeys who are very chilled, and don't mind those things happening. But I would say where I find most pleasure is working with people with anxieties, and shyness, and quietness, because to see them make that progress, and to be able to talk, even to their families, about the donkey that they've worked with is just amazing, really.

Jennifer Smith:  Wow, that's wonderful. In terms of the people who have the mutism, as you said, or if they're on the spectrum and not very, or nonverbal, have you noticed where they do become more verbal, or this therapy isn't really applicable for that? Have you noticed a change?

Ruth Stronge:  We do notice a change, yes. And for us, it's trying to not put them into situations where they become more anxious, or it's not putting them in those situations where it makes it more difficult for them to speak. Just by following those routines every time they come, and building a rapport with one of our support workers, and especially with the donkey, then we found almost that the donkey acts as that diversion, that there's someone else, so there's something else to talk about, to be involved with. And then our staff are very much aware of the sensitivities of some of the people we work with, and wouldn't then ask them direct questions. They are very good at supporting the people to shine, and to build on the skills they've got, so almost praising them in a positive manner, using the language of support, and making suggestions together to do things is the way that we tend to build on people's development.

Jennifer Smith:  That's fantastic. And this sounds so perfectly suited for you and your background. It's really wonderful that you've been able to develop this.

Ruth Stronge:  It has just been amazing. Yeah, I feel very privileged to be able to do that, and also then to look around at the other people that I work with and say, "Yeah, I couldn't do it all myself," because there's not enough hours in the day, but we have some lovely members of staff who themselves have maybe been through some of our systems as well, and are able to talk about how working with the donkeys, and following the routines, and just being out in the fields with them doing field work, and then having something to talk about to people. Because we have visitors coming to see the donkeys, and they've got something that they can talk about that they've achieved, they know about this donkey, in a supportive environment. There would always potentially be a member of staff or a key volunteer who would be around, if we saw them faltering or being more anxious, could then step in and support, so that they didn't have extra worries themselves then.

Jennifer Smith:  That's fantastic. Can you tell us about the program that you run with the BBC Children in Need? What is it, and who does it serve?

Ruth Stronge:  Okay. BBC Children in Need is a national charity, a national grant-giving charity here in the UK, and we've had funding for quite a few years from them. And our program for them has always been targeted at young people, so for them, that's under 18, who have social and communication difficulties. And that can be, from our point of view, I guess it started with shy people and quiet people with anxiousness, and that's how we've kept on going with that. We offer them one-to-one sessions for an eight-week period of an hour with an adult and a donkey, in a quiet period of our week. And then, if they are keen to carry on, then we offer them small group sessions for a longer period. So that, again, a bit linking what you were saying back to the exposure therapy, they are quite familiar with the donkeys and the donkey routine when they've done the one-to-one sessions for six to eight weeks, and wanted to come for longer.

The only thing that is different then is there may be more people around. The staff tend to be the same, so they've got familiar people to support them. They know the donkeys. It's just extra new people, then, and that seems to work quite well. And those groups then go on as they get older, and we've had some people with us for quite some time now, so we've moved to being volunteers, or we call them supportive volunteers. Again, they are supported by key staff, funded by Children in Need, familiar adults who know or are aware of their own personal needs. But the older young people then, one of the targets is to take our donkeys to a local agricultural show, and show the donkeys to be part of something bigger, and that works really well. We do that as a day out, so they take the donkeys out for the day.

The show is a four-mile walk to get to, so they have to come the day before and get the donkey ready for the show. Then they have to come early on the day it's happening, walk the donkey to the show, be in the show ring. They will have spent quite a few months actually preparing for all this, but that is on those following through, and that's what we aim for them to be part of, so that then, again, following the journey with Children in Need, then they can be active volunteers then, in some respects giving something back to us, as well as their own lives then.

Jennifer Smith:  Wow, that's a fantastic cycle. Like you said, people get help, and then they help others, and it's just a wonderful thing.

Ruth Stronge:  It's really important for me behind the scenes, to provide that route for people. And I guess that's not just my teacher background, but also the psychology side of it is where do you go? Where is your journey on it? And I would say that I actually do that for all the donkeys as well. They all have a learning journey, too, and targets that I need them to achieve, and things that they can be good at, and stuff like that. But if the young people or the adults coming to us on the one-to-ones are making progress and want to stay with us, then we discuss with them those journeys we would like them to be able to take, if that's what they want, and how we can best support them on that.

Jennifer Smith:  Wow, that's wonderful to have those specific goals to try to reach for, if they're able and want to. One thing I saw on your website was that there was a video showcasing the experience of Zoe, who is 16 years old. Can you tell our listeners a little bit about what she experienced in life, and why time at the sanctuary has been essential to her mental health? And this is just one story, but I think it really signifies what your sanctuary can do to help people.

Ruth Stronge:  Yeah. Zoe has been with us for quite a few years now, and when she first joined us, as with all our children funded through BBC Children in Need, we asked them to be referred to us by a professional working with them. That could be a school nurse, it could be a teacher. We have something we call CAMHS over here, which is Children and Adolescent Mental Health Services so that we had some kind of filtering system, and we'd sent information to our school nurses and CAMHS, and also I often will give talks to the local authority, and give them some examples so that we work with the right people, so that we can have those best outcomes for ourselves, and for the people we work with. And Zoe was referred to us by CAMHS. She had moved to Wales just before COVID time, it was. She'd moved to Wales with her mother.

It was a one-parent family, and moved to quite an isolated place in Wales, as well. Quite in the countryside, quite remote, but didn't go to school, so was homeschooled as well as moving to a new place with one parent. And so Zoe came to us doing one-to-one sessions for her eight weeks. We had to let Zoe know before she came which donkey she would be working with, which adult would be there, reassure her that the adult would be waiting for her when she got there, again, to remove all those anxieties. And we actually sent her, before she came to us, a picture of the donkey she would be working with, so that she had some knowledge of what she was going to be doing. We knew that Zoe liked animals, and this was a good opportunity for her.

After her one-to-one sessions, she wanted to carry on coming, which was wonderful. And so, she joined a group that stayed for more, so she came from morning session again, five or six children at the most, with adults that she had met. But again, those preparation time and the information, so she knew what was coming, who she would be working with. Zoe had quite a lot of anxiety, as it sounds like, obviously when I'm presenting that to you, quite a lot of anxiety. And her anxiety would not only manifest before she came, but also during sessions, as well. If there was going to be something new happening, we would tell her beforehand.

There would be a lot of demonstrations. If it was maybe learning how to tie the donkey up, then a lot of demonstrations, let her do it without being watched, because she found that very anxious to be watched, or if she felt she wasn't achieving it, or couldn't get it right. A lot of support for Zoe in that way, repeating, and again, positive reinforcement, the things that she had done right, and then taking those small steps.

Zoe came when we were talking before about the two-week course. Last summer, Zoe came on that course for two solid weeks and she had never been... She was 16 then. She had never been in education since 11. That was the first time she'd ever done anything like that. In order for her to get support at college, which she then managed to go to college on the basis of having spent a fortnight with us and could demonstrate to college that she could commit to something, and was able to do that.

She had to have a psychology report, an educational psychologist's report. And what I personally found quite touching, and also quite a big responsibility, is that we were actually the only outside organization involved with that child, because she was homeschooled, didn't attend anything. There was nobody else to talk to the psychologist about her needs, and how best she learned. I spent a lot of time with the team that would've been supporting Zoe when she moved on to college, with the local authority, explaining how we supported Zoe. And again, I would say had I not been in the profession I was, I wouldn't have liked to have taken it on. And fortunately for me, the psychologist who was assessing Zoe, I knew her from school. She used to be my Ed Psych in school, so it was like, oh, that's great. We knew the language we could talk, which was really useful.

Having set that up for Zoe, and then her doing the two-week course, she was keen, and as she said in the little video clip, she was keen to start college, and excited to start college. And she has now just completed her first year at college, and has had really good attendance, a few ups and downs along the way, as most teenagers would do, but was very pleased to have finished her first year, and be accepted into the second year. We are just so pleased for her.

And the time with the donkeys, when you listen to her talking about it, she has a favorite donkey, and that's the donkey she's drawn to every time she comes, and the conversations that she would have with that donkey to help her work through some of her anxieties, and also helping him to work through some of his, because sometimes, we ask our donkeys to do things they don't necessarily understand. And it is those conversations that are helping the children or the young people that we're working with understand why we're doing this with the donkeys, and how do we teach them to do that, enables them themselves then to think about themselves, and how they can move forward as well.

Jennifer Smith:  Oh, wow. I recall also in the video, and correct me if I'm wrong, that Zoe was initially homeschooled due to bullying, and she developed some severe depression. And it sounds like because of the social support that you offered her as an adolescent, which is really critical to maintaining good mental health, that she was able to really develop great resilience. And, like you said, now she's in college, whereas before, it sounded like her life was almost at a debilitating level, where she was unable to really just get out there and function with others.

Ruth Stronge:  Yeah, it is amazing when you listen to what she says that we were the only place she would come, and then small number of people around her was all she could cope with. She wouldn't talk to anybody else. And some of the young people that we work with in BBC Children in Need who did that video always ask us can we give them a case study? They'd asked before, and Zoe wasn't ready to talk, because, and this is something we've had on a couple of occasions from our young people, when I come to the donkeys, this is special and I don't want anybody to spoil this, so I don't want to tell people at school, because that isn't a nice place where I want to be. This is my safe space.

For Zoe, on a number of fronts, it was very brave of her to talk about, not just what she had been through, but then almost that this is what she does, and she loves what she does, and she's a wonderful advocate for it. But it was an incredibly brave thing for her to do. And the amount, like you say, her resilience, and how far she has come is all credit to her. She's worked really hard.

Jennifer Smith:  Oh, fantastic. And the donkey that she likes is Norman, am I correct?

Ruth Stronge:  No, that's Walter. It's Walter.

Jennifer Smith:  Oh, Walter!

Ruth Stronge:  She likes Walter, and she says they have the same birthday. They're exactly the same age. Yeah, he's her favorite, and she does have a special relationship with him. He can be, as most animals can sometimes, he can be quite cheeky, and she won't stand any nonsense from him. One of the wonderful things that they did with this group of donkeys, and she was in charge of Walter, is one of the walks, I know you went on one of our walks, and one of the walks that we do, there's a little bridge going over a small stream, and if we could cross the bridge, we can go on longer walks.

But Walter couldn't cross the bridge. He just couldn't cross over this bridge, because of the running water underneath it. He was quite frightened. And for long, I'm saying years here, we would stand and look at this bridge. And one day I was on site, but I wasn't leading the group that Zoe was with. I think there was four young people with one of our other members of staff. And apparently, they'd gone out for a walk, and I knew they were due back at a certain time and they were late coming back.

