Psychiatrist Peter Reiss on Psychiatric Medication Management

An Interview with Psychiatrist Peter Reiss

Peter Reiss, M.D. is psychiatrist at Seattle Anxiety Specialists, PLLC. Dr. Reiss specializes in the treatment and medication management of anxiety related disorders.

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're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us Dr. Peter Reiss, who is one of the psychiatric providers at our practice. Peter has extensive experience with psychiatric medication management and has worked in multiple levels of care in the Seattle area, including inpatient, outpatient, partial hospitalization, and residential treatment programs, as well as in the psychiatric emergency room.

Before we get started today, can you tell our listeners a little bit about yourself?

Peter Reiss: Yeah. Hi, Jennifer. Thanks for having me, and inviting me for this interview series. As you said, I worked in quite a few places before I started working as an outpatient psychiatrist here. I took a slightly different route than the traditional way of, "What do you do when you start working after residency?"

I initially started working as a locum tenens, which includes more short-term contracts. I was doing six months to a year at different kinds of levels of psychiatric care. It just gave me a way to see what kind of psychiatric jobs I like, and it gave me an opportunity to see what the mental health resources are in the area. And, just gave me a chance to see what I could see myself doing in the long run.

Jennifer Smith: That's great. I think, like you said, to have all that different exposure probably makes you a really well-rounded psychiatrist. I think that's fantastic. Great.

Peter Reiss: I did think that. It just gave me a little bit more opportunities to really see what different acuities look like on different levels of care.

I wouldn't change a thing, so I'm very happy I did it this way.

Jennifer Smith: Fantastic. Just to let our listeners know a little bit more about yourself as well, what are your favorite parts of the Seattle area or Washington as a whole?

Peter Reiss: So, the first time we came to Seattle, I just immediately loved the area. I do think that it has this very special kind of culture. I love how it combines the urban and the nature, and just the fact that there's so much to do. Especially in the summer, with festivals going on. And, even the winter, I mean, people do complain about, or some people say we have particularly bad winters, but, in the middle of winter, it's 55 degrees, and you can go hiking or do whatever if you're okay with a little bit of rain.

Jennifer Smith: The saying is "It's not bad weather, it's bad clothing," or something like that. Right?

Peter Reiss: Well, I think our weather is our best kept secret.

Jennifer Smith: Yes.

Peter Reiss: Not as bad as people say.

Jennifer Smith: Exactly.

Peter Reiss: Or, have the reputation.

Jennifer Smith: Right?

Peter Reiss: Yeah.

Jennifer Smith: Exactly. That's great. And, what is it that got you interested in becoming a psychiatrist?

Peter Reiss: So, I didn't start out in medical school wanting to be a psychiatrist. I did keep my options open. I was leaning more towards primary care, internal medicine, possibly emergency medicine. I always knew that psychiatry and mental health is important, and that it's kind of very ubiquitous anywhere you go in medicine.

I didn't think about psychiatry a whole lot until my third year in medical school when I had my real introduction to psychiatry, where I went to the psych ward and other psych facilities for my medical school rotation. And, I just immediately loved it. I liked how it's just slightly different than other fields of medicine. It kind of forces you to think more outside of the box. It doesn't necessarily follow the standard algorithms that we have in medicine. There's a lot more nuance and room for interpretation, and it's probably the least well-understood specialty in medicine as well. So, I did the fact that there's just so much more that potential will change in the specialty in the near future hopefully.

Jennifer Smith: That's fantastic. One question that we're often asked is, "Should I see a therapist or should I see a psychiatrist, or both?" And, can you explain the difference to our audience why should someone see either of these two professions?

Peter Reiss: Mm-hmm. Yeah. So, we do have quite a good variety of mental health specialists for anyone wanting to see treatment for any mental health problems. The two options, generally, are to see a medical doctor, so a psychiatrist, or see somebody who'll focus more on non-pharmaceutical management, which would be a therapist, which would typically be clinical social workers or psychologists by training. And, it sometimes comes down to personal choice what people prefer.

I would say, if somebody's psychiatric symptoms are fairly mild, they might need to see a psychiatrist. So, not everybody would be necessarily a candidate for psychiatric medications.

Psychiatrists themselves rarely practice psychotherapy anymore. It used to be different. We are trained in psychotherapy. We do go through all these different didactical trainings, how to provide different modalities of psychotherapy, and it used to be much more prevalent back, really, back in the seventies, eighties, up to nineties, where many psychiatrists were still offering psychotherapy. But, mostly due to our insurance landscape, it really has changed that that responsibility has fallen more to clinical social workers and psychologists who are very, very qualified to provide that training. And, they're really specialized in all these different training modalities, since there's just so many of them. So, somebody who has PTSD is getting different psychotherapy than somebody who has an anxiety disorder or depression.

And, it's really hard for a therapist to be very good at all of these therapy modalities. So, I think sort of the specialization among the different therapies works very well, and it's great to just share that professional space with all these very qualified therapists that we work with.

Jennifer Smith: Wow. Have there been times when a patient will come to you and you realize this person probably doesn't need medication - do you refer them to therapy? Does that ever happen?

Peter Reiss: Oh yeah. That is quite common.

I mean, I would say, in the majority of cases, probably at least a trial of medication might be helpful, just for the patient to engage better in psychotherapy if symptoms are just a little bit too severe at that time. But, for a lot of mild cases of the anxiety and depressive disorders, often starting with therapy alone might be a good option.

Jennifer Smith: Okay, fantastic. In what ways can someone's mental health impact their physical health?

Peter Reiss: So, that's actually a really good question. I think most people do understand the connection between chronic medical conditions causing psychiatric symptoms to worsen, but it's really also the other way around. So, I mean, for example, most psychiatric disorders, whether it's anxiety disorders, whether it's depressive disorders, trauma, excessive trauma responses, they typically cause physiological changes as well. Things like, for example, chronically increased stress hormones, like cortisol. And, that can have an impact on immune function, it can increase somebody's risk for cardiovascular issues.

And then also, indirectly, somebody who has low executive functioning, low motivation due do psychiatric issues, is less likely to take care of themselves and engage in these kind of activating behaviors that tend to improve one's mental and physical health.

If somebody, for example, is less likely to engage in things that are good for social connections, that leads to loneliness. And that, in itself, leads to worsening mental health and physical health as well just due to increasing chronic stress and things like that.

Jennifer Smith: Oh, wow. So, when they say, "Mental health IS health," it really is true.

Peter Reiss: Oh, it is absolutely true. I mean the two... It's not only that it's just in your head, right? It does cause real physiological changes, whether those are directly caused by mental health issues or indirectly.

Jennifer Smith: Right. Can you talk a little bit about your treatment approach?

Peter Reiss: So, I emphasize a lot of psychoeducation, making sure that I meet my patients where they're at, and also give them as clear information about what's going on for them to make the best informed decision.

Sometimes, maybe, they have a particular treatment modality in mind, particular medications or whatnot. Just, trying to understand what their idea is, where they're coming from. So, our treatment goals might be different; we might not always agree, and that's not necessarily wrong. But, giving them as much information as I can for them to make the most informed decisions, that's very important to me.

Then also, I tend to put a big emphasis on always reassessing... Just, speaking specifically about medication management, to reevaluate the need for a particular medication. Sometimes, patients come to me having been on one medication for 10 years. We don't know if they still need to be on that. We don't need... Maybe they need to be on something different. We need to reevaluate what, really, each component of their treatment is really doing, if it still has any effect on their mental health. Sometimes, less is more with psychopharmacology.

I do always want to do check-ins, even with patients who have been on a long-term medication, "Is that really necessary, and what can we do about it?"

Jennifer Smith: That's really great that you work with a patient. And, it sounds like you strive to just get the optimal dose and really not put things that are not... Meaning that you don't do unnecessary things.

Peter Reiss: Right, because each medication could not have side effects; it could have unwanted side effects; or, something else that the patient might not know about. So, they're still... Psychiatric medication's still among the safest medication in medications in general, but we shouldn't take it lightly to have somebody on long-term medications generally.

Usually, it's not a problem. We just have to do it the right way.

Jennifer Smith: Right. And, what type of disorders do you specialize in?

Peter Reiss: So, the disorders that I see here in the clinic are fairly standard, the average psychiatric disorders, including the depressive disorders, wide variety of anxiety disorders, including OCD and different kinds of phobia. We do see ADHD patients here in our clinic as well, patients with PTSD and more trauma-related issues, and also different levels of functioning. So, there's many of my patients who are really doing well, especially on the surface. They're able to do their day-to-day activities. And then, there's patients who are not doing well at this time, who might not be able to have a job right now. So, it's a big variety of different psychiatric issues that we're dealing with, but also, different, wide variety of patient needs.

Jennifer Smith: And, let's say that I was going to sign up for an appointment with you. You are a medical doctor, so of course, I would have to complete the intake paperwork so you have an idea of where I'm coming from, what medications I'm on, my past history. So that's, I think, pretty standard. But, after that, I have no idea what to expect. So, what can I expect in the first session with you? What would we do? What would we talk about?

Peter Reiss: Mm-hmm. Yeah.

So, after a patient signs up for an appointment, there's the initial intake. That can be done either here in my office, in person, or it could be done remotely. There's always those two options. On most days during the week, I have those two options available.

The first session is just gathering a lot of information, getting to know the patient. And, that typically takes at least 45 minutes to an hour so we are clear on establishing a diagnosis, getting enough information about the patient's medical background, mental health background, social background. And, the last part of the initial meeting... Well, there's initially the psychiatric interview, and then, we kind of talk about what we're going to do.

And, if there's any disagreements, or the patient might need a little more time to think about these different options, we might talk about... Besides different medication options, we might talk about potential referrals for therapy as well to see if there's somebody who might have that particular therapy skillset that the patient needs, whether that's in our office or outside of our office.

And then. If the patient decides to be a patient with us, there would be a follow-up appointment to check in, within usually two to four weeks or so. Depending on the acuity, really, and if there's any problems.

Jennifer Smith: Okay. And, that actually leads to my next question regarding follow-ups. So, at our practice, we have a form of concierge care. Can you explain what that is to the audience? And, how does it differ from a traditional practice, and what are the benefits that our patients may have?

Peter Reiss: Mm-hmm. So, the main difference with concierge care is really that it's a subscription-based access to our services.

In a traditional setting, patients would have their appointment and then schedule follow-ups, and then, essentially, the difference in payment would just be that they would pay for each follow-up appointment. But, a subscription-based model of concierge care, it's really that patients pay a monthly subscription for, essentially, unlimited access. So, they can have one appointment, they can have two appointments; they have access to their psychiatrist via messaging system or email. It just makes it easier for us to respond in real-time to any issues that might come up.

It also helps us to see who is continuing care at a regular interval. So, sometimes in outpatient psychiatry, it becomes a little tricky, because patients might be partially lost to follow up. They might not show up for an appointment, so we're not sure is that patient still patient with us, right? But, with a subscription model, we at least know, "Oh, that patient actually wants to continue, and that patient will continue with their follow-up appointments."

So, I think it helps with patient retention in the outpatient setting.

Jennifer Smith: Great. And, I think one thing that I've noticed from the administrative end is that, because we essentially cap the number of patients that our psychiatrists will see, and you've kind of alluded to this, that our patients really can have unlimited access, to a degree, because you're seeing X amount of patients and not thousands of patients. So, there's just more time that you can give each of your patients, which I really think makes more specialized care as well.

Peter Reiss: Mm-hmm. Yeah. So, our overall patient numbers are lower than you would see in a typical outpatient clinics, which helps with just the time that we give each patient. We're not necessarily back-to-back.

I mean, there's some days where we see more patients than other days, but it just feels a little bit more... It feels a little more less time pressure, to give that extra time as well, whether it's directly during the appointment or to communicate with the patient through our messaging system and hone in their treatment that way.

Jennifer Smith: Wonderful. So, our final question, do you have any words of advice, or anything else that you would like to say to our listeners today?

Peter Reiss: So, the main thing that I probably would say is that, to somebody who's starting out with their mental health recovery, really seeing that they want to get treatment, it initially seems very daunting, but I do want to say that it does get easier when somebody is actually establishing care and is getting the help that they need.

And, oftentimes, we often forget to check in with ourselves, especially when we're in treatment, making sure that we're really doing well, that we're not just doing okay, that we're really thriving and flourishing. And, that can mean different things to many people, obviously. But, often, what suffering from a lot of mental disorders and mental illness does to us, we're losing the sense of self-worth and almost like forgetting what our normal... We're getting used to this normal baseline of functioning and being. And, sometimes, it becomes difficult to keep track of what our purpose is in life and what we can do to thrive.

So, don't settle for any less when it comes to your mental health. That would be my main advice.

Jennifer Smith: That's great. Thank you so much for your time today.

If anyone is interested in scheduling an in-person or a telehealth appointment with Dr. Reiss to discuss psychiatric care and medication management, you can self-schedule at seattleanxiety.com

Thank you again, Dr. Reiss, we appreciate your time.

Peter Reiss: Thank you, Jennifer. Good seeing you.

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

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

Psychotherapist Rachel Kuras on Integrated Therapy

An Interview with Psychotherapist Rachel Kuras

Rachel Kuras, Psy.D., LMHCA is psychotherapist at Seattle Anxiety Specialists. She provides therapy for individuals and families, and helps clients of all ages - including children. Her clinical work focuses on: trauma, attachment, gender & sexual diversity, family conflict, grief, anxiety, depression, and ADHD.

Kate Campbell: Hello, everyone, and thank you for joining us for this installment of The Seattle Psychiatrist Interview Series. I'm Kate Campbell, a research intern for Seattle Anxiety Specialists, PLLC. We are Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us Dr. Rachel Kuras, a licensed mental health counselor associate who recently began working with the Seattle Anxiety Specialists as a psychotherapist.

Since graduating with a doctoral degree in psychology from Pacific University, Rachel has trained in trauma-focused cognitive behavioral therapy, acceptance and commitment therapy, and attachment therapy and commitment regulation. Prior to joining SAS, Rachel completed an internship through Idaho Psychology Internship Consortium, where she provided in-person, individual psychotherapy for children and adolescents, comprehensive neuropsychological assessments, and comprehensive diagnostic assessments. Welcome to the interview series, Rachel, and thank you so much for joining us.

Rachel Kuras: Thanks for introducing me, Kate.

Kate Campbell: Of course. So before we get started, can you tell our listeners a little bit about yourself?

Rachel Kuras: Yeah, so my name is Dr. Rachel Kuras, formerly Rachel Rower. I changed my name this year. I grew up in Tacoma, Washington, and I was a graduate from University of Washington Tacoma campus, where I majored in psychology and obtained a minor in global engagement. Directly out of undergrad, I pursued my doctoral degree from Pacific University in Hillsboro, Oregon. And the fifth year of that program was an internship in Idaho, where I worked at Pearl Health Clinic, as you already described. So a lot of what I'm saying is repeating what you already said.

But yeah, aside from pursuing my degree and being a student for most of the time that I've existed, I really love my pets. I have a cat who is a calico polydactyl cat, meaning that she has extra toe beans, so she has thumbs, which is really fun. Her name is Pickle. And then I have a dog who just turned six last week, and her name is Daisy. And I spend a lot of time with them. I'm a huge animal lover. And I really enjoy backpacking and hiking, which unfortunately I haven't done very much in the past five years. Graduate school takes up a lot of time and energy, but I'm getting back to it.

When I graduated high school, I worked in Yellowstone National Park as a room attendant for a summer. And I really enjoy going back to Yellowstone, spending time in the Tetons. But at heart, I'm a Pacific Northwest person. So yeah, I like national parks. I enjoy playing music recreationally. I sing recreationally. I also like gaming, but I'm kind of a cozy gamer. My favorite games are Animal Crossing, Mario Party and Stardew Valley.

Kate Campbell: Yeah, no “Call of Duty” or anything along those lines.

Rachel Kuras: No, I like games where I can catch fish and garden.

Kate Campbell: That's awesome. And I love that where you went to school for undergrad is where you are now a psychotherapist. So that's really cool that you continue to get to work in the same area. And on that note, I think it's just a cool thing to be able to see different parts of the Pacific Northwest, but I was wondering, what's your favorite part of being in the Seattle area now?

Rachel Kuras: I have been so grateful to be in Seattle. Growing up in Tacoma, Seattle was a north neighbor. So I spent a lot of time here growing up, and I missed Washington very dearly when I was away. Right now, my favorite part of Seattle is my neighborhood. My childhood best friend lives just like a five-minute walk away from me. So I've been moving around and away from home for a while, and now I have a best friend close by. So I've been enjoying going on walks with our dogs and just spending time in a neighborhood near people who I grew up with, which is really nice.

I also love Olympic National Park. The Olympic Peninsula is just magical, and the Puget Sound. I remember growing up, I heard stories from my dad about whales coming through the Puget Sound in the past, and I was like, "Oh, that would be so cool. I want to see a whale so bad," but not like whale watching. I want to just see a whale by chance. That sounds funner. And now they're back. They're coming through the Puget Sound, so I'm hoping to get to see them. But yeah, I love the ocean and I love the mountains, and the Pacific Northwest has it all.

Kate Campbell: Oh yeah, that's awesome. That's what I miss about the Pacific Northwest since moving back to the East Coast, so I totally know what you mean. So I was wondering what else got you interested in being a therapist? So you talked a little bit about loving where you grew up and being happy to be back in the area, but what else in terms of your experience growing up made you interested in therapy?

Rachel Kuras: Yeah, that's a big question that I could probably talk about for hours. I think to narrow it down a little bit, I had a lot of experiences growing up that really highlighted the importance of mental health literacy and access to mental health services. My experiences of being human and my experiences of suffering have fostered an interest in what it means to be human. And I really value every person that I work with sharing their individual experiences with me.

So ultimately, I have struggled with mental health myself, and mental health struggles significantly impacted my family growing up. And I saw multiple therapists as a teenager, and there was one in particular who really inspired me, and I was like, "Oh, that's who I want to be when I grow up." And I did it. So I think having access to quality mental health services is something that I'm really grateful for and I was very inspired by. And mental health is something that impacts literally every human. I think that, that did inform my interest in child and family work and in trauma work, with my own experiences growing up.

Kate Campbell: Awesome. Thank you so much for sharing. I was wondering, so what areas or disorders do you specialize in?

Rachel Kuras: So, I have the most experience working with people who have experienced childhood trauma, so post-traumatic stress disorder (PTSD), and other specified trauma-related disorders, and also anxiety disorders, like generalized anxiety, social anxiety. I've worked with lots of kids experiencing separation anxiety, and I've worked with a few people experiencing selective mutism, so kind of the whole anxiety disorders chapter of the DSM. And right now, I'm currently working on increasing my competence in obsessive compulsive disorder (OCD). So trauma and anxiety have been my main focus, and I am expanding my competence working with people who have been diagnosed with OCD.

