Sociologist Peter J. Stein on Genocide & Discrimination

An Interview with Sociologist Peter J. Stein

Dr. Peter J. Stein is a Professor Emeritus of Sociology at William Paterson University and a Holocaust scholar.

Jennifer Ghahari:  Hey, thanks for joining us today. I'm Dr. Jennifer Ghahari, Research Director at Seattle Anxiety Specialists. I'd like to welcome with us Sociologist, Peter Stein. Dr. Stein has a Doctorate in Sociology from Princeton University, and has been a professor of sociology for 33 years, primarily at William Paterson University in New Jersey. Most recently he was a senior research scientist at UNC Chapel Hill. Since 2018 Dr. Stein has been volunteering, educating groups about the Holocaust at the United States Holocaust Memorial Museum. Author of nine books, his most recent includes; “A Boy's Journey: From Nazi-Occupied Prague to Freedom in America.” Before we get started, can you please let our listeners know a little bit more about yourself and what made you interested in studying the Holocaust?

Peter Stein:  Thank you for the introduction, Jennifer, and I'm glad to be here. I was born about two years before the Nazis and Hitler occupied, Czechoslovakia. I was born in Prague. First couple of years of my life were fine. But on June 15th, 1939, Germans came in, and the Holocaust started not much after that. My dad was Jewish, Viktor Stein, and he married a Catholic woman, my mother, Helen Zdenka Kvetonova. They had mutual interests. They liked music, they liked dancing. They fell in love, they married. And the fact that my Jewish father married a Christian woman, pretty much saved his life.

Jennifer Ghahari:  Wow.

Peter Stein:  Because unlike the other eight members of his family, his brothers and sisters and his mother, were all sent to concentration camps in 1942. My dad was not sent until two years later. He was doing slave labor. That is manual labor in and around Prague, which was difficult and demanding, but he survived. So, then he sent to Terezin in Czech or, quote, "Theresienstadt" in German, which was a ghetto-labor camp about an hour northwest of Prague. He was forced - he worked on wood manufacturing, is what he did before the war. That is, he had the Bentwood Manufacturing Factory. So, they made chairs. Anything with bentwood. Tennis rackets, skis, ping pong paddles, and so on...

So, he was able to apply some of those skills in Terezin. He came back in 1945. I remember him jumping off a Soviet truck. About 12 Russian soldiers brought back survivors of the Holocaust. He was still wearing a yellow star, which was required. So, then we went back to democracy, but the communist party came into power, and it took my parents almost two years to get an American visa. We came to the states the same night that Harry Truman upset Thomas Dewey for the presidency in 1948. Sailed by, The Statue of Liberty, her crown lit up, the torch lit up, and I saw downtown Manhattan. And I wanted to stay up all night. Why? Because I was looking for king Kong and Fay – climbing the edifice with Fay Wray. Finally, my mother said, no, go to bed. So, we came to the States. My father came two years later. It's a long story, but basically he was arrested by the communists for trying to get his factory back. My mom was a governess for a family with two children. And we lived with them in Larchmont, New York. I learned English. I went to City College. Then I went to Princeton for my PhD degree and I've taught in and around the New York area, primarily William Paterson. Jennifer's alma mater and where we also met and the rest is history.

Jennifer Ghahari:  Great. Well thank you for sharing that with us and I'm sorry for everything that you and your family have been through, again, even begin to imagine. And again, thank you for speaking with us today. In terms of antisemitism that I think it's used fairly often. Can you explain to our listeners, what does that term actually mean?

Peter Stein:  It's interesting. Historians and scholars still research and write about it. And most recently the current Biden administration appointed Deborah Lipstadt, who's a historian of the Holocaust, to a position overseeing Holocaust and genocide developments. So, it's come to that level of importance. And basically goes back to the Nazi ideology that Jews are inferior. They're inferior physically, they're inferior mentally and intellectually. And basically they have no right to survive. I mean, that's the essence of the Nazi ideology. That they're less than humans. And one film that the Nazi's produced shows Jews as vermin, as roaches to be destroyed...

And many people hope that the use of that term and attitude towards Jews would change with the end of World War II. However, all kinds of studies, one by ADL, the Anti-Defamation League shows an increase in antisemitism, both in the United States and in Europe. So, much so the latest study is a 2021 study. And I want to make sure that I report the figures correctly.

Jennifer Ghahari:  Thank you.

Peter Stein:  They do something where they count anti-Semitic incidents in the year 2021. They discovered 2,717 antisemitic incidents ranging from vandalism, putting a swastika or something of that sort, to violence in the synagogue and Pittsburgh, most notably the Tree of Life Synagogue and others. So, the antisemitism continues and I have to quote one noted authority. My mother. And when she was still alive, I asked her, well, why do you think there was so much antisemitism in Czechoslovakia?

She said envy. And I think there's something about envy. The Jews for millennia in Europe were segregated into ghettos, they were limited in what they can do. But in the 17th, 18th centuries in Europe, they were given more latitude, more opportunities. And they went into the professions, law, medicine, manufacturing, banking, and they were succeeding quite well. And I think the envy came in there because for generations, Jews were seen as inferior, less than human, to be avoided. And suddenly Jews had power and some had wealth. But I have to be very clear that yes, there were rich Jews and there were also very poor Jews. Many of them, the poorer ones in Eastern Europe, in agricultural areas. But that antisemitism had been spreading for generations before Hitler ever came on the scene.

Jennifer Ghahari:  Wow. And as you said, it's spiking again. And it seems that hate groups are on the rise again. And aside from antisemitic attacks, there's also been a large increase in anti-Asian sentiments and attacks in the US. And it seems to correspond, especially with Asian Americans, with the outbreak of the coronavirus pandemic. And in America, we're talking about Jewish Americans and we're talking about Asian Americans. They're not outsiders, but some people are treating them as such. So, sociologically speaking, how can we overcome as a society, this discrimination against our own subgroups.

Peter Stein:  I think you hit the nail on the head with the use of the word outsiders. I think one way to look at all of these issues is who's the insider, who's the outsider - who are the we, who are the they, who are the people with power and influence and who are those with limited? And I dare to say that in every society that we know of, there have been some people with more power and they can use the power to label other people as different that as outsiders. And among outsiders, if you look at it historically, were women, African Americans, Asians, Jews, people with disabilities, people with different sexual orientations. Any number of those people who then can be painted as dangerous, as different, as our kids shouldn't associate with them. And you quite right about Asians. It's been an ongoing struggle that we're now more aware of...

And Asian community are saying, we want protection. We want equal opportunities. We want equal rights. Chinese of course were built sent to your neck of the woods, the West Coast, to build railroads, primarily male workers, very few women. And so they were doing that kind of labor. The Japanese were the “good” group. They were the ideal group to the World War II when they were suspected of being pro German and sent to internment camps, which is a different word for concentration camps. And they suffered. And if you look at just one quick figure I was looking at, if you look at the proportion of Asians in technical jobs, chemistry, other sciences, is quite high. If you look at the proportion of CEOs in American corporations with Asian backgrounds it’s about 2%. So, they're promoted up to a certain point and then I think the stereotypes come in.

Jennifer Ghahari:  Wow. Thank you. Sadly, and unfortunately, obviously it seems that you have firsthand experienced of the damage that extreme prejudice and discrimination can do. And are you comfortable to share some of your childhood experiences in Prague with our listeners?

Peter Stein:  For those people looking for holiday gifts? There's a wonderful book - my memoir.

Jennifer Ghahari:  It is a great book. I read it probably in two sittings.

Peter Stein:  Wonderful. You didn't have some Czech wine with it, I hope. I hope it was Czech beer. It was difficult. My dad, would disappear for periods of time and I always would ask, this is during the war, during the Nazi occupation, during the Holocaust, I would ask my mother where's dad. And also where's my uncle Richard, my favorite uncle, brother of his, who would always bring me stuffed animals and toys. He was wonderful. My mom's standard answer was, “Your dad's on a business trip. He'll be back as soon as he can.” I checked with my cousin Gerti. Gerti also has a Catholic mother, Jewish father and her mother had the exact same answer that her sister did. That is, “Your dad is on a business trip. He'll be home as soon as possible.” So, I had no idea. I of course, had no sense of what Holocaust, what concentration camps were...
 
None of that. I went to school. But we had German soldiers all around. And in my classroom, every classroom in the front, there was a picture of Adolf Hitler and the Nazi flag. The teachers were Czech, but they were instructed to be quite reverential of Hitler and the Nazis. So, I'll give you one quick example of what I experienced as cognitive dissonance. Monday through Friday, we were told in class, when it came up that the Germans were winning. They even took us to a couple of parades to honor German soldiers coming back from the east. But on Sundays, I and my mother would visit my Catholic grandparents. And my grandmother was a wonderful cook, wonderful baker, always had a good meal, despite food shortages. She could put a chicken on the table at six o'clock like clockwork. Every Sunday when we were there, my grandfather invited me and my cousin, Robert, who was nine months older than I into a study. He would put on his Blaupunkt short wave radio and listen to the BBC, the British Broadcasting Corporation, which started with the chimes of Big Ben then Beethoven’s 5th (sings a few notes).

Jennifer Ghahari:  That's very dramatic.

Peter Stein:  And we'd have a bulletin of the news. And my grandfather spread a map of Europe on his desk. He had a stack of black checkers, which indicated the German positions and red checkers indicating the Allied positions, including D-Day in Normandy. And it was just amazing. And whenever we finished with him at his home, he would say, “Don't worry, your dad will come back.” He told both of us. Sadly, my dad did come back, he survived - my cousin's father, Leo Perutz was killed in Auschwitz. But that dissonance, what was happening: so, for a seven or eight year old, who do you listen to? Well, I went with my grandfather, but he said never about this in school...
 
If the teachers get a wind of it, you could get into trouble. So, the whole thing, the war years were difficult, including a couple of bombings of Prague. I have a whole chapter about that, where an American squadron flew over Prague, the same day they were supposed to bomb Dresden in Germany. They mistook the topography. It's very similar rivers. And so we lived through that. That was one of the scariest moments, because my school is in downtown Prague and they hit some buildings, the church, so on. So, the whole thing, the war was there, but somehow we managed and my mother was terrific. She looked after me, made sure we ate and all of that. And at the end of the war, she and I both became vegetarians. Why? We couldn't get any meat. So, I had fresh bread, which I loved with several different mustards. No meat. No hotdogs. Not a problem in Seattle these days.

Jennifer Ghahari:  Exactly. You didn't stick with the vegetarianism. Did you?

Peter Stein:  It ended as soon as the war ended. Butchers opened businesses, stores.

Jennifer Ghahari:  Nice. Thank you for sharing that with us. It definitely helps to visualize what you and your family experienced. And now looking at what's going on in Ukraine, I think people might be able to see some connections. For those who aren't familiar on February 24th, Russian President Vladimir Putin ordered his army to invade Ukraine. And for those who have seen images on TV at home, the images and the stories are just gut wrenching and actually anxiety inducing. So, I can only imagine what you feel, seeing something like that. Cause it seems you some type of similar things that you went through back in Prague. From your own personal experience, can you speak of what you see going on in Ukraine? And are there any similarities?

Peter Stein:  How many days do we have for this?

Jennifer Ghahari:  Exactly.

Peter Stein:  It's quite tragic, I must say. A couple of historical examples come to mind. In 1938, before Hitler invaded the whole country, he went to liberate an area called the Sudetenland. Sudetenland: about three million Czech citizens who spoke German as their native language. And Hitler used that pretext to liberate them from the Czechs, who he accused of oppressing. Putin’s take on it certainly is influenced by that kind of structuring. Then in 1948, the communists came into power in February and again in one day dictated censorship. So, my dad came home from his office in February midday, and he showed me the newspaper. He said, democracy has died in Czechoslovakia. I said, what do you mean? He shows me the newspaper and there're several columns, completely white. Those are stories that were never printed. Critical of, in this case, the communist takeover, what was called a putch.

And so Czechs had to flee. 20 years later, 1968, the Soviet army, well, the Warsaw Pact Nations in invade Czechoslovakia. People are probably familiar with that. And rest of my family, the Czech Jewish family that survived the war, left Prague one person at a time, because the rumor was that if you try to take your whole family out, you're likely to be questioned, even arrested. So, I spent a week in Vienna with my dad and every afternoon at three o'clock, we'd go to the railroad station to see if any relatives, and it literally took two weeks for the father, the mother, the daughter, and the son to come out. And you see it, people weren't being bombed, but they were limited to one suitcase.

And since I was there, I did a little study. I interviewed people for a couple of days. Most of them were in their thirties or forties, single or young parents, doctors, lawyers, nurses, social workers, teachers. What we would call a brain drain. And I think we haven't looked at the full impact in Ukraine of the Russian attack. How many other people have fled, had skills that are necessary. And it's very close to a genocide. Certainly they’re war crimes, the bombing of hospitals, of children's centers, of theaters, killing women and children, tying them up “in the name of freedom.” And it's hard not to think about domestic situation. I'm not going to go there, but the use of the concept of freedom and helping people themselves, you have to ask, who's doing the talking and what are the actions like? What's the behavior. It's not propaganda. It's what they do. And it's troubling. And now, as you know yesterday, the Secretary of Foreign Affairs for Russia, Mr. Lavrov, is talking about, they “have nuclear weapons,” while we know that, but that's...

Jennifer Ghahari:  The similarities are highly disturbing, especially because it seems like you said that, it is ethnic cleansing, even though it's framed in the terms of liberation. But as you said, everything that they're doing is not liberation. It's the exact opposite.

Peter Stein:  Brave Ukrainians. I don't know how many people would do that to risk their lives.

Jennifer Ghahari:  Sure. And as you mentioned too, it's not only a brain drain. So, it's affecting Ukraine itself negatively because they're losing all of essential workers. And by essential, I also mean what you were saying, like doctors and people that keep society running. Like all of these people, it's millions have fled. But then also if you think of the flip side that now these people are refugees coming to different countries. I know out here in Seattle, we're supposed to get, I'm not sure how many refugees from Ukraine, but there's supposed to be several coming. And if they don't have a good handle on the English language, so you have someone like a doctor or professor or any profession, to get started over in a brand new country and to have lost so much. It's really heartbreaking. And I hope that when refugees go wherever they end up, whether it's here, whether it's the UK or anywhere, I hope people are cognizant of that. That these people are not here because they want to be. It's not that they left because they wanted to. Similar to you and your family. You left because you had to survive. And it wasn't an easy thing to do. Obviously you were a child when you came here and your English is perfect. But for older adults just getting a start, I can't imagine how difficult it is.

Peter Stein:  Even my little example. (phone ringing) Sorry.

Jennifer Ghahari:  No worries.

Peter Stein:  I don't know how to quiet this.

Jennifer Ghahari:  It wasn't me calling.