As you do, I was worrying, where had they all gone? The parents were arriving, and they all came back laughing, but very late. And I said, "So, where have you been?" And Zoe said, "Well, I just said to Walter, 'today is the day we're going to cross that bridge. Sometimes, we have to do things like that. It's hard, but we can do it.'" And she got him to cross the bridge, and they all went over the bridge and could go for a walk. But he couldn't come back over the bridge, so they had to walk the long way round. They were all laughing. These young people were just howling with laughter that they've managed to do this with Walter, and Zoe had been wonderful and got him over there, but he said once was enough.

Jennifer Smith:  Oh, that's wonderful. And what a fulfilling experience for her to be able to get across, at least that one time.

Ruth Stronge:  He will go now. Next time, he was fine. He was just once was enough on that day. Because we do say to him now, "Zoe, are you going over the bridge?" and she says, "Yes, and we're coming back over the bridge, too."

Jennifer Smith:  So Walter had his own exposure therapy, it sounds like.

Ruth Stronge:  His own exposure, but for her, when she was saying to him like, "Walter, we look at this so often, we are going to do this bridge now." And that was just like, yeah, you are an amazing young woman to be able to say, yeah, I'm going to do this, and do it for herself, and for him. So, yeah, it's lovely.

Jennifer Smith:  It's very empowering. That's wonderful. Thank you. During the pandemic, you started a Long Ears Listening Project. I know donkeys have long ears, but what is this project?

Ruth Stronge:  Long Ears Listening is really all my passions all in one place, which was quite a privilege to do. As an early years teacher, when I left school, I knew I still wanted contact with young children. We do a lot of work with young people and with adults, but young children is an interest I've taught all my life in the early years, we would call it here in the UK, and outdoors and environmental education is my other interest.

When I left school and worked with the donkeys full time, when the pandemic came, we have a lovely patch of woodland that we manage, and it was used a lot during the pandemic by people visiting. I would leave activities and resources in for people to use, and then when we could meet together, we started a formal parent and toddler group for parents, and it's outdoors in the woods, and the donkey comes every session and carries some of the resources. With a focus on language and literacy through storytelling, then, we have a group of parents who meet every Monday morning and share time together. And whilst it is an emphasis on language and literacy for them, it's also a time for them to get together and just be outdoors enjoying themselves, and giving their babies and young children exposure to nature, access to animals, in a friendly, supportive environment.

Jennifer Smith:  And the benefits of nature therapy, or ecotherapy, like you said, just spending time in nature, and then you're with an animal, and then there's the reading... It's just beneficial on so many levels.

Ruth Stronge:  It's been a fascinating journey, that one, as itself has developed, too. And we have a small number of songs that we now use every time we meet in Welsh, so that we are then doing that bilingually for them. And they are about donkeys, obviously, so we do a few counting rhymes that we have. If you've ever met early years teachers, they'll sing to anything, a song, a counting song or anything like that, to a familiar tune, so we've made up a couple of songs that we sing about donkeys to start it off, and just a relaxing place for them to be out there. And they all have a little activity bag, which would have some sensory activities in, and a book. And again, that bit started with COVID when we couldn't share resources the same, so everyone had to have their own resources, and we actually just kept that up. If the child is not old enough to walk around, they've still got activities that they can do and interact with their babies with, then.

Jennifer Smith:  Oh, that's great. This has been extremely informative, and I think this time has unfortunately flown, for me, anyway. As we wrap up, is there anything else that you'd like to share with our audience about the sanctuary, or anything else mental health related at all?

Ruth Stronge:  Yeah, I think one of the things that it makes me realize is that I started it probably by accident, and because I know the benefit I got from being with the donkeys, and stroking them, and mucking them out before and after school, and then part of my work, making time to be out of doors in nature was so important to me, personally. And to be able to offer those opportunities to other people that, as you said, I went back to Uni to do my clinical health psychology degree, because I'm thinking, I don't want to just be the person that says, "I know it's good, and it really is nice." I wanted to embed it in the research, really. And we still work with Bangor University to try and get the psychology students to use as case studies. And for us, it's often another pair of interested hands as well.

But we're really keen that the work we do is the best it can be, not only for the people we work with, but to give the work that we do with donkeys, who often get quite a bad press, or are often looked down upon, and they're very hardworking animals, to give them a value as well. Because it just doesn't happen by accident. If it looks from the outside that it's easy, then sometimes, I think, well, actually that means we're working really hard, and it is working well. But behind the scenes, all that theory, and the small steps, and the thinking about how people need to move forward, and how we can help them do that is important. And I guess I would also throw in as well that for our staff and volunteers, we try to make time for them always to have what we would call "donkey time," so that they have their own mental health moments where they can just be with the donkeys, and enjoy doing those things and being in the moment with them.

Jennifer Smith:  Oh, that's wonderful. For our audience listening, for those of you who are local, or plan on traveling to Wales or the Bangor area, we're definitely going to link up in the interview so people can check out your website. Also, learn about different ways to support your group, sponsorship opportunities. I know you have some wonderful little knitted donkeys. I forgot to bring mine. (*photo at bottom of page)

Ruth Stronge:  I forgot to leave one out as well. Yeah, should have done that.

Jennifer Smith:  Yeah, different ways to support you guys and this wonderful mission that you're doing, that's helping both donkeys and people in a really wonderful cycle. So, again, thank you Ruth Stronge, for speaking with us today. And tell Jenny the donkey that I said hello. That was my friend that day. And we wish you all the best.

Ruth Stronge:  Thank you very much for the opportunity to talk to you, and we would love to see people over here. It'd be amazing.

Jennifer Smith:  Thank you.

Jennifer Smith with Jenny the donkey. (left)

A souvenier “knitted donkey” from Snowdonia Donkeys posing for a picture near the sanctuary in Bangor, Wales. (right)

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.


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

Social Worker Elizabeth McIngvale on treating OCD & Anxiety with erp

An Interview with Clinical Social Worker Elizabeth McIngvale

Elizabeth McIngvale, Ph.D., LCSW is the Director of McLean OCD Institute in Houston, and a Lecturer at Harvard Medical School. She specializes in obsessive compulsive disorder as well as anxiety disorders.

Tori Steffen:  Hi everybody. Thank you for joining us 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 like to welcome with us today clinical social worker Elizabeth McIngvale. Dr. McIngvale is the director of McLean OCD Institute in Houston, and a lecturer at Harvard Medical School. Dr. McIngvale specializes in obsessive compulsive disorder as well as anxiety disorders. She founded the Peace of Mind Foundation and ocdchallenge.com, which is a free self-help website for OCD, which is live in six languages and serves nearly 4,000 individuals. So before we get started today, Dr. McIngvale, could you let us know a little bit more about yourself and what made you interested in studying OCD and anxiety disorders?

Elizabeth McIngvale:  Yeah, absolutely. So I'm actually a clinical social worker. I do have my PhD, but not a clinical psychologist. And I think for me, I really entered the field because of lived experience. I've lived with OCD since I was a young adolescent and went through intensive treatment that saved and changed my life. I then really led into advocacy and started doing a lot of advocacy work around talking and giving back in different ways, which led me into this field. So I ended up doing my undergrad master's and PhD in social work and really was just, and continue to be just really excited to be able to do for others what people did for me.

Tori Steffen:  Awesome. Yeah. Thank you for sharing that. Well, getting down to the basics around our topic, could you explain for us what exposure and response prevention, or ERP, is?

Elizabeth McIngvale:  Yeah. It's actually exactly how it sounds. So it's an exposure with response prevention. So what we mean by that is that from an OCD perspective, individuals with OCD have intrusive thoughts, triggers, things that scare them, and they engage in a lot of compulsive behaviors. And these compulsions or rituals are done to try to alleviate the distress caused from the obsessions. So when we talk about ERP, what we're encouraging patients to do is an exposure. So they face their fear, maybe they touch a doorknob that feels contaminated to them or they do some other exposure, but we're going to ask them to engage in response prevention. So we want them to prevent the response they usually do. So we want them to prevent rituals. So if you typically would wash your hands after you touch something contaminated, we want you to touch that doorknob and not wash your hands. So response prevention is that not ritualizing part. That's really important.

Tori Steffen:  Got you. Okay. That makes sense. Is exposure therapy similar to ERP in any way or how might they differ from one another?

Elizabeth McIngvale:  Yeah. It's a great question. Obviously there's a ton of overlap, and it's very similar in the sense that you are facing your fears, you're doing exposures. We see exposure therapy be really useful in trauma work, in social anxiety work, for phobias, you name it. But what we know is that individuals with OCD, if they're doing exposures, but they're also ritualizing, they're reinforcing their OCD. So for OCD, the big difference is that it's still exposure work, which is very similar, but we have to no longer do the ritual. If we follow the exposure with a ritual, we reinforce OCD versus being able to reinforce treatment and treatment outcomes.

Tori Steffen:  Okay. Awesome. Yeah, that definitely makes sense. And what are the main goals of ERP as a treatment? Are there any specific things that a clinician expects to see?

Elizabeth McIngvale:  Yeah. I mean, obviously we want to see a decrease in the anxiety in the disability and in the hold that someone's OCD has on their life. But across the board, the bigger pictures, we really want to start to change individual's relationship with anxiety and their relationship with their OCD. So we want to be able to teach them that anxiety and OCD isn't dangerous. It feels really dangerous because of how we respond to it, and that actually if we change the way we respond, we get to change the power that it has. So I think the bigger goal of ERP is that individuals understand how to change their relationship with anxiety, how to change their relationship or the way they feed their OCD so that this treatment can not just apply to any future OCD or anxiety triggers, but also to life as well.

When we think about fear in general, we either feed our fear or we fight our fear, and sometimes we think that what we're doing makes sense because it gives us short-term relief, but it actually just makes the fear bigger. If my daughter is afraid of a dinosaur in a room and I get rid of the dinosaur so I don't have to deal with her anxiety, I'm actually reinforcing that dinosaur's scary and that you aren't capable of being around it and being calm. Where instead, if I do exposures, I teach her to lean in and to not be afraid of it and to be with it, she can change her relationship with fear. She starts to realize that, "When I'm scared I don't have to run from it. I don't have to ritualize to make it go away. In fact, I can approach it," and that fear will go away.

Tori Steffen:  Okay. Awesome. Yeah. It sounds like almost a training of coping mechanisms in a way.