Kate Campbell: And it's interesting, because I feel like a lot of the times therapy is hardest for people that have anxiety and your OCDs, because opening up about those kinds of disorders make people feel extremely vulnerable. And then getting to know a new person, especially a new therapist, there sometimes can be a wall up. So I was wondering, what's your treatment approach when you're going into those kinds of situations when you first meet a new patient?

Rachel Kuras: I use a person-centered, integrated approach to treatment. I have training in multiple treatment modalities. I was really lucky to work with a lot of people with a lot of different perspectives and experiences. It's a long sentence that I've strung together to try to summarize my approach. I am an attachment-oriented, trauma-informed, cognitive behavioral, acceptance and commitment, and existential therapist. So that's a lot of different treatment modalities. My approach is to meet someone and go from there. Everybody has commonalities between our experiences, but we also have things that are unique to our own lives.

So I like to start with a conversation. The therapeutic alliance is at the core of my approach, because we know through research that the therapeutic relationship is one of the most important determinants in terms of the outcomes of therapy. So if we want positive treatment outcomes, the relationship is what's most important. And as you were saying, Kate, relationships are vulnerable, especially living with chronic anxiety. So my approach is to start by building comfort, to start by getting to know each other. I'm a feedback-informed therapist, meaning I solicit feedback often, and I try to integrate client feedback actively into my approach. So my approach is pretty flexible. I like to tailor it to client needs, but I also really enjoy acceptance and commitment therapy and existential therapy.

So that was a long-winded way of explaining what it means to be an integrated therapist. But yeah, I draw from a lot of different treatment modalities. I view suffering as a central part of being human. Everyone suffers. And it's a challenge to figure out how to build a relationship with suffering and with being human that feels authentic and genuine. So I like to provide support to people in increasing the amount of internal empowerment that they have over their lived experiences. So I like to help people build a relationship with life, build a relationship with their experiences of anxiety, and find ways to connect with the present moment and exist in a way that feels less laborsome. So I like to acknowledge the role that suffering plays in our lives, and inevitably suffering is there. It's just a matter of how do we think about suffering, how do we interact with our suffering?

Kate Campbell: Wow. That's really awesome. It just sounds so individualized. There's cultural competence, it's empowering. There's just so much wrapped up in that. So I think it's awesome, just all the different facets that you incorporate into your style and your approach, so thank you for sharing it really is amazing to hear.

Rachel Kuras: Thank you. Yeah, I think it can be a little overwhelming to summarize at times. I'm also very interested in liberation psychology. Liberation psychology is an area that I've been trying also to increase my competence. And within liberation psychology, there's this idea that what each individual needs to heal is already within them. So the role of the therapist is to help someone find that within themselves. It's not my job to give advice or to provide answers. It's my job to, if your life is a trail and you're walking on it, to walk with you for a moment and to observe with you and explore that with you. Yeah, so I do really value that individual experience. And I think that there's different value in different treatment modalities, but there's also a thread that connects a lot of them. So I like to see that thread, see where they meet, and try to integrate it in a way that works for my clients.

Kate Campbell: That's super cool. I'm excited to look up liberation therapy after this just to learn more about it. That's really interesting. So on that note, how is your approach with working with children, and what's your favorite thing about getting to work with that age group?

Rachel Kuras: My approach is sitting on the floor. I'm on the floor a lot. I'm coloring a lot, playing lots of games, doing lots of art, and exploring through play. I think that kids are so fun and funny. I'm laughing a lot. It brings out a youthfulness and a playfulness in me that I really enjoy cultivating in the therapeutic space. It's hard for me to really articulate how it's different from working with adults, because I think that all adults were kids once. So there's aspects of working with kids that mirror working with adults, but kids have never been adults. So there's a lot of emphasis on cognitive development and behavioral skills.

And I focus a lot on attachment relationships, working with kids. Another thing I enjoy about working with kids is that there's a lot of wiggle room in terms of their cognitive development. There's more neuroplasticity in childhood, meaning that there's more give. As we grow into adulthood, we often become more rigid in our behaviors and our beliefs and in our worldview. And we're digging deep into the roots of what's going on, whereas with kids, it's not as deeply rooted because there hasn't been as much time for-

Kate Campbell: Within their formative years, yeah.

Rachel Kuras: Yes, exactly. So I think that there's a lot of hope and playfulness. And I'm just honored when I work with kids and families to be a part of that development. And I think these things are true working with adults as well. It's just kind of less at the center of therapy. Yeah.

Kate Campbell: Yeah, I could definitely see that. And then also the family aspect, I assume that when you're working with kids, the parents are going to have a heavier involvement than, say, a spouse would be necessarily, if it's an individual.

Rachel Kuras: Yeah, that's a good point. Working with kids is working with systems, is working with family systems, is working with school systems, is working with the foster care system. So I think that I've also really valued the experiences I've had providing services to kids, in that they give me a big picture of what's happening in the world. I didn't mention this previously, but I take a systemic approach to therapy. So I like to view our internal daily struggles within the context of larger systems. And with kids, you can't avoid that at all. With adults, sometimes one-on-one work, systems is just as important. And since you're not doing as much collaboration necessarily, you're not thrown into that systemic involvement in an individual outpatient setting with adults as much as with kids.

Kate Campbell: Yeah, that makes a lot of sense. And I know that over time there may be different changes in the way that you would approach both your therapy with children and adults. So I was wondering, what was your favorite part about your initial training, and then how has your perspective changed over time with that, both with different age groups, or how you have to approach your end goal when you're working with each patient?

Rachel Kuras: Yeah, so my favorite part about my training is people. I'm trying to think of the best way to word this. I feel very honored throughout my training to have been trusted by the kids and families that I've worked with, and to see some really pivotal moments of growth, amongst some really pivotal moments of suffering and pain and setbacks and stuckness. I've really enjoyed seeing kids learn about their brains and their bodies and how it works and what's happening when they have an emotion.

And I think a lot of the time when talking to kids, we don't always realize how much they're retaining, but one of my favorite parts of ... I worked with a kiddo for a long time. And I wasn't quite sure if what I was saying was landing. And then at one of our last sessions, it was like they basically described to me what happens in your central nervous system when you're feeling afraid and how they know in their body when their central nervous system is starting to get activated. So I really enjoyed those moments of like, “Yeah, you get it.”

Kate Campbell: The light bulb. Yeah.

Rachel Kuras: “You get it and you're benefiting from it and you're applying it.” And I think sometimes we underestimate kids' ability to do that. So yeah, I really valued seeing those moments of growth. And there was another part to your question, right?

Kate Campbell: Yeah. It was just what was your favorite part about your initial training, and then how has it changed a little bit?

Rachel Kuras: It changed over time. I think that I was a graduate student at a very unique time. The COVID-19 pandemic hit during my first year of practicum. So I had been working with people for about six months and then everything went online. So I think the events that have occurred during my training have really emphasized the importance and the need for mental health services, for quality mental health care providers. And it's been exciting to see more people talking openly about mental health, where in a time where when I was a child, even with my own experiences, it wasn't something that was very openly talked about. We didn't have a lot of information in my family and my neighborhood and my community about what was going on.

So it gives me a lot of hope and excitement to see the stigma around mental health decreasing. I don't think that it will disappear, but it's changing. So I think the things that have happened while I've been in grad school have really emphasized the importance of mental health care, and I feel very honored to be a part of that process. Did that answer your question?

Kate Campbell: It definitely did. It actually carries really well into my next question, because you talked about how much the conversation around mental health has changed and just some of the generational differences. It's really nice to see that kids feel more open talking about some of their struggles. But I was just wondering, so what are some of the ways that you think that the psychology community can continue to grow? You did already answer some of the ways that you've seen it transform over time, but if you have details on that too, I'd love to hear too.

Rachel Kuras: Yeah. I think that there's been an effort to expand access to resources, even just with telehealth, being able to go to therapy from home. Yeah, so access to resources, I think there's been a push for that to increase. I think that will continue to happen. And the COVID-19 pandemic and other large-scale events that have happened over the past 10 years and really over the course of human history, but just viewing this snapshot, it's something we all experience together. So I think that it's been beneficial to have a sense of humanness, to connect in our humanness as a society, whether that's between therapists and client or on a larger scale. I've seen a lot of efforts towards connection and towards valuing ourselves and valuing each other. And I hope to see that continue. And I think it will.

Kate Campbell: Yeah, it's kind of ironic that COVID-19 brought us closer together, but in a weird way, it did too.

Rachel Kuras: Yeah. And I think for a lot of people, it really emphasized the importance of social connection, because working with kids, I mean, the effects of the pandemic have been incredibly destructive on people's routines. And for kids, not going to school is a huge thing. These really essential interactions that were once there weren't there anymore. So I think it, for me, has made me value our connections. And not that I didn't before the pandemic, but it just gives a different perspective and urgency around maintaining connective relationships that cultivate growth and love and acceptance of each other.

Kate Campbell: Yeah, absolutely. And as a final question, do you have any words or advice that you would like to say to our listeners?

Rachel Kuras: Yeah. I think that if you are seeking therapy services for yourself or for a family member, I encourage you to try it, right? Even if there's fear about how it might go, dive in, be vulnerable. There's so much value that each individual person has, and I think it's easy to lose sight of that and feel disconnected from that, and it's easy to be hard on ourselves in this society. So, if you are feeling like you would benefit, even just from having a space to come and be witnessed and be heard, I encourage you to seek out therapy services, try it. And yeah, be vulnerable. Talk about mental health. Don't shy away from subjects just because they've been taboo. Yeah. I think that's it. Be open, dive in, be vulnerable.

Kate Campbell: Yeah, absolutely. Thank you for those words of encouragement, Rachel, and for joining us in our interview series. Hopefully, everyone can take something from this, and thank you all again for joining us.

Rachel Kuras: Awesome. Thank you, Kate, for having me. I'm really  grateful for this opportunity.

Kate Campbell: Of course.

* For those interested in working with Rachel, click on our appointment page to see her current availability.

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

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

Consultant Leon Seltzer on the Effects of Childhood Self-Shame

An Interview with Consultant Leon Seltzer

Leon Seltzer, Ph.D., holds doctorates in both English and Psychology. He recently retired from general private practice with clinical specialties in anger, trauma resolution (using EMDR and IFS), couples conflict, compulsive/addictive behaviors, stress control, and depression.

Jordan Rich:  Hello, everyone. Thank you for joining us today for this installment of the The Seattle Psychiatrist interview series. My name is Jordan Rich and I'm a research intern at the Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice with a specialty in anxiety disorders.

For today's interview, I would like to welcome Dr. Leon Seltzer, possessing doctorates in both English and psychology. Dr. Seltzer has previously functioned as an English professor at Queens College and Cleveland State University, and then later, as a psychologist, maintained a private practice for 35 years.

Upon retiring from his private practice, he's continued to offer private professional and personal consultations. In addition to publishing two books titled The Vision of Melville and Conrad and Paradoxical Strategies in Psychotherapy.

Dr. Seltzer has also been an extremely prolific writer on Psychology Today's website, authoring over 550 articles relating to psychology and psychotherapy, particularly on topics such as problematic relationships, compulsive and addictive behaviors, controlling one's anger, suffering from deficits in self-esteem and one's general self-image, and issues inherent in narcissistic personalities. Dr. Seltzer’s blog is titled Evolution of the Self with the subtitle On the Paradoxes of Personality, and his varied articles for Psychology Today have received over 50 million views. Thank you for joining us today, Dr. Seltzer.

Leon Seltzer:  And thank you for having me. I'm very happy to be part of your series.

Jordan Rich:  So to start, Dr. Seltzer, would you mind telling us a little more about yourself and what drew you to the study of psychology?

Leon Seltzer:  Well, I guess one of the things that's most interesting about that is my starting out majoring in English and becoming an English professor for over a decade. And the reason for that was that I had gotten the message, this is many decades ago, that what psychologists did was diagnostic testing, which wasn't a particular interest of mine, whereas psychiatrists were the ones who did the therapy.

And because of that, well, I had basically tried to decide whether I wanted to major in psychology or music because I love music, that I got so much encouragement from English professors that by default almost I majored in English. Which I don't really regret that much now because even though I left the field, it enabled me to really see myself as much as a writer as a psychologist and gave me the opportunity to do a lot of writing as I have on psychology, on psychotherapy once I entered the field. So no regrets there. The only thing I might mention is that I did a human growth training.

And it was interesting because it was during the training that I realized that if I had it to do over again, because my first love even after getting tenure was psychology, that that would be my preference. It was that training that made me realize if I were willing to go through what frankly is the torture, another doctoral program, that it was a possibility. And that's what I did. So I don't know if there's anything more you'd want to know about my past, but that is probably the most curious thing.

Jordan Rich:  Yeah, it's a fun little journey back around to your calling. It's very fun to see the kind of cyclical nature of it. So on your blog you describe a lot of your articles as surrounding the paradoxes of personality, which is a very specific phrase. Would you mind explaining to us what that phrase means to you?

Leon Seltzer:  It's interesting that Niels Bohr, the physicist, and I think it was back in the 1920s, said something like, "The opposite of any profound truth is equally true." Which would surprise a lot of people, but what I discovered is that there are many different perspectives toward one and the same thing, each of which has a certain validity.

And I think one of the things that most therapists do, regardless of what school they believe in or practice, is basically to have people understand some of their, what? Maladjusted behaviors as behaviors that were once necessary for them, that they weren't mistaken at all. And that the problem is simply that those behaviors based on self-protective mechanisms have basically become less and less adaptive as they've gotten older.

So, just to be able to see how things can be understood in different ways. One of the things I did actually before today was to kind of look at some of my more recent posts, or—and articles for Psychology Today. And I might just want to read some of the titles if I can find this here, simply because almost all of them are imbued with paradox.

So, looking at the most recent one, I did an article called Determinism vs. Free Will: A Contemporary Update. And my point was that to think that we have absolutely free will is probably not very accurate for the simple reason that if you believe at all in cause and effect, then it is also true that one cause can have many effects and many causes can have one effect.

Then anything like absolute free will doesn't square with the research that's been done, particularly in the last decade or so. The same thing with determinism. To say that our lives are predetermined is also reductive. It really doesn't get at the fact that there are certain choices that we do have. So it's like it's a paradox, that even people who don't technically, theoretically believe in free will live their lives as though they have free will.

So again, whatever it is, I'm always looking for the paradoxical element because it's a way of going deeper. And when I go deeper, I generally find I have a more profound understanding of whoever it is I might be working with. Let me look at a few other titles. The one before that was Why Discord, Paradoxically, Is Vital in Close Relationships.

And I think the very title is paradoxical because why would you want discord in a close relationship? And basically, what it is about is that, if in fact when we grew up our family, our immediate family disapproved of certain of our behaviors, then if our spouse enacts any of those behaviors, the child part of us will feel threatened. Because if this is our intimate other, our other half as it were, then it's going to feel threatening to us.

So we're going to have to dissociate from our partner. And a lot of times people don't even really understand the basis, the crux of why they've suddenly moved from harmony to disharmony. So it's very useful when they're in a suggestion of discord to realize they're not just talking about money, they're not just talking about how introverted or extroverted the other person ought to be, maybe depending on how introverted or extroverted their parents were, that they're talking about something that is most likely unresolved in their past.

So to give an example of this, let's say that a child by nature is kind of boisterous, asks a lot of questions, always wants to share everything that's going on with him or her. And the parents are both quite introverted, they're quiet individuals and they're made uncomfortable by their child's extroversion.

In a sense, they feel invalidated by that extroversion. It's going to be very hard for them not to be critical of their child, although the child isn't doing anything wrong. But if the child is young and, of course, very susceptible to his parents' ideas about him, he is going to think, “I need to be less loud because they keep saying, shh.”

And that makes me feel ashamed. It makes me feel that my bond with my own parents is tenuous. And I can't think of anything that would be scarier for a child not to feel secure, not to feel safe in their attachment bond with their parents. Now to the degree that the child tries to conform to what the parents need or want of him, then he will be, in a sense, suppressing his essential nature. And I've seen so many adults in the past that felt empty, almost as though some part of them was missing.

And it was a part that they had repressed because it was associated with parental disapproval, maybe even parental rejection. And I won't go into it, but it's the same thing if the child is very introverted and had two extroverted parents who felt that he was too insular, that he was isolating himself from his peers, that basically he needed to be in more group activities even though he enjoyed collecting stamps, whatever it was, or maybe just watching baseball games by himself on tv.

And it's a shame because most parents just want to socialize their kids because they realize that's their responsibility, but they have blinders based on how they were parented. So a lot of the problems that I had dealt with with clients basically had to do with the fact that their parents had blind spots.

And I think one of the things that is so useful about all forms of therapy is to the extent that the client gives the therapist a certain authority comparable or hopefully greater than the authority he gave to his parents and gets the message that who he is is acceptable. It may deviate from the norm, but that doesn't make it unacceptable.

And even if he's engaged in antisocial behaviors, although the therapist would like not to see that kind of behavior, the therapist would help him understand compassionately why he developed those behaviors. And it could be that he had to suppress his anger toward his parents because that would further alienate his parents from him. So that was too scary. But the main thing is if you experience anger and you don't express it, it doesn't disappear.

It just goes in deeper and deeper and then it gets displaced onto other people who don't deserve your anger, your aggression, whatever it might be. And it's the same thing with passive aggression. And on the other side, and this is more true of girls than of boys, what girls may do is try to please their parents because their parents react to them favorably or more favorably or only favorably when they're putting their parents' needs in front of their own.

And then the problem is I have seen adults who when asked, “Well, what do you need?” They didn't know. They had never thought about it. They had never had the luxury of asserting their needs to their parents without being told that they were being selfish. So and again, this goes back to the paradox of it all, that what happens is you end up blending with your defense mechanisms, and people pleasing can be seen as a defense mechanism.

And when you do that, you basically become alienated from yourself. And when you think about it, being alienated from yourself is probably even worse than being alienated from your parents. And the main thing about giving authority to a therapist who can have a deeper understanding of what's unconscious in you and bring it into consciousness is you can't change outdated defense mechanisms without making them conscious first.

And a therapist has to find a way of helping you do that without, in a sense, revitalizing or reawakening defenses that the child part of you still thinks are essential. I'll do one more title and then we can move on to whatever your next question is. Yeah. This is one of my favorite titles.

It's called, The Monster Once Beneath Your Bed May Now Be in Your Head. And this too is about internalizing those things that threaten you from outside. I once had a client who had this dream of being followed by a monster, being chased after by a monster. Maybe she was five, six years old. And she ran into her parents' bedroom and basically wanted to cuddle with her mother, and her mother was really the monster in the dream.