Peter Stein:  Okay. My first few days in an American school with my lousy English, couple of kids thought I was German. Stein. I said, Stein, I'm Czech. I'm Jewish, I'm not German. And so imagine if you come... As you have said to be an immigrant, it's a difficult status. And is there anybody there? Fortunately had a wonderful teacher, Mrs. Murray in the seventh grade who took me under her wing and she helped me with English and writing and she was wonderful. And you think about the importance of teaching for immigrants English as a second language. My dad took one of those classes. He spoke Czech, he spoke German, he spoke French, but he didn't speak English.

Jennifer Ghahari:  Wow.

Peter Stein:  So, he had to come up to snuff and pass the citizenship exam. And you're so right, because it takes you out of your home. Out of settings of familiarity, to a brand-new country where they may or may not welcome you. And yet immigrants have done so much to build up this country. I mean the number of immigrants from Southeast Asia, from Asia. Seattle is certainly one place.

Jennifer Ghahari:  And anxiety that comes from that type of move, especially when it's forced upon you. It's really detrimental. So, again, I hope that people are just a little bit more aware and a little bit more sensitive and will just kind of maybe take an extra step to try to help people however possible.

Peter Stein:  And government policy is so critical. We won't speak about the former president who wanted to stop the incoming of any Muslims, of anybody. I mean, just willy-nilly. Well, so then it's not surprising that when they come, some Americans are upset. “You shouldn't be here, go back to where you came from.” And that kind of antisemitism and anti-minorities just makes being an immigrant that much more difficult. And I got to put a plug in for education because I think that's critical. That schools ought to welcome different points of view, different languages, different cultural patterns. And not start burning, taking books away. And no, you can't learn about this one or that one. That kind of blinders that some folks have.

Jennifer Ghahari:  So, it sounds like multiculturalism and education are pretty much key to overcoming this anti-racism, antisemitism, basically all types of anti-discrimination. Correct?

Peter Stein:  I would certainly hope so, because you may get it at home, but you may not. And so that's critical. Speaking one other point about antisemitism that the ADL League found, they're now looking at social media and the spread of antisemitism there. And they found that in one year in the United States, there were 4.2 million antisemitic tweets. And they go into their methodology, which is quite sophisticated, but 4.2 million antisemitic tweets.

Jennifer Ghahari:  Wow.

Peter Stein:  So, somebody's writing it, somebody's reading it, somebody's sending it out. And that's new. I don't think anyone else looks at the use of the media in that way.

Jennifer Ghahari:  Right.

Peter Stein:  Now one gentleman just bought a big media outfit and we'll see how goes.

Jennifer Ghahari:  That should be interesting. Well, thank you. And so, as someone who specializes in antisemitism and wartime atrocities, do you have any other advice or any parting words for our listeners? Anything else that you want to add?

Peter Stein:  Well, again to educate not only in schools, but educate yourself because the media, as, as lovely as it is, can be influenced. Who's saying it? Where does the message come from? Who's got what kind of vested interest in having you, accept this as a fact, as opposed to just an opinion. But also to communicate, to talk to other people, to talk against people who have racist jokes or sexist jokes, or rather than just ignore it and laugh, suggest how does this impact other people. Anti-gay or lesbian jokes, or what have you, and to support the right to vote. Another key issue that maybe needs more attention and the democracy supposedly is helping people, encouraging people to vote, to express their opinions. Well, if you make it more and more difficult, it's easier for people of one opinion to get in it and not others. So, I just would hope for more tolerance, more understanding of other people, as the salvation and the Golden Rule is to do unto others, as you would have them do unto you. And I think that's an important rule to keep in mind in our lives.

Jennifer Ghahari:  Great. Well, thank you so much. And again, thank you for sharing with us, what you and your family had gone through. And I'm very sorry that you have experienced all of that. And if we could have you back sometime, we definitely will. Again, thank you for talking with us today.

Peter Stein:  Thank you so much for inviting me. If anybody has any questions after they see the tape, feel free to communicate with me or through Jen. Glad to answer and thank you for what you are doing.

Jennifer Ghahari:  Perfect. And you had mentioned that there may maybe some photos that we could add along with the interview.

Peter Stein:  Sure.

Jennifer Ghahari: Perfect. So, for those listening we'll put that into the transcript section on our website and you'd be able to access that along with the link to Dr. Stein's book.

Peter Stein:  Thank you.

Jennifer Ghahari:  Thank you again.

Photo gallery images courtesy of Dr. Peter J. Stein:

Zdenka Kvetonova and Viktor Stein (Peter Stein’s parents), married in Prague’s Old Town Hall, May 1934.

Peter Stein and his Mother (left).

School children in Prague (2nd grade).

Photo taken during the May 5-8,1948 uprising by Czech partisans battling remaining German troops--eventually chasing them out of town.

1946 Prague: Peter Stein’s family along with Kurt Fuhr (Peter’s Father’s cousin) and his wife, Malvinka. Both Kurt and Malvinka were Jewish and Captains in the Czech Army, fighting with the Soviet Army against the German Army. They each received medals for bravery (he was wounded in battle and she was a nurse).

Arriving to the U.S. and seeing the Statue of Liberty for the first time.

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 Timothy Strauman on Self-Regulation

An Interview with Psychologist Timothy Strauman

Dr. Strauman is a Professor of Psychology and Neuroscience at Duke University and is an expert in self-regulation.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Nicole Izquierdo, a research intern at Seattle Anxiety Specialists, and today I'd like to welcome with us Clinical Psychologist and Researcher, Timothy Strauman. Dr. Strauman is a professor of Psychology and Neuroscience at Duke University. He is also an affiliate for the Center for Brain Imaging and Analysis, the Duke Initiative for Science and Society, and the Center for Child and Family Policy. He is an expert in self-regulation. His research has amounted to over 13,000 citations and focuses on the psychological and neurobiological processes that enable self-regulation, conceptualized in terms of a cognitive-motivational perspective as well as the relation between self-regulation and affect. Before we get started with some questions, can you please tell us a little bit more about yourself, Dr. Strauman, and what made you interested in studying psychology and, eventually, self-regulation?

Timothy Strauman:  Sure. Well, thank you for having me. It's actually hard to know. I've never quite been able to figure out why I got interested in psychology. I think very early on, I remember in high school being interested in mind-body things, and what at the time were called "psychosomatic illnesses," so I think I was sort of going back and forth between, did I want to be a physician, or did I want to be a psychologist? Psychology just appealed to me partly because it was a science and partly because the idea of intervening the way psychologists intervene and seeing impacts that it can have on people's behavior, on how they think, on how their bodies are responding to stress, it's just something that's always been interesting to me, so I'm very grateful to have the career that I have, and I'm as excited about it as ever.

Nicole Izquierdo:  That's awesome. Do you want to talk a little bit about where you went to school, what your training kind of consisted of, and then, I guess, how you ended up with a position here at Duke?

Timothy Strauman:  Sure. I was an undergraduate psychology major at Duquesne University in Pittsburgh, which I actually went to because their Psychology Department was very humanistic. I got there and, you know, that was fine, but I sort of realized that for me, personally, I needed to be in a mainstream, so I went to the University of Chicago into an interdisciplinary program called Human Development. Got there and decided that's not exactly what I wanted to do either, so I got a master's degree there, and then I actually went to work for a drug company doing cancer research, clinical trials, and it was a great experience. I did that for four years, learned a ton about research, a lot about statistics, and then kept applying to graduate schools, and eventually got accepted at New York University, and I was able to do both clinical psychology and social psychology there, which was absolutely phenomenal.

The research that I do takes how a social psychologist thinks about experimentation and thinks about mental processes and applies them to what makes people feel sad and what makes people feel anxious, and then what would you do about it, and how would you know that the treatments were working? I did my internship at Einstein in New York and it was absolutely fabulous. Then went to the University of Wisconsin, where I was for 15 years. I was in the Psychology Department, and then I moved over to Psychiatry because I wanted to do more clinically-focused work, and then I came to Duke and I've been here ever since. It's a great place to work and it's particularly good because the medical center's right next door and it's a wonderful place. Amazing students, by the way. Very smart students.

Nicole Izquierdo:  Thank you. Yeah, we're lucky to have you here. So, I guess your research revolves around this term called "self-regulation." For our audience members that aren't too familiar with what that means, would you mind defining it to someone that could be listening to this?

Timothy Strauman:  Sure. Yeah, it's kind of a fancy psychology term, but what it really boils down to is all of us when we were growing up learned that it was important to be a particular kind of person and it was important to not be a particular kind of person, right? It's kind of what it means to have family, what it means to have parents. We learned very early on to constantly sort of monitor ourselves. What are our goals? What are our standards? What are we trying to be? What are we trying to not be? That's really what self-regulation means. Part of what's interesting about it is it's always happening. We do it unintentionally, but it's always happening in the background. It's always happening, pretty much automatically. It's as automatic as if you look at the letters C-A-T, you can't not see the word "cat." It's impossible, it's so overlearned.

Self-regulation is the same way. Any situation that we're in, there's something in the background saying, "How am I doing in this situation? Am I being the person I want to be in this situation? Is it working? Is it not working?" That's really the approach that we take. We spend a lot of time in our research, basically, it's pretty straightforward. We ask people, "What kind of person would you ideally like to be? What kind of person do you think you ought to be, you're supposed to be, and how are doing in reference to those standards?" We basically will bring people into the lab and have them think about it or expose them to those ideas and just watch what happens. See, if you get people thinking about a goal that they feel like they're attaining, they'll feel positive. If you get people thinking about a goal that they feel like they're not attaining, they'll feel negative.

The other thing, though, that's an important twist to this is there are basically two kinds of goals. There are goals about making good things happen, which we call "promotion," and there are goals about keeping bad things from happening, which we call "prevention." One of the things we've learned in our research is that depression is associated with not being able to make enough good things happen, whereas anxiety is associated with not being able to keep bad things from happening, at least in your own head, so in the treatment research that we've done, part of what we do is to try to help people understand that there are both of these kinds of, two ways of thinking about goals, and depending on which way you're thinking, it could make you happy or sad, or it could make you anxious or calm. We try to integrate that into treatments. That's not in and of itself terribly revolutionary, but what we do in our work is really try to help people focus on it and actually learn it as a skill.

Nicole Izquierdo:  I noticed that one of your papers was on a model for generalized anxiety disorder and depression comorbidity. Would you say that these individuals are with these deficits to their self-regulatory systems that makes them more vulnerable to both not being able to make good things happen and not being able to stop bad things from happening?

Timothy Strauman: Yeah, that's the model. You're absolutely right. A lot of the work that we've done has been developmental, where we basically, we either ask people to look back on what things were like with their kids, or sometimes we've just studied groups of children and followed them. Everybody learns how to make good things happen and everybody learns how to keep bad things from happening, right? I mean, anybody who's a parent will say, "Oh my gosh, of course I want my kids to know that," and anybody who's ever been raised by an adult says, "Oh, I know exactly. I know exactly what I was supposed to be doing and what they really wanted me to be doing." That's part of human nature and we carry it with us and it's really adaptive.

We've actually found that there are two ways that these things can get disrupted. One is for people who are used to succeeding, sometimes when they get into a patch in life when they're just not getting the positive reinforcement, it creates a sense of, "I'm not being the person I really would like to be," and that in the moment it leads to sadness, which that's not a big deal because that just motivates us to work harder. But what if you keep working harder and harder and harder and nothing's changing? Part of the work we've done is to say that's a potential pathway to depression.

The other thing that we've learned is many people when they're growing up are raised in a family environment where the focus is really on stay out of trouble, be careful, make sure the world's a dangerous place, and as a parent, of course, is exactly what I did with my kids. But if you focus on that exclusively, it ends up having the unfortunate side effect of you never learn how to make yourself feel good. You only learn how to keep yourself from feeling bad and that's actually not enough, and so our model of why generalized anxiety and depression go together is because for lot of people we've found that they're really focused on keeping bad things from happening because that's all they actually ever learned to do. We'll say, "What do you do to make yourself feel good?", and they'll look at us like, "I don't know. Nobody ever told me it was okay to do that."

A lot of us grew up in different kinds of families. That doesn't mean we had bad parents. It means we had parents who really wanted to keep us safe and just one of the byproducts of that is sometimes we're not balanced about, "Oh, actually, I need to make myself feel good so that I'm not constantly focusing on things that are dangerous and things that might go wrong." That's a long-winded answer to your question.

Nicole Izquierdo:  Would you say that these people are essentially doomed or are there some strategies that you have found that they can implement to restore their self-regulation?

Timothy Strauman: Oh, first of all, people are amazingly resilient. One of the things that's a real privilege as a therapist is to work with people and watch as they think through, "Okay, I have a set of standards. Some of them are from a long time ago. Maybe I don't need them anymore," or, "No, I like the standards I have, and I'm going to stick with them, but I'm going to explore what am I doing to pursue them, and can I do that differently?" People are amazingly resilient and the work that we've done developing and testing therapies where we're really focusing on this, people understand the distinction between ideals and odds. I think they feel really comfortable with the idea of getting balance.

In fact, the whole wording of “make good things happen versus keep bad things from happening” came from people who were in our early studies because we were using all this psychology terminology. You're like “No, no, no, no, it’s just what you're talking about,” which is, “Am I trying to make something good happen? Or am I trying to keep something bad from happening?" We were like, "Yes, that's exactly what we're talking about." Both of those things are essential, they're just different. If you want to be happy, you have to do the one, and if you want to be safe, you have to do the other. In a complex world like ours, you really want to be able to do both. No, I don't believe people are doomed at all. Folks are amazingly resilient and these are skills that we know people can learn and we know they're helpful.

Nicole Izquierdo:  I guess to make this more applicable to our listeners, I was thinking about it and, you know, not everyone has the access, the time, or the money to afford to go to a therapist and sit in a therapy session so what are some techniques that you would recommend that could fall under the umbrella of restoring these systems that people can do in their everyday life?

Timothy Strauman:  Oh, sure. In fact, the work that we do and the work that the people at your clinic do, the whole goal is to help people acquire new perspectives and skills that they take with them out into the real world and not just in the therapist's office. There are a couple of things that I think can be really helpful. One is just the recognition that it is always going to be important to us to make sure we are being the kind of person we want to be. That's just human nature. That's really what it means to be human. That's all always true, it's always happening, and we get to decide, what are those goals and standards going to be?

Yes, as we grew up, we acquired a set of beliefs about what's a good person and what's a bad person from the people around us, of course we did, but we always have the opportunity to say, "That worked for me when I was younger. I'm not so sure it's working for me now. Do I want to tweak it? Do I want to change it?" I think one of the things that's really empowering is just to be able to say, "Yeah, you know what? That actually matters. It always matters. Even if I'm not thinking about it intentionally, it's always going to be there in the background. I care if the people I love think I'm a good person or not. I care if the people I love think I'm keeping myself safe and avoiding danger. It matters. It matters to them, and therefore, it matters to me." That would be one thing.