Elizabeth McIngvale:  It is a little bit. I think the thing we want to be careful about when we think about coping mechanisms is a coping mechanism often makes us think that we're going to give you a tool to make you feel better. Actually, what we're really doing is trying to allow you to change your relationship with distress. So when you have distress, we don't want to just get rid of it or make you feel better, we want you to learn that you can sit through it and you don't have to respond to it, and it doesn't have to be dangerous.

Tori Steffen:  Okay, great. Thank you for explaining that. So when might a clinician know that ERP is the right treatment option for a client?

Elizabeth McIngvale:  So ERP should always be the first line treatment for OCD, it is the most evidence-based and has the most research to support it. So we always want to start with exposure and response prevention. When we're treating a patient with OCD, of course, the most common treatment is a combination of ERP and medication, and that's often the route that most individuals will go, but we definitely always want to start there. We never want to start with other modalities that are not as proven because I mean, we want to start with what we know has the best chance of success and the best chance of helping our patients. What I will say is that it's really important if you're an outpatient clinician or a clinician who specializes in ERP, if a patient is not making progress, it's really important to sit back and understand why instead of to just keep trying the same thing we're doing.

So some of the reasons why, it could be that a patient... It appears they're trying to do ERP, but maybe they're actually holding on, maybe they are still ritualizing, maybe they're doing mental rituals or avoidance behaviors, and they're still feeding OCD or anxiety somehow. Maybe they need a higher level of care, maybe their OCD is so severe, so debilitating that they're not able to do ERP on an outpatient basis in the sense that if they just come and do it for 45 minutes with you every week, but they go home and they're ritualizing, we're not going to see progress there either. So they may need some support, maybe they need a more intensive treatment program. So lots of things to think about when we're doing ERP with our patients as well.

Tori Steffen:  Okay. Awesome. Could you provide an example for us of an ERP treatment for a client that has a specific phobia, maybe fear of dogs?

Elizabeth McIngvale:  I mean, I think that typically for phobias, we're going to do more exposure therapy than ERP, so it's really going to be getting them to approach that dog. So we might start with looking at pictures, watching videos, and eventually we want to get them working up to being able to hug their family dog, be with their dog, live by their values. I want them to tell me why being able to be close to dogs is important to them, or the reasons that if they don't do it will impact their life in a negative way. We want to really push on those values. I guess if it was an OCD fear, so for example, if the dog is contaminated, we want to do the exposure of getting them close to touching the dog and the response prevention of not washing their hands or not changing their clothes or not engaging in cleaning rituals that they may normally do.

Tori Steffen:  Got you. So it's important for them to understand that even if the dog is contaminated, it's not going to kill them or give them a disease. Would you say that that's true?

Elizabeth McIngvale:  Yeah. So it feels like that's what you'd want to tell the patient. You'd want to give them that reassurance, but actually we want to lean more into the fact that like, hey, people touch dogs all the time and there's value behind it. It's more important for us to focus on doing an exposure and touching our dog, but we don't want to reinforce that, I'm safe. It's okay. Nothing's going to happen. People don't get sick because the reality is that people could get sick. I can't guarantee if you touch a dog, you're not going to get sick. I also can't guarantee that if you touch a dog, you will get sick. So we want to focus less on confirming or denying our certain fears and more on living by our values and not responding to our fears, letting that fear be there that, well, what if I get sick? Being able to acknowledge that and not respond to it. So not try to make sure you don't.

Tori Steffen:  Okay. Awesome. Thank you for clarifying that. What does the process of habituation look like in therapy? How is it usually conducted?

Elizabeth McIngvale:  Yeah. So habituation is a term we don't really use as much anymore in ERP. Habituation traditionally is the thought process that when you face your fear, when you do something challenging, while it will be triggering, eventually your anxiety will subside, you will habituate. It's like you go into a locker room that smells, if you choose not to leave, eventually you'll get used to the smell. The smell doesn't go away, but you habituate to the smell that you were experiencing. And that's really the thought process behind habituation, especially for OCD, is that if you face your fear and don't do anything about it, eventually your anxiety will drop and you'll see that you didn't need to do that ritual to feel better.

We have transitioned in recent years to what we call inhibitory learning, and the point of inhibitory learning is for us to recognize two things. The number one thing is that not everybody habituates the same, and so we don't want to give you the thought process of like, you're going to just sit in habituate, because some people, it takes a couple of hours or their anxiety lingers, and I want them to be able to go do what they want to do and be able to live their life, not sit there and feel like I have to wait to habituate first. But the second, which is more important, is what is the message of habituation versus what we call inhibitory learning? Habituation is an old school model where you might sit and touch something that's contaminated if this is contaminated, and the thought process was you just sit there and you sit with the distress until it goes away.

The problem with that is that what we're teaching you is that you can't move on until you feel better, and we're putting a lot of emphasis on the anxiety and distress. On like okay, the success measure is if you start to feel better, that means that you can face this habituate. What inhibitory learning says and what we're learn, what we learn and really want to practice is that actually you can face challenging things. You can lean in all the way and you can still move on while you're experiencing some distress.

So we want the emphasis to be much less on the distress because again, we don't want you to believe the distress is dangerous, and we don't want to send that message that the distress is really important. It's actually not that important, and it will subside if you don't feed it. But what we don't want to do is sit and wait. We want to make sure that we're emphasizing the distress less, and we're more living by our values. So you're touching this contaminated thing. You're still slowing down to lean in to feel the distress, to think about the fear and choosing to move on and go do other things even if the distress is still lingering.

Tori Steffen:  Got you. Okay. That definitely makes sense. What can a client expect to experience when ERP is working correctly for them?

Elizabeth McIngvale:  I mean, alleviation across the board, they should start to see their intrusive thoughts come with less frequency and with less intensity, and they should start to feel like they're able to get back to their life and functioning the way they want to. They should be able to envision living by their values and OCD not having a grip. My biggest piece is that I want all my patients to be at a place where OCD no longer makes any decisions for them or their life, and instead they're making those decisions for themselves.

Tori Steffen:  Okay. Awesome. How can a clinician tailor ERP for a client? So for example, how might ERP differ for a client with OCD versus panic disorder?

Elizabeth McIngvale:  Yeah. So again, remember with panic disorder, you're going to be doing more exposure therapy because there's not going to necessarily be as many rituals. There will be avoidance. So we're going to get patients to avoid less, start living their life, and we're going to encourage them to engage in exposure therapy. We may also be doing some CBT skills with panic disorder because there may also be a lot of distorted thinking, or maybe there is some ruminating after certain events that we want to help break that cycle. But there's not as many outward rituals with panic disorder, and so the emphasis is much more on exposure compared to OCD. It's going to be much more focused on exposures and preventing those rituals or responses.

Tori Steffen:  Okay. Awesome. How can a clinician train a client to continue ERP or exposure therapy on their own, even outside of therapy?

Elizabeth McIngvale:  Yeah. This is a great question, and really this is about that bigger piece we talked about early on is what do you want patients to get out of ERP? What we don't want them to get is just that they succeeded because their symptoms went down. While that feels like that's successful, what's really successful is that their symptoms go down and they understand the why, and that learning actually took place. So the goal with ERP treatment is that patients understand across the board that they've truly changed their relationship, their responses to anxiety and to OCD.

And if they've done that, then they get to do what I call ERP as a lifestyle where all the time you're having opportunities to face anxiety, to feel it, to lean in, versus to respond to it in a way that you run from it, or you try to get rid of it with a ritual. So ERP should be something that it shouldn't have to feel like sometimes when you're first stepping down from treatment, you need to do more dedicated ERP, but eventually it should just come innate. It should be natural that I'm responding to my life, to my values, not to my OCD, which means I'm doing active ERP all the time. But it shouldn't have to feel like it's active ERP, if that makes sense.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Is it ever possible for ERP not to be effective?

Elizabeth McIngvale:  Absolutely. I think that we definitely see ERP not to be effective if there's a lot of comorbid conditions. I think for me, one of the big things I want to know is if ERP isn't effective, why? We want to understand the why, and oftentimes it's because the patient's not ready or able to do ERP yet. So just because ERP is not effective right now, it doesn't mean it won't be in the future. For example, if a patient is dealing with a lot of distress intolerance difficulties, they're struggling to emotionally regulate, they may need DBT skills first so that they can do ERP. ERP probably wouldn't work right then for them. If their emotion regulation skills were really poor, their insights really poor, but it may be able to in the future.

Tori Steffen:  Okay. That's great to know. How might a clinician move forward? Let's say ERP isn't working for the client, and yeah, that definitely makes sense with DBT. Is there any other ways that you might move forward in that scenario?

Elizabeth McIngvale:  Yeah. I mean, I think the biggest thing when ERP isn't working is to make sure that your patient's ready for ERP. So we need to slow down. We need to think about motivational interviewing, we need to think about rapport building. We need to make sure that they understand why we're asking them to do this, that they're bought into it. No patient should be doing ERP because we're telling them to, they should be doing ERP because they see the value in it and they want to be doing it.

Tori Steffen:  Okay. Awesome. Well, do you have any final words of advice for us, Dr. McIngvale, or anything else you'd like to share with the listeners today?

Elizabeth McIngvale:  I think the biggest thing is just to remember that help and hope are always available, and what I want to make sure people know is that there is evidence-based treatment for any diagnosis you're going through. Make sure you figure out what that is and that you find somebody who has specialty training and background in that area.

Tori Steffen:  Awesome. Great advice.

Elizabeth McIngvale:  Okay. And for OCD resources, please always check out iocdf.org, which is an incredible nonprofit for OCD and host an annual conference, and is a great way to continue to get connected with the community.

Tori Steffen:  Awesome. Well, thanks so much for sharing your knowledge with us today, Dr. McIngvale. It was great speaking with you.

Elizabeth McIngvale:  You as well. Thank you.

Tori Steffen:  Thank you guys, 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.


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.


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

Ecologist Lance Risley on Mitigating the Phobia of Bats

An Interview with Ecologist Lance Risley

Lance Risley, Ph.D. is Professor Emeritus of Biology at William Paterson University in Wayne, New Jersey. He is an expert on bats and has conducted field research on bat populations for 20 years for the Federal and State Governments to study their health and ecological significance.

(Click here to access the photos at the bottom of this transcript)

Jennifer Smith: Hey, thanks for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Jennifer Ghahari Smith, Research Director at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. Today I'd like to welcome with us ecologist Lance Risley. Dr. Risley is Professor Emeritus of Biology at William Paterson University in Wayne, New Jersey, and is an expert in bats. Before we get started today, could you tell our audience a little bit about yourself and let us know what got you interested in becoming an ecologist -- and I have to ask, why bats?