So what do you do with that? And this is how people end up kind of suppressing things and then later repressing them. The difference between suppression and repression is suppression is feeling something but not allowing yourself to express it because it feels way too dangerous for you. Over time what happens is just having that feeling is scary and you can try, and it's amazing that human beings can do this, not to experience the feeling.

This is why a lot of people have anger problems, don't realize that the anger isn't the source so much as anxiety is the source. Boys more than girls may suppress, well, I should say, yeah, girls more than boys, but both genders do this. What they will do is basically, in order not to feel an anxiety, which is disabling. Anxiety is obviously one of the most uncomfortable emotions that anybody could experience because it feels as though you're about to go over a cliff.

What anger does, anger by definition is always self-righteous. So it makes you feel that at least you have reason on your side, that basically the way you're being treated is unfair. You don't deserve to be treated that way. So anger feels a lot better than anxiety. The problem is if anxiety is what's underneath the anger, you never get a chance to work through the anxiety, and that is what would be ideal.

Then you wouldn't need the anger, to the degree that anger is a defense against anxiety. And in my earliest writings for Psychology Today, and I don't know what I mentioned, at this point, I think there's something like 554 articles. And you did mention very prolific, I think in your introduction.

And I'm surprised myself that I wrote that many, but I'm just dedicated to try to share whatever I've learned in all the 35, 40 years I've been doing therapy to kind of disseminate whatever clinical wisdom I have earned so that people don't have to necessarily read a 300-page book, but can maybe just read an article and get a sense of what they might not have realized beforehand. I probably have been talking too much. What's your next question?

Jordan Rich:  Never talking too much. So thank you for breaking that down. I had never heard that phrase before. So hearing your explanation and your examples was very helpful. Speaking of your writing on Psychology Today, one of your recent articles is titled, Does Self-Shaming Help You Avoid Being Shamed by Others? Could you elaborate on what you mean by this and what you think kind of gives rise to these defense mechanisms and how while we're still kids, they might serve us in positive ways but might not ultimately be good for us? Could you break that down for us a little?

Leon Seltzer:  Yeah. And that itself is paradoxical because the question would be how in the world could self-shaming be beneficial to us? But what we internalize defensively if our parents are shaming us, is to say, "Okay, I must be bad." And I think I also wrote a post saying, Do You Need To Be Bad To Feel Good? If feeling bad in some strange, not to be paradoxical, but perverse way helps you to feel more connected with your parents, then it's going to feel safer.

It's going to feel a lot less dangerous to agree with them on how you think they are assessing your behavior. So it's almost as though in shaming yourself, if they give you the message explicitly or implicitly—and it's actually more dangerous if the message is implicit because then you really can't work with it, because they never actually said it.

It was maybe just the look in their eyes. Because I remember one client I saw a long, long time ago who talked about one of her worst memories being when she went into the kitchen, her mother was preparing a meal and needed to talk to her about something. And her mother looked at her in such a way that she basically ran out of the kitchen because she felt so denigrated, so put down. And I think she ran into her bedroom and cried.

Her mother didn't say a word. But basically if a child says, “Okay, they think there's something wrong with me, I think there's something wrong with me.” So it's almost like they're asking their caretakers the question, “Can you accept me now? I think about myself the same way you think about me, doesn't that join us?” And that to me is the saddest thing in the world. And I don't know that anybody has ever written about self shaming being a defense mechanism, but I think that illuminates why it would be.

Jordan Rich:  Yeah, that's definitely a very heartbreaking scenario. So looking at the long term, what do you see as some problems that could arise as a result of a person having this harsh sort of judgment of themselves?

Leon Seltzer:  I'll give you another example. I worked with a client whose parents basically believed in corporal punishment and the father probably found something to beat him for on, pretty much on a daily basis. And one of his worst memories was he had made a mistake and his father said to him, “Here's $5. I will give you this $5 after you pack your suitcase because you're not welcome to live with us anymore. You keep making mistakes.”

This father also expected him to follow rules that were never described to him. And kids can make mistakes because they don't automatically know what the rules are, and different families have different rules anyhow. And when his father would beat him, and tears came to my eyes when he told me this. His father said, “Take off your belt. I'm going to beat you with your own belt.”

And as he was beating him, this is almost unbelievable, the father said to him, “See, your belt hates you, too.” How can anybody say anything like that to his son? Of course, one of the things I learned that his father was comparably abusive to him. And remember what I said before that basically a lot of these behaviors aren't thought out, they're automatic, they're programmed in.

And the problem is, unless you reevaluate how your parents treated you and recognized that it was abusive, you didn't deserve it. Because you may have thought you deserved it. That's what self shaming is about. “If they're treating me this way, I must be bad and all I can do is agree with them that I'm really a bad kid. So at least that is some way that we will be on the same page.” But in any case, there was one time when he did pack his bag.

He did take the $5 and he went out into the fields. He didn't know where to go, so he just walked as far as he could. It was also cold. And at three o'clock he heard coyotes and that scared him to death. So he ran back to his house, begged to be let in, but feeling an incredible amount of shame because he knew he had to adapt to however his parents saw him.

Now the final irony in this story, which speaks volumes, is he became a renowned surgeon and never stopped seeing himself as a fraud and was just waiting for the other shoe to fall. Because even though everybody told him what a fantastic surgeon he was, he was called in to deal with the most difficult cases the other surgeons frankly didn't know how to handle and routinely he would know what to do.

It's like his hands were an unbelievable gift. But he still had this sense of inferiority. And in close relationships, he had been married more than once, he had difficulty making them work because the passive-aggressiveness that he felt as a child would come out in various ways, he could easily be triggered. The other thing is if you haven't worked through your childhood issues, you are going to be reactive.

And what that means in psychology for a person who's reactive is you are dealing with something that doesn't really exist in the present, but because it's a reminder of what typified your past, it feels like your past is in your present. So you react accordingly. And the main thing is for any therapist is to get people to respond. That puts you a choice.

When you react, it's basically the dominant programs that you internalize that have the final say. So again, working with somebody like that, you give him a message opposite from that person's parents, and you do it with an authority that ideally the person would respect and you go slowly. It has to be incremental. Because there's no way that a person could assimilate a message about himself that's directly contrary to the message that he got earlier.

So in terms of defense mechanisms, I would say all of them are maladaptive once you become an adult. So dissociation is the biggest one. Because dissociation takes you out of the present. And if there's some conflict, if there's something that feels threatening and you can't get hold of that and talk to yourself in a way that in the moment it dissolves, then basically you can't think clearly.

Because anybody whose emotions get hold of them is going to be, in a sense reduced to a childlike reactive state. So denial is similar to dissociation. It also takes you away from the present, which is what all defense mechanisms do. And the only defense mechanism that it occurs to me is always adaptive is sublimation.

Because what sublimation is about is defined in earlier, the earliest psychoanalysis vision with Freud is that basically the impulses that you have that are destructive, that are anti-social, that are overly libidinous, whatever you want to call them, you know at some level would be inhumane to express, dangerous to express, probably illegal.

So Confucius said something like 2000 years ago that if you embark on a journey of revenge, first build two pits. Is it pits, what would it be? Or burial sites. And the whole idea is you end up killing yourself even as presumably you're killing someone else. So it is normal, I think it's really in our DNA to have nasty vengeful thoughts about somebody who's exploited us, taken advantage of us, deceived us.

But to seek revenge on them, it's like giving them a taste of their own medicine, doesn't really resolve the problem. We somehow have to say, “Okay, what is it that I can learn from this? Revenge is not the answer.” And then move forward. The problem with somebody who is really immersed in getting revenge on others, retribution, if you will, is that they're really not focusing on what their personal welfare is.

I don't think that anybody can really be fulfilled by getting revenge because they're still back in the past. So sublimation is basically saying, “Okay, let me take up a musical instrument. Let me color a mandolin or something like that.” That basically you're trying to use that energy, and this is what sublimation is, transform it into something positive and something fulfilling.

So any form of play might be seen as a healthy return to childhood because I think that the healthiest adults are childlike. Not childish, but childlike. And that's one thing about having children, when parents play with their children, they are childlike and they can play a game with the children. And as much as the children love having their parents play with them, they are in a sense restoring something that may have been lost with all the adult obligations that on a daily basis they need to fill.

Jordan Rich:  Yeah. So thank you for diving into some healthier means of self-defense. I think that's going to be very helpful for our audience. So you've touched on reprogramming the self-defense mechanisms you've developed, specifically self-deprecation. Is there any specific advice you would give as to how to reprogram those behaviors or any therapies you would recommend to help someone through that process, any specific therapies?

Leon Seltzer:  The main thing is ultimately all healing comes from within, that therapists need to facilitate the process, they need to kind of guide it. Because basically, people who go into therapy go into therapy because they're stuck. It's not as though they need to have schizophrenia to go into therapy. And schizophrenia is handled as much by medications as anything else because it's considered a brain disease mostly.

And in terms of getting unstuck, some people can do it through what's called bibliotherapy. If you look at my background, you can see that I am pretty much enamored of books, and I stopped buying them when I realized that there was absolutely no more room on my bookshelves to put them. You can see how crowded they are.

I have to really work hard to extricate one book from the book on the left side and the right side. And I probably would not have anywhere as many books if I didn't start buying them before I knew how to use computers or there was all this information available on the computers. I know one thing I do in terms of consulting is I basically recommend books and articles and even videos they can read or they can see, because there's so much psychotherapy material now just on YouTube.

Basically, I'll want them to get a sense of what outdated defense mechanisms may be getting in their way. So sometimes I would explain core concepts to them. Given the fact that I function as a psychotherapist for so many years, I don't want my accumulated clinical wisdom if we can call it that, to go to waste. So I make myself available.

And generally I consult with people who've read one or more of my articles for Psychology Today and have questions. And if the questions are simple, I'm happy, gratis, to answer them, whether it's email or on the phone, maybe 5, 10 minutes. What I find sometimes is that they're complicated and without knowing more about their past, I wouldn't want to be glib and suggest something that would be untenable for them.

So then I make myself available, say for a more formal 60 minute consultation or more than one if that's necessary. But basically the model that I suggest to them is called Internal Family Systems Therapy. And what that means as opposed to Family Systems Therapy, is we have a family inside ourselves, and that internal family can easily give us different messages. So the essence of ambivalence.

And most people who go into therapy are ambivalent. I remember a cartoon I saw many years ago, I think it was called Cathy, it hasn't been in there for a while. But Cathy said something about the fact that she wants to be totally different, but please don't ask her to change.

Because change is very scary. What happens with change is you immediately find your level of anxiety elevating. Of course, because you're asked to change in different ways that your parents that are also inside you have been telling you, or you think they've been telling you not to change because it would endanger this core relationship that you have.

But in any case, with Internal Family Systems Therapy, it's interesting because Schwartz has written at least three or four books for lay people. Richard Schwartz is basically the originator of that particular model. And more and more people are seeing it as state of the art, although it's a very eloquent, elegant theory at the same time that it's not that easy to implement.

But basically, his second book for lay people. I love the title, is called You Are the One You've Been Waiting For. And what he talks about is a person's essential, authentic self, liberated from all these protective mechanisms that he refers to as protective parts. And those are parts of you, spontaneous, playful, wise even, that we all have.

And when we're feeling emotionally overwhelmed, because maybe we're in an incident that's shaming. And anything that's shaming to a child really is traumatic for that child because what defines it as trauma is they feel that their bond with their parents in the moment is being endangered, and they know that they're not self-sufficient, they're not mature enough to live on their own.

They can't run down to the Jones' house at the end of the street and say, "Would you please adopt me? I'm having problems with my parents." So they have to make all these adaptations that I've already talked about. So the main thing about IFS, Internal Family Systems is basically to get more and more in touch with the behaviors that really inhibit you from realizing who you truly are.

And basically, when I advise people, what I advise them to do is to think about how they needed to adapt to their parents' orders. It'd be one thing if the parent made a request, but it was okay if the child refused the request. But frequently, if the child feels that they have to have certain unalterable rules for the child, then the child doesn't have any sense of choice.

So even in self shaming, the protective part inside the child says basically, "You have to do this, otherwise you'll just constantly feel anxious." And I think the saddest thing is I've worked with people in the past that basically would engage in all sorts of extracurricular activities when the school day was over or would go to their best friend's house and come back only when they knew they had to come back for dinner, because as soon as they walked through the front door, their anxiety level would escalate.

And I can't think of anything more disturbing, more horrible than to never feel safe in your own house. And that hardly reflects the majority of people who are in therapy, but to some degree, they had to change who they authentically were in order to adapt. It's not always to the parents. It can be to an older sibling. It could be to kids in the neighborhood.

It could even be to their teachers, because teachers unwittingly can shame students very easily without even knowing that they're doing it. And it's not as though the child can go up to them after class and said, “You just shamed me.” No, they bear that burden inside. And basically what therapy is about, particularly in IFS, Internal Family Systems Therapy is basically to release those burdens, to integrate that wounded child part of you with your adult, and basically bring that child into your present life.

Have the child remind you when it's time to play, maybe even when it's time to get silly. Because being an adult really isn't that much fun. If you think about it, when we think of our adult selves, we think of being conscientious and responsible and productive, and that definitely has its place. But if that's all our life is, then our adult life becomes as burdensome as maybe our childhood was.

Jordan Rich:  Well, thank you for that advice, Dr. Seltzer. That actually concludes my questions for today. So to close, are there any final words of advice or anything else you would like to share with our listeners?

Leon Seltzer:  Well, I don't know that I can say anything that I haven't already said, or I could speak for another 10 hours, one or the other. So we should probably leave it as it is right now.

Jordan Rich:  Right. Perfect. Well, thank you again for meeting with me today, Dr. Seltzer. And thank you to everyone else for tuning in.

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

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

Atmospheric Researcher Kyle Hilburn on Wildfire Anxiety

An Interview with Atmospheric Researcher, Kyle Hilburn

Kyle Hilburn, M.A. is an atmospheric researcher and research associate at the Cooperative Institute for Research in the Atmosphere at Colorado State University. He specializes in the use of technology to study natural disasters, such as wildfires.

Theresa Nair:  Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us atmospheric researcher, Kyle Hilburn, who is a research associate at the Cooperative Institute for Research in the Atmosphere at Colorado State University. Kyle has a Bachelor's Degree in Atmospheric Science from the University Of North Dakota and a Master's Degree in Meteorology from Florida State University. He was recently a presenter at NASA's Earth Science Applications Week, where he discussed the most recent breakthroughs in the use of NASA satellites to assist emergency responders in tracking the directionality and impact of fires. Thank you so much for joining us today. Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying meteorology?

Kyle Hilburn:  Thank you, Theresa. It's my pleasure to be here with you today. Growing up in Minnesota, I was fascinated by the weather for as long as I can remember. Minnesota has plenty of crazy weather to observe. I will admit that as a young child, I was afraid of loud noises. And so, thunder caused me distress. Some of my childhood interest in lightning was motivated by that. Even though I couldn't control it, I could at least understand it. And that helped me deal with the stress more effectively. I find it incredible that despite millennia of meteorological observations by humans, we are still learning new things about the weather.

For example, when I was in high school, the first photographic documentation of sprites was captured, which are electrical discharges from the tops of thunderstorm clouds. There are undoubtedly many new discoveries still to be made in meteorology. What makes new discoveries possible are advances in technology for observing the atmosphere. And while the public may joke about the accuracy of weather forecasts, there have been steady improvements in weather forecasts over the last 30 years, coming from increased computational power, more sophisticated weather models, and more observations.

It wasn't until I was living in Northern California that I had personal experiences with wildfire, and I realized its important role in the Earth atmosphere system. The growth rate of wildfires rivals that of thunderstorms. The first fire I witnessed relatively up close was the Valley Fire in 2015. It grew from 10,000 acres in the first six hours and 50,000 acres in the first 24 hours. Within two weeks, it had burned 76,000 acres. When fires become large enough and hot enough, they even begin to create their own weather, capturing the physical coupling between fires and the weather is an important theme in my current research.

Theresa Nair:  That's incredible. I mean, I think sometimes we don't realize how quickly fires can spread. Some of the comparisons that you're giving us are amazing. We don't realize that it can spread even faster than a storm.

Many of our audience members are in the Pacific Northwest where wildfires are becoming a growing concern. Since the time you began researching atmospheric behavior, are you noticing any significant changes to wildfires, either in frequency or behavior?

Kyle Hilburn:  Yes. What I've observed and what multiple studies confirm is that wildfires are becoming more frequent, they're growing larger, they're exhibiting more extreme fire behavior, and the fire season has gotten longer. And with population growth in what's called the wildland-urban interface, there are more people with greater exposure to wildfire risks. And it's not just droughts and fires that are becoming more frequent and more extreme, but heavy precipitation seems to be becoming more common as well.

For example, the six 1-in-1,000-year precipitation events that occurred in August in the United States or the recent flooding in Pakistan. This leads to the concept of cascading natural hazards, where heavy precipitation falling after a fire can cause erosion, debris flow, and have impacts on watershed, ecology, and water quality. This recently occurred with tropical storm Kay over Southern California. This cycle of drought, fire and flood is surprisingly common. And the National Weather Service actively monitors for these situations.

Throughout most of my career, the concept of attributing extreme weather events to climate change was considered impossible or at least dubious science. However, with advances in computing power, one can now simulate extreme events with and without the human influence on the climate and thus attribute those events to climate change with some level of confidence. This attribution is being performed almost in real time today.

Theresa Nair:  That's great. Yeah, I think those types of models are important for answering that question of whether we are affecting the atmosphere or not. In your recent presentation for NASA's Earth Science Application Week, you discussed extreme fire behavior and how some fires are large enough to create their own weather. I know you mentioned it a few minutes ago also in this interview. I was wondering if you could give us some examples of that and discussed what types of phenomenon you observe.

Kyle Hilburn:  A primary example is called a “pyrocumulonimbus” cloud, which is a type of thunderstorm that gets its buoyancy from a heat source, such as a wildfire. This type of cloud has only been widely recognized in meteorology in the last 24 years. There are even examples of pyrocumulonimbus clouds that get strong enough to produce lightning that ignite new fires, such as the pyrocumulonimbus cloud created by the Mallard Fire in Texas. Strong winds cause extreme fire behavior as we saw with the Marshall Fire in Boulder, Colorado. This was just a grass fire, but with winds stronger than 100 miles per hour, this fire was able to get out of control and enter an urban area causing so much destruction. People who thought they live far from the wildland-urban interface found out they are more vulnerable to wildfire risk than they thought. The Tubbs Fire in Santa Rosa, California in 2017 burned from Calistoga to Santa Rosa in just three hours’ time, propelled by very strong Diablo winds. Those winds are strongest along ridge-tops and created tendrils of fire that spread down into the valleys and neighborhoods, reaching within half a mile from my house.