The other thing that I think can be really helpful is just when you're in the middle of a situation and you're starting to feel something's not right, something's not working here, maybe you're feeling frustrated, maybe it's making you sad, maybe it's making you anxious, and maybe you can't do it right at this moment, but after that moment say, "Okay, what was happening there? What was my goal? What was I trying to make happen? Was I trying to make a good impression on somebody? Was I in talking to my boss and worried about somehow my boss thought I had done something wrong? What was I trying to do? What was the goal? How did the other person respond? Did they respond the way I wanted them to? Or did they not? Then how did that make me feel?"

Those three things: what was my goal in that interaction? We always have one. How did the other person respond to whatever it was I did that I was trying to pursue this goal? Then how did their response make me feel? That's a very old psychotherapy technique, it's not new, but thinking about it in that language makes it really easy to do in any situation. Then you can sort of stop and say, "Okay, is there anything I might have done differently? Did I do a good job of what I wanted to do and just didn't get the reaction I wanted? Is that my fault? Is it nobody's fault?" Then you're in a position to be able to say, "Okay, what happened?"

You can use the emotion as a signal that something important happened, and you can really dig into it and look at it rather than having the emotion be the endpoint. The emotion is sort of like, "Okay, something significant just happened here, but I'm going to figure out what it is, and I'm going to figure out why it made me sad versus guilty versus anxious." I'm going to figure that out and that's going to put me in a position that next time I'm in that situation, I'm going to know a little bit more about what's in my mind when I'm going in there, what's going to be in this other person's mind. I think that's really helpful to people and you don't need to be in therapy to be able to do that.

Nicole Izquierdo:  Thank you. Thank you for that. I guess in terms of the pandemic itself, what we've seen, especially in the beginning, a massive increase in anxiety and depression symptoms across the population. Have you done any work on this yet? Or have you found, I guess, any connections between the self-regulation model and this uptick in symptoms?

Timothy Strauman:  Yeah, I think so. I mean, obviously, this doesn't explain everything because the pandemic is enormously stressful, but one of the things that it has done is, just to use the example of parents, it's made it harder to be a good parent. Let's say you're a working parent and suddenly your kids are home. You have a whole set of expectations about what does it mean to be a good worker, and you have a whole set of expectations about what does it mean to be a good parent, and because of the pandemic, you're really not able to live up to either of those sets of expectations. You just can't. It's not possible, right? That puts us in a situation of something in the back of your head saying, "I'm not being the person I want to be. I'm not being the person I'm supposed to be." It's totally out of our control, but that doesn't stop. We're so used to evaluating ourselves that way.

I think one of the things that's very important for people to do to cope with the pandemic is to say, "Okay, I'm going to have to adjust what I expect of myself because there are things happening that I have no control over." In pre-pandemic days, what did it mean to be a really good parent? Okay, it meant certain things. In the middle of the pandemic, what does it mean to be a good parent? It's a very different set of things and it's okay to let yourself say, "This is what it means right now and I'm doing everything I can."

I think it's really important for people to be able to distinguish what's under my control and what's not under my control and not let all of the pre-pandemic stuff that, of course, it's how we lived our lives, and then suddenly we're in this situation where we just don't have the ability to do it, and it's really important just to say it this way to let ourselves off the hook, and knowing we're going to do everything we can do, but knowing it is artificially limited right now, and that does not feel good, but it doesn't mean we're not being good people. We're being the best people we can be under a set of circumstances that's absolutely extraordinary.

Nicole Izquierdo:  When I took my psychology stats course with you, I remember mentioning that you had some work about some public school interventions in relation to the self-regulation. Do you want to talk a little bit more about that, how that process has been? I imagine the pandemic probably caused a stint in that progress, but how has it been collaborating with public schools and implementing the work from the research to the real world?

Timothy Strauman:  Boy, it is such a privilege, and it's so exciting. Yeah, it's been on hiatus because of COVID. We are actually just now getting back to where, and probably within the next two weeks or so, we'll be back in at least one of the schools. The work that we're doing is really simple. This is with my colleague, Dr. Ann Brewster, who's an Intervention Scientist. We're trying to help people, especially people who are at risk for bad academic outcomes, so folks who've had long-term suspensions, or people who are moving from middle school to high school, but already have some academic indicators that they're probably going to struggle when they get to high school. We're trying to help them learn what I guess I would call "metacognitive skills," which is this general ability to stop, take a step back and say, "Okay, what's happening here?" We have really good data that that’s an enormously helpful thing for people to be able to do, and not just adults, but teenagers.

It's funny because when we got into doing this work, there was some skepticism about, can teenagers even do that? The answer is absolutely yes, they can do it. They do it all the time. There's nothing that we've tried to teach that has been at all foreign to people and students are amazing at it and it's really empowering because it puts them in a situation to be able to make better decisions. Just as an example, a couple of the people that we were talking to recently, why are they long-term suspended? Because they got into fights. Telling them, "Hey, don't fight," is not an effective intervention. Giving them the opportunity to step back and say, "Okay, what was happening in that situation? What was I trying to accomplish? Was I trying to make something good happen? Was I trying to keep something bad from happening? What were my options at that moment? One option was fight. Maybe that was the only good option. Okay, then it was the only good option. Maybe it wasn't the only good option."

What's powerful about it is, it's not us telling them this, it's us saying, "Here's a set of skills that we think might be useful. Give it a try. Tell us if you think..." And then they do it and then they come back and say, "That's interesting, because at the moment it didn't occur to me that I had any other options, but now as I look back, I can see that I did." As adults, we're not immune to that, we know exactly what that's like, but we do know it's enormously powerful.

The work that we did first that really got us established working with the Durham Public Schools was with these kids who were really at highest risk, and a lot of people, I think, probably just thought, "It's too late. Nothing can be done." It's absolutely not true. It is never too late. These folks helped us learn how to do the intervention. They helped us shape what the skills would look like. It is enormously inspiring and it's such a privilege to be able to do that work. We're actually hoping this spring we'll be back in the schools and in the fall we're going to roll it out through a couple of the Durham public high schools, and we're hoping by about a year from now, it'll be rolled out through the entire school district.

Nicole Izquierdo:  That's amazing. Would you say that they're receptive, both students and their parents and caregivers about these programs, and even the teachers and administrators themselves?

Timothy Strauman:  Yeah. There's a history of, there are some really well-thought-out interventions that are not punitive. They're not stigmatizing. They're not presented as, "Okay, you are getting pulled out of the classroom because you're a troublemaker. You're getting sent down the hall to this other thing where you have to see the psychologist who's going to make you a better..." It's not like that at all. It's for everybody, everybody in the school. It's a skillset and it's very respectful of the individual. Some of the interventions that we base this on are about, "What do you want your legacy to be? 10 years from now, 20 years from now, what do you want to be known for? Oh, and by the way, in the interim, what are the kinds of things that might get in your way? What kinds of situations might make that harder for you?"

We do a lot working with the older adolescents with frustrations they have about trying to get a driver's license, trying to find a job, helping them problem-solve about it, but what's really gratifying is once they learn the skills, they do the problem-solving, so they're able to say, "Okay, I went, I filled out an application. I handed it in, the person kind of grimaced, and took it away from me, and that was that, I haven't heard back from them." Okay, let's analyze that situation. Did you meet your goal? Absolutely, you met your goal. Your goal was to apply for a job. Beyond that, it's out of your control. The person's grimace, who knows why that person was grimacing? Maybe they're having a bad day, maybe they're... But whatever it is, you met your goal, your goal is to apply for a job.

Now, what are your options? One option is, "I'm never going to apply for another job. That was it. I'm done." Maybe another option is, "That was one possibility, but there are lots of other possibilities and I'm not going to let that person's grimace stop me from applying for the next job, or reapplying to that place," right? But they don't need an authority figure telling them that. That doesn't work. What works is for them to arrive at those kinds of options for themselves in a way that's empowering and non-critical and non-stigmatizing.

Nicole Izquierdo:  I guess the main takeaway among all the things for the interventions from the adolescents to with older adults is just remembering that some things are out of your control, whether it's the pandemic, or school systems, and then I guess, reframing the issue and evaluating all your options after the fact, and then, hopefully, implementing those in the future, would you say?

Timothy Strauman:  Yeah, I think that's a really good summary. To take it back to the whole idea of self-regulation, in every interaction, we have a goal, and there are aspects of those situations that we have control over, and there are aspects that we don't. We don't want to evaluate ourselves based on things we had no control over. We want to evaluate ourselves in, "Is the goal reasonable and did I do a good job of pursuing it?" We definitely want to evaluate ourselves, but not about things we have no of control over, and just learning to sort that out puts people in a situation to say, "Okay, I didn't get the job, but good for me for persisting, even with this person who was grimacing at me while I was filling out the application. Good for me. Whose problem is that? That's not my problem." Or, "I tried something and it didn't go the way I wanted." Okay, that's important information.

Just being able to take that step back and say, "What was the goal? Is it a reasonable goal? Did I do a reasonable job of pursuing it? Then is there anything else that was under my control? Maybe not. Okay, then I'm not going to hold myself responsible for the things that weren't under my control. That's asking too much." Yeah, I really like your summary. I think you nailed it.

Nicole Izquierdo:  Thanks. I guess we're going to shift a little bit. I saw that you have some papers on the training of clinical psychologists, mainly graduate students, and I also noticed when I was registering for courses last semester that you offer one for graduate students, kind of like a training course. Don't remember the name, but maybe it involves some ethics or something. Do you want to talk a little bit more about that and I guess what you think should be the core values in our future clinical psychologists and what it's like teaching graduate students here at Duke?

Timothy Strauman:  Sure. Yeah, thank you for bringing it up. That's an important part of my job and it's something I'm really committed to. The way that I think about Clinical Psychology is first and foremost, it's psychology, it's a science. There are a lot of things we know, there are a lot of things we've learned, and it's the job of a clinical psychologist to take that knowledge into a situation and somehow find a way to address whatever its public health problem it is, or whatever sort of problem it is you're trying to deal with. The training always has to be about that. It always has to be: get the knowledge base and then learn how to apply it.

Therapy is clearly one way of doing that, but it's not the only way of doing that. For example, it's become much more sort of an ethical responsibility of psychologists to advocate for their clients, to advocate more broadly in terms of social justice, and the American Psychological Association actually is saying that now. It's like we have a set of ethical principles and those are now part of the ethical principles, as they should be, because other healthcare professions were already doing that. It is our job to advocate for our clients, and that can mean a lot of things, but it's something that we need to do.

The other thing that is really important to us is, like many other sciences, clinical psychology has fallen short because we've basically only studied privileged people. We are as guilty of systemic, structural racism and its unintended consequences, let alone its intended ones, as anybody else, and it really is our responsibility to take a step back and say, "We can actually do better." It boils down to things like in my research study, who are the people that I'm recruiting to be participants? Why am I recruiting them? Are they representative of the people in my community? Are they representative of the people more broadly that I think my research is relevant to? If they're not, then I need to stop and say, "Okay, that's a problem."

We know a lot about intervention, but we don't know a lot about what interventions work for different kinds of people from different backgrounds who have different needs and who live in different kinds of communities and we absolutely need to learn those things. When we do learn those things, we will be better at our jobs, we will help more people. I definitely believe there are universal principles of behavior. I don't think it's the case that people from different communities are not like each other, but I think we've made a big mistake in not looking closely at people's individual circumstances.

There's so much that goes on in our society that is tainted by privilege and tainted by racism and the impact that it's had on education. When we go in and work in the schools, part of one of the reasons we're working the Durham Public Schools is that there is a history of discrimination in that school district and they're very well aware of it and it continues to reverberate. I mean, if you're from minoritized background, you're five or six times more likely to have academic difficulties than if you're not. It has nothing to do with your innate abilities, it has nothing to do with the quality of your parenting, it has to do with racism. That's something that I think psychology in general and certainly our training in particular, we see that as a mission is we have not been broad enough. We have not been comprehensive enough and we absolutely need to do that or we're not doing our jobs.

Nicole Izquierdo:  Yeah, I totally agree. Actually, an article will be published soon on The Seattle Psychiatrist site. It was some research that I did on the disproportionate impact the pandemic has had on the mental health of racial, ethnic, sexual, gender minorities, and it is due not to their abilities or some innate differences, but because of these systemic and institutional inequalities that we have in the US and you can argue around the world.

Timothy Strauman:  Yeah. You can't overstate how powerful those forces are. I mean, they're in the air, like that trivial example I gave before, you can't not see "cat" when you see C-A-T. If you are from a privileged background, you can't not see the world through the lens of a privileged background. That doesn't mean that you're a bad person, it doesn't mean you created the world that way, but it's still a fact, and we have to tell the truth about it. It's too easy for psychologists to say, "I'm going to do my research with a bunch of undergraduates at my university," which is fine. It's probably a good place to start, but it's certainly not a good place to stop.

Some of the best work that psychologists have ever done is work that's been underpinning changes in how our country deals with social justice. The Brown vs. Board of Education decision that the Supreme Court used to legally eliminate discrimination in education was entirely driven by psychologists who were doing research saying, "This occurs and it's harmful." I would say even the Supreme Court got it and that's a proud part of the legacy of psychology. There are a lot of parts of the legacy of psychology that are not so proud, but there are some good ones, and that's the one that inspired me when I was in graduate school because I was at New York University, and a lot of that work had been done by people who happened to have been in that department, so it was in the air and it was a good thing. Those things are in the air again now and that's exciting.

Nicole Izquierdo:  Thank you. Well, I guess we're going to wrap up now. I don't know if you'd like to add any last words or anything else you'd like to share, advice you'd give to our listeners?

Timothy Strauman:  Boy, advice. People are amazingly resilient. People are amazingly resilient and there is always a way. It is absolutely mind-blowing and a total privilege to work as a therapist, as an interventionist, and watch people empower themselves. It is remarkable and I've been able to participate in that in my career and it's so gratifying. I am a relentless optimist and I really believe that for everybody, there is a way. Thank you. I mean, it's a privilege just to be able to talk. I really appreciate being able to share some of my experiences and I hope this is useful to people who are listening.

Nicole Izquierdo:  Well, thank you so much for joining us, Dr. Strauman. We really appreciate you taking the time to speak with us and we wish you the best.

Timothy Strauman:  Thank you. I wish you the best as well.

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.

Journalist Kenneth R. Rosen on Wilderness Therapy

An Interview with Journalist Kenneth R. Rosen

Kenneth R. Rosen is an award-winning journalist and best-selling writer of “Troubled: The Failed Promise of America's Behavioral Treatment Programs.”