Lance Risley: Well, thanks for allowing me to talk about bats. I appreciate that. I was born in California, so I'm from the West Coast, traveled across the country, lived in different states growing up, and always loved the outdoors, wherever the family was and liked identifying things. And that led me to major in biology to graduate school, and then to get into the world of ecology, which is what I spent my professional career working in - in the world of ecology, mostly ecosystem ecology, studying forests. And then I got into insects somewhere along the line and worked in the treetops and did some canopy related work. And doing that work, that was now in New Jersey, I spoke to a fellow who was a state biologist, and he asked me if I'd seen bats when I was up climbing around in the treetops. And I had no idea why he would even ask such a question because I didn't know much about bats except I thought they were underground, only came out at night and that was the end of it.

And he said, "Well, there's more to it than that, and that they might actually be eating and somehow regulating the insects that I was studying." That got my interest. Now then I thought, "Well, what do we know about bats? "Asked questions. He knew a few answers because there weren't very many answers, and that got my interest. So I attended a workshop on bats from Bat Conservation International and got over my fear of being out in the middle of the night in the woods because I hadn't done that before and wound up studying bats for about 20 years, and definitely got past the business of being out at night because it turns out it's a great place to be at night. Much different than I thought it would be, but that's what got me into bats.

Jennifer Smith: Wow, that's great. And can you discuss some of the research that you've conducted on bats?

Lance Risley: Yeah. The research that I did in New Jersey was very fundamental because we didn't have a lot of information on bats. We had, at that time, an endangered species, later, another endangered species. And so in trying to find out about bats, it was very simple in a way. It was going to different locations in the state, catching bats with nets, identifying them, so figuring out where bats were in the state, what areas did they like, maybe more than others, what species were there. And that focus later developed into one looking at mostly female bats. They're very picky on where they go in the summertime. So this was summer work, and then using radio transmitters to follow these bats around, find out where the females actually spent their time raising young and that was valuable information for the people that I usually worked with, which was everything from state wildlife there in New Jersey to the US Fish and Wildlife Service Department of Interior.

Oh, well, the Department of Interior, but well, what was National Park Service and the actually Federal Aviation Administration for some of the work that I did, but fundamental stuff. And then later in the research, as you know, recording devices got to be pretty sophisticated and pretty good at allowing us to record bats when we weren't there. Just put a recorder in the woods and listen in to those recordings, identify the bats, and then deal with that kind of information. So it has become more sophisticated now with technology, which I guess is a good thing. We know more about bats now.

Jennifer Smith: Great. And for our audience, a little bit of fun here. I actually worked with Dr. Risley back in the day. He was my professor, so we know each other pretty well, and I helped assist with some batting projects. Sorry, mom. Yes, it's true. So I can provide a picture for people too in the transcript, which is pretty fun, I think.

So, it seems like bats have gotten a pretty bad rap over time, and I don't know if it has to do with Hollywood or folklore, and it causes some people to have pretty bad anxiety about them. Only about 0.5% of bats actually carry rabies, but people tend to associate them with being disease carriers and dangerous. So do you know what has caused the association with people fearing the mammal?

Lance Risley: There's no one thing you could point to. Maybe it's because bats come out at night and that's mysterious by itself. They're the only flying mammals - that makes them maybe more mysterious. Somewhere along the line, they got connected with Dracula and then linked to Halloween. And of course, people have seen Batman movies and bats are portrayed in maybe not the best light. So in this country, they've been the subject of some maybe negative stories would be putting it mildly, some superstition. There's much superstition in the world about bats. In some places, the folks in different countries really have placed bats on a pedestal in a way with high value. And in other countries, they're the subject of superstition. We don't know for sure. And by the way, in October, I think it's the last week of October, it's officially Bat Week in this country to celebrate bats.

And the disease business has become interesting because we've all experienced COVID, some literally. And COVID has changed all of us. And where COVID began has been of great interest. So there's been a great deal of scrutiny put on bats, and were bats somehow responsible? So I can say that there is no direct link to bats or between bats and COVID-19, that particular virus. Bats do carry viruses, but about the same amount as any other mammal. There is no direct evidence that bats have contributed to Ebola virus being caught by humans. That's another story. So in the end, bats are much less disease issues than what we've given them way too much credit for. Bats have never caused epidemics of disease in humans. They do not have epidemics within their own populations. We know that if you carry rabies, and we can address that in more detail, it's a very small percentage. So they're much less of an issue than we've given them credit for.

Jennifer Smith: Oh, wow. Okay. And I think it's probably akin to "Jaws," right? There's a story goes out there, a book, a movie, and then like you said, just one thing platforms onto another, unfortunately.

Lance Risley: And there are a lot of myths and misconceptions. And maybe later we'll have a chance just to talk about a few of those that may surprise some people if they don't know a lot about bats, that some of these that have been brought down through generations are just absolutely false.

Jennifer Smith: Great.

Lance Risley: If we have time.

Jennifer Smith: Sure. So how likely, you had mentioned rabies, how likely is it that someone can catch rabies from a bat? If they're outside at night and you see them flying around, should a person run inside and seek cover? Do bats tend to attack people?

Lance Risley: So bats don't attack people, and we do know that there is a small proportion of rabies within bat populations. It never causes epidemics in bats. We think rabies probably evolved in bats. So within this country, if there are any cases of rabies caused by bats in humans, then it's typically because a human handled a sick bat. They didn't know it had rabies. You can't tell it has rabies. It looks like any other sickness. So maybe they picked up a sick bat off the ground, handled it, they were bitten or scratched, they were not vaccinated.

The researchers in this country that handle thousands of bats a year, I know of no cases of rabies and any of them, and I'm one of them. All of us get vaccinated before we do the work, much like a vet technician would, and that helps protect us. So bats and then rabies, it's real. But bats giving rabies to humans, it's just so, so unlikely. Meanwhile, if you're outside and you see a bat flying around, it's a healthy bat, doesn't present a problem for you, enjoy it. They're incredible to watch. They're aerial acrobatics are just second to none. So it should be a pleasure and certainly not a fear.

Jennifer Smith: Great. Regarding mental health, if someone has a phobia or extreme fear of bats and gets anxiety thinking about them, one way that they can help lessen that anxiety is to participate in what's called Exposure and Response Therapy, or ERP. Exposure therapy helps by slowly exposing someone to the thing that they have a phobia of in helping them overcome their fear responses. So in addition to (if they have this phobia or anxiety of bats) in addition to working with a licensed mental health provider to do ERP, what are some ways that you could recommend that a person could potentially be exposed to bats in a safe manner?

Lance Risley: One way, and there are all kinds of different ways to do this, some more direct. Some are the real kinds of things where you might enjoy watching bats fly around in the evening, and there are a lot of places to do that, whether it's a city area like Seattle or out in the countryside, whether it's a grassy area, forested area, the bats are there. And they're, again, they're a pleasure to watch. It's not a danger. There are other ways though, to get exposed. One is the zoo. I mean, zoos have bats from different countries, and they're pretty incredible. The bats in other countries are sometimes quite large. They have all kinds of really interesting eating habits different than the bats in this country, which for the most part, eat insects except for a few along our southern border with Mexico that feed on flower pollen and nectar.

So for the most part, enjoying bats outside is a great way to get exposed to bats. Seeing them in the zoo, which is a very protected space, and maybe even attending bat talks. Bats Northwest is an organization, a nonprofit in the Seattle area that probably has programs that are offered, I would imagine, educational programs for school groups and for adults alike. If there are local nature centers, I used to give talks at local nature centers in New Jersey about bats, and it's a pleasure for me to do that. And I think people really appreciate when they hear more about bats. And if that talk at a nature center is followed, maybe it's in the summertime, followed by a little walk into the area around the nature center to actually see a bat. It gives you just a much greater feeling of, I guess, appreciation for those animals. And those might be ways. I'm not in the world of mental health working, so I can offer up those kinds of ways to be exposed to bats in one way or another.

Jennifer Smith: Yeah. No, that's great. Thank you. And I think also just people listening to talks like this, as you said, it's just more education. It's just a way to learn a little bit more about them and be exposed in various ways. So it's definitely helpful.

Lance Risley: Yeah.

Jennifer Smith: So ecologically speaking, what roles do bats have?

Lance Risley: In this country, bats are primarily insect eaters. And in that, they eat insects, including mosquitoes, which plague us all. And they eat a lot of other insects that are negative influences on crops and crop production. So the feeling is, even in this country that bats may represent several billion dollars worth of value in protecting crops from getting eaten by some kinds of insects. So if a caterpillar is feeding on, let's say cabbage in a field somewhere in maybe California, Oregon, Washington, then that caterpillar will develop later into a moth. And that could be the favorite food of bats that fly around those fields at night. So in that respect for this country.

The pollinating bats along our southern border with Mexico are incredibly important to Saguaro Cactus. Those really tall columnar cacti that grow in the desert southwest are pollinated mostly by bats. So they're presence is mostly because of bats. Agave, the cactus that is later used to make tequila a valuable beverage. And whether you care for it or not, it is valuable economically. Bats are the sole pollinator of that particular species of plants. So in the world, bats pollinate over 750 species of plants. They're incredibly important in pollination. Some plants owe their existence to the bats. A big literally example is a baobab tree that grows the national tree of Madagascar, owes its existence to bats. It's a habitat for a lot of other animals.

So in other places, bats eat fruit and disperse seeds much like birds do and can be really important as dispersers of seeds, especially in rainforests. So just offering those up as bats being really, really important ecologically.

Jennifer Smith: Wow. And it's kind of ironic, because you had mentioned that bats eat insects like mosquitoes. Mosquitoes are notorious for spreading disease.

Lance Risley: Yes.

Jennifer Smith: So it kind of proves the point that bats are even more helpful. They're not really the disease carriers, but they're helping prevent the spread of disease, ironically.

Lance Risley: In that sense. Yes.

Jennifer Smith: Great. Okay. So you had mentioned that if bats were to go extinct, it sounds like agave, for example, that would not be able to reproduce, right, because bats are the-

Lance Risley: Correct. And it's not unusual in the world for plants to have very, very specific pollinators that they depend on for reproduction.

Jennifer Smith: Okay.

Lance Risley: Some plants can reproduce in other ways just through roots and other structures, but if their sole means is through flowering, bats can be incredibly important to those.

Jennifer Smith: Sure. And I would imagine too, that just ecological balance would be thrown off too, in terms of the insects that the bats eat, for example, if the bats were to go extinct.

Lance Risley: Well, good point, good point, because if bats are eating and focusing on one particular thing, then if the bat isn't there, those organisms are going to maybe have other predators in the case of insects, but maybe not very many. So those particular species of prey in that case might do quite well, and that might be an issue for us.