The other ingredient in extreme fire behavior is heavy fuel loading, where the term fuel dispassionately refers to trees, shrubs and grasses. Drought, historical forest management practices, and pernicious species have played roles in creating the dead fuel conditions that we find ourselves with today.

In Lauren Johnson's interview on environmental justice, she described Native American forest practices of thinning trees to control fires. That practice is now referred to as a prescribed burn. Although New Mexico, this year, we witnessed a tragedy when a prescribed burn got out of control and became the Calf Canyon/Hermits Peak Fire, the largest in New Mexico history. The goal of my research is to use sophisticated weather models to provide improved decision support tools for prescribed burns and wildfires.

Theresa Nair:  That's really interesting. There's actually a couple follow ups I think I'd like to ask you on that. So with these weather systems that develop in fires, are some of the tools that are being developed able to begin predicting those?

Kyle Hilburn:  Yes, absolutely. We're able to put together all of the physical processes. And a lot of these have been understood for some time, but it's about having the computing power to be able to run these models fast enough to provide the information to people in the field, dealing with the fire.

Theresa Nair:  Okay, and one other thing. You had mentioned the benefits of controlled burns, but then also the risk if it gets out of control. Given the risk of it getting out of control, does it seem like it's better in general to do the controlled burn or is it maybe different in different circumstances?

Kyle Hilburn:  Yeah. I'm not a forest ecologist, but my understanding is that in general, controlled burns are an effective practice for controlling fuel-loads in forests.

Theresa Nair:  Okay, great. In your presentation, I did attend your NASA presentation, you were discussing the most recent applications for using satellites to assist in responding to fires. Could you tell us about the developments in that area and how it differs from previous methods that were used to track the directionality and impact of fires?

Kyle Hilburn:  Satellite remote sensing has been used to detect thermal signatures of active wildfires for over 20 years. Recent developments have improved the spatial and temporal resolution of the observations. For example, currently, the highest resolution satellite sensor with publicly available data has pixels that are 30 acres in area. However, that satellite is on a low Earth orbiting satellite, about 500 miles up, which only observes a given location twice per day. In contrast, geostationary satellites currently provide updates as fast as 30 seconds, but because they're so much farther from Earth, 22,000 miles up, they have pixels that are 1,000 acres in area.

So, part of my research concerns combining these observations from different sensors to get the best of both approaches. Over the coming decades, we will get new sensors and satellites with even finer spatial resolution and faster temporal refresh. These are being designed right now. While small satellite constellations and unmanned aerial vehicles will offer new observing approaches.

The other major development is how we forecast fires. Older models treat fire as an uncoupled system where you have wind blowing over a fire and they use simple assumptions to predict the fire spread based on the wind, but in those models, the fire does not in turn affect the winds. In my research, we're using a fully coupled model. Its name is WRF-SFIRE, which has physical processes in the atmosphere, the fire, and the vegetation coupled together and interact as they do in the real world. This is the only way that you can have fire that creates its own weather. Examples of fire atmosphere interactions include fire-induced winds that can further dry fuels and smoke shading that could inhibit air mixing. Uncoupled models do not represent those types of physical connections. I discussed more technical details about physical processes of WRF-SFIRE in my NASA Earth Science Applications Week presentation, and I've provided the link. (Kyle’s presentation starts 1 hour 32 minutes in.)

Theresa Nair:  That's great. Thank you. And that sounds like incredible research being able to combine all of those different factors and get more accurate predictions about how the fire will actually behave. Are these recent developments in the use of satellite data and the work you've been talking about, are they solely intended for the use of professionals and disaster responders, or is this knowledge that's available to the general public?

Kyle Hilburn:  I would encourage the general public, not to attempt to interpret forecasts from fire models for the same reason your doctor encourages you not to obsess on WebMD. You need to be a trained meteorologist to be able to understand the characteristics of the particular forecast system in order to understand what those forecasts mean. On the other hand, there are websites that provide information on fires, smoke, and weather that are suitable for the public, and I'll provide you links. You should also look for information at your state and local levels to get the information that is most specific to you.

Theresa Nair:  That is great. And we will be linking to all the resources that Kyle's talking about in the transcribed interview below. So if you're watching this interview or if you're on the podcast listening to it, there was a transcription available that we'll have all of the links that he's discussing. Let's talk for a little bit about the relationship between wildfires and mental health. You have extensive experience dealing with wildfires, both from a personal perspective and a professional perspective. When people find out that they may potentially be in the path of a wildfire or that they're in the general proximity of a fire, what steps do you believe would be the most helpful in dealing with the anxiety that might arise from that situation?

Kyle Hilburn:  Well, recognize that a fire doesn't need to be particularly close to cause major impacts on life and various impacts can last days to weeks to months. Even when a fire is 30 miles away, its impacts can make it feel very close. The smoke from a nearby fire can produce a suffocating sensation in a matter of seconds to minutes, which is anxiety provoking. The sky can darken, turning day into night and falling ash can produce an “end of the world” feeling. The smoke can make outdoor exercise impossible, which removes a potential coping mechanism, and it can trigger PTSD in people who have lived through previous fires. Having to leave everything behind at a moment's notice, not knowing what you'll come back to is incredibly stressful. And the aftermath of a fire in an urban setting looks like images from a war.

I've experienced living near fires in Santa Rosa, California, and Fort Collins, Colorado. The Cameron Peak Fire near Fort Collins started in August 2020, and it wasn't 100% contained until December. Fortunately, I was not directly in harm's way with any of these fires, but I still experienced some anxiety. The thing that produced the most anxiety for me was the lack of specific up-to-the-minute information given how fast conditions can change. While messages go out from emergency managers to people currently in evacuation zones, being close to, but not in an evacuation zone can be frustrating because it is hard to get the hyperlocal up-to-date information you want.

So, when confronted by wildfire hazards, one way to deal with the anxiety is practicing mindfulness by which I mean observing your environment and your thoughts about it. Some questions you can ask yourself, is the smoke aloft, or is it near the surface? That can make a big difference in terms of impacts on whether your air quality is healthy or not. How dense is the smoke visually? What is the color of the smoke and how does it affect your perception of the sun or the moon? What does the smoke smell like? Is it spicy and pungent like fresh wildfire smoke, or is the smell more muted? Indicating the smoke has traveled some distance. Is there falling ash? What is the wind direction?

By remaining mindful, you can avoid black and white thinking about the fire. You can observe that its impacts vary from day to day and over the daily cycle. And you can see that like everything, it comes, and it goes. Emergency managers also recommend staying observant in wildfire conditions, which they call maintaining situational awareness. So, staying aware has benefits both to your psychological state and your physical safety.

Another strategy for dealing with the anxiety, turn your focus outwards and practice gratitude for the wildland fire crews responding to the fire incident. Wildland firefighters work extremely hard, and they deserve our appreciation and support. Also, there may be evacuees who need support, but please listen to your local officials and make sure you don't get in the way of their response efforts.

One issue I've experienced during fires is obsession over the latest observations. I found I have to ask myself, is there really any new information? And, when do I expect new information? To keep myself from spiraling into an obsessive-compulsive cycle of refreshing websites repeatedly when fires are nearby. Finally, preparing for wildfire hazards can give you comfort and can make a big difference when the worst does happen. So, I've provided links from Ready.gov, CAL FIRE, and the Red Cross, discussing steps you can take to be prepared.

Theresa Nair:  That's great. And I think we've probably all been in situations where you're repeatedly refreshing that website, trying to get the latest news. Following up on that. You mentioned the importance of not only staying up to date with those resources, but also your own observational skills, keeping an eye out for things, like whether the smoke is closer to the ground or further up, whether there's ash falling from the sky. If somebody notices that their situation is changing, but maybe there aren't any alerts yet saying to evacuate, should they kind of follow their observational signs that they've observed or should they wait to receive specific instructions from authorities?

Kyle Hilburn:  That's a difficult question and it will depend on your own personal feelings about the situation. Things like ash can be transported for many, many miles, and aren't necessarily an indicator that you're in imminent danger. I would definitely recommend that people listen to their state and local authorities and to emergency managers. They will let you know if there is an immediate risk to your safety. But if you're uncomfortable, you can make the choice to leave at any point, if that makes you feel better.

Theresa Nair:  That's true. It never hurts to be more cautious, right? Are there any further developments in tracking or responding to wildfires that you think might be helpful for our audience to know about? And are there specific tools you would recommend for those who are concerned about fires in their area?

Kyle Hilburn:  Yes, I would recommend four websites. First is the AirNow website, which provides information about air quality. In particular, the quantity called PM 2.5, which measures the concentration of particles smaller than 2.5 micrometers, which is a key indicator of the severity of wildfire smoke. And whether it's healthy to be outside. Keep in mind that air quality sensors represent the conditions at a specific point and conditions can vary dramatically with your location. Second is the InciWeb website, which provides information on active wildfire incidents for the United States. You can click on specific incidents and read more information about the current situation and the outlook.

Third is the CIRA SLIDER website, CIRA is where I'm located, which provides access to satellite imagery of fires. When you go to that site, it defaults to the GeoColor product, which is very good for looking at smoke plumes during the daytime, because smoke generally has a darker color than clouds. Under “Product”, you can select fire temperature or natural color fire, and then zoom in on your location. There are color bars at the bottom of the image that tell you what each color means. Under add map, you can add cities, roads, and county boundaries, and other information to see where the fire is located. Keep in mind that clouds and even heavy smoke can obscure the heat signatures from fires. And finally, the National Weather Service at weather.gov is an excellent resource for the official weather forecast coming from human experts with local knowledge and to learn whether there are any watches or warnings for your area.

Theresa Nair:  This is some great recommendations. Thank you. And once again, for our audience, we will provide links for all of those in the description. So if you didn't quite catch that, you can just look at that on the transcript and they'll be there. As an atmospheric researcher who specializes in creating weather prediction models, do you have any other parting words of advice or anything else you'd like to share with our listeners?

Kyle Hilburn:  Well, nature is very restorative for the soul. Florence Williams described nature therapy, such as forest bathing in her interview. And so it is extremely distressing to see nature burning down, but we must remember that fire exists as part of a natural duality between creation and destruction. There are artists such as Erika Osborne, who are exploring this duality and human's relationships with fire. But the increasing rate of changes in our environment is very distressing and climate change anxiety is real. And so, I've provided a link discussing that. Thank you again, Theresa, for this opportunity to discuss managing wildfire anxiety.

Theresa Nair:  Thank you so much for speaking with me today and taking the time to participate in our interview series.

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

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

Social Worker Erin Maloney on the Innocent Lives Foundation

An Interview with Social Worker Erin Maloney

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

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

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

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

Erin Maloney:  Thank you for having me.

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

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

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

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

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

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

Erin Maloney:  Yes, yes.

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  Yes.

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

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

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

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

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

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

Erin Maloney:  Yes, yes, exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  It truly is. Yep.

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

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

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

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

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

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

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

Erin Maloney:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  Yes, yes.

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

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

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

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

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

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

Erin Maloney:  Yes.

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

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

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

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

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

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

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

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

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

Erin Maloney:  Exactly, exactly.

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

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

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

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

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

Erin Maloney:  Exactly, exactly.

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

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

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

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

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

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

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

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

Erin Maloney:  Wonderful. That sounds great.

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

Erin Maloney:  Of course. Thanks for having me.

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

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

Psychologist Jonice Webb on Childhood Emotional Neglect

An Interview with Psychologist Jonice Webb

Jonice Webb, Ph.D. is licensed clinical psychologist located in Boston. She specializes in identifying and treating childhood emotional neglect.

Preeti Kota:  Hi, I'm Preeti Kota, and I'm a research intern here at Seattle Anxiety Specialists. And today I'm joined by Dr. Jonice Webb. Dr. Webb is a licensed psychologist whose interests concentrate on childhood emotional neglect. She's a speaker and bestselling author of two self-help books, Running on Empty: Overcome Your Childhood, Emotional Neglect, and Running on Empty No More: Transform Your Relationships. She has increased awareness of the effects of childhood emotional neglect, and trained hundreds of licensed therapists in identifying and treating childhood emotional neglect in their clients. Dr. Webb, would you like to introduce yourself and share a little bit about your research?

Jonice Webb:  Yes, absolutely. Thanks for having me on. So, I am a licensed clinical psychologist located in Boston, and I've been practicing psychology for, I hate to admit it, but probably like 25 years now. And during that time, having worked in a lot of different settings, I noticed that I started seeing this pattern among my clients, and I got very curious. What is causing this particular group of symptoms to appear in people that seemed to have nothing in common? Otherwise they were from different socioeconomic backgrounds, different cultures, different diagnoses, different types of families, and backgrounds, and yet I kept seeing it over and over. And I just got very curious and started trying to figure it out and eventually realized that what I was seeing was a very pure form of emotional neglect that all these people had in common in their childhood homes. And when I saw that and realized what it was, I started doing research among the databases of the American Psychological Association, trying to find research on emotional neglect, specifically childhood emotional neglect in its pure form.

Meaning not necessarily accompanied by abuse, but just, and not physical neglect, but just pure emotional neglect. And I realized that there really wasn't... It wasn't being talked about it. Wasn't being written about it, wasn't being studied. And that's when I realized I needed to write my first book Running on Empty and it's just taken off from there. And so at this point, then I wrote another book and that was in 2012. In 2018, I wrote Running on Empty No More: Transform Your Relationships, which took the concept and applied it further. And I have a blog on Psychology Today and emotional neglect recovery programs on my website. So it's pretty much everything I do now. I'm very passionate about it.

Preeti Kota:  Wow. That's great. So to dive into the questions, can you talk about the process of early childhood emotional neglect, leading to a lack of self-trust?

Jonice Webb:  Sure. So, childhood emotional neglect happens when a parent fails to respond enough to the feelings of their child. And it doesn't have to be zero amount that they respond, but parents who tend to minimize the importance of feelings, or are even blind to feelings. And there are many, many people in this world who are good people who want to be good parents, but who just don't understand that emotions matter so much. So, when they're raising their child, things like just ignoring the child when they're really upset about something, pretending not to see it, or just not seeing it, not asking questions, not being interested in the child's inner life, or what they're experiencing and not responding to that. When a child grows up this way, they tend to get the message that is not necessarily ever said out loud, but is communicated by a lack of asking the right questions, and saying the right things.

So, sort of like if your parents just pretended that your right arm didn't exist, and just acted as if it wasn't there, you would grow kind of ashamed of your right arm. And you would be like, "Why do I see this, but no one else does?" And you'll try to hide it from other people and from yourself. And that's what children do when their feelings are ignored is they get the message their feelings are irrelevant at best, or bad at worst. And then they block them off so that they won't get in their parents' way. They won't have to deal with them themselves. They just sort of build this wall inside their brains, not consciously, it's just sort of an adaptive mechanism so that their feelings are cut off, and this might get the child through their childhood, but it doesn't really work as an adult because we really need our feelings.

Our feelings are the deepest expression of who we are, and they provide us guidance, and motivation, and all sorts of connection and great things that are really important as we go through our adult lives. So people who grow up with their feelings cut off, don't even realize it don't remember anything happening to them that could make them have problems in their adult life necessarily, and end up just sort of secretly struggling with it, and not understanding what's wrong. And that is the essence of childhood emotional neglect. It plagues a lot of people who aren't aware of it.

Preeti Kota:  And is it the parents that have the most impact on childhood emotional neglect, or can older siblings, or friends have the same effect?

Jonice Webb:  That's a great question. It's primarily the parents, because the human infant is wired to need affection, and emotional connection from their primary caretakers, which in most situations are the parents. Sometimes there can be like, I've heard stories of a nanny providing it when the parents couldn't so there could be a substitute stepping in to provide it, but to be deprived of it, it really is to be deprived of it from your parents.

Preeti Kota:  And then do those with childhood emotional neglect tend to be more prone towards any comorbid mental health disorders, such as anxiety or depression?

Jonice Webb:  Yes. First I want to say all people with childhood emotional neglect, which I call CEN, do not... It's not like everyone develops a comorbid disorder. I've seen lots of CEN people who don't have any history of diagnosis and don't qualify for one when I see them. But nevertheless, they're struggling in various ways, but it does make you more prone to both depression, and anxiety. And I think that it's because when you have your feelings walled off, you're not processing them as you go through life, which most people just do naturally, you get upset, you deal with it, and then you've dealt with it. So you move on. But when your feelings aren't, when you don't have that natural connection with your feelings, they just all sort of pool together on the other side of the wall.

And because you're not aware of them and you're not connected to them, they just kind of mix together and they can turn into basically three things that I've seen, depression, anxiety, or irritability. Some people just become very irritable people, and it's because they haven't dealt with their feelings, or they'll end up depressed or they'll end up having anxiety, free-floating anxiety, or anxiety about certain things. And it's because they haven't dealt with their emotions.

Preeti Kota:  Is there a certain factor that makes a person more prone to having irritability, or anxiety, or depression in reaction to the same thing?

Jonice Webb:  I wonder that myself, I wish I knew the exact answer, but I don't, but I can tell you what my hunch is, which is that it depends on the nature of the walled off feelings. If most of your walled off feelings have to do with sadness or loss, I think you're more prone to depression. If most of your walled off feelings have to do with fear, or trepidation, or any of the sorts of fear based types of feelings, you're more prone to anxiety. And if it's more anger, you're more prone to irritability. That's my guess.

Preeti Kota:  Interesting. So, how do you not confuse following, or listening to your emotions as a source of guidance with giving into your impulses?

Jonice Webb:  First, I'll just explain that one of the things I talk about a lot and try to teach people to do is to pay attention to their feelings, and to listen to them. So I think that's what you're referring to here in this question, and to follow them. But that doesn't mean just like knee jerk following, because emotions can be excessively strong. They can be misplaced at times. And sometimes we feel things really intensely that actually are, we're feeling it so intensely because it's touched off something from the past that we haven't dealt with that feeling enough yet. And so that feeling attaches itself to the current situation, and makes you feel you can have big feelings over something that seems kind of ridiculous, or small. And it's because it's just blown out of proportion by the past. So, there are many reasons why we can't just knee jerk trust our emotions.

So, the way it works well is to take note of what you're feeling, process it with your head, meaning, think it through what is this feeling? Because every feeling is a message from your body. So what is my body trying to tell me here, by making me feel angry right now, could it be this, could it be that? And you sort it out with your head, and then you say, should I be angry right now? Actually, yes, I should. Someone just insulted me. What should I do? And then you think it through, and that way your body informs your head, and your head informs your body, and the two work together to make a good decision, and choose a correct action or the most correct that you can.

Preeti Kota:  How do you find the balance of if you are using your head too much, it's like overthinking, but if you're using your emotions too much, it's kind of impulsive?

Jonice Webb:  Yeah. Well I think we all struggle with that, and it really is a matter of just trying to really consciously do this process enough that you get better, and better at it. And we all are going to mess it up. We all do. There's no way to be perfect at this, nor should anyone expect themselves to be. Really for every human being who's alive, it's a work in progress. Getting our brain to work with our body, to get good results is the essence of being healthy, and living well.