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 Kenneth R. Rosen, who is an award-winning journalist. His book, Troubled: The Failed Promise of America's Behavioral Treatment Programs was an instant number one bestseller on Amazon, a New York Times Editor's Choice, and one of Newsweek's most highly anticipated books of 2021. He has personal experience with the tough love industry and how it often fails the young adults of this country. He's also been featured on NPR, The Sun Magazine, and the Very Bad Therapy podcast, which is how I found him.

Ken, would you like to introduce yourself, and maybe start off by talking a bit about your own experience with wilderness therapy?

Kenneth Rosen:  Maya, thanks so much for the opportunity, and for reaching out. I think this is great.

My experience with therapy started back when I was 16, after a few years of individual one-on-one therapy and outpatient treatment programs that didn't work for me. I was taken in the middle of the night by two transporters to a wilderness therapy program in upstate New York. Over the course of the next 288 days, I would stay two stints in wilderness in upstate New York, while also being shuttled between a therapeutic boarding school in Massachusetts, and a residential treatment center, vis-a-vis ranch in Southern Utah. So, my tackling of Troubled which was a product of journalistic endeavoring, as well as a personal unearthing of my own past issues, and time spent at these programs, was an attempt to understand what had happened to me back then. And what had happened to me in the years that followed those programs and that type of treatment.

So, while wilderness is discussed in Troubled, I also follow four students who went through residential treatment centers, therapeutic boarding schools, and then into their adult lives thereafter.

Maya Hsu:  Great. And for our listeners who are unfamiliar, can you define and distinguish wilderness therapy versus a residential boarding school, and versus a therapeutic treatment center?

Kenneth Rosen:  Wilderness therapy is often sometimes called adventure therapy, or outdoors therapy. And I think it's a misnomer because it leads people to believe that it's something that it's not. Wilderness therapy, in a large portion of the country, is a holding place for children to sort of ease their way into more residential programs. So, they're stripped of their civil liberties, and taken to remote places, and given uniforms, and told to hike and fend for themselves in a wilderness theater, as it were.

The point of this is to ingratiate those students and those clients with a sense of a hierarchy in program language, and also the therapeutic language that they'll be using in the programs to come. A lot of times the rejuvenating capacity of wilderness is missed in large part because of how students get to these programs, to the wilderness programs, which is through a transportation service, which I briefly outlined that I went through, is when two men or women come into the room in the middle of the night, and take them at the request of parents, in large part because parents feel that their children might be flight risks, or that the programs require this sort of treatment to ensure the safe transportation of children to these programs.

Unfortunately, recent studies have shown that that transportation in and of itself is very traumatic and leads children to then miss out on all the rejuvenating qualities of wilderness. I think nobody will argue that spending some time in the woods is a great thing. That fresh air is healing, no doubt. It's just an unfortunate side effect of the way we treat children in America, writ large, that they feel the need to be transported against their will.

Maya Hsu:  Great. So, what I heard was that wilderness therapy is an avenue toward a therapeutic boarding school, or a behavioral intervention center later on. And that the lack of therapeutic benefits that don't happen is due to that traumatic transportation system that often happens in the beginning.

Kenneth Rosen:  Correct. In part a lot of the residential treatment facilities that I researched, and spoke to for Troubled required it to be part of the acceptance package into their program. So, a child had to go through therapeutic wilderness programs beforehand. Some programs had, at times, had that integrated into their school, so that it could be a one step to the residential program straight from wilderness, rather than a secondary program.

But it's not only the fact that they're transported to these programs, but it's also that some of the staff members at the wilderness programs aren't necessarily qualified to handle the students, and the needs that they have, whether it be psychologically, or physically, or emotionally. When I was in wilderness and when a lot of the people who were mentioned in the book were in wilderness, they would meet with licensed clinical social workers or therapists maybe once or twice every week... once or twice, every few weeks. It wasn't a consistent therapeutic environment, that day-in day-out 16 hour environment was run by people who had an interest in outdoor education, who liked hiking, who had a keen sense of direction, but weren't necessarily equipped as a licensed clinical social worker would be, or a clinical psychologist.

Maya Hsu:  I remember from the Very Bad Therapy podcast, you talking about the lack of adequate supervision, and training with the counselors of these programs. And that even very, very recently, maybe within the last year, you found that still their hiring requirements are that you only have to be over 21 to be a counselor of these programs. Can you talk a little bit about the impact of having untrained counselors on these grounds of these programs?

Kenneth Rosen:  Well, the children are always marked as troubled from the get-go. And so, when the programs ultimately fail, wilderness ultimately fails a child, and they relapse, or they go back to doing drugs, or sexually deviant behavior, or what have you… they blame it on the kid who was inherently bad before, or just difficult. Rather than saying that the people who were meant to care for them in those programs, the ostensibly trained individuals who could handle different situations, whether it be a traumatic situation, or any number of difficult children who are experiencing trauma and dealing with things that are cropping up from their past, end up not being able to handle that, whether it be first aid, or just any clinical psychological training.

So when you have someone who's 21, who's fresh out of high school, who just has a high school diploma, they're oftentimes making the situation worse. If not, just setting a low bar for children to go on living the way they had before, without the supervision, without real mentorship that they need in order to benefit from such a program. Of course, a lot of the programs are in such remote places that getting the type of staffing that is required to care for children in need, and at-risk youth, it's not always possible. But there needs to be a more stringent and due diligence on the part of the programs in looking for, and hiring staff, who can better their programs, and who can offer more insight to children as they need it.

Maya Hsu:  Are there other types of wilderness therapy options that don't fall into the category of this type of program that you're describing, where the counselors aren't fully trained to help kids with their mental health issues?

Kenneth Rosen:  So, the third prong, I mentioned two prongs initially, I mentioned the transporting to the programs is an issue. The second is the staffing of the programs is an issue, the unqualified nature of some of the staff. The third is the fact that children can't leave, or communicate with their parents. That they are restricted to this environment against their will. And having gone through AA, having gone through therapy all my life, I know that you are not going to change if you're forced to it.

So, to answer your question, the better programs that I've seen are the ones abroad, the ones outside of America. The ones that offer a child an opportunity to have this experience, to go into wilderness therapy, or adventure therapy, or outdoor behavioral therapy, and experience it for themselves. And if they don't like it, or if they're finding it difficult, or if they want to go home, they're allowed to. And in that way, you give the agency to the child. And the child is then making the choice to be in therapy. And that's already empowering rather than stripping them of their rights to feel empowered.

And people who run these programs overseas, I'm thinking specifically of one in Australia, they have come out with recent studies as well that suggest that the transportation of the kids is so effective in damning the child through the rest of the program that it almost negates any sort of positive behavior, positive outcomes from wilderness therapy.

Maya Hsu:  I'm so curious, is this the case for the majority of programs in the U.S., all programs in the U.S., are there some that you've heard of over the years, like private companies that run more modern, more updated versions of these programs with maybe not that kind of transportation process?

Kenneth Rosen:  I think this gets to one of your next questions, is that after I published a book, I did receive a lot of letters, and notes, and emails from people who run smaller programs for disadvantaged youth, for neurodiverse children, all different types of smaller programs who said that, "This isn't me, that my program is not like the ones you described." And I heard them and I still hear them.

The issue is that in the course of reporting Troubled and interviewing more than 100 former staff, and parents, and people who went to these programs, the majority of the time people were sent to the programs that I've described that required transportation, that stripped children of their right to feel unique, and heard, and cared for, and then sent them on to several other programs without ever giving them the true treatment that they need. And I've never disputed the fact that a lot of the children, including myself, needed some sort of help or treatment.

I wouldn't have written the book, if I felt that there was a minority of programs that were doing this. That these were programs that were just the odd person, odd program out. These are the majority of programs that I came across privately funded, even some who received federal funding. So, there are programs that are doing good, but I'm not, as a journalist, here to say, congratulations, you deserve a profile and an award. I'm here to say, there's a problem with the majority of the programs that are operating in this realm, and they need to be looked at, and adjusted.

Maya Hsu:  Sure. Something else that stuck out to me from the Very Bad Therapy podcast was how you talked about how students, or the kids who were sent to these programs were extremely motivated to alter their behavior so that they could go home. And that the problem behavior would stop in the short-term so that they wouldn't be sent back. Can you talk more about that, and maybe any other misconceptions about how therapeutic or effective wilderness therapy is?

Kenneth Rosen:  The identified patient has always been in this privately funded, troubled teen industry, wilderness therapy included-- the identified patient is the child. And time and again, I found that the identified patient should be the family, the parents who inevitably have not changed by the time the child comes home. With that said, the child comes home and has to act accordingly because they are afraid of being sent back to a program, or messing up and having their parents call someone to take them again in the middle of the night, traumatic as it was.

What the industry, including the Outdoor Behavioral Health Council, and all these other people who are industry leaders, and published their own industry funded studies will tell you is that all of the evidence shows that after six months at these programs children do better. That they're no longer doing drugs, that they're getting better grades… 6 months, 12 months. What they don't don't tell you is that those kids are still in different programs, 6 months, 12 months after those programs.

So, the attrition rate after the lead program in reality, two years down the line is a lot different than what the studies are showing. They're not doing quantitative studies of these children once they graduate, and go off to college, or go off to their first job, or go off to an internship, and see how they fare there. They just see how they fare within this realm of programs, which we talked about a little earlier, wilderness to residential, to maybe a lockdown, if it's necessary, or back to a therapeutic boarding school as they roll back the need for the hands-on treatment.

So, that's I think one of the misconceptions is that one is beneficial, but for the need of the other programs that come later, it's not that wilderness therapy has ever proven well enough because children don't often stay only in wilderness. They don't often go home after wilderness. They often go somewhere else. Are there cases where children go home after wilderness? Of course, but they are among the minority.

Maya Hsu:  So, what kind of programs or interventions do you think would be helpful to replace wilderness therapy, or in any case supplement?

Kenneth Rosen:  I'm not saying anything should be replaced. And I've long given up on suggesting the crumbling of the entire industry. I think that if American-based wilderness therapy took a play out of the books of foreign wilderness programs, allowing the children more leniency and latitude, working with the parents more directly, shortening the timeframe away from their discourse community, and their friends, and the people who they'll have to go back and integrate with later, rather than stripping them of any way of connecting with their peers. I think those are positive ways of changing.

Of course, there's a litany of reasons why they won't do that. Several of which I couldn't even tell you myself because I don't run a program. But I think that there needs to be a concerted focus on the family first and foremost. And with that, secondarily, comes this idea of intensive outpatient, and group therapy within the community that a child is in. To then, expect them after two years away to go back and function in a society that isn't based on a hierarchy of levels and treatment scoring, is beyond irreconcilable.

So, these local treatment programs, these options for in-school programming should be developed further. And, of course, there are state level state funded options where there are checks and balances. And there are people who are looking into the progress, they're making sure there aren't abuses. These things are available. I just think a lot of times, and this goes back to your question about some of the misconceptions, is that parents feel that they don't have any other choice when they meet with an ed consultant, who says wilderness therapy is great. They feel that they've run the course of every other treatment. It's just not the case. And as states become more aware of what's happening in some of these privately funded programs, I think that there will be concerted effort to bolster the capabilities of community-based treatment.

Maya Hsu:  I've got quite a bit of background noise right now. I don't know if you can hear it. Can you still hear me?

Kenneth Rosen:  Yeah.

Maya Hsu:  Okay, great.

Well, you touched on what in this industry needs to change to serve its clientele, which would be more autonomy, kind of just the overhaul of the current policies, and just some major renovation of structure. Is there anything else that you would change that you might not have mentioned to make these programs beneficial for its clientele?

Kenneth Rosen:  I just really want to reiterate the notion that parents should be brought in a lot earlier. There's programs that offer therapeutic lessons for parents on the side, so they can track along with their children in their treatment program, and their treatment plan for the child. But it's just not as intensive. They're not just receiving the same sort of attention that the children are, so there's a dissonance between the therapy that the child is getting, excuse me, and the therapy that the parents need to get.

I often found that the parents really did have a lot of issues that were going on, and inadvertently put those onto the children, so that the safe environment at home, that environment that gives rise to really obedient, and caring and empathetic children was long dismantled. And rebuilding that is very difficult. So going very, very, very far back, having that open discourse with your child and focusing the efforts in-house, I think will yield better results in the end. But, again, I always preface that I'm a new father and I have very young children myself, so I'll learn as I go as well.

Maya Hsu:  Yeah. I do agree that a more systemic holistic approach would probably be the way to actually resolve some of these deeper issues that are the root of the problematic behaviors.

Kenneth Rosen:  Yeah, I think there's something to be said for just a general ethos of how we treat pain, and psychological ailments, and therapy in this country as a monetized, capitalistic approach to... There's a way to pay for it, to get it taken care of. And if we just pay more money, and put it aside, something will fix itself. It's just not the case. It requires a lot of work.

I don't necessarily want to do all the work. It's very difficult. I have my own life. My children have their own lives. And the same goes for when I was a kid, I had my own life. My parents had their own lives. That division is coarse, and it's difficult to overcome. But there are ways to do it. And there are ways to foster that relationship and really work on it long-term so that when it comes time to grapple with internal struggles within the family, we don't just sit back and say, "Well, if I could send them away for two years, maybe they'll change."

Maya Hsu:  Speaking of sort of throwing money at the problem, how much do wilderness therapy programs typically cost?

Kenneth Rosen:  So, again, we've been somewhat focusing on wilderness therapy in this conversation but, generally speaking, it could be anywhere from $30-50,000 for a full course, whether that be for 30 days or 60 days, generally it's paid out as the first 28 days is X amount, 30 grand, and then 5 to $600 a day thereafter if the child takes longer to complete the program.

Maya Hsu:  So, is there incentive then, for counselors and these programs to keep the kids there longer?

Kenneth Rosen:  There is, but I'm not necessarily sold on the idea that counselors are doing this because they're not getting the money directly. I think there are probably considerations insofar as where the child goes next after the program. I know that the three programs I went to, for instance, and this is fairly typical, were all owned by the same health group. So, every program was sort of feeding into the next one and my parents were convinced that this was the sort of treatment path that I needed.

Of course, by the time I got to the end of the 28 days, I came back home and I just couldn't function as a normal person among high school colleagues, high school contemporaries, because we had very different experiences. And that followed me into my early adulthood.

Maya Hsu:  That makes me curious, what kind of therapy, or healing did you have to do? What did that look like for you after returning back from these programs?

Kenneth Rosen:  For me, I ended up going through a lot of trouble. I did a lot of bad things, I got into a lot of trouble as I grew up, and I learned the hard way, a lot of different things that I didn't have to learn. And then, just at some point, at 25, I changed. I decided that I wanted to focus on writing and be a certain type of person, and contribute to society. And I met a woman, and she changed the way I perceived my future. And, from then on, I wasn't really thinking in that juvenile notion of, "Oh, well, instant gratification. I'm only looking a week ahead, maybe a night ahead." Now, I was thinking 10, 20 years ahead.