Jennifer Smith: Wow. Okay. Bats in the US have been suffering from a disease called white nose syndrome, which was initially detected in New York in 2006. According to whitenosesyndrome.org, it's been unfortunately detected as far west as Washington since 2016. And can you explain for our listeners what this sickness is and how it affects bats? And also can it affect humans in any way?

Lance Risley: Well, first, it does not impact humans at all. Humans do not get the fungus, other animals don't either. So it seems to be very, very specific to bats and bats, not just in this country, but also Europe and Asia. This country's the worst. So it's a fungus that causes this thing called white nose syndrome. It's a fungal infection of exterior tissues, kind of like skin. And the problem is that it infects hibernating bats. So I'll give you that in a moment. The name "white nose" is from the fuzzy fungal growth that occurs on the noses of bats infected. And at that point is bad news for the bat, because at that point, if the bat has an obvious white nose, it's probably the death of that bat. So when bats hibernate, they do so because of fat reserves that they've built up in the summertime and in the fall, late fall, usually they go into hibernation, which is a very, very profound kind of sleep.

And they spend several months hibernating, waking up here and there during the winter. So white nose syndrome as an organism that infects them, causes their metabolic rate to pick up. And because that increases that causes more fat to be burned. So the bats infected with this fungus wake up instead of April when they should and go out and start feeding on insects, they wake up too soon because they're now starving to death. Their fat reserves are depleted, and they either die in place and there are piles of thousands of dead bats in areas where white nose has hit. It's really horrible. Or they fly outside, it's winter, and they die of starvation pretty quickly and freeze to death, also. It's a gruesome death for the bats, and it's caused the mortality of over well over 90% of some species in the Eastern United States where I live. And it's marching across the country.

It's hit Washington state in 2016 and continues to spread. It's almost in every state now. It's not every state of the lower 48, but about 37 states. And it continues to increase. There is no cure. There's treatment for it after a sort. Bats are stable now in some places in the Eastern United States, however, bats have such a low reproduction rate that it's going to take a long time, if ever, for bats to return to numbers that once existed. So this is the fear for the Western United States, for Washington, Oregon, California, to suffer these same decreases in numbers. So it's a fungal disease. It's only in bats. It's gone through the populations of bats in this country like wildfire. It's killed millions of bats. We don't know exactly how many. It's the biggest mammal or well, mammal die off in recent history on the planet. So this is huge. And the good news is it's not as bad in Europe and Asia, but it continues.

So we're fighting it as best we can as biologists. There's some bacteria that have been used to fight it, and there may be vaccine for the bats in the future. It's difficult to vaccinate bats. It's difficult to reach them and numbers enough to be helpful doing that. So I guess that answers most of what I wanted to say about white nose. It's just been incredibly important to bats. It doesn't hit all bat species equally. So some species are surviving as if there was no white nose syndrome because they don't get it. And that includes some here in the East.

So there'll be some species out in Washington. Washington has about 15 species of bats that reside in the state. Some of those do not go underground to hibernate, so they will not be impacted by the fungus, and they'll do just fine and that's good news. So bats won't disappear completely, but the ones that have disappeared a lot, you have one in Washington called the Little Brown Bat, which has been proposed as an endangered species by US Fish and Wildlife Service because of white nose because the numbers have fallen so much. We don't know if it will be. There are, I think this year in 2023, the Fish and Wildlife should let us know if it's going to be endangered.

Jennifer Smith: So what are some ways that people can help protect the species? Is there any way that a random person can help make a positive impact in any way?

Lance Risley: Well, I think being positive about bats in conversations and being better informed. It's that negativity that seems to be easy with bats because it's already there among us. And I've seen this in programs that I've done on bats at nature centers, that folks in general seem to be sitting on a fence about bats. They're not quite sure which side they want to lean toward, whether bats are bad and they should be afraid of them, or if bats are good and they should enjoy them flying around just the presence of bats. And it's interesting. So I think even in conversation being more positive about bats, seeing bats and talking about how great that was to watch bats fly around. I mean, I can say that more here in the East with maybe more emphasis because we have fewer bats now. And I've talked to folks who've said they used to enjoy watching bats, and now they rarely see one.

And that's sad. But just being, I think, better informed. I mean, bats have been killed off by the hundreds of thousands. I know of some specific cases because of misinformation and prejudice against the bats, because thinking that they're bad somehow and being afraid of them. So what better way to deal with bats than to kill them? So that's sad. And it's typically from misinformation. So just that alone is useful to think more positively and talk about them in a more positive way. There are other indirect ways. There are certain kinds of plants that you could actually grow in a garden that might be good for the bats, and that might be indirect because of plants that you put in there to attract certain insects that the bats eat.

Even a pool of water in the backyard might be useful if bats are roosting nearby. Female bats in the summertime get really thirsty during the day, and when they come out at dusk, the first thing they want to drink is water. So they may take a dip, literally kind of skim along the surface of water and get a drink at a local little pond or pool.

Building bat houses. People have done that. It's a more direct way of being a bat proponent. And those have been really good scout projects, by the way, for bat houses to be built and mounted. There are all kinds of ways to do it properly. So you do maybe even attract bats. Bats need to be in the area for a bat house to work, but there are many plans available online. Those are ways.

And bats cannot be kept as pets in this country unless you have a special permit. And usually those are only with pet dealers, people that own and run pet stores. And those kinds of bats are maybe fruit bats. So if you ever go to a pet store and you see a bat that's a fruit bat that's in the store, unless you had a really super duper kind of wildlife keeping permit, which are difficult to come by, you couldn't keep one as a pet.

So as a result, if you ever found a bat that was wild in Washington or wherever, here in the United States, it's illegal to keep them. You can't keep them as pets. I would not recommend it. They're wild animals. But we have had interesting cases where bats roost on or near houses, and these are typically females that roost in groups in the summertime, and people have put cameras on. So if you want to have a bat cam on a local group of bats, it turns out to be really entertaining.

New Jersey did this. Their state and wildlife folks did this to a group of bats that were roosting on screen in a window. The window wasn't open to the interior of the house. And the bats would... They'd groom, they'd groom each other, they'd stretch their legs out and do all kinds of things that mammals do. And they even had pups, which were the young that females give birth to, and it turned out to be a really, really popular website. So there are all kinds of interesting ways then to support bats if you want to. You could be part of the big tourist groups that go see groups of bats.

The Congress Avenue Bridge in Austin, Texas is famous for its colony of bats, thousands of them that roost under the bridge in the summer. And then at dusk, they all come out by the thousands, and it's a huge tourist attraction. And there's even, I think, a bat parade that celebrates those bats. So I guess there are all kinds of ways that you can participate and be a part of the bat advocacy crowd. You can visit these places, or you can simply go out and watch bats on your own and enjoy that and talk about.

Jennifer Smith: Wow. I have to say, one of the most amazing things I ever saw was in Lake Tahoe about two years ago, just walking around, and it was around dusk and just happened to look up, and the sky was swarming with bats, and it was beautiful.

Lance Risley: Really?

Jennifer Smith: Yeah, it was amazing. And just as you said, they're very acrobatic in the way that they were just moving all around. And I was cheering them on because that means less mosquitoes for me to have to deal with. But it was just really wonderful to see them in action like that and in such healthy numbers as well.

Lance Risley: It is. And whenever you mention bats in numbers, that's the thing that we see in the movies that's supposed to make us afraid. But it turns out those are really places people like to go, and they want to witness that for themselves. Keep in mind that if you ever hear about those places, you never hear about bats coming out of the sky attacking people. You never hear about those people that are there getting rabies. So it becomes a popular and safe thing to do. So I guess there's some proof in that that bats are safe to be around, even if there are thousands and thousands of them not very far from you.

Jennifer Smith: Right. You had mentioned about how bats can roost by people's houses. So if someone was to come home, or they go in their attic and they see there's a few bats there, or if a bat somehow flies into your house and they make a wrong turn, what should someone do if they do find a bat or encounter bats in their home?

Lance Risley: So I've talked to people that have bats in their house. Love it. I don't recommend that they love that, but they do in some cases. And in one case, they would sit out in lawn chairs in the evenings and watch the bats emerge from the attic of their house and get a real kick out of doing that while they were all around their barbecue. Meanwhile, if you don't want bats inside your attic and you have them, you can call animal control experts. Animal control companies usually do have training on how to handle bats, how to evict them. They can't kill them. They can't use chemicals against them. So it's all mechanical based, and there are only certain times of year's to do that. So if you have bats in your attic, it's probably a bunch of females.

In the summer, they probably are giving birth to pups. So if you evict the bats at the wrong time, it strands all the pups, they'll die. So there are ways to do it correctly to protect the bats, protect yourselves, and that's typically done through an animal control company of some kind. Meanwhile, if you have bats that are on the outside of the house and you're okay with that, fine. The guano that they produce, guano, that's the bat poop, so to speak, guano is harmless. You can actually buy it as fertilizer. It's expensive to buy. So it's safe for people, and it is good fertilizer for the garden. It's about 10% nitrogen, I think. And so it doesn't present a threat. But if people don't want bats on their house using their house as a roost, and bats are loyal, they'll come back to the house year after year after year. And that could be for 20 or 30 years.

So evicting them is a good way to do this. If you don't know how, call the animal patrol people. Some people put up bat houses near their house, and upon evicting the bats from their house, the bats will then be looking for a place nearby, find the bat house and use it. So that could be good for the bats. Good for you, if you're okay with having that bat house.

Meanwhile, it's a whole different ballgame if the bat is in the house, in the living quarters of the house. So I went to a church once in New Jersey, and it happened to have bats in it and had probably for 100 years. The church was old. And every once in a while, the bats would get down in the sanctuary and fly around. And people didn't like that very much, especially during a church service. So I came in and gave some advice on how to cure that particular issue. So bats do sometimes get into living spaces or even working spaces. The Centers for Disease Control have very specific guidelines on how to handle that.

And there are different means of handling that bat or bats. Typically, it's one. Typically it's in the middle of the summer. It's a juvenile bat that's exploring and gets itself in trouble by flying into a house. So one way to get a bat out of your house is to try to close that space off except for a door or a window to the outside. If it's a window, make sure the screen isn't on it. Open that and wait for dusk. The bat will most likely fly out, and they're very good at navigating inside closed spaces. I've seen one fly inside a car, fly around in the car, eating insects attracted by the dome light of the car and fly right back out again without hitting anything in the car. Bats are very good at what they do, and they can do it in pitch darkness.