Preeti Kota:  And then how does indecisiveness relate to people's inability to trust themselves?

Jonice Webb:  So when your feelings, so our feelings, as I said a minute ago, really inform us, and they're our guide to what we really want, what we need, what we like, and dislike what we care about. It all is communicated to us through our feelings. And so when you're cut off, I think cut off is a strong word. When you don't have a good connection to your feelings, then you don't really have the sort of weather vane that your feelings should be providing you. Your feelings, or the rudder is what I meant. Not a weather vane. Your feelings are your rudder. And so to use a boat metaphor. So it's very important to be able to consult your body, and get answers that come from your deepest self, which is your feelings. And if you don't have a good ability to do that, it's kind of consulting your gut, right?

A lot of feelings occur in our gut. We now know there are neurons in our guts, in our GI system. And there's a reason why you feel things in your gut, but if you're disconnected from your feelings, then you're disconnected from your gut, and you don't end up trusting yourself nearly enough when it comes to making decisions. And you're much more vulnerable, and prone to asking other people, "What do you think I should do? What do you think? What do you think of this? What do you think of that?" And that's a kind of dangerous way to live because people can have all sorts of opinions and it doesn't mean it's right for you.

Preeti Kota:  So then how do you start to trust yourself if you think you're going to make the wrong decision?

Jonice Webb:  Get in tune, get in tune with your gut. And start the process of healing childhood emotional neglect. It really involves getting in touch with your feelings, starting to value your feelings more, and paying attention. I've probably told hundreds of people with childhood emotional neglect, what does your gut say? Let's ask your gut about that question. And it's a foreign, it can feel weird at first, but if you do it, if you keep doing it, and keep paying attention to your feelings and processing it with your brain, it's a matter of practice, and changing old habits and filling them with new ones.

Preeti Kota:  And then how are self-trust, self-esteem, and confidence related?

Jonice Webb:  When you have a good gut sense, and you trust your gut. No one's gut is right all the time. When you trust your gut, you're trusting your feelings, and you're trusting yourself, and you're valuing your own internal world, and your own internal process and sense of self. So when you have that, you trust yourself, and you can feel more confident. And that leads to all sorts of good things, feeling comfortable in your own skin, feeling comfortable around other people. It's the process of overcoming social anxiety, just becoming comfortable with who you are and trusting yourself so that it all goes together.

Preeti Kota:  So, you would say the first, are they kind of linear or..? Like increasing your self-trust, leads to an increase in self-esteem?

Jonice Webb:  Yes, I would say so.

Preeti Kota:  Okay.

Jonice Webb:  Vice versa though. It goes the other way too.

Preeti Kota:  Okay. How do you break the habit of dismissing your feelings to start accepting them?

Jonice Webb:  Yes, that is a whole process. I developed this technique for people to use, it's called the identifying and naming technique. It's in, I think I have it in both of my books, but it's definitely in Running on Empty. And basically it just involves turning your attention inward, and checking in with yourself and asking yourself, "What am I feeling right now?" And then following that up with some other questions that help you identify why you might be feeling it and what it's coming from. And just doing that check in with yourself if you can make yourself do it several times a day, even starting with once a day or at whatever level you can handle.

And it's okay if you come up empty and it doesn't feel like you have a feeling, because a lot of people with emotional neglect have that experience that they ask themselves, "What am I feeling?" And that they come up with nothing. But if you keep doing it, and keep trying to tune in, it's sort of like that process, it's so simple. But what you're doing is you're connecting your brain and your body. And every time that you try to forge that connection, you're chipping away at that wall that's blocking the two off. And even if you don't come up with a feeling, you're making progress and you just have to keep at it, keep at it.

Preeti Kota:  Is that kind of related to mindfulness?

Jonice Webb:  Yeah. It's a mindfulness technique, because basically you're turning your attention inward, and you're putting your full focus on your inner world. And that's something with people with emotional neglect are usually not very good at because they're used to focusing outward. Everybody else is what's important. Everybody else, everything else, the outside world, and this kind of makes you look inside at yourself.

Preeti Kota:  So, how does the need to belong relate to the need to trust yourself? Are they conflicting?

Jonice Webb:  The more you trust yourself... So, interestingly, I'm going to start somewhere else for a second. Interestingly, people with childhood emotional neglect have a proclivity to feel out of place. And they tend to have an almost verging on social anxiety, if not social anxiety. And it's because they feel disconnected from... They feel like when you have your feelings blocked off, some part of you feels something's not right. It's like you're missing something that everyone else has. And I've heard many emotionally neglected people put this into words and say, "I feel like I'm on the outside looking in on everyone else who's really living life." Or "I feel like I'm living in black and white and everyone else is living in color." Or "I walk down the street and I see other people smiling, and laughing, and walking together. And I feel like, why can they do that so easily? It doesn't come easily to me."

And when you're cut off from your feelings or disconnected from your feelings, it can feel like you're different than everyone else, and something is secretly strangely wrong with you. And that makes it hard to feel like you belong anywhere. And it makes it hard to feel like you can be yourself in any social situation. So, you can end up feeling like you need to be a certain way, or do a certain thing, or act a certain way in order to get accepted and fit in, because you just haven't figured out yet that what you need is just to be your true self, which includes your feelings, and your thoughts about those feelings, and that whole process that you're skipping over in your life it's needed in order to be able to be your true self and feel like you really belong and are worthy.

Preeti Kota:  But what about when during childhood, when you don't really have that mindfulness technique in hand, and you feel like with friends, or something and you feel like you want to belong, but you don't really know how to trust your feelings first?

Jonice Webb:  There's no simple answer to that. I mean the real answer, the real, real answer is really work on being your true self. If you are your true self and your friends reject you, it means you're with the wrong people, and that's all there is to it. It doesn't mean you're bad. It doesn't necessarily mean they're bad. It just means you're trying to squeeze yourself into the wrong space with the wrong people. And it's hard to find the right people unless you are being your true self, and showing who you are so that those people can connect to your true self.

Preeti Kota:  How do you change your existing relationships with people who have already learned that you distrust yourself, and therefore don't respect you as much?

Jonice Webb:  Well, I think the most important thing to say about that is that people read each other on all sorts of levels that are not conscious. And we tend to trust people as much as they trust themselves. So, we sense how much someone trusts themselves, and that's how much we trust them, and how much we respect them. And so the best way to help people around you trust you more is to be yourself more, and to show your own true feelings more. And that doesn't mean all the time, just impulsively. It means being in tune with yourself so that other people can be in tune with you. And when people feel truly in tune with you, like you're authentic, and you're being your real self and they're allowed to see who you are, that's when they really value and trust you.

Preeti Kota:  But how do you overcome the possibility of rejection, or invalidation when you show your true self?

Jonice Webb:  It's always possible. And so part of this has to do with believing, with accepting who you are, and how you feel about things. And if there are things about one's self that you don't like, then you can work on changing yourself. You can even change your feelings to be the way to feel about something the way you want. So, in a way we all shape ourselves, but in order to truly shape ourselves, we have to be in touch with who we actually are, what our feelings are, and who we want to be. And so the key really is to tune into yourself, believe in yourself enough that if someone does reject you, you're able to weather that and say, "Okay, I guess that person doesn't value who I really am. Is that someone I really wanted to be in my life anyway?"

Preeti Kota:  And then a lot of people have a self critical part of their self that makes it hard to believe in themselves, so how do you suggest overcoming that?

Jonice Webb:  People with childhood emotional neglect tend to be very, very hard on themselves, and it could be, they had a critical parent and they internalized that. Or it could be that they had zero, or very little feedback about themselves growing up, which is true for many, many people with CEN. And if you're a child growing up and you don't have much feedback coming in, if your parents aren't giving you observations about who they see that you are, if they don't see your deepest self, and reflect that back to you, as a child, you have to fill in all the blanks, and children can develop a very harsh internal voice that's sort of like their creation of the parent they need. And that parent, kids don't really know necessarily, especially if they haven't received it, they don't know how to accept, or they don't know how to talk themselves through a difficult situation or a mistake. So it just turns into the mean parent, "What an idiot. How could you do that?" Talking to oneself the way you would never talk to a friend.

And so that can be a hard thing to overcome, except that the more that you can value yourself, and listen to yourself the more, and actually deal with your own feelings, then you can also start challenging that voice, catching yourself when you hear it, or catch yourself when you use it. And really start talking back to it, and say things like, "It's not true I'm stupid. Everybody makes mistakes." It really is a critical voice or a critical part of yourself is a really difficult thing to beat back, but it's absolutely not impossible. I've seen many people do it just by doing that whole process I just described.

Preeti Kota:  So I think you've already touched upon this, but what strategies do you have for listening to your emotions and turning inwards specifically any daily habits?

Jonice Webb:  Yeah. Doing that, identifying and naming, I think is the number one thing to do. The technique where you tune in and ask yourself, what am I feeling? And then there are other things you can do once you are identifying some feelings which involve processing the feeling and asking, and I created this technique also called the IAAA, where you identify the feeling, you accept it for what it is. Then you attribute it to a cause, and then you decide on an action. So that whole process pulls your brain and body together to start using your feelings instead of just shoving them away. So, practicing that another thing people can do is try to start identifying what other people are feeling, and if you're too good at that, it's not something to do, it means you're over focused on other people.

But just becoming aware of emotions, watching how other people handle their emotions, watching for emotions and other people, and what they do with them can be very instructive. I call it becoming a student of emotions and feelings. And just starting to... Once you make up your mind, I'm going to learn everything I can about how emotions work, what I'm feeling, and how my emotions work. Once you declare that to yourself, and start tuning in, it's really a great start towards fixing everything that didn't happen for you as a child.

Preeti Kota:  So, would you say, I think we touched upon this earlier, but about balancing between the mind and your emotions, would you say that's like the rational and irrational split or I don't know.

Jonice Webb:  Not necessarily, because feelings are not always irrational and thoughts are not always rational, so I wouldn't put it in that camp.

Preeti Kota:  Okay. And then do you have any parting words of advice or anything else you'd like to say to our listeners?

Jonice Webb:  Sure. I just want to emphasize that emotional neglect, childhood emotional neglect is not something your parents do to you. It's something they fail to do for you. And so it's not an act, it's not something that happened to you. It's something that failed to happen for you. And because of that, your brain as a child, doesn't record it, and then as an adult, it's really hard to remember childhood emotional neglect happening to you, because it wasn't an event. It was a non-event, right? And our brains don't record things that don't happen. So, it's hard for people to know whether they have childhood emotional, neglect or not, but people can go to my website, and take the emotional neglect questionnaire. And that will give them an idea of whether they fall in this camp or not. And when they take the questionnaire, they'll also be a member of my newsletter, and they'll be kept informed of every blog I write on Psychology Today, and every interview I do, and everything I write, and talk about, so.

Preeti Kota:  Great. Thank you so much. I learned a lot about childhood emotional neglect, and I think it's very helpful for people to go back and see how that could have affected them today and definitely has a very influential impact on our daily life. So thank you so much.

Jonice Webb:  Absolutely. Thanks for having me.

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

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

Therapist Amanda Ann Gregory on Trauma & Roe v. Wade

An Interview with Therapist Amanda Ann Gregory

Amanda Ann Gregory, LCPC is a psychotherapist, national speaker, and author. She holds licenses in the states of Illinois, Texas, and Missouri, and has EMDR certification. She specializes in working with trauma survivors.

Anna Kiesewetter:  Hi, thank you so much for joining us today on this installment of the Seattle Psychiatrist Interview Series. My name is Anna Kiesewetter, and I'm a research intern at Seattle Anxiety Specialists. I'd like to welcome today with us the trauma psychotherapist, Amanda Ann Gregory. Amanda is a trauma psychotherapist, national speaker, and author. She holds licenses in the states of Illinois, Texas, and Missouri, as well as an EMDR (Eye Movement, Desensitization, and Reprocessing) certification and a National Counselor certification. Amanda has provided individual, group, and family therapy for more than a dozen years in outpatient and residential settings, and is currently in private practice in Chicago.

Her work has appeared in Psychology Today, Psychotherapy Networker, Happiful Magazine, Addiction Professional, and other magazines. Amanda has also served as a presenter for clinical conferences, employee trainings, and community events and has spoken for the American Counseling Association, the National Alliance on Mental Illness, the Missouri Department of Mental Health, the Missouri School Counselor Association, Prevent Child Abuse Illinois, and the Missouri Association of Marriage and Family Therapy.

Before we get started, could you please tell us a little bit more about yourself and how you came to work as a trauma psychotherapist?

Amanda Ann Gregory:  Yes. How I came to work in trauma was actually by accident. My very first job out of graduate school was at a very specialized residential treatment center for teenagers, which specialized in treating developmental trauma, which especially at that time really wasn't well known and it’s trauma that basically occurs in childhood over a period of pivotal development. And when I was there, I absolutely loved it. I loved working with trauma survivors, and I didn't want to leave it. And so I took those skills into the outpatient world in community mental health centers. Now, I'm in a group practice. And so this is a population that I just fell in love working with. And later, honestly, realizing that I'm also a developmental trauma survivor, and so, really feeling that I'm connected to this population. I was able to do my own work, my own trauma treatment, which is a big part of being a trauma clinician. And so really it's twofold. It's a wonderful population to work with, and also I consider them my people, my tribe, so to speak. Yeah. And I just always feel grateful to be able to do this work.

Anna Kiesewetter:  That's really beautiful. Thank you for sharing that with us. What does this therapy generally look like for you?

Amanda Ann Gregory:  And can you say that again?

Anna Kiesewetter:  Yeah. What does therapy generally look like for you as a trauma therapist?

Amanda Ann Gregory:  Right. Dealing with trauma, it's a little bit different sometimes from other types of therapies. When we think of therapy, sometimes we automatically think of talk therapy, which is typically cognitive behavioral therapy, but with trauma work, it's a bit different because you have to bring in other interventions to address those earlier developing parts of the brain. And so therapy for me really depends upon the trauma survivor, what they've already been exposed to, what work maybe they've already done, or is this their very first time participating in treatment? I tend to combine a lot of methods, so I'm attachment based. There's a big focus on the relationship with the client and creating that safety to start. And I bring in a lot of interventions to help the brain such as EMDR, somatic experiencing, maybe even at times play therapy, animal assisted therapy, internal family systems. It's really eclectic depending upon what the client needs, but it does look a little bit different at times from what people may think of as that talk on the couch type of therapy.

Anna Kiesewetter:  That's really interesting. Could you tell us a little bit more about how it differs from the talk therapy practice... It sounds like it's a little bit more hands on for the things that you do. Is that right?

Amanda Ann Gregory:  Yes. It could definitely be more hands on and a bit more interactive. Here's an example. Let's say I'm working with a client about, let's just say one experience that they've had that they've really kept with them. It's really blocked them in areas of their life. And we would call that trauma. Some people, if they're working with a client, they may want to talk through it. They may want them maybe to create a narrative of their experience, which can be wonderful. My type of therapy is bringing more things, for example, the body. When you recall that memory, what do you notice in your body? Connecting with that sensation, helping that sensation to process.

With EMDR, we do a lot of that bilateral stimulation to desensitize the actual impacts of those experience and reprocess adaptable core beliefs. Instead of the client telling me what happened and going through the story of it, I might move their eyes back and forth, back and forth. I may have them hold onto these vibrating tactiles that go back and forth, back and forth in their hands. And that's what's helping them process and I'm going to help them along. I'm going to be right there. It's definitely not hands off, but it does tend to be a bit more experiential in nature.

Anna Kiesewetter:  I see, yeah. Thank you for explaining that. Awesome. Okay, now that we've gotten to know a little bit about you and the therapy work that you do, today, I'd like to address a topic on a lot of our minds. On June 24th, 2022, the Supreme Court overturned its Roe v. Wade decision in the US, ruling that the right to an abortion is not protected under federal law and delegating jurisdiction over abortions to the states. Following that ruling, abortion has become or will become illegal in over a dozen states whose legislatures had passed automatic trigger bans, as reported by the New York Times. In a recent article that you wrote, you write that this ruling is particularly harmful to trauma survivors. I'm wondering, what are the implications of this ruling on survivor's physical and mental health?

Amanda Ann Gregory:  Yes. The issue about this ruling that tends to threaten, sorry, trauma survivors is it really does threaten that sense of safety. And if we can just use that as a foundation: just safety. And if we look at trauma, trauma is usually created by an experience or a bunch of experiences where that safety wasn't there, or perhaps that agency or autonomy wasn't there and that's created this response. If we take these folks who've had those experiences and then we have something like this happen, which does strip people of that agency and that autonomy, that does not feel safe. And so basically what we're asking now is trauma survivors to try to heal, try to recover, try to not offend others because of their trauma, which at times has happened. We want them to do this work, but we're not going to provide that safety.

It's kind of like you get healed, you do your best, but we're going to take some of that safety away. And in trauma treatment, any trauma therapist knows that doesn't work. There has to be maybe not 100% safety, but some foundation of safety for trauma survivors to be able to work on this and to be able to really move past surviving to thriving. And this ruling makes that so much more difficult, because it really does strip that safety and really specifying that, and I'll just use the word agency, taking away that agency, that bodily agency, that relational agency, which directly has a negative impact on mental health.

Anna Kiesewetter:  Right. Yeah. Thank you for that. And here at Seattle Anxiety, we focus a lot on anxiety disorders. I'm wondering with the implications of this ruling on trauma survivors, how this impacts anxiety disorders or any anxiety symptoms in survivors?

Amanda Ann Gregory:  Sure. If we look at anxiety, we just take trauma out of it for a second, trauma is anxiety. They're very much mixed up, but if someone, let's say, has a generalized anxiety disorder, and they're in this world, this is definitely going to create some anxiety because it's, well, now my choices are restricted. Now I may have to worry about this and that. And even if you feel like it doesn't apply to you, for example, if you are someone capable of giving birth, you don't want to do that at all. Don't want to even be involved in that. Knowing that somebody else is restricted in some capacity in their choices could make you really feel unsafe and it could lead to a lot of additional worrying. Folks who experience anxiety tend to struggle with racing thoughts, worrying, issues like that. And this could really infiltrate that and actually make that significantly worse.

Anna Kiesewetter:  That makes sense. And then on the physical health aspect, I know you write also a little bit about how there is a continuation of trauma and often being more exposed to the source of the trauma if you are put in a place where you're forced to carry a pregnancy to term. Could you talk a little bit more about that and the continuation of that trauma?