And this isn't just a silly parable that I'm giving you. This is truth insofar as the adolescent brain developing fully by 25. 19, 20, it still sort of erratic. 21, 22 it still isn't fully developed. 25 things starts to settle in place. And that goes for your brain as well. So, I just figured it out. I don't have a really good answer. I'm not in therapy anymore. Unfortunately, I've been turned off to it. I don't seek it out. I don't want to be a part of it. I find it all to be phony. And I hate saying it out loud because I know it helps people. But, for me, and some of the people that I interviewed, their experience at a young age with therapy was so traumatic, and so difficult that they just gave up. And that even if help were available, and it isn't always available, even if help were available, they'd still choose just to be on their own.

Maya Hsu:  And you touched a little bit earlier on critique that you received on your publications. Was there anything else that jumps to mind that you think might be worth mentioning?

Kenneth Rosen:  Sure. A lot of parents write to me and tell me that the program was beneficial for their children. Whatever I experienced was not what their child experienced. And that clearly, their child is doing better. And invariably, somewhere at the end of the email, they note that the child just got out of the program. And we already discussed this so we don't need to rehash it. Or that their child is still in the program. Or the child is very young. And it always strikes me as curious that the parents feel the need to write me. And I never get messages from children, or past clients who say, "I had a good time. I learned a lot. And now, I'm a young adult, or an adult who feels more empowered and better off than when I was before the programs." That's never happened.

It's always been a defensive parent who writes and tells me that their reasoning, through no fault of their own... Again, I say that they were led astray, that they were misdirected by an educational consultant, or the schools in which the child was attending. And they want to defend their position for what they sent their child through. And I think it's also sad that they feel they need to do that, in large part, because it wasn't their fault. And they were at their wits end and they chose what they felt was the best option. Unfortunately, the long arm of these programs, the troubled teen industry as it's become known as, is so strong that it makes these parents feel like this is the best option. And it isn't.

Maya Hsu:  On that note, is there anything else you would like parents, educators, or therapists to know about these different programs?

Kenneth Rosen:  I think do your research as best you can, but consult multiple people, don't just rely on education consultants. Rely on parents of troubled teens, rely on a lot of the networks on social media that will share stories and alternatives to these more drastic solutions. And really just, at the end of the day, it's about communication and setting yourself aside and listening to the child.

I think the biggest mistake that was made... To me, the biggest mistake that people made while addressing me and talking to me as a teen and the young adult was trying to liken their experience to my own. And I find that the most aggravating tactic that therapists and social workers use because they don't know.

My son is two and a half years old and what he's going through right now, pandemic aside, is so inconceivable. And when he's 10 and I'm still 30, 40 years older than him, I won't understand what he's going through. And that's okay. And understanding that and admitting that to a child opens up an avenue of communication that isn't there if you say, "I was your age once, and I get it," because we don't.

Maya Hsu:  Well, thank you so much for joining us for our interview series, Ken. It was great to have your perspective and to hear more about wilderness therapy, and these different programs.

Kenneth Rosen:  Maya, thank you, I appreciate it.

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.

Registered Dietician Michelle Babb on Mindful Eating

An Interview with Registered Dietician Michelle Babb

Michelle Babb is a Registered Dietician with a master’s degree in nutrition from Bastyr University who utilizes a holistic approach to teach mindful eating and anti-inflammatory nutritional perspectives.

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I like to welcome with us registered dietician, Michelle Babb. Michelle has a master's degree in nutrition from Bastyr University. She is also trained at the Center for Mind, Body, and Medicine and her special training and functional medicine gives her a unique holistic approach and perspective.

In addition, Michelle is a cook's instructor at PCC Market and the author of three books: Mastering Mindful Eating, Anti-inflammatory Eating Made Easy, and Anti-inflammatory Eating For a Happy Healthy Brain.

Before we get started can you please let us know a little bit more about yourself and what made you interested in leaving your former career to go back to school to become a registered dietician?

Michelle Babb:  Absolutely. Thank you for having me, Jennifer. Let's see, so I actually was, I had a career in marketing and public relations before this, and I worked for a company called Health Com that's in Gig Harbor, here in Washington, and I had just this wonderful experience of exposure to the brilliant biochemists who started the company, but also a lot of very dedicated health professionals who were really trying to teach health professionals how to integrate nutrition into their practices.

And that was just the experience itself was really unique, but I had interaction with in particular one person who became my friend and mentor, who was a registered nurse, and then went back to school a little later in life and went to Bastyr University and got her master's degree in nutrition. And so, I ended up kind of following in her footsteps and really kind of moved from being in that world of public relations, communications into nutrition, but being able to also use some of those skills to be able to educate and inform around the topic. So, yeah, it seemed like a good fit.

Jennifer Ghahari:  Absolutely. In your book, Mastering Mindful Eating, you talk about an integrated view on nutrition and that people should not just focus on the whole notion of calories in versus calories out, which I think we've all heard of, and can you explain what you mean by that to our listeners?

Michelle Babb:  Yeah. I think we actually live in a pretty diet, obsessed culture. People who are really... There's always the diet of the minutes. So, whatever the fad diet is that people are latching onto, there's always this kind of obsessiveness around often tracking, counting calories, counting grams of fat. Now it's carbs.

So whatever it is at the most that people just kind of get hyper-focused on, I think makes us lose sight of some of the more important aspects of feeding and nourishing ourselves in particular the manner in which we eat. So just taking the time to engage with our food in a respectful way and to really optimize, not just digestion, but how our body is receiving the food so that we can self-regulate without having to do this incessant amount of tracking, which for most people is not sustainable long term. And it feels like another part-time job. And quite frankly just sucks all the joy out of eating. So, yeah.

Jennifer Ghahari:  Yeah. When you need a calculator and a notebook in order to eat it, it kind of ruins it a little bit.

Michelle Babb:  Exactly.

Jennifer Ghahari:  On page 17 in your book, you note that, "Ironically, we spent so much time trying to figure out what to eat and what to avoid, that we've completely lost sight of the importance of how we eat." And can you explain what mindful eating is and how someone could practice eating that way?

Michelle Babb:  Sure. Yeah, so I have a question on my questionnaire that patients fill out before they come in to see me. And the question is, "Are you generally multitasking while you eat? Yes, or no?" And as you can imagine, I would say 85% of the people say, "Yes, multitasking." And I mean, anything that takes your focus away from food. So even if you're sitting with a cell phone or anything that's screen related, of course, but standing over the kitchen sink and just hurrying through breakfast. Those kinds of things are more mindless eating, right? So, there's other things going on. You're just trying to get the food in your body and then you're moving on.

So this idea of mindful eating is really about creating the time and space for self-nourishment. And I recognize that this is not probably practical for people to do it for every meal and every snack throughout the day. Busy schedules and families and sometimes things that just will take us away from that. But if there's a way to integrate it, even in small ways, in most of the meals and snacks that we have through the day, it just creates a really nice awareness and ability to self-regulate.

And so just to describe a little bit more, what mindful eating, what it looks like and feels like, and how to do it, essentially. What I mean by that is that you would clear a space and it doesn't have to be a dining table. It can be just any space where you can get a little bit of a peace zone for eating and you put food on a plate or in a bowl and sit down, remove the distractions. I think it's okay to listen to music if that's something that you enjoy, but I really have been encouraging people not to have the news on and the background because there's nothing good happening there. So, they're not going to be getting good, happy messages that help with relax during eating.

And then I encourage people to just breathe. So, take a minute to just kind of get grounded and centered in your breath. And that act of breathing, that deep belly breathing, is what can stimulate the vagus nerve and tell your body, "You don't have to be in fight or flight anymore. You can be in rest and digest." So, you're really preparing your body to be in the optimal state for eating and then really starting to engage your senses.

So when I'm walking my patients, or when I'm teaching a cooking class, and walking people through this whole mindful eating activity, and I say, "Just take a minute to look at your food and let yourself salivate." And I always ask people, "How often do you just let yourself salivate?" That just doesn't that doesn't generally happen. We're in such a hurry, in such a hurried state, we're not doing that.

But that's kind of that first level of digestion. So just kind of noticing the food. Some people like to have a gratitude practice. It doesn't have to be religious in nature, but just having gratitude around having this food in front of you and all of the people involved to get it on your plate and then really engaging all of your senses in this sacred act of eating. So, what do you smell? What do you pick up on your taste buds? What is the texture of the food? Can you hear sound crunching or whatever it might be? And then kind of just noticing as you're eating the food, as it moves into your body, putting the fork down and just taking a minute to finish one bite before you move on to the next.

So, that's kind of mindful eating in its amplified version. And there's lots of smaller ways that you could do that to just have awareness while you're eating that doesn't have to be that kind of full-blown version if you don't always have the time for it.

Jennifer Ghahari: And I would imagine that would make food taste better too, right? If you're actually involving all of your senses into it?

Michelle Babb:  Yes.

Jennifer Ghahari:  As opposed to just kind of wolfing it down, which many of us probably do.

Michelle Babb:  Yeah. Yeah. And it can go both ways. There's more enjoyment in much of the food that you eat, but I've also had patients who one who was talking about how they didn't want me to tell them that they had to give up their Egg McMuffin that they like to stop and get every morning. And I was like, "Okay, well, how do you eat that?" "Oh, well, I'm driving down the road and I eat it and I get to work and I'm done with it." He said. "Okay, well just take a minute and sit and eat that one bite at a time." And lo and behold, they came back and reported like, "That's one of the worst things I've ever eaten." So sometimes it happens where when you do a down and you have these habitual foods that you eat, usually the highly processed things or something like that, that when you really start noticing the taste, texture, feel of it, you're not as enthusiastic about eating it. So, it really can go both ways.

Jennifer Ghahari:  That's amazing. And noticing how food can taste better or worse and, in many regards, and also you have a mention the vagus nerve. So, what are some benefits of mindful eating?

Michelle Babb:  Yeah, well, so if we think about just the physiological benefits, I'll start with that. And I talked about being in the rest and digest mode instead of fight or flight. And that actually is so critically important for digestion. In my practice I work with a lot of people who have some kind of digestive disorders or difficulty with digestion that might include like IBS type symptoms or irritable bowel type symptoms, bloating, just abdominal discomfort often when they eat. So, when we really work on relaxing while eating and trying to do things, like I mentioned, optimize your digestion, they will often report improvements in how they're digesting their food and how that feels after they eat.

So, one of the things that happens when you stimulate your vagus nerve through, simply by breathing, is that you actually will, you can salivate more, you produce more digestive enzymes in your stomach and your pancreas. So that does a better job of breaking down the food and your body is ready to just kind of organize and assimilate the nutrients that come from the food because you're in this rest and digest mode. That's exactly what your body is meant to do when it's in that parasympathetic state.

Conversely, when you are eating when you're more stressed, and it doesn't have to be hair on fire kind of stress, it can just be that you're looking at something on the computer, you're under a deadline and you're eating your lunch with one hand. You're doing this shallow chest breathing. And now you're in that sympathetic state where that really is more similar to if you were running from a bear in the woods and you wouldn't be salivating. You produce less digestive enzymes. Your body just is in a very different mode and it needs to be because you need to be able, you wouldn't be eating a sandwich while you were running from a bear in the woods, you would just be like, "I need to get away."

So that's what's happening and you're not producing as many of your digestive enzymes. Your motility in your gut changes. So, the way that things move through your digestive tract is different in both of those states. So, that's, what's happening with one versus the other. And so, I think it feels empowering for most people to know that you, just even by the simple act of breathing, but just sitting for a minute and relaxing into the meal can really change that state, the physiological state that your body's in.

Jennifer Ghahari:  Wow.

Michelle Babb:  And then there's' of course the, so that's the physiological benefit, and then there's the kind of more on the emotional side of the equation. If someone tends to be what they describe as an emotional eater or a stress eater or eating for any other reason that's not rooted in physical hunger, then taking that time to really have the awareness and recognize what you're doing instead of going into autopilot really can help in terms of kind of that compulsive eating that sometimes people will describe where they will just kind of check out and can eat an inordinate amount of food, because they're just not paying attention. And their body goes into a very different state when compulsive overeating is involved.

So, it helps to just kind of recognize, even if it's just an awareness of what you're doing. And even if at the beginning doesn't necessarily change the behavior with the food, it definitely creates and starts to create a different relationship with the food.

Jennifer Ghahari:  Oh, wow. Yeah. A lot of our clients will come to us under massive amounts of stress and anxiety. And also, they have a lot of people report having some type of difficulty with food, whether they're overeating or under-eating. There's so many different combinations out there people suffering from. So, you're saying, if people are trying to eat while extremely stressed or anxious, they tend to overeat or just kind of go into this mode where they're not really conscious of what they're eating?

Michelle Babb:  Exactly. Yeah. And there are people who have a difficult time eating under stress and that happens too. But what I'm referring to is more the using food as kind of a coping mechanism for stress, for anxiety. Something that feels like it's self-soothing. And the downside of that is that, generally speaking, people afterwards don't, whether they physically don't feel good from overeating or emotionally, mentally don't feel good because they feel like, "Oh, I should have better self-control." Or all of this self-talk that happens around that. And really, it's like I said, it's almost like flipping a switch. So, the control around that or the self-control that people think they should have, the willpower, that's that ends up being kind of a fallacy because this is a, a device or a technique that people are using to just kind of numb themselves and check out.

And so it's, I think, challenging when that tends to be for some people that's the go-to response to stress or depression, or any number of emotions. Food is readily available in a very easy way. It feels like an easy way to self-soothe and some people have grown up doing that. So, they've been doing it for decades, for a lifetime. So, trying to kind of break or interrupt that pattern can be really helpful. And, and sometimes it's just, like I said, noticing and having the awareness, but also, I talk about treating mealtime more like a mini meditation.

So, for those who had been interested in meditating, but say, "Oh, I can't sit and quiet my mind." Eating can actually be a great way to practice a more dynamic meditation where you are just... When your mind starts to wander and go into different places, you just bring your mind back to the place mat or bring it back to the plate and use the sensations, where you're engaging your senses, use that to keep you really present in that moment. That can also be really helpful and prevent you from doing that thing that's just like the, "I just check out and I'm on autopilot."

Jennifer Ghahari:  Yeah. Can you explain a little more about the difference between physiological and emotional hunger?

Michelle Babb:  Sure. Yeah, I like to describe it as physiological hunger, physical hunger, is what you feel from the neck down. That kind of a little bit of a grumbling in the tummy. You start to sometimes get a little shaky if you've gone too far, if you tend to start to get hypoglycemic. And then emotional hunger is more what you feel from the neck up. So, this is really more about a lot of the self-talk that happens, the things that feel more kind of impulsive, that's more emotional hunger.