So them flying out of a house will be easy for them. If you don't want to do that and you're uncomfortable, again, you can call animal control. They'll come in. They'll probably catch the bat using a bucket, heavy gloves, something like that. They'll catch the bat alive, take it outside and release it. If it's a healthy bat, it'll fly away and be just fine. If you find a bat right outside your house, a cat brought it in, a dog brought it home, maybe the bat's injured, you don't know if it's injured because of the animal. You don't know if it's injured because of the sickness it has, not rabies, maybe something else. And you don't know if it's dying of dehydration, which they do sometimes on really hot days in the summertime.

So treat it as if it could cause you harm and either don't handle it at all or handle it with gloves. Put it in a bag or a container of some kind. Call a local health official. And that could be, it depends. It could be a state agency, it could be a county agency, it could be a city agency. It depends on where you live in the United States, how they handle things like this. You can submit the bat for having test... You can have it tested for rabies if you're concerned at all about the bat. You can simply hand it over to someone who knows how to deal with that bat. And in many cases, bats fly into a house. People have experienced it before. If these are places where there are a lot of bats and they either calmly go catch it with gloves and a pillowcase or something similar. Take it outside, let it go, and hope it doesn't fly back in again.

So in other words, there are all kinds of ways of doing this, but there are official guidelines that the CDC has provided for homeowners in case the bat's flying in a room with a child like an infant or with someone that's mentally disabled and would otherwise not know what to do if there was a bat nearby. So does that person need to be immunized against rabies? Maybe. And that depends on the situation, but there are ways by you if you have that bat to call either the city, the county. They have a health person that you could talk to and get some advice.

Jennifer Smith: Fantastic. Thank you. Is there anything else that you'd like to share with our listeners today? Earlier you had mentioned some myths about bats, I believe. If you want to-

Lance Risley: Yes. If we have time, that'd be a pleasure.

Jennifer Smith: Absolutely. Yeah.

Lance Risley: Bats are so amazing. And one thing I mentioned earlier, they live long lives. So the longest recorded lifespan we have is about 41 years for a bat. And bats, they're small, say about this large in this country, have been in zoos documented at over 30 years old. They're not ecologically speaking, little animals, mammals, never live that long except bats. So they're incredibly long lived, which is kind of neat. The bats in this country, for the most part are pretty small in terms of their body. Their wings may be about like this. Depends on the species. And the sad part with this white nose syndrome is they usually produce maybe one pup a year, rarely two of young. So thus, it takes a long, long time for bat populations to come back in numbers if those numbers have been depleted by disease.

So that's an issue just to bring up they're long lived, but they reproduce in very, very small numbers. I guess for the females out there that might be listening to this, when the typical US bat gives birth, that one pup might weigh a third, the body weight of the mother at birth, they're huge. And it requires a tremendous amount of food for that mother to get, the mother bat, to produce enough milk to feed that young pup. So female bats that are taking care of young eat huge amounts. They almost eat nearly their body weight per night, which is a lot of insects if you're counting the insects they're eating. So those are cool things.

The next part gets to expressions like "blind as a bat," which all of us have heard, and who knows where that came from. Bats have eyes, and they may be small in some bats, but bats can see incredibly well.

They see so much better than we do at night. And they see in shades of gray, for the most part, just like most night active animals do, but they see quite well, so they're not blind. So that's completely incorrect. Other kinds of things like "bats are rodents." There's an expression in Europe called "flittermouse" or a word. "Flying mouse," that's a term they use for bats. Meanwhile, bats are more closely related to us as humans than they are to rodents like mice or rats. And a real simple way to tell is if you've ever seen a picture of a bat, bats don't have buck teeth like rodents do. Rodents like rats and mice are built more for chewing very hard things like seeds. And bats meanwhile have teeth that are very much like cats and dogs. So bats are predators. They look way, way different in terms of teeth.

So that's a quick way to tell that bats are not rodents. "Bats get caught in your hair." You used to hear that a lot. The fear that if you had hair, I guess, and a lot of it, and you had that distinct risk of going out at night and a bat would fly in and get caught in your hair-- it doesn't happen. I've never heard of it happening. So you don't have to be afraid of that. I've heard of "bats flying right at me," especially for those people that have had a bat in the house. "It came right at me. It was going to attack me." And a bit of a story there. Bats, when they take flight, they're usually up relatively high because they don't jump into flight as many birds do. Birds can kind of jump up and then take wing. Bats don't have calf muscles that are developed.

They can't jump. So instead of jumping, they don't. They're hanging upside down, which is a longer story to explain. They hang upside down, which is called roosting. And they literally let go when they want to fly, they drop a few feet until they get air under their wings, then they can fly and maneuver. So if you approach a bat in a house and it's roosting, the first thing it needs to do to get away from you is fly. And that means it has to drop down, probably glide toward you for just an instant until it has enough air under its wings to then flap its wings and maneuver.

So that's a different kind of perspective, I suppose, on bats and let's see. Are there any other things? Let's see. On my little list here, I suppose I should mention echolocation, just because bats make sounds at night. Unfortunately we don't hear most of those sounds. It's out of our range of hearing. And they use those sounds to listen for echoes, to catch insects or to just avoid objects in their path. But sometimes you can hear bats. There are some bats that emit little clicking sounds. So if bats fly over and you hear something, it's okay. They're making clicking sounds and that helps them navigate or hunt something to eat. Just that most of the time you don't hear those sounds.

 And I've heard this one too. I just thought of this that people used to kind of in a guilty way, tell me, "Well, as a kid, they used to throw rocks at bats because the bats would dive at the rocks or move out of the way to avoid the rocks." And I can tell you, I've never heard of any bat ever being hit by a thrown rock because they can detect the rock coming and will first explore it. So probably fly around it and then realize it's nothing of interest, and then just let it go. So if you wind up throwing a rock up in the air thinking you're going to hit a bat, don't worry, you won't. And meanwhile though, the bat may come down and explore the rock, because it may think it's something to eat at first until it realizes it's just a rock. So don't be worried about that.

Other than that, I mean, there are lots of stories about bats. There are a lot of interesting superstitions people have about them. But I think blind as a bat is probably one of the big ones. We've already talked about the disease issues and basically the non-issues about bats and not to be worried about that. Just don't handle a bat with bare hands. That would be something you'd never want to do.

Jennifer Smith: Right.

Lance Risley: Enjoy them. Yeah.

Jennifer Smith: That's wonderful. Thank you so much Dr. Risley. And for our listeners out there, if you are anxious about bats or have any type of phobia about them, hopefully this will help and lessen your anxiety. And we'll have some links attached in the transcript. You can learn more. And thank you again, Dr. Risley, for joining us today and wish you all the best.

Lance Risley: All right. Thank you.

*For more information about bat conservation, check out www.merlintuttle.org.

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.

Jennifer Smith examining a Big Brown bat while assisting on a research team, under the direction of Dr. Lance Risley. Note: red lights are typically used as they cause less distress to the bats’ sensitive eyes (and are less harsh for humans, as well).

Photo Credit: Lance Risley, Ph.D. - Hibernating bats

(2) Indiana bats (grayish) - This species is located on the Eastern coast of the US. Heavily impacted by white nose syndrome and listed as Endangered.

(4) Little Brown bats (deeper brown) - This species ranges from East to West coast of the US, including Washington. Heavily impacted by white nose syndrome and likely to be listed as Endangered soon.

Photo Credit: Lance Risley, Ph.D. - Silver-haired bat

These species of bat ranges from East to West coast, including Washington. Since it roosts on the sides of trees, it has faced little impact from white nose syndrome.


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

Psychologist Travis Osborne on OCD & Hoarding

An Interview with Clinical Psychologist Travis Osborne

Travis Osborne, Ph.D. is the Clinical Director at the Evidence Based Treatment Centers of Seattle (EBTCS), as well as the Director of the Anxiety Center and Co-Director of Research and Outcomes Monitoring at EBTCS. Dr. Osborne specializes in the treatment of anxiety and related conditions, including OCD and hoarding disorder.

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're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today clinical psychologist, Travis Osborne. Dr. Osborne is the clinical director at the Evidence Based Treatment Centers of Seattle (EBTCS), as well as the director of the Anxiety Center and co-director of Research and Outcomes Monitoring at EBTCS. Dr. Osborne specializes in the treatment of anxiety and related conditions, including OCD and hoarding disorder. He has multiple appearances on the television show, Hoarding, Buried Alive on the Learning Channel TLC, and he is also a longtime consultant to the Seattle OCD and Hoarding Support Group and is a training institute faculty member of the International Obsessive Compulsive Disorder Foundation, IOCDF. So before we get started today, Dr. Osborne, could you let us know a little bit more about yourself and what made you interested in studying various obsessive compulsive spectrum disorders, including OCD and hoarding?

Travis Osborne:  Yeah, well thanks for having me today. So as you mentioned, so I'm a clinical psychologist, so the biggest part of my job is actually working with clients who have anxiety and related conditions. And the center where I work, in addition to being an anxiety specialty center, is also known for being an OCD specialty center. So when I joined that, when I joined EBTCS about 16 years ago, I actually had never treated clients with OCD before. I had treated anxiety, but I hadn't treated OCD. And so pretty quickly had to learn the treatment for OCD and get up to speed.

So I actually attended a training with the IOCDF International OCD Foundation, which you mentioned a minute ago that does these really great three day intensive trainings to teach clinicians how to treat OCD from an evidence-based perspective. And they're really doing a lot of good work to try to train as many therapists as possible to treat OOC because there's a huge lack of specialists trained in that treatment. So pretty early in that work went through that training, really fell in love with both the treatment but also working with OCD in particular.

One of the great things about the treatment, which we might end up talking a bit about today, exposure and response prevention is that's incredibly effective. Research has actually founded it to be one of the most effective forms of psychotherapy across all disorders. So it works well, which is exciting. And OCD is a really complex disorder. The symptoms can be very difficult for people to manage and figure out how to overcome on their own. So it's super rewarding to be able to deliver a treatment, has a lot of science behind it, and actually see the vast majority of people that do it get better. So fell into that work and then it's become one of the bigger parts of the work that I do over time.

Tori Steffen:  Awesome. Yeah, that sounds like a very rewarding field.

Travis Osborne:  Yeah, for sure.

Tori Steffen:  And I'm sure it's nice to have more specialists for the OCD and hoarding, so that's awesome. Well, getting down to basics, could you explain for our listeners what OCD is?