Amanda Ann Gregory:  Right. If we go back to safety and look at that agency being stripped, it's like you're suspecting to be back in that situation again, or you already feel like you're back in it. And so actually, I believe the United Nations actually believes that forcing a woman to carry a pregnancy is a crime against humanity. And so I think that's interesting that they have that set and then yet we have that overturned here. And if you just think about the restriction of that, and if we look at relational trauma. Okay. If somebody has a relationship, it could be with a parent, it could be with a romantic partner, it could even be with a friend or a community member, and that relationship is not safe. Let's say it's toxic. Let's say there's abuse involved. What do we tell these people as a society? We say, “Get out.” Right? “End the relationship, have some boundaries, get out.”

Okay. But what if certain decisions made by other people are forcing you to stay in that relationship in some capacity? There are states that a rapist can sue for parental rights of a child. And that means that you will need to have a relationship with this person in some capacity going forward. And so you can't just get out. You can't just have these boundaries because that's very much restricted. And so let's just take rape out of it for a second. Let's say you're in a relationship and it is abusive and you get pregnant. Would you be required to carry that child to term? And is that going to hold you to that other person for at least 18, 19, 20 years, maybe the rest of your life, honestly? Is that going to help you or is that going to traumatize you or is that actually going to feed more of those trauma responses? And it will. The thing about trauma is it compacts upon itself. It's very rare just to have this one event.

Now, some people do have one traumatic event that I need to address, but when it comes to developmental trauma or complex trauma, it compacts. It's a series of these progressive experiences. And what we sometimes see with trauma survivors is their old coping mechanisms, what they needed to do to survive, they keep doing it into adulthood. They just keep doing it. And so this can create situations for folks to continue to have that trauma compacted upon itself.

Anna Kiesewetter:  Right. Yeah. That's very important. You also write about the implications of this ruling on the messaging it would send to children about consent and bodily autonomy. Would you be able to tell us a little bit more about how this ruling affects childhood development?

Amanda Ann Gregory:  Sure. A couple of ways, one, I'll talk about the children being around the adults and then just the children. And so when adults don't feel safe, when adults don't feel like they have a sense of agency, children pick up on that. They do. And we try to keep that from them. We try to protect them, but we have to understand that we're actually putting that off in all this nonverbal communication all the time and children constantly pick up on that. When a child is with an adult who, let's say, is their primary attachment figure and the adult is struggling, then the child's going to pick up on that in some capacity. And so now we have parents who may not feel as safe as they did before this was overturned. And we have those children in the home who are going to also pick up on that.

And if you think of it from a child's point of view, I'm requiring, I'm really relying on this adult or this set of adults or maybe multiple adults to keep me safe. But if they're struggling, if they don't feel safe, how are they going to keep me safe? And these aren't words that are spoken. It's very nonverbal. That's one thing that may negatively impact children. Second is as some cultures, we tend to struggle at times with teaching children about bodily agency and consent. Sometimes we will do these things of “Give me a hug, give me a kiss, go hug grandma, go do it.” We send those messages, which isn't great, because it doesn't really line up with what we say and “Hey, if anybody touches you, you need to tell us. These are the places that they can't touch.” We have to provide that education, but then somebody in your family or somebody that your parents trust can just do whatever they want and you have to consent to that. We do tend to send some mixed messages to children, I think.

And there is a movement in child psychology to really encourage parents to request children to provide physical intimacy if they would like. For example, “Would you like to hug grandma? Is that something you would like to do?” Or asking a child, “Can I give you a kiss?” Things like that could actually build up more of that sense of teaching a child, “This is your body - yes, within reason, some adults may be making some medical decisions or things like that for you, but I'm going to expose you to the fact that this is your body. You get to decide what you do with your body. You get to decide who touches it, who doesn't touch your body.” And those messages can be pretty mixed. And now we're in this society with this Roe versus Wade being overturned, which well now, what are we telling children? Are we telling children that only the boys have controls over their body? Where is that line there between, we're trying to teach them to be safe, but then we're not providing this global safety or this national safety for them. For children, very, very confusing.

Anna Kiesewetter:  Right. That makes a lot of sense. Still on the topic of children, you've written another piece on how to talk to children about the experience of growing up in the era of school shootings, in light of the mass shooting in Uvalde, Texas. I was wondering if we could relate this a little bit to this question and think about how you would approach conversations with children about abortion rights.

Amanda Ann Gregory:  Right. When it comes to these big national events, it could be very intimidating for us to talk to children about that and to know what to do, whether it's a school shooting or a decision being overturned that really impacts us and them. I always tell parents, start with curiosity. Don't assume a thing. Sometimes we come to children and we assume they know nothing. And then we get all this information about things they've heard. And of course in our digital age, it's just one click away for them to find all of this information. Even very small children know how to do that. We don't know what information they've already been exposed to. The first thing I tell parents is, just be curious. Approach the conversation with calmness, just very gentle, and just be curious, "Hey, what have you heard about this?”

“What have you know about this? What are their friends saying?” Just be very curious and to listen first. We want to jump in. We want to give insights and advice. And sometimes, especially if a child reports not feeling safe, we want to fix it. We'd be like, "You're safe. I'm going to keep you safe. It's not going to happen to you." Well, hold on. Let's listen first. Do they have any concerns? Do they not feel safe? Do they have any questions? And then really validating what are they going through? If a child is confused about this, validate that. Absolutely it's confusing. This is a really tough thing to understand. If a child doesn't feel safe, validate that. If a child doesn't care, they're just like, "Ah, I don't really care about that." Okay. Validate that and acknowledge that. And notice that there's so many steps before we get to actually implementing or speaking. We're being curious. We're listening. We're validating.

Then I think if we need to, we can move into problem solving. We can move into providing them maybe some education or some information, but not before we go through all those steps, because that really opens up the line of communication and it keeps it open. Because things like this, whether it's a school shooting or Roe versus Wade, it's not going to go away. These things are going to keep happening. They're going to keep developing. With kids, we really want to keep that line of communication open. We want them to know it's safe to come to me. It's safe to talk about this.

Anna Kiesewetter:  Yeah. Thank you for that. I think that's going to be really helpful for parent listeners. I'm also wondering: what do you think that the mental health community and psychotherapy can do to help survivors post-Roe?

Amanda Ann Gregory:  Yes, there's a couple of things. First off, when it comes to mental health providers, and I'm sure they're already facing this, it's so important to allow clients, members of your family, people in the community, really a safe space to process this. And that's really exploring their thoughts and feelings related to this. Sometimes we want to shut that down. We want to move people over here, over here, but what if we just step back and we just allowed them to process. There were quite a few clients the next day and this week in my sessions with them that they needed that time. They needed that space. And as a clinician, it may be tempting to say, "Whoa, hold on. This isn't what we're working on. We're working on your trauma or we're working on this or that. Let's focus on that."

No, you can't. You have to address what's happening in their lives here and now to not only support the relationship you have with them, but free them up, get these wheels going, get that processing going. And when it comes to trauma survivors, we can't pick and choose. We can't say, "Okay, well this is something going on now, but let's focus on your past." It's interwoven. It all comes together. I think it's really important to give the people in our lives the time and the space to really explore this. And that can be really difficult. And again, when putting this to members of the community, it's the same thing. We're all going through this together. And it's regardless of if you agree with the decision or if you don't agree with the decision. I think this is really stressful for everybody. And I think when we provide those safe places for people to explore that, it's one of the best things that we can do.

Anna Kiesewetter:  Yeah. Thank you. I think that's very important. With that, do you have any final thoughts or insights that you'd like to impart to our audience, on the Roe v. Wade decision or about children or school shootings? Anything that you'd like to talk about?

Amanda Ann Gregory:  Yeah, I do have one more point. This might be a little controversial, but this isn't political. If you really take a step back and look at it, whether if it's Roe v. Wade, whether if it's the war in Ukraine, whether if it's a school shooting, it's not political. And I think we sometimes use that as a mask or a band-aid to hide these things. And as a clinician, I had people reach out to me and say, "Thank you so much for just talking about, for just writing about this because we don't really see this from a whole lot of clinicians." And that shocked me.

And I saw just online and in social media, there was this movement to try to get counselors therapists, social workers, to stop talking about this. People were saying, "This is political. You need to just treat people. You need to keep this out of the conversation," but that doesn't work so well. We don't live in a vacuum and if we are devoting our lives to treating these folks and helping them, then it's very difficult to stay quiet when things happen that we know is going to have a direct negative impact upon them and could very easily sabotage treatment and make it so much more difficult. And so I did hesitate before writing that article that you read or even doing this interview.

There were some people that said, "Oh, you're not going to get certain clients" or this and that. I was like, "I get that. That's a risk. But I can't pretend that it doesn't impact the same people that I'm trying to help." And so I guess I would say that if something is going on that impacts your clients, think about that. Do I want to say something? Do I want to advocate? Does that feel right for me? And if not, simply allowing your clients or the people in your life that space to process that and process that with you might be another good option, but when it comes to these events that cause trauma in folks, that really perpetuates trauma, it's not political not anymore.

Anna Kiesewetter:  Right. Thank you. I think that's so important. And thank you so much for everything that you've talked with us today about. I think you have a very powerful message and it's really important at this time to have that. We wish you the best and hope to have you back for another interview in the future; thank you again for coming. And that'll conclude this installment of The Seattle Psychiatrist Interview Series. Thank you all so much for listening and we hope that you'll tune in next time.

To read more about Amanda Ann Gregory, click here.

To access our PTSD Self-Care page, click here.

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

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

Therapist Kate Willman on ACT & Writing Therapy

An Interview with Therapist Kate Willman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kate Willman:  Yeah. Thank you, Amelia.

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

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

Psychologist Michele Bedard-Gilligan on Trauma & Recovery

An Interview with Psychologist Michele Bedard-Gilligan

Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us, Dr. Michele Bedard-Gilligan. Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery. She has numerous publications on PTSD and individual responses to trauma, including one of her most recent publications on the topic “PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies,” co-authored with her close colleague and collaborator Dr. Emily Dworkin. Before we get started, Dr. Bedard-Gillian, can you please let us know a little more about yourself and what made you interested in studying trauma?

Michele Bedard-Gilligan:  Sure. Thank you so much for having me. I'm so grateful and happy to be here today. Yeah, I actually got my first experience working with people who had survived traumatic events right after I was an undergraduate. So after I graduated, I worked for a bit at the VA hospital in Boston and worked with veterans returning from conflict either recently or many years ago and did some work trying to understand mechanisms of recovery and how trauma affected them and really just became very passionate about trauma recovery from both a research and clinical perspective. And so from there, pursued that path of really that being my career in terms of studying and treating clinically working with and individuals who've been exposed to trauma.

And so, I'm a Clinical Psychologist by training. I, like you said, I'm faculty at the University of Washington School of Medicine in the Psychiatry Department. I have a clinical practice where I see patients for a variety of reasons, including reactions following traumatic events. And then I have an Active Research Program. So, I'm the co-director of the Trauma Recovery Innovations Program at the UW School of Medicine and the associate director of the UW Center for Anxiety and Traumatic Stress, which is affiliated with the Department of Psychology.

Amelia Worley:  That's great. So to begin, would you mind defining what trauma is?

Michele Bedard-Gilligan:  Yeah. It's a great question. Trauma is something that actually means something very specific in the mental health field. So in the field of the study of mental health disorders, when we talk about trauma, we actually talk about something very specific. So, we define trauma exposure as being exposed to an event that either causes injury or threatens injury or threat of death or is a threat to personal integrity or physical integrity. So that is meant to characterize events where maybe there was no injury or maybe not even threat to life but they were characterized by violation of one's physical being, if you will. So, things like sexual violence fall into that category. And those types of events that meet that bar or threats of injury or threats of violence have to be either experienced directly by the individual, witnessed -So you watch it happen to somebody else, or something that you're confronted with. So, you learn about it happening to someone you really care about or someone you love or someone you're close to.

And then finally, exposure to being confronted by a lot of violence or really negative outcomes or negative harms to other people if it's in the line of work. So, this is things like emergency personnel or people who work in combat zones or war zones who are exposed repeatedly to really terrible things that happen to others that they don't know. They don't know those people personally, but they're just constantly exposed to it because of their occupation. That is also concluded in our definition of trauma. And so really specific actually in terms of how the mental health field defines traumatic events or trauma exposure.

Amelia Worley:  How does trauma relate to post-traumatic stress disorder? Are some traumatic experiences more likely to develop into PTSD?

Michele Bedard-Gilligan:  Yeah, that's a really great question too. So post-traumatic stress disorder is one set of symptoms, one diagnosis that can develop following trauma exposure. But I also want to be clear that following exposure to the kind of events that I just described, it can lead to a host of negative outcomes. So, we can see people develop mood problems or anxiety problems, which I know is your specialty. We can see people develop substance use problems or thoughts about suicide that they didn't have before. So, it can lead to a host of negative outcomes.

The post-traumatic stress disorder, PTSD, is one of those and it's a specific set of symptoms that really involve the traumatic events specifically. So, it's a set of symptoms where the individual re-experiences the event in terms of having nightmares or intrusive images or really strong cued reactions to things that remind them of the traumatic event. It involves avoidance of things that remind them and things that are objectively faced. But because of their association with the traumatic event, the person goes out of their way to really avoid them, which can really narrow life and cause a lot of impairment.

PTSD also involves mood and thinking disruptions. So, if we see things like anger or lots of pervasive sadness or guilt. We see things disconnecting or isolating from others, as well as really impacted belief structures, negative beliefs about oneself, negative beliefs about the world. Sometimes people take on responsibility for the event that isn't necessarily accurate, but how they view it in terms of holding themselves responsible or accountable for what happened to them. And then we see lots of hypervigilance and hyperarousal type symptoms in PTSD. So, this is on-edge, difficulty sleeping, feeling very easily startled, and very hyperalert about your environment. Those kinds of things. And so PTSD really refers to that specific symptom constellation of having symptoms in all of those categories that I just mentioned.

And following traumatic events, we see PTSD develop in what I would call a substantial minority. So, if we look across the spectrum of people who in their lifetime meet diagnosis for PTSD, it's around seven to ten percent, something like that. So, it's not most people who experience trauma exposure actually, but it's still enough and it's a substantial minority of people who will go on to suffer in this way from these specific types of symptoms.

And yes, some events are more likely to lead to PTSD than others. So we see events that are characterized by interpersonal violence in particular having higher rates of PTSD develop. So you can think about my definition of trauma exposure per the mental health field, and that encompasses the huge range of events, from natural disasters, to motor vehicle accidents, to the whole host of things life-threatening illnesses that come on very suddenly. And then it also includes things like violence that's perpetrated by someone you know or by a stranger, sexual violence, childhood abuse, so things that happen early in childhood that fall into the physical abuse or sexual abuse category. It's a huge range of traumatic events and some of those, particularly the ones that are characterized by being interpersonal in nature are more likely to lead to PTSD diagnosis than some other types of events.

Amelia Worley:  Do you often see substance use overlap with PTSD?

Michele Bedard-Gilligan:  Yeah, so we do. We see PTSD as something that is commonly comorbid with a variety of things. So we see very high overlap in PTSD and depression, for example. We see overlap in PTSD and other types of anxiety disorders, like experiencing panic attacks. But one place where we particularly see overlap is with substance use.

So this is true for both people who identify as male and people who identify as female. But it's actually a little more common in people who identify as female, where we see rates of maladaptive or unhelpful substance use be increased. So, people with trauma exposure and then people with trauma exposure and PTSD, specifically, will show higher rates of using substances in a way that is problematic, in a way that is getting in their way in some way shape or form. And often we think of that as sort of likely attempts to cope with some of the distress and the symptoms that develop. So substance use can be a way to either deal with negative emotions or to try to cope with those negative emotions. But unfortunately over time, what can happen is that it can then escalate in this way that it can cause problems to the individual. So we see elevated rates there for sure, yeah.

Amelia Worley:  So in your experience, what is the most effective treatment for PTSD?

Michele Bedard-Gilligan:  Yeah, that's a great question, and fortunately we do have really good treatments for PTSD. So I think for a very long time there was a myth that PTSD was something that couldn't be treated. After being exposed to traumatic events and developing distress related to those, that was a burden that would be there for an individual's lifetime. And fortunately, we actually know that, that's not true.

Just like any other mental health disorder, we don't have treatments that work for everybody all of the time in all circumstances, but we do have treatments that we would call pretty effective. So we have medication options. Which is not what I do, because I'm a Clinical Psychologist. But we do have medication options. So medications such as SSRIs are often used and they have effects sizes of about 0.5 and response rates of about 50%, it's about that ballpark. So a number of people who are prescribed to those medications will get a lot of relief from taking them for their PTSD symptoms.

There's also a lot of alternative therapeutics that are being investigated right now, which I won't go into too much because it's not my area really. But things like cannabis, which I do a little bit of work on. But then also things like MDMA-assisted therapy and ketamine-assisted therapies that are being looked at for helping with PTSD. Early stages, but there might be some initial promise there. But really when we think about treatment for PTSD, a lot of where it's at is in therapy approaches. So a lot of where we can be really effective has been therapy behavior change treatments for PTSD. And there's a number of them out there, so there's a number of different approaches and they have a lot of overlap with how we might approach anxiety disorders more generally.

So, for example, a lot of the treatments that we do have a sizable exposure component. So this is about helping the individual approach the reminders of the traumatic event that are causing a lot of fear, a lot of anxiety, those re-experiencing and hypervigilant symptoms that I talked about earlier. So really decreasing their avoided symptoms by using these exposure approaches. So it's involving going out into the real world and doing things that are reminiscent of the trauma but actually safe. So for an example, someone who's in a motor vehicle accident who has developed a fear of driving, and most of the time driving is actually a safe activity. And so helping the person gradually expose themselves to driving again is often a key component of treating trauma reactions.

In addition, in that same exposure realm, we think of PTSD as being a disorder that is also characterized by the memory itself and the memory taking on a very dangerous quality. So when individuals think about the traumatic event, it triggers a lot of anxiety and guilt and distress more generally. And so the exposure really involves helping individuals reprocess that memory. So go back to that memory and approach it in a way where they can sit with it, they can feel some of those emotions that that brings up. But also have that experience of gaining new perspectives and new meaning about the memory to really being able to shift their relationship with that memory, shift their relationship with the way it's impacted, the way they see themselves in the world, and also sit with those emotions so they can start to feel some decrease in them. So, it's really about processing through that memory in a way that helps them make sense and meaning out of something that, quite frankly, is quite senseless, as trauma is. And so really helping them figure out ways that they can see it and find ways to see it, so that they can gain some new perspectives and move forward. And also, correct any beliefs that might have developed that are really triggering a lot of emotion that may be not 100% accurate. So, we talked a little bit earlier about taking responsibility for traumatic events when in fact they were not your fault. And so doing exposure to the memory can help people see the places where, although they've been carrying this burden of guilt or carrying this burden of blaming themselves, and in reality that's not actually true. And so going back and going through that memory can help people shift there.