So, if you're tuning into the physical hunger, and one question you can ask yourself is, "Am I feeling it somewhere from the neck down? Am I experiencing a physical hunger?" That's starting of a, like I said, the grumbling in the tummy or a little bit of it feels almost like a pit in your stomach, like, okay. And the feeling of, "Okay, I could eat something now." Not waiting until you get to a place where you're starving, but just that, “Oh yeah, I feel like I could eat." That's the physical response to hunger.

Jennifer Ghahari:  Great. Also in your book, which I love by the way, your book discusses the five spheres of wellness. And can you explain their importance to our listeners? (*Image here/below transcription)

Michelle Babb:  Sure. Yeah. So, a lot of times I mentioned in the dieting culture, we have this “calories in, calories out” idea about things. And so, people start to get really discouraged when they're trying to work on weight management, let's say, and they think they're doing, they're being very restrictive with their eating and they're exercising like crazy, and why aren't things happening the way that they should?

And so I like to describe all of, and I have it organized in these spheres of wellness that are kind of that they're all interacting with each other. So, none of these things are independent. So, we have of course nutrition and how we nourish ourselves and physical activity. We'd never deny that that is a big part of wellness and important, and it doesn't have to be kind of traditional exercise. It could just be any way in which we move our bodies and try to stay active through the day and then sleep. So that's a big one that gets overlooked often. People who have sleep issues and either have just the fatigue that comes with not sleeping enough. Or the physiological impact of not having a rest period that allows your body to rejuvenate and allows you to have proper hunger and tidy cues. So, sleep can be a really big one. Stress, as I mentioned.

The other thing that happens with stress. So, there's the stress response, but there's also, what I think is really fascinating, is acute and chronic stress. Stress that's prolonged and ongoing, which is more the chronic stress picture. It influences the prefrontal cortex of your brain. So, it can shut down some of those functions and that's where kind of the high-level intelligence decision making happens, right? So, that can also lead to more compulsive overeating, so that stress management. And I always say, "You're in this business." So, I always say, I feel like it's not, if I just tell people, "Stress is a contributor," that feels like it makes people more stressed out.

So truly trying to find ways, other coping mechanisms for stress, or ways that you can view stressful, you have stressors in the environment that don't go away, ways that you can do them differently. So, coping mechanisms for stress, acknowledging that stress as a whole will never go away and we're meant to have stress in our life. So that in and of itself is not a bad thing, but how we deal with it is important, physiologically and emotionally. And then the other spheres are also probably less recognized, but relationship and community.

So how people are engaging and interacting with others, I think, is also really important. This has really, the pandemic has really shown a spotlight on this, for sure. And what happens when people feel isolated and how that influences and impacts people's coping mechanisms and how their ability for self-care and how they view that when they're more isolated.

And the sphere that I have kind of in the middle is connection with higher power. And that can be a higher self. And that for some people that is rooted in religion, but that is just more about kind of having faith that there is a higher power that exists. And how all of those things kind of interplay. So, when I'm working with clients, we sometimes do an activity where I ask questions in each of those spheres, so that you can kind of prioritize, where am I lacking? If my sleep is great, but I don't have any sense of community and I'm not really engaging in the way that I want to be. Maybe that's where we need to shine a spotlight before anything else. And all of these things influence how we eat, how we nourish ourselves.

Jennifer Ghahari:  Yeah, that's great. Thanks. I think you kind of touched on this, but about self-compassion. Self-compassion’s incredibly important and a major component in many mental health practices. And I was really delighted to see that this resonated in your book as well. There's a section titled, "You Are Not Your Scale Weight." And I think this can really hit home for a lot of people listening. Can you talk a little bit more about how self-compassion factors into mindful eating and also overall wellness?

Michelle Babb:  Absolutely. I think people are just really hard on themselves when it comes to this, all of the “should’s” around self-care. And when you think about it, all of the messages that we get about the need to be exercising every day, need to be eating perfectly, need to be avoiding this, need to be eating more that, it's so constant and it's not practical in the course of, however many waking hours we have in our day, to fit all of these things in. So, people get really just, I think, down on themselves when they're not doing this perfectly. Or when they tend to revert to some of the old habits they have.

So I just find that people come into sessions with me and the first thing they want to do is confess all of the things they did wrong in the two weeks prior, two weeks from when we last met. So, I really try to encourage people to really think about the things that you're proud of, that you have done, or the things that are starting to feel like you're forming different habits or things that you notice your body is responding well to that that just feel different when you're doing it in a way that feels productive to you individually. Who cares what anybody else thinks?

And recognizing that we also have this habit of hinging so much importance on those three numbers that show up on the scale. And people defining their self-worth or how successful they are with their wellness plan based on those three numbers. All kinds of great things can be happening in your body that, independent of what's going on with the scale weight, and people will discount those or not even notice those because when they stepped on the scale that morning, it said something different than they wanted it to say.

So really trying to unhinge from that and really drop into what's going on in your body and your mind and spirit. And noticing how that's being influenced by the self-care that you're doing. And knowing when enough is enough. You don't have to sacrifice the good enough for the perfect. You can just really acknowledge that we're all trying our best here and there will be times when days that aren't great and that's okay. Getting up and dusting yourself off and getting back to your plan and doing it in the spirit of nourishing your body in a way that helps you feel better and stronger versus any other standards by which we think we need to judge this, I think can be really helpful, just in terms of that self-compassion that we all need to find.

Jennifer Ghahari:  Great. It almost seems like if we're trying to integrate a new eating plan or something like that, to maybe just stay away from the scale for a while, like you said, to see how you feel and what's actually working as opposed to just concentrating on that number, right?

Michelle Babb:  Yes. There's part of me that wishes everyone could just get rid of their scales all together, but I recognize that for some people that is a tool. It's, just, I think, how much importance you're putting on the scale. And to recognize that there are other ways to monitor your success. Anytime you're trying to make habitual lifestyle changes, and I do have people and I mentioned this in the book, this is modeled around Danielle LaPorte did a book where she talks about setting goals with soul. And that really resonated with me. And I try to use some version of that with clients that is, the way you ask yourself, why am I doing? Why am I making these changes? How do want to feel as a result of making the changes that I'm making?

Because that goes a lot deeper than... That has nothing to do with the three numbers. That's not how you're feeling, that's what you're seeing, but how do you want to be feeling? And for a lot of people, I get these really great responses. "I want to be active with my kids." "I want to see my grandkids grow up." "I want to be able to keep my body active and in shape because I love to do X, Y or Z activity. And I don't want to have to give that up." So, a lot of really great things can come out of that.

And I encourage people to keep a list of your why's. Why are you doing this? How is this going to really resonate with you? So that you can check back on that and see notice where you are making some gains and making some improvement. Maybe your body feels more flexible. Maybe you feel stronger. Maybe emotionally, you feel like you are more grounded or stable as a result of some of the changes you're making. So, all of those things are so important and will often get overlooked. If we have just one way of measuring things.

Jennifer Ghahari:  I like also how you had mentioned that people come to you and say, "All right, these are the things that I did wrong in the past week or two." But like you said, they should really focus on not the negatives, or potential negatives, but what they had done right. And that sounds like it's healthy mentally and overall, just healthy.

Michelle Babb:  Yeah. I think that that makes a big difference. It's the same way when I'm trying to help guide people through whatever food changes they're going to make. And there's not just a one size fits all diet, but I would say in general, some version of a Mediterranean style food plan probably works well for a lot of people. So, when people are trying to make those changes, instead of saying, "Don't eat this, can't have that, shouldn't eat that, this is horrible. This food will kill you." Instead of doing all the don't haves, can't haves, because immediately you want to rebel against that and it's not sustainable. So, if it's more about what foods you want to get more of in your diet, so that you have the energy and vitality and that you can have some joy in your cooking and eating.

And that becomes a very different experience. Where you're thinking about, "If I want to get more vegetables in my diet, can I think about more color or more variety? Can I think about what's in season? Can I learn how to do different things, different, new things with some of these plant-based foods?" It then becomes kind of a fun challenge or an adventure and less of a, "Oh, sorry guys, I can't go to this party because I am not eating any of the things." So, there's definite cross over there too with just how you're viewing your self-care changes and these lifestyle changes just in general.

Jennifer Ghahari:  That's great. So as a registered dietician who focuses on a holistic approach, is there any other advice or anything else you'd like to share with our listeners who may be struggling with dieting or have any type of difficult relationship with food or just sort of looking to feel better in general?

Michelle Babb:  Yeah. I think the most important thing is that, I just mentioned that there is not a one-size-fits-all. So, anytime you hear about, "This is the new dieting out of the moment." Really go into that with a lot of skepticism and understand that your body is the very best judge of what feels right for you. So, whenever I'm working with clients to make the changes, and I'll say, "When you go away from this session and you work on this action plan, either keep a journal or really be too tuning into how your body feels and then we'll discuss what kind of revisions we want to make based on how your body's responding." And sometimes I'll have them try a different breakfast composition one day over the next and sort of see, and then notice, how your day flows and what your energy feels like.

So some people will eat oatmeal for breakfast and they'll feel satisfied for hours. And it's the best part of their day is their nice bowl of oatmeal in the morning. Other people are like, "Oh, I can't. Oatmeal doesn't work for me at all. I get hungry right away." Or, "I feel really weighted down. I really like to have eggs and veggies for breakfast." So, that's different for every person. And so just know that you really are an authority on what nourishes you and how your body feels. And the same goes with exercise too. We often get pushed in the direction of more intensity. And when I'm working with people who suffer from, chronic stress, high anxiety, doing things that are very intense workouts are often not the best kind of approach for them because that's showing up as more stress to the body.

So, doing more restorative gentle exercise can help them get to their goals easier or more readily than the more intense stuff. And that surprises people. Because if you're thinking like calorie in calories out, you're thinking more exercise, more intensity, less food, fewer calories, and it's not necessarily, that's not the prescription for every person. So really honor that body wisdom that you have and try to, not just recognize and hear it, but to really be responsive to the cues that your body are sending you.

Jennifer Ghahari:  Fantastic. Thank you so much. We really enjoyed having you with us today for this installment and wish you all the best. We'd love to have you back in the future if possible?

Michelle Babb:  Oh, thank you so much. It's been a pleasure.

Jennifer Ghahari:  Thank you.

Source: “Mastering Mindful Eating” by Michelle Babb, 2020

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 Karin Sponholz on Codependency

An Interview with Psychologist Karin Sponholz

Dr. Sponholz is a licensed clinical psychologist with extensive experience employing a variety of modalities, such as dialectical behavioral therapy and relational therapy, and specializes in the treatment of: trauma, relationship issues, identity development, and codependency.

Maya Hsu:  Thank you for joining us today on this installment of the Seattle Psychiatrist Interview Series. I'm Maya, Hsu, a research intern here at Seattle Anxiety Specialists and I'd like to welcome Dr. Karin Sponholz.

Dr. Karin Sponholz is a licensed clinical psychologist with a doctorate in clinical psychology from Pacifica Graduate Institute. She has extensive experience working with individuals, couples and groups employing a variety of modalities, such as dialectical behavioral therapy and relational therapy. She specializes in the treatment of many different issues including trauma, relationship issues and identity development, and has helped many people heal and recover from issues related to codependency. Dr. Sponholz, would you like to introduce yourself and tell us a little bit about what makes codependency interesting to you?

Karin Sponholz:  Thank you for the introduction. I'm happy to be here and talking about one of my favorite things, which is about relationships and relationship dynamics, which includes codependency. I think I'm just fascinated by how people come together and the dynamics between them, whether it's healthy dynamics or not so healthy dynamics. And also, understanding what motivates or how people fall into these patterns and habits and how do we break out of them? That's what fascinates me about codependency.

Maya Hsu:  Awesome. And would you mind defining codependency for our listeners who might be unfamiliar with that term?

Karin Sponholz:  Sure. So, let me first start by saying that the term codependency is often misunderstood and often overused by a lot of people. And actually, believe it or not, the actual word codependency started from the legal use of a term to mean an agreement in contracts. Meaning, there's an action that is mutually dependent on two parties. And then it turned into more of a psychological term in the '80s and it's actually coined by Melody Beattie, who's a self help author. She famously wrote about codependency and she defines it as two people who impact each other. Meaning, someone's behavior influences the other person's behavior in such a way that their wants, needs, desires, sense of self is wrapped up in the other person. So, there's a lack of independence, so to speak, hence the word codependency and there's an addictive quality to that kind of enmeshment, is another way we often talk about codependency.

Maya Hsu:  And what causes codependency? Or what things can lead somebody to be more predisposed toward developing codependent habits than someone else?

Karin Sponholz:  Yeah. Oftentimes it's learned. We learn that in childhood from our parents or caregivers or modeled in the family somehow. Oftentimes you see it in families where there's one person who needs a lot of attention, whether it's because of their own mental health issues or health issues and all the emotional resources are funneled towards that person. So, the people in this family system learn that their sense of self and their way of being in the world is wrapped up in caretaking for that one person.

So, that's how the habit gets ingrained and then it gets reinforced. That, “Oh, this is how we should be, this is how we should relate to one another, which is through caretaking.” And there's a lack of reinforcement in learning to know what your own wants or needs are in life. So, it's more like, well, my wants and needs are about helping you and that's how-

Maya Hsu:  Can you give a-

Karin Sponholz:  Yeah.

Maya Hsu:  Sorry to interrupt. Can you give a specific example of what that can look like within a family system early on? Just, I don't know, some common dynamics you've noticed?

Karin Sponholz:  Sure. So, a common one that we often, we learned about in the '80s is often where one person has an addiction, whether it's an alcohol addiction or drug addiction. So, what happens is that the family system revolves around that one person. So, the whole caretaking is about trying to get that person into recovery and everything is geared towards helping that one person.

So, everyone else's own wants and needs are put on the side. The system then, everyone has a role in the system. There's the patient, the identified patient. And then there's people who are termed the enabler or caregivers. And people just stay stuck in these roles and they can be for years. So, especially kids that grew up in this environment learn that that's just how people should relate. So, there's a sense of reward in being able to either help somebody who's in need and forego their own wants and needs because there's a sense of reward there. Or there's an enabling aspect to it. So, the patient or the person who is struggling, they're enabled to stay stuck because the whole system, the whole dance is dependent on them staying stuck.

Maya Hsu:  Right.

Karin Sponholz:  So, that's why there is a codependent dynamic that happens.

Maya Hsu:  The idea of roles is really interesting. I'm curious how it would look in families where addiction is not the issue, where there is nobody with an addiction. How would codependency arise in a family where that's not really a relevant issue?

Karin Sponholz:  Sure. Yeah, great question. So, addiction might be the extreme example. So, oftentimes it might be somebody who may have mental health issues, whether it's an anxiety, they struggle with anxiety or someone might struggle with depression, more so maybe than the other family members. So, it's usually just one person who's struggling a lot or who has a lot of needs. Somebody who even might have a learning disability, again, not necessarily a disorder but just somebody in the family who has a lot of needs.