Travis Osborne:  Absolutely. So OCD used to be classified as an anxiety disorder, so that's kind of how it was thought of in the field for decades. And then around 2013, a new version of the classification system for psychological disorders came out. It's called the DSM-5 for a Diagnostic and Statistical Manual of Mental Disorders, version five came out. And in that version there was a major reorganization of several conditions and OCD and hoarding were a part of that major reorganization. And after a lot of research and work by the committees that put this together, there was a decision made to move OCD out of the anxiety disorders into its own new category called obsessive compulsive spectrum disorders. And as part of that decision, there was also a decision to make hoarding disorder formally its own disorder. So previously it had been considered a type of OCD, there was a lot of research suggesting that was not quite right, which we could talk about today.

And it also became its own disorder. So OCD kind of now anchors this whole new category that's been created. And so what OCD is, is a combination of intrusive thoughts and those can be words or images or kind of movies playing in one's mind that are very distressing, cause anxiety or related emotions. And then people do a whole range of rituals or compulsions, which are behaviors that are done repetitively over and over again in an attempt to bring down their anxiety and distress. And OCD can present in an infinite number of ways, but there are seven or eight kind of really common kind of subtypes, ways that it can show up, but really can be just about anything as long as you see this combination of these repetitive thoughts that are really bothersome and then these repetitive behaviors as an attempt to reduce that distress.

Tori Steffen:  Gotcha. Okay. That definitely breaks it down for us. And then hoarding disorders, since those are two separate things, could you explain for us that one a little bit?

Travis Osborne:  Yeah. So as I mentioned prior to 2013 hoarding had always been considered a subtype of OCD. So if you had hoarding behaviors, you came to a mental health professional, you would've gotten a diagnosis of OCD and they would've just said that the subtype that you had involved hoarding behaviors. Unfortunately, what we discovered is, I've mentioned a little while ago that the treatment for OCD works very well. It's an incredibly effective treatment. And so we had several decades of research showing that this treatment, ERP or exposure and response prevention works great for OCD when they started doing some more fine grain analysis of what happens when we looked at just the subgroup of people in those research trials that had hoarding symptoms, what they found is those folks were actually doing terribly. So the treatment was not working for them very well at all, but it was working for all these other OCD presentations.

So it kind of started giving us the hint that something is different about these symptoms and the way that we're treating it isn't working for these folks. So a fair amount of work in the '90s, early 2000s went into flushing out some more specific diagnostic criteria for a separate hoarding disorder diagnosis would look like. And then also developing a completely different treatment approach for the disorder given that ERP was not working very well. The other thing that was discovered is that if OCD, if hoarding was a subset of OCD, we should see really high rates of other OCD symptoms in people with hoarding if it really was a type of OCD. What they found is only about 18% I think it is, of people with hoarding actually meet criteria for other OCD behaviors.

So it's a pretty small group. So there was all this research that started coming out, but these are different things. So in 2013, hoarding disorder actually became its own standalone disorder. So that's not that long ago, it's less than 10 years ago. So if you think about that in the history of mental health field, that's a pretty new classification of disorder. Obviously the symptoms have been around forever. What that means though is that the treatment research and the research on hoarding is lagging decades behind disorders like OCD and depression and anxiety, things like that because it is a pretty new kind of standalone disorder. And so what the criteria for hoarding disorder look like is people basically holding onto or saving a large number of things regardless of their actual value, having considerable difficulty getting rid of things and often only get rid of things if sort of pressed by others.

So it could be other people living in the house or landlords or other outside entities that might be involved and a fair amount of distress when faced with actually having to get rid of things. And then what that leads to is a tremendous amount of clutter in people's homes and an inability to use their homes as they're designed. So perhaps the kitchen table is so cluttered you can't actually eat at it. Maybe your kitchen counters are so cluttered you can't use them to prepare food. Your bed might be so cluttered you can't sleep in it, so you really can't use your home as it's intended. And so when we look just at the symptoms, they're actually pretty different than what OCD looks like. OCD, we have these recurrent thoughts and then these recurrent behaviors that people are doing in response to those thoughts.

And although hoarding could be seen as a compulsive behavior, it's a much more varied and complicated picture. And then you also have all these physical belongings that make it very different too. So the good news is a new treatment has been developed, that treatment is showing good promise, certainly much better promise than what we were doing before. But it has also really helped us understand that these are two very separate disorders. People can have both, but the majority of people that have one don't have the other. It's a relatively small number of people that have both.

Tori Steffen:  That's pretty interesting. It sounds like there's a lot of differences in the way that they present themselves as far-

Travis Osborne:  For sure.

Tori Steffen:  ... as symptoms go. Are there any ways that OCD and hoarding disorder are connected?

Travis Osborne:  I think the shared connection, and I think this is reflected in this new category of DSM that I mentioned of obsessive compulsive spectrum disorders. So they're both sort of under that umbrella, which is a recognition that there are some shared components. I think the component that probably would be arguably the most shared is that the compulsion, if you will, in hoarding is saving things. So not getting rid of things. And then for some people excessively acquiring things. So not all people with hoarding acquire things at a really rapid rate or excessive rate, but some do. And I think that as described as a compulsive type behavior, you could argue sort of fits, but there's actually I think actually more differences than similarities, kind of reflecting the division of them. For example, in OCD, the emotion that tends to be most predominant when people have their obsessive thoughts or encounter triggers for their OCD is anxiety usually, or fear.

There are other emotions too, but that's the most prominent. And anxiety is not necessarily the most prominent emotion in hoarding, it could be loss, feelings of sadness and loss when you get rid of things or anger when people suggest that you do get rid of things or try to help you get rid of things or push you to get rid of things. And so there's just a lot more variability in the emotions that come up, what those emotions look like. Whereas in OCD we see a lot more kind of narrower range of it typically looks like fear and anxiety, some other emotions sometimes. So they're pretty different in terms of the emotions that pop up too.

Tori Steffen:  Okay. That definitely makes sense as far as how they can be differently understood. So I saw an article on the EBTCS site that noted most OCD symptoms can begin in childhood. Do signs and symptoms of OCD tend to defer among children and adults?

Travis Osborne:  That's a great question. So the vast majority of people with OCD do show symptoms in the childhood or teen years. It can come on in adulthood, but that's more rare. And when most adults look back, even if they didn't have kind of full-blown OCD, they can see the traces of those behaviors. What's interesting is the symptoms themselves look pretty similar in childhood and adulthood.

So the subtypes that I mentioned of OCD that are pretty common are kind of the same subtypes show up in kids as show up in adults and what the big broad categories of those look like is contamination concerns where people probably the rituals are engaging a lot of hand washing or showering or washing their clothes, cleaning that kind of stuff, doubting whether you've done something. So did I check the stove? Did I check the lights? Did I check the car? The fear being that something bad could happen if I didn't do those things. And then the checking behaviors that can go along with that.

Obsessive thoughts about harm are really common. It's one that's not talked about a lot, but they're very high number of percentage of people who have what we call harm obsessions, which could be worries that they're going to harm other people in some way or concerns that they're going to harm themselves. And then usually lots of avoidance of situations where that could be potentially possible. Another major subtype is sexual obsessions, people having unwanted sexual thoughts. And we see this in kids and teens just as much as we see them in adulthood as well. And then what we call just right obsessions, which are needing things to be a particular way. And that could be anything from needing things to be symmetrical or done a certain number of times or done a particular way or doing something until you get a feeling that it's right. And then you can see a lot of repeating of behaviors until you get it right, in some sense.

Probably forgetting one of the subtypes. But those are the main kind of subtypes. And then from there, OCD can really be about, oh, the other one is called scrupulosity. So this kind of either religious or morally themed obsessions about, "Have I done something wrong? Have I done something sinful?" And then lots of rituals usually that are related if it's religious like praying or confessing or things like that. If it's more moral, it could be asking reassurance about whether somebody else feels like maybe you did do something wrong or whether you did X or Y or trying to evaluate whether you have made some kind of mistake or transgression or things like that. And so what we see in kids is the same subtypes, but maybe the way they show up just isn't as developed as it might be in an adult brain. But the things that kids with OCD worry about essentially are the same things that adults with OCD worry about.

Tori Steffen:  That's very interesting. It sounds like anxiety and then fear are probably the main symptoms that show up for OCD. Are there any that we're missing from there?

Travis Osborne:  So sometimes people can have disgust and disgust can show up in different types of contamination. So people feel like if food is rotten or if they feel like it's spoiled. Or some people with contamination concerns won't handle raw meat or eggs because they worry about salmonella or they worry about other diseases. They can actually feel fear, but also just like, this is gross, this is just kind of a disgust response. So disgust can definitely come up. And then I think guilt and shame can come up a lot when people have harm and sexual obsessions, so worries that they're going to hurt people or behave sexually in a way that's inappropriate. People can feel a lot of shame and guilt about those thoughts as well. So fear is kind of the biggest one and then disgust and shame and guilt can sort of pop up too.

Tori Steffen:  Okay, great. What kind of treatment options are available for those with OCD and hoarding disorder or maybe just OCD and/or hoarding disorder?

Travis Osborne:  Yeah, yeah. So for OCD two, clear treatments, one would be medication. So medication has been very repeatedly proven to be helpful with OCD, particularly the SSRI medications, which are also used for things like depression and other kinds of anxiety. Those can be extremely helpful for folks. The caveat is oftentimes for people with OCD, the doses of those medications need to be higher than for depression or other types of anxiety. And not all medication providers have that training. And so don't always know to try higher doses if lower doses aren't working, the medication can be very effective. And then the therapy that's most effective, as I mentioned, is something called exposure and response prevention, ERP for short, that's a treatment that was developed in the '80s and has 30 plus years of data behind it. There's probably somewhere between 40 and 60 randomized control trials evaluating that treatment with kids, teens, adults, very robust database.

And what ERP involves is having people systematically approach the things that trigger their OCD, make them feel anxious, and then have them practice not doing their rituals, not avoiding in response to it. And doing those two things together kind of helps people learn new ways of facing their OCD symptoms and breaks the cycle of OCD that people get stuck in. It's hard to do because it involves facing your fears, but what I usually tell clients is that, "It's no harder than living with OCD because if you have OCD, you're also feeling fear all the time anyways. At least with treatment, if you're feeling fear, it's in the service of you getting better as opposed to your OCD you're feeling fearful all the time, but you're just stuck in this endless kind of loop."

So the treatment for hoarding so far, we do not have any medications that are a clear home run for hoarding symptoms that is unique in the psychiatry psychology world. We do have medications for most disorders and we don't have a clear medication for hoarding. So what we think about for medication with hoarding is treating other conditions that might go along with it. So if someone is hoarding and also has depression or has a problem with hoarding and also has anxiety or an attention deficit disorder, we think about using medications to treat those other conditions because sometimes they make it harder for the person to do all the work involved of going through all their belongings and getting rid of stuff. There's no medication yet specifically for hoarding.