In addition, a lot of the trauma treatments that we do, so the empirically supported therapies for post-traumatic stress disorder also involve more general cognitive approaches. So, helping people identify the ways that the traumatic event has impacted their view of themselves in the world. Like how has it impacted how they think about things and learning concrete skills for being able to take those beliefs and when they're not accurate, be able to shift them to be more balanced. And so for an example there, we might have people who after a traumatic event have developed very strong beliefs that the world is just always dangerous. It's just a dangerous place. And there's a kernel of truth to that maybe. Bad things do happen and the world can be dangerous, and people who've survived traumatic events know that better than anybody. And the world is probably not 100% dangerous 100% of the time. And so helping people learn the skills to be able to see the places, “where am I safer” or “where are things more dangerous.” Being able to see that nuance again, because after traumatic events that can be really challenging and so helping them learn skills in that area.

And then finally, most of our ... all our treatments for post-traumatic stress disorder really involve a high degree of validation and support. So, following traumatic events, it's just hard. It's challenging to connect to people. It's hard to feel safe anywhere. And so really these events enable people a safe place and a safe space and hopefully a really strong, supportive environment in which to approach all this stuff. To approach their beliefs and approach their memories and approach the things in the environment that scare them and to do it in a way that's supported and gradual and systematic, and we can really make strong gains with those approaches. Yeah.

Amelia Worley:  So, in the publication I mentioned earlier, PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies. You talk about how it is common for PTSD to develop following a sexual assault. Additionally, the first three months post-assault may be a critical period for natural recovery. Can you explain that idea of a critical period for recovery a little more?

Michele Bedard-Gilligan:  Yeah, absolutely. So, as I mentioned earlier, when we think about PTSD and the development of PTSD, it is a substantial minority of people who develop and so it's not everybody. But immediately after a traumatic event, particularly a really severe traumatic event, we will see symptoms of PTSD, symptoms of distress in almost everybody. So, the normative reaction to something really traumatic and terrible and horrible happening is these symptoms of re-experiencing it and having nightmares about it and wanting to avoid and all of those things. But for many people, fortunately those things will go down on their own with time, and we often call that natural recovery, this idea, and what we mean by that it's just recovery that happens without intervention. It just innately or inherently occurs for the person.

And what we mean by this period, this critical period, is that what we've seen from the data and what we observe clinically is that when that natural recovery, that recovery without intervention, that organic recovery happens, it usually happens within those first three months. So those first three months, those first 12 weeks or so. I mean, obviously it's an estimate. But around that time, is really crucial for whatever learning and whatever meanings going to happen for the person innately and organically, it usually occurs in that time. And probably a lot of what that is, is people who in that aftermath of traumatic events are getting that support and that validation that I talked about or they're getting that encouragement to talk through what happened and to really confront the emotions that it's bringing up. And they're doing that on their own naturally. And so, we see this decrease in symptoms that will occur. And again, it occurs for quite a few people or quite a big chunk of people exposed to trauma. And then it seems that as the months go on, if that process hasn't happened in that natural way, then we often see people get stuck with the symptoms that they've developed and so we see those symptoms persist.

In the article you're talking about, the percentage of people who had PTSD symptoms following sexual assault one month after was quite high. It was a very large majority. And then when we followed them or we looked at the studies that have been done and we looked over time at them, we find by a year out it's less, it's slightly less than half who still have the symptoms. And that's actually high. So, for sexual assault to look and see that in a year out, almost half of the individual studied had symptoms that still met criteria for PTSD is pretty high. When we look at other types of traumatic events, we definitely see it being lower. It's lower than that. And so sexual assault and that interpersonal violence is definitely one where we see less of the natural recovery.

Amelia Worley:  So digging into that further, I know you talked a little bit about the positive way that the environment can help with the recovery during those first three months. What are some environmental factors that may be harmful to the individuals' recovery during those first three months?

Michele Bedard-Gilligan:  Yeah, yeah. It's a great question, what keeps those people at risk. So, we see some of the resilience surround where people are able to recover on their own comes from some of the things I talked about. And some of the risk probably comes from the inverse of those.

So people who for whatever reason aren't able to not avoid, they're not able to go back and engage in their world, either because it feels intolerable or because they're not given the opportunity. So they stay isolated or they stay, are really avoidant of things that trigger trauma thoughts or trauma memories. People who don't have natural avenues for support, either because they don't exist, social support is what I mean, either because they don't exist or because they're not able to take advantage of them or because they are experiencing so much avoidance, there's so much distress that they don't reach out or they don't share or they don't talk about it. Or because sometimes what people, sometimes even well-intentioned, reactions we might get in our natural social support environments just aren't helpful.

And again, this is in our culture pervasive. Something really bad happens, you reach out for support in your natural environment and some of what you might get back is, "Just don't think about it. Just try not to think about it." But that's actually the opposite of what we think is helpful. And it's well-intentioned and I see where people come from when they give that kind of feedback and it can also really backfire. If we think what we need is actually to process and to feel the emotions and to really engage with the experience and the memory in order to make sense of it and move forward, not talking about it is the opposite of that.

And then of course there are also extremes. So, we know from the research that's been done that, unfortunately, a sizable number of people when they disclose traumatic events will get what we would call negative reactions. So, they will get either somebody blaming them for what happened or telling them that it was their fault or telling them that they should have done something different or telling them that if they were stronger, they would've just moved on from it. Those kinds of things that we know are actually incredibly harmful. So, for people who get those reactions, they're at much greater risk for developing long-term symptoms.

And then finally, substance use and the overlap of substance use with PTSD is something I care passionately about and something that I do a lot of work on. And we also know that substance use in the immediate aftermath of a traumatic event can keep people stuck as well. So, when people are using substances maybe to cope or for other reasons, it can prevent that processing and prevent that adaptive coping and can unfortunately cause more negative outcomes as well.

Amelia Worley:  That's really interesting. I noticed that you have many research projects working with young adults. What are some differences in the way adolescents and young adults process traumatic experiences compared to older adults?

Michele Bedard-Gilligan:  Yeah, it's an interesting thing to think about, about how age and developmental period impacts how we might make senses of the really difficult things in life and how we might cope or find resources following traumatic events. In general, age has not been found to be a very robust predictor of who's likely to develop PTSD. So it's not something where we think about as a background characteristic that's really going to impact whether or not someone goes on to develop distress. That being said, I do think there are some things that we know about what is important to pay attention to. So younger people in general are more likely to be exposed to traumatic events and so there's just a slightly higher risk there. So, in terms of being exposed to trauma, which then obviously puts you at risk for developing post-traumatic stress disorder.

In addition, I think depending on developmental period that younger individuals sometimes have less access to resources, less access to outlets for support. They may be living in environments that are perpetuating the traumatic events or trauma exposure, and not have a whole lot of control on how to get out of those environments. Just because, generally speaking at younger developmental ages, we often have less agency over our environments and in what's going on around us than we do as adults.

So that could be a difference. As well as depending on how young an individual is, what cognitive and emotional resources they have to make sense of things, that can be challenging as well. And so those are some of the main differences, whereas ... Yeah, I think I would just stop there. Those are some of the main differences, I think in terms of how we think about how different age categories might respond to traumatic events differently.

I think your observation that a lot of the work that I do is with younger adults really reflects that first point. That when we are doing studies or where we're intervening and promoting trauma recovery with various therapeutic approaches and we're looking to the community for people to come in and participate in our study and help us learn about these therapies we often see a bias towards individuals who are younger wanting to do those things and or having more of a need for it.

So when you do a research study, for example, where we're providing treatment free of cost. This is really helpful to individuals who may fall into a bracket where they don't have health insurance or the health insurance plans their parents and they don't really want their parents to know that they're doing this. So something along those lines. And so, I think some of it is also a resource thing as well as a need and a vulnerability thing. Yeah.

Amelia Worley:  Lastly, do you have any advice or anything you want to share with our listeners suffering from exposure to trauma or PTSD?

Michele Bedard-Gilligan:  Yeah. I think hopefully some of the things I've talked about in terms of what it looks like and the treatments that are out there for it is helpful to people in terms of if they're looking for options and they are feeling like they need help. I think the couple of things that I would really want to drive home I guess.

One, being that trauma exposure is actually incredibly common. So, when we do big national surveys, it's anywhere, it's over 75% of Americans who've experienced, or people living in the U.S., who have experienced at least one traumatic event by our definition. So, this is an incredibly common thing and so experiencing trauma, it's not unusual and it doesn't make you an outlier in any way actually. And then that it does lead, we know that it leads to all kinds of increases in distress and makes people vulnerable for all outcomes. It's not a guarantee. Many people are very resilient, and like I said, many people can use the resources and the things they have around them in order to not develop things, distress that is impairing. But many people do and it's not abnormal and it's not something to feel ashamed of. It's not about strength, it's not about being weak, it's not about any of that. It's just about the real effects that these really kinds of horrific experiences have on us as human beings. And because we know this, because we know it can have these predictable effects, I think anything we can do within our communities, within ourselves, within the people close to us to decrease stigma around it. To decrease this idea that experiencing trauma is something that we should be ashamed of or something that leaves us to be marked for life or any of that, is something that I really hope we can start to move past and instead really think about it as something that shapes us as people.

And when it causes distress that's impairing, when it causes symptoms or problems that are getting in the way of us functioning or leading the lives we want to live, that there are things we can do about that. And there're treatments out there that are helpful, that we can start by just reaching out for support if we have people in our lives who can provide that. But when that's not enough, there's other more professional, higher level care options as well. Yeah, and so I think those are just some of the things that I would hope people would be able to hear and understand and that hopefully would be helpful.

Amelia Worley:  That's great. Well, thank you so much, Dr. Bedard-Gilligan. It was wonderful having you on our series today.

Michele Bedard-Gilligan:  Thank you. I appreciate it.

For more information, click here to access an interview with Psychologist Robyn Walser on trauma & addiction.

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

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

Therapist Kelsey Devoille on Equine-Assisted Therapy

An Interview with Kelsey Devoille, LMFT, MS

Kelsey Devoille is a licensed Marriage and Family Therapist and founder of Unbridled Counseling, which hosts equine-assisted therapy. Kelsey specializes in treating anxiety, eating disorders and depression.

Maya Hsu:  Hi, welcome to this installment of The Seattle Psychiatrist Interview Series. I'm Maya Hsu, and I'm a research intern here at SAS. Today, I'm joined by Kelsey Devoille, a licensed Marriage and Family Therapist practicing in Washington state. She received her Master’s of Science from Seattle Pacific University in Marriage and Family Therapy and founded Unbridled Counseling in 2012, which is her practice of equine-assisted therapy. Kelsey specializes in anxiety, depression, eating disorders, relationships, and fertility. She is also a member of International Association of Eating Disorder Professionals and a member of the American Association of Marriage and Family Therapists. Kelsey, would you like to introduce yourself and start us off by talking about how you became interested in equine therapy?

Kelsey Devoille:  Yeah, absolutely. Thanks for having me, Maya. As Maya mentioned, I'm Kelsey Devoille. I started Unbridled Counseling about 10 years ago, noticing a need in the community for ways in which people can engage in the therapeutic process outside a traditional office setting. I grew up riding and training horses and started coaching about 15 years ago, and really recognized the therapeutic impact of the horses and the relationship with the horses on my students. I also noticed that in my own relationship with horses growing up, that it was often when I felt most grounded and connected. I then started looking into how to go about setting that up in a more professional way, starting on my graduate program and looking into what the field of equine-assisted therapy looks like.

Maya Hsu:  Yeah. How would you describe the field of equine-assisted therapy for someone who's never heard of it before?

Kelsey Devoille:  Yeah. Equine-assisted therapy is anytime we bring horses into a therapeutic setting to promote healing or promote growth. It can look very, very different based on the models used and based on the preferences of the clients. For some people, it truly is just having a horse present while utilizing talk therapy models, simply to be outside and be more grounded, connect to their body a little bit more. In other models, it can be very, very relational and deep work, where the relationship with the horse is truly used to model relationships that happen outside of the therapeutic setting. It just depends on the goals of the patient and how they best engage in their own growth.

Maya Hsu:  It sounds like you can really access a wide variety of types of therapy treatments with horses.

Kelsey Devoille:  Yes.

Maya Hsu:  Is there something specific about equine-assisted therapy that makes it therapeutic that's different from just interacting with horses or going for a horseback ride?

Kelsey Devoille:  Yeah, I think, partially it's how the therapist directs the interactions, so knowing what the patient has to work on and knowing how we can bring in the horses to access areas in which they may be stuck or may be having a hard time experiencing the growth. It's very easy to talk about change in an office, but leaving that office, it's harder to practice. It's really about how the therapist can use the horse as the facilitator.

Maya Hsu:  Cool. Could you give an example of how somebody with anxiety who wants to address their anxiety, how their interaction with equine-assisted therapy might look different from somebody who might have an eating disorder?

Kelsey Devoille:  Yeah. I think that can vary. Given that eating disorders often are grounded in anxiety, it can look similar, but with anxiety, oftentimes, it's recognizing the person's internal experience and noticing how that may be affecting the horse. The horses often mirror the anxiety, and so it can make the connection with the horse a little bit more difficult when the person is less grounded and feeling emotionally flooded. Oftentimes, that's really where working to help the patient, in the moment, connect to their body, become more grounded through self-regulation methods so that they can interact with the horse in that way.

Whereas eating disorders, say, for example, someone maybe has a hard time using their voice or being assertive or feeling powerful in a room, it can be useful to then bring about those characteristics in their communication with the horse. Otherwise, often they get walked all over by the horse. It's activating fairly different communication skills in each of those different settings.

Maya Hsu:  When you talked about anxiety and the horse picking up on a person's anxiety, it made me wonder, does it ever happen where the client and the horse both have anxiety and then it escalates because they are receiving feedback based off of each other and then they're just engaged in this co-dysregulation?

Kelsey Devoille:  Absolutely, yeah, and that's the moment where we generally pause and say, "Okay, what are we noticing? What are you noticing in your body, and now what are you noticing in the horse? What are we observing? Is the horse becoming more vigilant? Is the horse becoming more nervous, spooky, reactive? and I wonder why," because oftentimes patients don't even realize that's happening in their body. Being able to see it in the horse is the feedback they need to say, "Whoa, what's happening here? Let's pause and let's check in to how we can break this cycle," because it likely is happening in their relationships outside of equine therapy.

Maya Hsu:  That's so interesting. What about horses make them unique and effective for therapy?

Kelsey Devoille:  Yeah. Well, the first is that they are thousand-plus pound animals. For a lot of people, it naturally brings about levels of fear, levels of vulnerability that can mimic some of the other areas in their life where they feel anxiety or fear come up. Automatically, we're tapping into that nervous system activity.

The other thing is that they, in the wild, are part of a herd and so they're very social animals. That means that when a patient does attempt to connect with them in a relational way, as long as it's skillful, most of the time the horse will reinforce that behavior and enter into relationship with them, whereas some animals are less inclined to want to do that.

I would say the third aspect, that's probably the most powerful, is because they're prey animals, they really pick up on the emotional states of the beings around them. They rely on being able to pick up cues that might tell them there's a predator in the area, which then makes them very highly attuned to the emotional states of the patients, and again, able to give that feedback that we were just talking about.

Maya Hsu:  Are there other animals, other prey animals, that you know of that would also be effective in this type of work?

Kelsey Devoille:  Hmm, that's a good question. I don't, actually. I know dogs and cats have been used in therapy, but they don't have those dynamics of being prey animals or herd animals. To me, that's why equine therapy feels really unique.

Maya Hsu:  Yeah. How can horses be used for emotional regulation or healing from trauma?

Kelsey Devoille:  Yeah. For the emotional regulation piece, it's the feedback that the horses provide and helping patients to recognize when they are regulating in their body. Like we were talking about, they might notice that they're becoming anxious and the horse is feeding off of them, and then they might be able to engage in some sort of self-soothing or some grounding work, some breathing work. Then they might notice the horse starts chewing or licking their lips or lowering their head, which is all signs of relaxation, which then gives the patient cues, "Oh, wow, something changed in my body. What happened? I just got feedback from the horse." That can be a positive reinforcer to learning how to self-regulate.

In terms of trauma, oftentimes the relationship with the horse can mimic or activate the neural pathways in the brain where the trauma is held. A benign example might be they're working with the horse and the horse turns around and walks away from them, which can then instigate the feelings that they had, say, as a child when they were abandoned or neglected. In that moment, those neural pathways are activated and that truly feels like that past experience for them. It's in that moment that we can stop, pause, and rewrite the script a little bit and change the way in which they interact in that moment. As opposed to, say, shutting down or feeling abandoned, they might be able to work themselves through engaging with the horse in a different way to achieve a different result, which then rebuilds more healthy neural pathways in those interactions.

Maya Hsu:  It reminds me of ecotherapy and how sometimes therapists can go on walks in nature with their clients and use the scenery and just whatever organic things are happening in their environment, they can use that as jumping off points for conversation or for sparking memories. It sounds like with the horses there's sometimes an unpredictable aspect of working with them, where you don't know if they'll turn away, and if they do, what that'll provoke inside the client. It sounds like that's really helpful for just bringing up things that you might not know to bring up.

Kelsey Devoille:  Yeah. I think oftentimes it can be really organic, like a deer could run across the pasture and spook them and then all of a sudden it's like, "Whoa, what did that feel like? Or what did you see in the horse that feels familiar to your experience when scared or in fight or flight?" That's what makes it a bit exciting, is sometimes it's hard, because what happens and those are interactions can be painful, but yeah, it ignites change in a way that feels less predictable.

Maya Hsu:  Yeah. What type of people would you recommend equine therapy for, and also sort of related to that, are there certain disorders or challenges that people have that might not be best addressed with equine therapy, for instance, maybe social anxiety or ADD, off the top of my head?

Kelsey Devoille:  Mm-hmm (affirmative), yeah. I love equine therapy for work with kids, teens, people who would be unwilling or uncomfortable to engage in therapy in an office-type setting, just because it creates such a more creative environment. As far as symptoms, I think working with the anxiety disorders, eating disorders, OCD, depression can be useful for working on the emotional regulation, and any time we're working on social dynamics, so relational issues, family dynamics, social skills. I actually do think for ADD and social anxiety it can be really useful because you have to be present to really, truly engage with the horse. It's an opportunity to focus on being mindful, being present, being focused. Again, the horse will give feedback when the person tends to check out.

Nothing really comes to mind in terms of a patient who would not be a good fit for equine therapy, just simply because it's so flexible that we can alter how we use the horse to determine how best to engage the client. There's really not a population that I feel like is a bad fit for this type of work.

Maya Hsu:  Yeah. I'm curious, you might not have an answer for this, but as the therapist, your role is the facilitator and the observer. Are there any things that you intentionally do to try and mitigate any projection onto what you think you might be interpreting between a client and a horse?