And the family system then, again, shaping itself around the person versus having more of a healthier balance with “sure, help the person” but also then meet your own needs as well.

Maya Hsu:  Okay. Yeah, so it can range from more mild issues, just like anxiety, common everyday struggles, all the way to addiction.

Karin Sponholz:  Right, exactly.

Maya Hsu:  And is it also typical for, within a family unit, for every member aside from the most struggling person to develop codependency or is it usually one other member in the family?

Karin Sponholz:  It's usually the person who's most empathetic. The most empathetic person is the one that tends to fall into this role. And it's interesting because you see roles in the family. So, you might see the person, the one with the empathy, tends to be the caretaker, tends to be the person who's the codependent one. And then you see the identified patient in the family, right? And then you see maybe the joker or the rebellious one. So, you see all the roles that people play. Or the avoidant one. And everyone has this unspoken contract to remain in these roles, which is why, especially again, with the extreme example of somebody who has an addiction, family therapy is so vital to breaking out of these habits because it's the system that is set in place to keep everybody stuck in these roles.

Maya Hsu:  It sounds like if one person just seeks help on their own and gets therapy when they return back to the family unit the strength of the rest of the dynamic is so strong that that individual work is not enough. It has to be a cohesive, holistic approach.

Karin Sponholz:  Exactly, exactly. Yup, exactly.

Maya Hsu:  What happens when somebody who's learned and adopted codependent behaviors leaves the family unit and then starts to build other relationships or friendships or romantic partnerships? How does codependency then affect those future relationships?

Karin Sponholz:  Right. Again, the terms that I'm using are pop psychology but people who tend to be more codependent find or date friends or date people who are more wounded birds. So, they're recreating the family system or the family dynamics. So, they're finding people that they can caretake because their whole sense of self and sense of approval is this deep need to caretake and to be needed by others. So, that's why it runs very deep. It's more than just people-pleasing. Because that's another term that often gets used in relation to codependency.

And to be fair to everybody, we all fall in and out of codependent moments or people-pleasing moments. The problem is when it becomes this rigid habit or way of relating to others. And it really gets in the way of relationships, as we're saying, because there's a one-sidedness to these relationships then. Someone always has to be struggling and the other one always has to be the caretaker.

And there's a huge sense of guilt or shame if you start to figure out what you're wanting and what your needs are. So, in extreme cases people who are very codependent have a hard time identifying something as simple as “what's your favorite dish?,” “what's your favorite color? or “what do you even want to do?” It's so wrapped up in what the other person wants or does. And even feelings. “I can't be happy unless you're happy.” That's often... We see that. Or “if you're sad I'm not allowed to be happy. I have to then also pull myself and be sad.”

Maya Hsu:  Yeah. You mentioned that everybody falls in and out of codependent moments and empathetic moments. When somebody has codependency that's been ingrained in them from the beginning of life they might not even realize that they have codependent tendencies or codependent habits. Are there any big signals that you can say that would help somebody realize that this might be something that they could get help on if they just are unsure whether this is something that resonates for them and applies to their life?

Karin Sponholz:  Sure. I'm going to read off a list because there's some common signs that I think that might be helpful for people to recognize in themselves. And again, any one of these signs in and of themselves doesn't mean that you have codependency. It's usually several of them clustered together over a period of time that you would maybe say someone might be codependent. So, I just want to put that caveat out there. So, I'll read just a few of these from the list that I have.

There's a deep seated need for approval from others. Again, that sense of approval comes from care taking and the recognition that what I'm doing for you is very strong.

Self-worth depends on what others think about you. So, again, your sense of self is wrapped up in what other people think or feel about you. It's what we call externalizing. There's no sense of who I am in and of myself.

A pattern of avoiding conflict. So, people who are codependent really just want to try to keep the dynamic as stable as possible but stable in this sort of enabling, enmeshed pattern.

A tendency to minimize or ignore your own desires.

Excessive concern about loved one's habits or behaviors. So, the upside of codependency, if you will, is that you really know what the other person wants and needs, which is great. At its core, there's a sense of thoughtfulness, empathy, almost a radar-like sense of what people might want and need-- helpful. But it needs to be tempered.

A habit of making decisions for others or trying to manage loved ones. So, again, in extreme examples we might say, somebody has an addiction and the person who's a caretaker or an enabler might say, "Oh, no that's not what they want. They want this." So, they would be speaking for the other person because there's such an enmeshment. And they might be right to some extent but there's such an over investment in the other person's life.

Guilt or anxiety when doing something for yourself. Like, “God forbid I decide that I want a dish that might be different from you.” Like if you wanted chicken and I decided I want beef there would be such anxiety about that.

And doing things that you don't really want to do simply to make other people happy. There's that people-pleasing aspect about it.

And then overwhelming fears of rejection and abandonment. And that's what keeps people locked into this dynamic, again, because their whole sense of self and self-worth is wrapped up in this other person and caretaking for them.

Maya Hsu:  Wow. There's a lot there, a lot to unpack there.

Karin Sponholz:  Yes. Are there any that stand out for you or that you have questions about that I can maybe explain more?

Maya Hsu:  That was a really helpful list of just general ideas. It did get me thinking about gender and how codependent habits might manifest differently among different genders. Is that something you've noticed in your work with clients?

Karin Sponholz:  No, it's pretty equal between men and women or other genders. I think the common denominator are the empathy piece. So, regardless of gender and how people identify, the person who's more empathetic, maybe HSP...

Maya Hsu:  What’s HSP?

Karin Sponholz:  Highly-sensitive persons. That's it, yeah. So, and that can be a whole ‘nother talk, but people who are more empathetic or highly sensitive tend to be those that fall more easily into this dynamic because they can pick up other people's situation. And the people who draw others into a codependent relationship with them tend to pick out those people who are sensitive.

Maya Hsu:  Yeah. I'm thinking of how this might be a cyclical thing and how somebody with a parent struggling with addiction grows up with codependent habits and then gets into a relationship with somebody else who has a lot of need and a lot of struggles and then they recreate that dynamic and then they have children. The children will learn and pick up on that. It will just reinforce and self perpetuate.

Karin Sponholz:  Exactly.

Maya Hsu:  How does one break... What is the process like of breaking that cycle and of recovering and healing from and moving on from codependent tendencies.

Karin Sponholz:  It really takes to be in relationship with somebody who is healthy, so to speak. So, a friend, maybe, who can recognize the signs of codependency and really help that person identify, “Oh wait, no, you decide what you want to do,” can really help the person, help push that friend to recognize what their wants and needs are.

Professional help is certainly a big key influence here. Whether it's individual and especially group psychotherapy. And the reason why I say group is because there's a... With a therapist certainly there's role modeling in what's a healthy relationship or healthy dynamic. With a group you also then are relating with peers in the group. And together you're also learning and holding a mirror to each other about dynamics. So, it's really, really helpful to experience because it's experiential learning that is necessary for breaking those habits. Knowledge is powerful for sure, understanding logically what codependency is. But it's really on the visceral level that really makes the permanent change.

To fuel the fear of like, oh my gosh, I want chicken and you want beef, right? And it sounds, to some people who aren't in it, it sounds maybe silly or rudimentary but to somebody who's had years and years of codependency, something that simple can feel so distraught and very horrific to them and difficult.

Maya Hsu:  Yeah. So, therapy, professional help and then just experiencing it through healthy relationships is part of the process of unlearning codependency.

Karin Sponholz:  Exactly. Exactly, yup.

Maya Hsu:  Yeah. You touched on several of the downsides of codependency and some of the benefits, like being empathetic, observant, in tune. And the downsides being maybe dependent self-worth, things like that.

Karin Sponholz:  Yeah.

Maya Hsu:  I'm still curious, because it can be so scary to leave a codependent past and put yourself into a place of limbo where now you have to figure out who you are, figure out how to get self esteem and self-worth from not a source that is comfortable and familiar, what would you say is the enticing appeal of unlearning codependency? How different really is life once you have moved away from a codependent past?

Karin Sponholz:  Right. There's a sense of freedom, right? There's a sense of freedom to be yourself in relationships, right? So, codependency can show you what you don't want in a relationship because what we really are striving for, all of us, is called interdependency. There's a sense of connection while there's also independence in the relationship. And that's really where there's space, there's freedom, at the same time there's connection to the person that you're with. And that's really what's important because we don't want to swing to the other extreme and just be independent and self-reliant and I don't need anybody.

And certainly people who are trying to break out of codependency can do that. They can swing to the other extreme. And sometimes there's a period of time we all need to do that, but we're relational beings. So, we're wired to our connection. So, I forgot now your question.

Maya Hsu:  Well, you answered it by mentioning the freedom and interdependency piece of letting go of that codependent history.

Karin Sponholz:  Right.

Maya Hsu:  Yeah. What advice would you have for somebody who's thinking about maybe seeking help or leaping in to trying to figure out what a less codependent life would look like but who's scared?

Karin Sponholz:  Yeah. I would say first start with a Google search. There's so many websites out there that define codependency. I'm sure there's some quick quizzes that you can take to see, are you codependent and take them and just start to see for yourself if you identify with any one of those.

And the other thing you can start to do is just practice every day. Decide what is it that you want, what is it you need? Start to figure out, what are your likes apart from what somebody else might want. And it might be a struggle. There might be some grief, loss, anger that might come up because, especially, again, if you've done years and years and years of just living for somebody else, your own house, so to speak, is empty. I always say you're jumping into somebody else's home and decorating and setting up shop and making it pretty over in their house while your own house has just boxes that are unpacked and it's hollow, so to speak.

So, there is a bit of a shock when you start to come back home to yourself and you realize, I'm using the metaphor of the house, there are no pictures up in the house. It's cold. There's no-- boxes are unpacked, there's no bed. And it feels like, “Oh my God,” it's like starting from scratch, to some extent. And that can be a stark reality. That can hit hard when you realize that you've neglected yourself for many, many years.

So, I would say be kind to yourself, be patient with yourself, again, practice with lower hanging fruit type things, of “I like this sweater because why?” Or “I like this color because... It doesn't have to be a because. I just like this color.” And then certainly get professional help if you feel like you need more support.

Maya Hsu:  Thank you. The last topic that I wanted to cover was how codependency might intermingle with other mental health issues. And earlier when you were talking about the symptoms and how it manifests in different people I was thinking about social anxiety and I imagine there's a link there. Can you talk a little bit about how it relates to social anxiety and anything else that might come up really often with codependency?

Karin Sponholz:  For sure. There is a comorbidity with anxiety and depression because again, their sense of self is so wrapped up in somebody else. And there's a sense of trying to control the other person. And I don't mean that in a pejorative way. They're trying to do it because their self-worth is wrapped up in the other person. But as we know, we can't control people, which then creates that sense of anxiety because I can't... I think we all know, although we might try, we just can't control the other person. So, there's a constant insecurity about that dynamic.

And then there's the depression because so much is getting ignored. And so the depression with a sense of self-worth, lack of getting your own needs met, lack of really attuning to yourself, a lot of that creates a sense of depression. And of course the anger that's developed through the years. You see a lot of unresolved rage and grief for people who've been codependent because when they start to do therapy they start to realize, “Oh my gosh, I was reinforced. My self-worth was reinforced in taking care of my brother.” Something as simple as “My little brother who had ADD, and then I got reinforced. I was never encouraged to do my own thing or to discover my own desires.” So, that needs to get worked through and unearthed. So, again, the anxiety, depression is often what we see in conjunction with codependency.

Maya Hsu:  And that reinforcement with the younger brother who has ADHD, would that look like praise for being really thoughtful and being really in tune with the brother?

Karin Sponholz:  Exactly. Yup, yup. Praise for “Oh, look you're such a good sister, you're such a good person.” Or for example, if you got invited to a birthday party but you decided to stay home because you had to take care of your brother. There's praise for that. “Oh see, you're such a good person. You didn't go to the party where all your friends are where you wanted to have fun.” No, you stayed home and that was reinforced, reinforced, reinforced. So, it makes sense that somebody, again, especially as a kid, who wouldn't want to feel that feeling of reward and praise?

Maya Hsu:  Totally, totally. Yeah. It's a really fascinating topic and very complex.

Karin Sponholz:  Mm-hmm (affirmative).

Maya Hsu:  Thank you so much for all of the information. Is there anything else about codependency that you would like our listeners to know about?

Karin Sponholz:  I would say to think about codependency on a continuum, whereas people-pleasing might be on one end. There's codependency and there's a newer term that people may not be familiar with. It's called fawning. And that often gets confused with codependency. So, again, think of that as a continuum. People-pleasing, again, we all kind of fall into that. It's not really problematic, per se, unless it becomes rigid. Codependency again, we can fall in and out of it, but, problematic if it becomes more rigid.

And codependency, we often think of an addiction, right? People say codependency is love addiction. Fawning comes out of a trauma response. So, there's less of an addictive quality about fawning and more of a life or death situation with fawning. It looks very similar to where people are staying in unhealthy, destructive relationships but they're doing it because there's, again, a life or death. If they don't fawn or people-please there's a sense of “Oh my God, I'm going to die if I don't do this.” So, there are terms that get thrown around and people quite don't understand the differences but that's one way to think about it.

Maya Hsu:  Yeah. It almost sounds like a continuum of urgency where people-pleasing might be like “Oh, this is a common thing.” Codependency might be more of a habit and then the fawning is a very urgent, dire need to do that.

Karin Sponholz:  Yes, great way to describe it. For sure. Yup, yup.

Maya Hsu:  Wonderful, wonderful. Well, thank you so much. Dr. Sponholz.

Karin Sponholz:  Yes.

Maya Hsu:  It was really wonderful having you on the Seattle Psychiatrist.

Karin Sponholz:  Thank you for having me. Thank 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.

Psychologist Milla Titova on Happiness & Well-Being

An Interview with Psychologist Milla Titova

Dr. Titova is an assistant teaching professor at the University of Washington, whose research interests focus on happiness and well-being.

Maya Hsu:  Hi, I'm Maya Hsu and I'm a research intern here at Seattle Anxiety Specialists, and today I'm joined by Dr. Milla Titova. Dr. Titova is an assistant teaching professor at the University of Washington, whose research interests concentrate on happiness and well-being. She has numerous publications about positive emotions and well-being levels, and is specifically drawn to the effects that cultural and individual personality differences have on people's happiness. She has also given many talks about prosocial behavior, happiness and well-being around the world. Dr. Titova, would you like to introduce yourself and share a little bit about your research?