Then the treatment, the therapy that's been found to be most helpful for hoarding is a type of cognitive behavior therapy or CBT that has been specifically developed for hoarding that teaches people strategies that address the three components of the problem, which would be acquiring if they're bringing things into the home, the saving, not getting rid of stuff, and then the clutter that develops in the home.

So there's different strategies to help people tackle each of those things. And it's a pretty hands-on treatment, like ideally it's actually done in people's homes. So therapists often go into people's homes, actually help them go through their belongings, learn how to make decisions about what to keep and what to get rid of, and then actually practice going through that process until it becomes less distressing and they get better, better and better at it. Can take a while as you can imagine if a home has a lot of things in it, that process can take a long time, but for now it's the only treatment that we have that has some research behind it.

Tori Steffen:  Well, it's good to hear that there is the research out there and techniques that can help people with both hoarding disorder and OCD. So thank you for explaining that. That was very educational. Well, a past interview of yours with NPR notes that one goal in treating OCD as you mentioned is to limit that amount of ritualizing. Can you explain for us how that's usually accomplished in the treatment process?

Travis Osborne:  Yeah. So that part of the treatment is the response prevention part. So the exposure is facing the thing that makes you anxious and the response prevention is the trying to not ritualize or avoid in response to that. So I think there's lots of ways. Some people we can get them on board with just stopping certain rituals and they're able to do that in response to very specific situations. They might not be able to stop the whole thing, but if we're working on something, they might just be able to say, "Okay, I will work on just not doing this ritual and I will ride out this wave of anxiety that I'm having." Not everyone can just do that.

So other ways that we help people is usually rituals are pretty repetitive. Someone's washing their hands, they might be washing their hands multiple times. Usually the rituals take up quite a bit of time. So if there's a way we could say, let's say somebody always washes their hands like five times, can we go from five to four? Can we go from four to three? Can we go from three and fade out the hand washing over time? That's one way we might do it. Or maybe they're just at the sink for 20 minutes and they're just washing the whole time. Can we go from 20 to 15 to 10 to 5 getting down to what would be a normal 10 20 second hand washing? Sometimes we have to shape things in the right direction, slowly cut things out.

For other people; let's say some people get really stuck when they're leaving the house. They have a whole sequence of things that they have to check before they leave to make sure everything is safe. So maybe they check the lights and the stove and the door locks and make sure they unplugged anything that was plugged in anywhere and they go through this whole sequence before they leave.

In that case, what we might do is eliminate one step at a time. So for this week, could we eliminate this particular thing and you're going to do the rest of it, and then next week could we add another thing? Could we slowly cut down that? And so we have eliminated all of those things, but what we're always looking for is how to create a pathway for people to get to where we want to go at a pace and a way that they feel is doable. So if someone can just say, "I could just stop doing that," then we'll do that. If they can't do that, then we'll start thinking, "How do we get you from where you are to where we want to get you and how do we slowly break that down into smaller and smaller steps?"

Tori Steffen:  Okay, yeah, that definitely makes sense how that could be helpful to phase people out if needed. So that's great. And one thing we also touched on earlier is the success rates for treating OCD. They're often much higher than other mental health problems. Do you have any ideas what might cause the differences between the success rates?

Travis Osborne:  Yeah, that's a good question. So anxiety disorders, broadly speaking, have pretty high success rates. So I think part of it is as a field we understand fear a lot better than we understand a lot of other disorders. And I think our science has helped us figure out what are the strategies that worked for fear. And what's interesting is intuitively we all know that to get over fear, you have to do it. So the way you get over fear is by doing it. So it's like you're afraid of swimming, what you need to do is get in a pool. If you're afraid of flying, what you need to do is fly more. We know that as humans, but it's so hard to do that a lot of people just end up avoiding and not actually doing it.

So I think because we have some pretty good basic science around fear, what's actually happening in the brain around fear, what happens when you don't avoid that has really led to the development of treatments like exposure therapy, which turned out to be really effective because they're really linked to the science of what happens with fear and treating fear. And I think with other disorders we're still trying to understand better what's happening in the brain? What's some of the basic science of what's happening, and then how do we link treatments to those things? And then some other areas I think we just don't have that quite figured out as well. So exposure turns out to be a really powerful intervention that works well, which I think is why we see such big effect sizes in the studies that show that it works.

Tori Steffen:  Gotcha. That's great that we have those scientific backed up techniques on how to treat that.

Travis Osborne:  Yeah, I mean one of the things that's incredible to me is prior to the 1980s, OCD was really considered a form of severe mental illness that was largely considered untreatable. We did not have treatments really that worked well for OCD and it was considered a chronic untreatable or not very successfully treated illness. Then the '80s we had these two breakthroughs, we had the breakthroughs of SSRI medications that started to be found to be really effective. And then we have the development of ERP exposure therapy in the early '80s as well. What's amazing to me is just in the span of 30 years, 20, 30 years, we went from OCD being essentially a untreatable severe mental illness to the disorder that has some of the highest success rates in the whole field, all driven by science, all driven by evidence based procedures, which I think also just underscores the need for science backed treatments like that basic science that helped us understand what's happening in the brain when fear is activated, what happens when we do exposure and stick with the fear, how that changes things.

All that sort of led to the development of a treatment that now is highly, highly effective, which is super cool and exciting. And how in that span of... well, some people's lifetimes, I've treated clients who were much older who when they were kids, teens, early adults, there was no treatment for their OCD then by the time they were older, there now was a treatment for their OCD and then they finally got the treatment that they needed and it worked really well for them, which is pretty life changing.

Tori Steffen:  Absolutely. Yeah, that's really good to hear that a lot of people have been helped by that. So hopefully those scientific findings can keep coming and helping us for other disorders as well. So in an article, you mentioned that hoarders can sometimes perceive themselves as collectors. Could you explain maybe the difference between a hoarder and a collector for the audience?

Travis Osborne:  For sure. Yeah. I think the term hoarding and hoarder are so negative and have so many negative connotations in our culture. That makes a lot of sense to me that if somebody is struggling with clutter, it's way more comfortable to see oneself as a collector than as having a problem with hoarding. So I think people will gravitate toward that term because it's just not a term that has a lot of negative sort of bias and kind of stigma attached to it. When we look though at what collecting looks like and what hoarding looks like, they're totally different things.

So most people who are collectors, it is true, they might have a lot of possessions and they might have categories of things that they collect a lot of whatever, whatever it is they collect, whether it's baseball cards or fashion or artwork or cars or whatever it is they collect, they probably have a lot of those things and they may have a hard time actually getting rid of things that they collect because they're pretty attached to their collections, they like their collections and they've spent a lot of money and time on their collections.

So parting with those things could be pretty hard. However, they don't tend to have any issues with acquiring other stuff. They don't tend to have any issues with getting rid of other stuff. And most people who collect are super proud of their collections and will go to great lengths to display them in their homes, keep them really organized and beautiful. They get a lot of joy from sharing their collections with other people, showing people their room that has baseball memorabilia in it or whatever it might be. It's something that they get pride from, share with others, and there's a lot of joy around that.

In hoarding what we see is the complete opposite. So there's rarely organization, there's a lot of clutter and difficulty to navigate or find things. And most people with hoarding do not want anyone coming into their home. So whereas a collector might love having somebody over and sharing their collection with somebody, somebody with hoarding typically does not want anyone seeing the state of their home that would cause severe shame, distress, they actively work to actually keep people out of their homes and keep people away from their homes.

And most people with hoarding, some people with hoarding do only hoard specific things, but a lot of people with hoarding the stuff is the collecting is or the acquiring, accumulating is pretty broad based. They have too much of all over the place, too much of everything and it's not usually as specific to something like a collection. And then of course they also have the broad base difficulty with parting with things. So I think what the home looks like is pretty different between collecting and hoarding and then the fact that people with collecting want to share it, want to show it off, get a lot of joy from that versus the sort of shame and keeping people out away I think are some pretty big differences.

The other thing is that for most collectors it's not getting in the way of their lives and hoarding really gets in the way of people's lives. They usually can't socialize in their homes. They often can't have family or friends over to their homes. They can't find things. Sometimes in more severe situations there's health hazards or for older adults like falling hazards and tripping hazards. It actually gets in the way of living makes life harder. Whereas collecting usually doesn't make life harder typically.

Tori Steffen:  Right. Yeah, definitely some pretty big differences there between the two. So while treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things adults can do on their own to, or even children as well to potentially reduce or lessen any symptoms of OCD and hoarding disorder?

Travis Osborne:  Yeah, well for folks here in Seattle, and this is true in other major cities too, there actually is a free OCD and hoarding support group here in Seattle. That is an awesome resource, particularly for adults but also for family members and friends. So parents of kids or teens with OCD or hoarding behaviors, ocdseattle.org is the website for that. They have free meetings that are a huge source of support and help for folks. So looking for local support groups that are often easier to access sometimes than therapy, maybe less scary to access than therapy sometimes can be good. There's also great self-help books. That's so readily available online now, the internet has helped with that.

The IOCDF or international OCD foundation that I mentioned earlier has tons of not just resources, but they have an annual conference every year that's open not only to professionals but also people with OCD and hoarding disorder. They now actually have separate hoarding conference as well. Those are really helpful resources and they also run some other programs throughout the year that can be of help. And like I said, some great self-help books as well. I think all of those are kind of resources that can be useful to folks. I think the reality is most people with hoarding and OCD are going to need some form of professional help typically because it's just a very complicated problems to solve, but some people can often get a lot out of those other resources too.

Tori Steffen:  Okay, that's good to know. I'm glad to hear that there's those resources out there. So thank you for sharing that info. But yeah, like you mentioned, it's with the success rates, I'm sure it's most ideal to seek out professional help.

Travis Osborne:  Yeah, for sure.

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

Travis Osborne:  I think just the key thing that like OCD has come so far in the past 30, 40 years. I mean, we really have great treatments if folks are willing to do them and just the awareness that folks should have that we are still figuring, hoarding out because it just became its own disorder just under 10 years ago, has really put the research behind. So we're moving in a good direction, but I suspect in another 10 or 15 years we're going to have even better treatments than we have today.

Tori Steffen:  Awesome. Yeah, I'm definitely hoping as well that the research continues for that. Well great. Well thank you so much Dr. Osborne. It's been really nice talking with you today and thank you for your contributing to our interview series.

Travis Osborne:  You're welcome. Thanks for having me.

Tori Steffen:  Absolutely. And thanks for everybody for tuning in and we'll see you later.

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.


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