Kelsey Devoille:  Yes, and that can be pretty tricky given that I also come from a background of teaching and training. In that world, certain horse behavior always means something and there's always a right answer for how you interpret behavior, or how you respond. In a therapeutic setting, that's really not my job-- to interpret the relationship for the patient. Oftentimes, they see something in the horse and interpret it a certain way and my observation was different, but it's not really that relevant to me or to them. It's really accessing how the person is perceiving the engagement with the horse.

There may be times in which I'm noticing a theme, where the person might be interpreting the behavior in a way that doesn't really sit with me or that I'm not seeing, and so I might be able to just ask the question and say, "I wonder if it could be this. Is it possible that the horse is responding due to A, B or C," but it's really my job to be curious and allow the patient to interact in the way that feels the most powerful for them.

Maya Hsu:  Yeah, that makes sense. I appreciate your response because that clarified what I was imagining a therapist's role to be in equine-assisted therapy. It sounds like you stick more to objective observations, like the horse turned away or-

Kelsey Devoille:  Absolutely.

Maya Hsu:  ... the horse is not making eye contact or something factual, and then piecing together patterns and connections just within the client's own interpretations.

Kelsey Devoille:  Yep, absolutely.

Maya Hsu:  What has been your most rewarding or favorite experience with equine therapy?

Kelsey Devoille:  Yeah. I love when people are able to bring the experience in the therapeutic setting into their world. They experience something with a horse and then they come back next week and say, "Okay, I was having this conversation with my boss and I was able to really imagine how it felt for me when I was able to back the horse up. I was able to access the feelings in my body of assertiveness and confidence and trust in myself to make those connections." Or, for example, when it's the other way around, so they're working with the horse and they're like, "Oh my God, this is exactly how it feels when I'm fighting with my husband. I'm actually seeing my husband in the horse right now." Creating those metaphorical situations, where we're really joining the two experiences to make the bridge for what's happening in therapy and how it's being applied in their life, because they can get really creative with it in ways that I wouldn't have even seen myself.

Maya Hsu:  Yeah, yeah. I also have an additional curiosity. Are there horses that have their own trauma that don't necessarily make good candidates for equine-assisted therapy?

Kelsey Devoille:  Yeah, great question. I think it depends on your setting. When I'm working with kids, I tend to want to make sure I have horses who stay fairly grounded and regulated and predictable, just given the safety factors involved. However, if it's an adult who's pretty aware of their surroundings, actually, working with horses who've had past trauma can be challenging, but really rewarding. I had an older pony once who had a fairly significant trauma background and it took one patient six to 10 sessions to be able to even touch her, but the process of doing that and the end result was so rewarding that it really was valuable in the patient's growth. Whereas, a kid might not have the patience for that, but I think if you have the right patient-to-horse combination, it can be really useful.

Maya Hsu:  Yeah. When a patient or a client finishes treatment, I imagine there's some attachment work that you might have to do to terminate working together. What does that look like, if they formed a really close bond with a certain horse?

Kelsey Devoille:  Mm-hmm (affirmative), yeah. I mean, I think it often mimics how we end relationships in our own lives. You notice when, say, therapy is coming to an end, I think it's interesting to notice our patients purposely detaching and how they're doing that is really good awareness. I think it's being open and communicative in the process to say, "What are you feeling here? As we're starting to end this, are you noticing wanting to pull away or are you noticing wanting to find closure and an effective goodbye in that?" It just provides a lot of good information to how people handle goodbyes in their own life.

Maya Hsu:  Right. Is there anything else you would like people to know about equine-assisted therapy?

Kelsey Devoille:  I would just say that there isn't a rigid model for what it looks like and you don't have to be this lifelong horse lover to find it valuable and powerful. I think as long as you can be open-minded to what the horses can offer, in terms of growth, it can be really useful for most of the population.

Maya Hsu:  I'm definitely interested in trying it at some point.

Kelsey Devoille:  Yeah.

Maya Hsu:  Sounds really helpful. Well, thank you so much for joining us on this installment. It was such a joy to speak with you and hear more about equine-assisted therapy.

Kelsey Devoille:  Of course. Thanks so much for having me.

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

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

Psychologist Robyn Walser on Trauma & Addiction

An interview with Psychologist Robyn Walser

Dr. Robyn Walser is a Psychologist in the Bay Area, specializing in the utilization of ACT therapy to treat issues such as trauma and addiction.

(note: this interview is also available as a podcast)

Jennifer Ghahari:  Thanks for joining us today. I’m Dr. Jennifer Ghahari, Administrative Director at Seattle Anxiety Specialists. I’d like to welcome with us licensed psychologist Dr. Robyn Walser who is Director of TL Consultation Services, Co-Director of the Bay Area of Bay Area Trauma Recovery Center and Staff at the National Center for PTSD Dissemination and Training Division. A master ACT trainer, much of her work is focused on trauma and addiction, and that’s what we’ll be discussing today. Before we get started, Robyn, can you please let us know a little bit about yourself, some of the work you’ve done and the books that you’ve written? 

Robyn Walser:  Ah, sure. Thank you and thank you for inviting me to be here today to chat about these important topics. Let’s see, I got interested in ACT in 1991, long time ago. I did my first training in 1997 or ‘98 in Ireland, which was such an amazing experience, and then I think wrote my first book on PTSD and trauma in 2007 for ACT, for PTSD and trauma. And then I’ve written several books since then and just released ACT for Moral Injury, The Heart of ACT (one of my favorites), and then a colleague and I are working on ACT for Anger so we’ll be getting that out pretty soon, too. Pretty exciting stuff in terms of the publishing world.

Jennifer Ghahari:  That’s fantastic, it’s a good base. So today we’re going to be discussing PTSD and addiction. Just to kind of get us started and provide a basis for the discussion, can you explain what is trauma?

Robyn Walser:  So, that’s a very interesting question in a number of senses because when you are working with clients or you’re just talking with people in sort of the lay world, and sometimes even in the clinical world, “trauma” gets used a lot for things that are not actually criteria made traumas which is the DSM diagnosis or criteria for getting PTSD. So, those criteria are life-threatening typically, hearing about the sudden loss of another person, an ongoing trauma of past lifetime such as sexual abuse and sexual assault or something like that. Often people will come and say they were traumatized by this experience and what it was, was somebody perhaps said something really threatening or something really awful or maybe they got fired from a job or something like that. Those wouldn’t actually meet the criteria for trauma. Although the client or the person may experience it as a very horrible and challenging event, trauma – as defined by the diagnostic system – is actually a life-threatening experience where intense fear and horror or response of helplessness are part of what the individual experience is. Just making a little clarity around those things can be helpful.

Jennifer Ghahari:  Right. Perfect. So then, in terms of PTSD, how does a trauma contribute to it and what types of events or traumatizing events are most commonly leading to the development of PTSD in a person?

Robyn Walser:  Well, so, it’s normal for almost anyone to respond to a traumatic event like a natural disaster, a man-made disaster, like a shooting or maybe a crash or work accident or anything like that, with some degree of fear and panic and feeling unsettled. Most of us would have that response. But what you would expect is that it would linger for a bit of time, that we might be edgy and jumpy and worried and not feel safe for a period of time. But, typically what happens is people begin to go down in that kind of reactive emotional quality within a week or a few weeks after the traumatic event. What happens is that some folks have all of these reactions and they actually don’t experience a decrease and, after about a month of these kinds of reactions continuing, they would get the diagnosis of Post-Traumatic Stress Disorder. They’d have to meet certain criteria. So, hyper-arousal where you’re feeling keyed up and on edge and you’re searching the environment for danger. Mood struggles and thought struggles like your mood is low or blue or anxious and your thoughts are about the trauma or about safety or worrying about things. There’s also avoidance, this is another criteria, so you stop going to see people that you know, you stop visiting places, you stop going anywhere where you might be reminded of the trauma, you try not to think about what happened, you try to get away from the memories  and so all kind avoidance inside of that as well. There’s a forth criteria of that hyper-arousal…avoidance, mood & thought struggles…slipped out of my mind at this moment; here, the expert on PTSD not getting the last criteria…  (laughs) it’s intrusiveness. Keep experiencing the event over and over again, like you have memories of it intruding on your normal time and you’re struggling with those intrusions.

Jennifer Ghahari:  So, in terms of avoidance, it sounds like becoming addicted to something or some type of addictive behavior might develop to try to break away from those intrusive thoughts and the fears and the ongoing stresses. How prevalent, in your experience, is addiction in those with PTSD and are there certain types of addiction that are more common than others?

Robyn Walser:  Well, PTSD and substance use are highly co-morbid. It’s not unusual to have somebody come into the clinical setting who is using a substance in some way, it may not be a full addiction but often it would qualify for abuse or regular use that’s not of the social nature. Where they’re using to actually suppress the anxiety and fear that they are experiencing to try and block the worry that’s happening. So, it’s quite co-occur relatively at a great rate. There are lots of co-occurrences though with PTSD – like depression – is also quite highly co-occurring. You know, it’s got something an 80% rate. The co-occurrence of PTSD isn’t quite that high but it is something to be assessed if you’re seeing individuals who have Post-Traumatic Stress Disorder or just some clinical trauma. People can be seeking ways to escape their experiences by using substances and probably, the one I see the most, is alcohol. People, it’s easy access, it’s you know, legal and so people are drinking as a way to suppress I mean not that they couldn’t have other experiences on board like other substances; I’ve certainly seen plenty of those as well. Poly-substance use can also be part of the profile where they’re using multiple substances to try to escape their experience. 

Jennifer Ghahari:  You had mentioned that PTSD is diagnosed after someone is experiencing these symptoms for about a solid month or so and have you found that prompt psychotherapeutic treatment following a trauma lessens the chance of developing an addictive coping behavior or does the timing not really make too much of a difference? And, just as a quick follow-up to that in terms of timing, is there ever a time where it’s essentially too late to seek treatment for a trauma or is psychotherapeutic treatment helpful at any point for somebody following PTSD and a trauma?

Robyn Walser:  No; let me answer the latter half of your question then I’ll answer the first part of it. It is, you can get treatment at any point in time for trauma especially if you’re having ongoing and lasting symptoms. I mean there’s a couple of models about how trauma can work…like one says that right after the trauma you’d have long-lasting and sustained symptoms across time; the other is sort of more waxing and waning…it comes and it goes and it comes and it goes and it depends a little bit on the situational factors like maybe life isn’t too stressful for you at one point and you’re doing ok and your symptoms are lower but then a life stressor happens and the symptoms get triggered and are up again.  And then there’s also this idea that you can go for a long time without really struggling too much with symptoms, sort of a delay onset and you get symptoms much later in life. So, a good example of this might be let’s say a WWII veteran who was maybe was a POW and saw lots of, had lots of terrible experiences in battle and actually had symptoms but came back from the war and went work and had a family and did all the things that thought, to help sort of manage and avoid or distract, maybe even using substances along the way. It’s not that unusual for me to see somebody who, for years & years, like 30 years of using alcohol to kind of keep the symptoms down, they retire or they have a significant event that sort of lowers their coping ability – like the death of a spouse – and suddenly their symptoms are really high and they’re struggling with the PTSD late in life. So, there’s different courses and it just depends a little bit on who’s sitting in front of you and what their circumstances have been

With respect to intervening right after the trauma, the data is a little more mixed. There’s some data that says if you can come in and help people with their cognitions post-trauma, the cognitions that are the intrusive thoughts that are coming in, that you can perhaps lower the possibility of getting PTSD later. There feels like there’s something important about that. And there is certainly work of, like psychological first aid, where mental health providers can come in and provide psychological first aid immediately following the trauma, like within a few days or so, and that can be helpful. But some of the key factors are social support like, right after the trauma, are there people there to help you, re-establishment of safety, do you feel you are safe again, are people hearing you and helping you, getting connected to resources if you need resources. So, you sort of feel  like that if you can get that kind of social and resource foundation underneath somebody right away that it can be helpful. But some people are just going to struggle because of earlier vulnerabilities, like maybe they’ve had other traumas prior to a significant trauma and that that puts them at risk for developing trauma in this one circumstance and so there’s an ideo-graphic quality to it in some way as to who will and who will not get PTSD.

I think I answered both of those, did I catch them both?

Jennifer Ghahari:  Absolutely, thank you. In terms of overcoming addiction when you have PTSD and when you’re suffering from that, is it possible to overcome and conquer some addiction without treating the PTSD or is it really fundamental to first conquer the PTSD and get some type of treatment for that and then be able to battle and conquer whatever addiction that a person might have? Or are they completely separate?

Robyn Walser:  They are heavily intertwined. So, the lore for a long time, and we now know this is not the case but it stills happens, is that you go and get your substance use handled first and then you come and do the trauma treatment. That’s sort of been the way that people think about…take care of this, and then  we’ll take care of that. But actually, what the data shows is, it’s better to treat simultaneously to be addressing both the PTSD and the substance use at the same time – that’s where you get the greatest outcomes and recovery. It’s hard to do though, I mean there aren’t a lot of programs that are designed to treat both of them simultaneously and not everyone knows exactly what to do in terms of how you address those. There are a few treatments that are out there that have proven effective but they tend to be IOP type, in-patient type and then one other treatment, that addresses both simultaneously, is seeking safety. If you think of Judith Herman’s model of treatment, it’s sort of like safety then trauma then reintegration kind of processes. This sort of follows in that initial stage where you’re teaching coping skills to deal both with drinking or whatever substance it is and the trauma at the same time. There are 24, 25 different skills in there…there sort of DBT-like in terms of the type of skills that you would teach and the data essentially shows that it’s about as effective as relapse prevention. So it’s one of the few and we really need to do a lot more work in this area. One of the reasons why I like acceptance and commitment therapy, and you might think about PTSD, is because of that overarching quality that it has where it’s addressing multiple things at the same time. I still think you’ve got to do exposure work, like if you’re going to address the trauma, but ACT kind of has this nice quality of addressing avoidance and looking at how substance use is part of that avoidance process, while you’re simultaneously working with the trauma and reducing the avoidance.

Jennifer Ghahari:  Lastly, I recently saw you had an interview regarding the social and psychological impacts of Covid-19 and wanted to know have you seen effects of PTSD due to the pandemic yet, particularly those who have gotten the virus or have lost loved ones from it? And what’s the importance of self care during this uncertain environment?

Robyn Walser:  Yeah, we do know this - that there’s often a second pandemic that occurs behind the first, like Covid, which is a mental health pandemic and all of the data isn’t in on Covid-19 because we’re still right in the middle of it. So, while I don’t have any exact facts and figures about what’s happening, I can speak a little bit anecdotally about it. I can also speak in terms of the, larger impact and maybe even some about what’s happening in our clinic. We do know that numbers of things can happen and that the kind of stressors that people are experiencing right now can increase their symptoms of PTSD. So, if you’re tracking symptoms, let’s say if you working on treating them and they’re not going down, I’m kind of curious… is it because of the treatment or something’s not happening with the treatment or because everything is so stressful right now that’s it’s just kind of hard so maybe keeping them steady is helping, they’re not going up in the time of Covid, not going up in their increase in symptoms. People are struggling and I think it has impacts that we still haven’t quite figured out yet fully and how it influences PTSD, I think, is a little bit unknown. In our clinic one of the things we are noticing in our Bay Area Trauma & Recovery Clinic is that the clinicians are also really stressed. They’re trying to work with people who have trauma and who are really stressed and so you can kind of feel that there’s this environment of just trying to get the work done without sort of burning out and helping people manage their own stress of job losses while having PTSD or losing individuals to Covid and not being able to say goodbye. So a lot of emotional turmoil and we may see increases in experiences of traumas due to the loss/losses that people are experiencing as a result of Covid. I’m hearing whisperings of those kinds of things. And, that people feel more vulnerable right now and I think there’s a little bit of a kind of something that’s not really spoken to in terms of the kind of ongoing, iconic isolation that people might be experiencing and the sort of repetitiveness that is now happening in people’s days due to, you know, restaurants being closed, can’t go to the movies, can’t go see your friends and so it’s like each day starts to look like the last day… maybe you’ve even experienced that yourself? I know I have… I’m like is today Thursday or Friday? What is the impact of that kind of repetitiveness, like we’re sort of curious animals in a way, right? We’ve got a lot going on up here and we’re into discovery and technology and all of these explorers in a way and, on an individual level, being able to get out and connect is, I think, pretty important and so for those who are isolated, lost jobs, lost family members, I think it’s hard for me to imagine that their PTSD symptoms aren’t worsening as result of that. There are papers being written, people are doing the research in real time and I can’t keep up with it, myself. I’ve done some reading and I’ve just published, with some colleagues, on things to be looking for in terms of pandemics but the full outcome of this pandemic I don’t think is going to be known but I would not be surprised if its intense in terms of mental health outlooks.

Jennifer Ghahari:  Ok. So, it seems that, especially if people are suffering or find themselves under the stressors of what’s going on, they should seek help just to make sure it doesn’t develop into something that would be more chronic?

Robyn Walser:  They should seek help and if they can’t find help clinically because – maybe you’re experiencing this you’ll have to let you know – but every clinician I’ve talked to is like I’m full I’m full, I’m full. I’m getting emails that say things like I’ve contacted 10 therapists and nobody is available and, you know, I would invite people to persist and maybe to consider other options as temporary kind of space holders like, I hope this doesn’t sound too trite because I know some people are really suffering, but looking online for social groups that you can join if you’re having a substance use issue and you know that you’re struggling, you know, take a peek at some of these online recovery groups like Smart Recovery or AA – like if you can’t get a hold of somebody, if you can’t make something happen, don’t suffer alone JUST KEEP TRYING. I would download apps that are you know helpful, doing like mindfulness apps or listening to meditations on the internet… just almost anything that sort of helps you through the process especially if you’re unable to get services at the moment. Hopefully you can but, I don’t know if you find this happening in your area, where clinicians are saying they’re full?

Jennifer Ghahari:  Unfortunately, yes, and I think you brought up an important point is that people are not alone in this. The amount of suffering is so widespread and it’s just an active part of the  pandemic, unfortunately – so, like you said, pursuing and being persistent and trying to get some type of help is really necessary at this time.

Robyn Walser:  And even if you have to do something like join a social group online, like a book club – these are not enough, I know that – but just somehow feeling like you’re connecting I think can be useful and helpful, cause you know social support in the middle of such a huge, you know, worldwide-like forced isolation process can be just invaluable. 

Jennifer Ghahari:  Perfect. Well thank you so much for your time we really appreciate it. Be safe and well during this time and we look forward to speaking with you again in the future.

Robyn Walser:  Thank you again for having me.

Jennifer Ghahari:  Thank you.

For more information, click here to access an interview with Psychologist Michele Bedard-Gilligan on trauma & recovery.

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

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