Milla Titova:  Sure. Well, thank you for having me first of all, and you already said my name, so I don't need to repeat that. My research concentrates on happiness and well-being in general, and one of the more specific things about happiness and well-being that I'm interested in is how relationships play a role in that, and in particular prosocial behavior, concentrating on others rather than concentrating on ourselves and how that can be beneficial to our own well-being. And one of the recent projects that I conducted looked at how maybe in situations where we want to improve our happiness and well-being, instead of actually concentrating on ourselves, we can turn that from inside out and concentrate on well-being and happiness of others. So, particularly, trying to make others happier, actually leads to more happiness for ourselves, even though that might sound a little bit contradictory at first and surprising. As always, often, when we are not feeling maybe the best, we are trying to actually keep the focus on ourselves and not necessarily interact with others in those situations.

Maya Hsu:  Great. Would you mind defining prosocial behavior and how that term relates to what you're talking about here?

Milla Titova:  Sure. So prosocial behavior is what you would think it is. It's just helping others, doing something for others, just being social in a positive way towards someone else. So that's the larger definition of prosocial behavior. In the project that I just mentioned in particular, what me and my co-author were interested in was mostly actually asking people to do something to improve happiness and mood of other people. So that was a more a smaller chunk of prosocial behavior, so to say, that you are looking at.

Maya Hsu:  That sounds kind of like altruism, where you're doing something almost charitable. Would you say that that is a subset of prosocial behavior or are they different? Do they overlap?

Milla Titova:  Yes, so, altruism is usually something that doesn't necessarily have that selfish part of helping others. So prosocial behavior, I would say is more general. That includes that you might be helping others because you want some benefit for yourself. Altruism is more that maybe it's even hurting you and you are still helping someone else. So usually, the true altruistic behaviors are things like when you risk your life to help somebody else, that's usually what I would give as an example of altruism. Which the things that we were looking in, in this particular research, I wouldn't call them altruistic per se. People weren't really suffering in any way or taking anything from themselves in those prosocial acts that we asked participants to do.

Maya Hsu:  Okay. So altruism requires, or it involves an element of sacrifice, and prosocial behavior is more, if you are somewhat aware that you're gaining something back?

Milla Titova:  Well, I would say that prosocial behavior includes both altruism and a more selfish things, it's just a more broader term.

Maya Hsu:  Okay.

Milla Titova:  But altruism is, it's usually this true selfless act of helping someone.

Maya Hsu:  And in your paper that you published this year, “Happiness Comes from Trying to Make Others Feel Good Rather than Oneself,” you studied pro-social behavior— just that more broad version, so it encompassed the altruism and the more selfish acts?

Milla Titova:  Yes. And in this particular project, we just give specific instructions of what to do or what to recall, because we had different studies. Some of them we actually asked people to do something and in other situations, they were just recalling a recent time when they engaged in a particular activity that we were interested in. For the most part, we asked participants to either do or recall something that makes someone in their life happy or improves their mood. And we were just, like, whatever works. Like, you know you're going to be doing that, you know what they like, what would elevate their mood and improve their happiness. So that's the definition of that prosocial behavior that we were talking about in this particular project.

In one of the studies, we also, that was a little bit different from the others, where we had a very specific thing that we asked participants to do, and that had to do with feeding expired parking meters for other people. So that was something, I wouldn't call it an altruistic behavior because again, there's not necessarily that much of a sacrifice that the person was doing. But we provided a couple quarters for our participants, and we asked them to feed the meters that have expired, to make that person happy in that particular way. So that was one of the other definitions of prosocial behavior that popped up in this project.

Maya Hsu:  For the people whose meters that expired that got re-pumped by the participants in your study, if they didn't know that it was re-pumped by somebody generously, so it didn't necessarily make them happy because they didn't know it was happening, were the participants, did their mood still elevate after donating that money, even though they didn't necessarily get feedback that they succeeded in making someone else happy?

Milla Titova:  That's a great question. That's one of the reasons why we did do that last, which was the last study in our package of studies. Because we were interested in, well, does this effect that we find that improving somebody's else's happiness is so good for our happiness, does that happen because people in our early studies were usually picking their roommate, their mom, their sibling, their significant other? So it was always, well, I'm doing something for this person who I'm interacting with and I really know very well. We were like, okay, what about those situations who have strangers, with those parking meters, and the situations where there might be not an interaction actually present? The person might not even ever find out that you did that for them.

So that's why we wanted to do this a little bit different study and what we found, so we actually had multiple different conditions for that parking meter study. We had two variations for the condition where participants were feeding somebody else's meter, and in one condition, they just fed the meter, that's it, they responded to our survey and then they went on their merry way. And then in the other condition, we actually provided them with these little index cards and we asked them to write something to the person that they did that for. So something like, “Hey, I fed your meter. Enjoy your day,” whatever. It was whatever they wanted to write. We found that the happiness levels of people who left the note were a little bit higher than those who didn't leave the note.

We don't really know what exact explanation for that was. And there are multiple hypotheses that I have that can explain why we found that difference. One of them is more selfish. It's more like, “Okay, I let the person know that I did it for them, so they’re going to know that I'm such a good person and I did something for them.” So that's one explanation why that could improve that happiness boosting effect. But the other explanation is that it could be that by asking participants to write that note, we actually provided them with an additional nice activity to do. First, they feed somebody's else's meter, and then they also write a nice note to them. So in that way, it's like they're doubling up on those prosocial activities, so maybe that's why their happiness levels are higher in the note condition rather than the no-note condition. So not sure which one it is, we don't have the data to show which one of the two. I hope it's the second one just because it's a nicer explanation, more positive, but I can't say which one it really is.

Maya Hsu:  It would be interesting to see the data on that, on whether it's the first or the second one. If it was the second one, then it would, I'm guessing, promote almost excessive niceness or excessive kindness in people, because then they would not only want to do one charitable act, but two or three at a time to reap the most benefits.

Milla Titova:  Which also reminds me, there is some research on random acts of kindness that has been done with college students. And in that particular study, researchers found that just doing one small act of kindness per day for a week, didn't actually show huge effects for happiness boosts. But doing multiple, kind of a lot more, did. And the explanation for that, that researchers in that particular study showed, which was, I think was done by Sonja Lyubomirsky and colleagues, and it's just that college students are, they usually do random acts of kindness. That wasn't a big intervention on the researchers’ part when they only asked for one small thing. But if you ask for a lot more, then you really feel the difference. So maybe that's also why that worked in our study, that the more things you pile up, the more boosts you might have. I'm sure there is some limit where it all becomes a burden of some sort, but at least with, for us, the two things versus one thing worked better in this particular study.

Maya Hsu:  Do you know if there's any data on if there are more mood-boosting effects for altruistic behaviors or behaviors that require a sacrifice, require a little bit of suffering on the part of the giver?

Milla Titova:  That is a great question. I don't know, actually. I know that prosocial behavior of any kind usually has mood boosting happiness, boosting effects. Which also leaves researchers open to there is always different camps of people saying that there is no true altruism. Because as we know, prosocial behavior always has this positive effect, so are you really selfishly doing it when you know you're going to have that positive boost in that way? And even with the extreme altruistic behaviors, when somebody is literally risking their life or even maybe losing their life, that even then there are some people who are like, well, but then if you literally die saving somebody, could you get the fame that comes with it? Yes, you're dead, but everyone's going to remember you.

So there's often, it's a big debate. So there are some people who say, yes, altruistic behavior can be truly altruistic and really just want to help somebody without any selfish benefits. But there are other people who say, no, there's just always benefits of some kind that you will have. Or another explanation with that is that it's not necessarily maybe the benefit, but if someone is really needing help and you are going to risk your life and potentially lose your life to help them, if you don't do it, you're going to be feeling guilty for the rest of your life. So again, it's selfish to help because you're avoiding that feeling of guilt that you never helped that person. Even if you might end up dying doing this, which is again, very extreme examples here, but lots of debate. People fall on the different spectrum of that. I personally would like to believe that people can be truly altruistic, but I can see both sides of the debate having some legitimate points there.

Maya Hsu:  It sounds like it's a little bit difficult to draw a conclusion that altruism versus more selfless or more selfish prosocial behavior, that one will lead to more happiness or mood boosting effects because that concept of altruism is so heavily debated and subjective at this point.

Milla Titova:  Yeah. I would say so because it's hard to draw the line and again, some people would just say that altruism doesn't even exist.

Maya Hsu:  I see. Okay. What are some everyday examples of other focused acts of kindness?

Milla Titova:  So in our study, we mostly had college students. We obviously read things that we asked them what they did and read what they said. And a lot of the things were fairly simple and easy to do. Some students called their mom because they knew they were going to make their mom happy. Other people would take their roommate out for dinner or buy them coffee, things of that nature, or just doing some favorite activity that you know that person likes, like watching their favorite movie, listening to their favorite song. It's oftentimes really very small things, but it worked. It was beneficial for at least our participants. I don't know if it actually made whoever they were trying to make happy, happy, but our participants thought that they did well and it improved their happiness.

Maya Hsu:  So listeners wanting to incorporate more acts of other focused kindness into their days, it sounds like just putting others first in smaller, very casual scenarios would work.

Milla Titova:  Yeah. It's often very small things. And then you're just thinking, what do people in your life like? If you know that maybe surprising them with a cup of coffee that you got from their favorite coffee shop just out of the blue, it's so small, but as a recipient of something like that you're like, oh my God, this is awesome, and then you're doing it to somebody. So it really doesn't take that much necessarily to improve somebody's happiness and elevate somebody's mood. It's just that conscious decision to do that and actually follow through with that, that’s all it takes. But sometimes we're just so wrapped up in our own head that we are not necessarily thinking about doing those things.

Maya Hsu:  How long roughly can that last, that shift in mood when you sacrifice or when you do something prosocial? Is it minutes, hours, days? How long does that effect last?

Milla Titova:  That's a great question. So in our particular study, we only looked at later that day, and that's where it ended for us, or even immediately after activity, or we also did a recalling paradigm when you were just like, remember the last time you met somebody happy, how did you feel? But I know from other studies that do look at prosocial behavior or random acts of kindness that are more longitudinal in nature, they usually show that the effects can linger for a while as well. But with the nature of psychological research, it may be a month later, a couple of months later, usually people don't check further than that for those interventions where people are asked to participate in random acts of kindness or something like that.

But generally, if we know that it works, if you did it earlier that day in our study, and then you are happier in the evening of that day, if you keep doing it, it should work. If you do it today, do it tomorrow, do it the day after and so on, so it should prolong this effect. With that being said, there is also something to be worried about, which we often refer to as hedonic adaptation, or it's sometimes referred to as hedonic treadmill, which is something how people psychologically are built, that we tend to get used to good things. So with that bearing those things would be, so if someone wants to do this as a long time intervention, you got to be aware that you need to vary it so you don't just get used to it.

So let's say, you're like, okay, “I really love my roommate. I'm going to surprise them with their coffee every day.” By the end of whatever, week one, the roommate is over it, you're over it, it's too much of the same thing. But varying it, like today, I'm going to surprise my roommate, tomorrow I'm going to surprise my coworker, the day after I'm going to do something for my mom, whatever. So it's just making sure that you're not getting into this routine where something that is exciting and you do get that boost from, doesn't become something that you are really used to. So you enter that hedonic treadmill where it's not going up anymore, it's just the same place.

Maya Hsu:  That makes sense. Did you notice in your studies anything about just overall a decrease in time of how much happiness was gained from each prosocial behavior just as the novelty of it wore off?

Milla Titova:  So in our studies, we only asked, one participant did something one time. So we didn't have that data in terms of that. But again, from other broader research body from other people and stuff that do longitudinal stuff, I know that that tends to happen, that hedonic adaptation. I'm not sure what the sweet spot for it is in terms of how long do you do something until you are tired of it necessarily, or at least until you know the effect wears off. So I'm not sure about that, but this is just something to keep in mind in general. And I would bet it's different for different people. So for some people, maybe doing the same thing for a while might actually work longer than for some other people. So there's big individual differences when it comes to pretty much everything, but especially those things. You got to find what works for you, what fits your style, that kind of stuff.

Maya Hsu:  You used the word intervention earlier about implementing this into your life. And I could see applicability for everybody, but do you think there are certain people or certain mental illnesses or challenges that this type of intervention would be particularly beneficial for?

Milla Titova:  That's a great question. I have personally never worked in clinical populations. So all the participants in any of the studies that I have conducted, they're always just college students, people on the street, people I found online. So it's usually not people who are particularly diagnosed with any conditions or anything like that. However, you also know how prevalent those things are in populations, so I'm sure I've gotten some in those samples, even though I wasn't looking specifically. But again, from a broader literature that I know, I know that those small activities, we often refer to them as positive psychological intervention in positive psychology in general, which challenges you to do small activities designed to promote happiness. It’s a simple definition of positive psychological interventions. They have been applied on various populations, including people who are depressed and have various concerns that they might have about their mental health, and it seemed to be working for various populations pretty well.

I wouldn't say that if you have a serious problem with depression or anxiety at the clinical level, doing something like that is just going to fix it. But in addition to seeing a therapist, doing other things, that can be helpful, especially I think for people who, oftentimes, when we do have mental health struggles, we become so self-centered. We are just really thinking about ourselves and everything that's happening with us. And we often think that, well, we are in too bad of a spot to be really interacting with other people. Well, we know how important other people are for us, we're social creatures. So reaching out to others, doing something nice for others, is almost always a good idea.

Again, maybe if a person has social anxiety, maybe not. I'm not talking about when it becomes a much larger issue, but for most people even in situations of mental struggles, it's just we’re naturally just like okay, “I need to fix myself first and then start reaching out to others and think about my social connections and stuff,” but others can help you fix whatever you're trying to fix. So it is, I would think, that it could be applied in many, many different situations for many people who are having issues with very different things.

Maya Hsu:  So would you say, aside from social anxiety in general, people, it often would be wise to do a counterintuitive measure where if you have the tendency or the inclination to isolate yourself, hide from the world and focus inward, that you should do the opposite and go and be with people and do something kind for others?

Milla Titova:  Yeah. I would say so. And I also, with all of that being said, any psychological study we are talking about this works on average, and any psychological finding that you ever encounter, my advice for everybody is, okay, this works for a lot of people. You can try it and see if it works for you. You know what I mean? So the findings that whatever research that you read or hear about, it suggests to you that it works for a good chunk of people, that there is a significant effect, but then there is also a lot of individual differences and individual things that might not quite, you know… Because there's outliers in every study and that outlier could be you or anyone else.

So my advice is always, okay, we find this effect, go try it out and see if you will feel, maybe you'll be like, “oh, wow. Why did I not consider that before?” Or maybe you're going to be like, “yeah, no, I don't know. That's not for me.” So with literally any finding, it works that way. But on the other hand, knowing that research suggests that for a bunch of people that was beneficial and that worked, is usually a pretty good sign that it might work for you as well.

Maya Hsu:  Thank you for that.

Milla Titova:  Sure.

Maya Hsu:  Is either other-focused happiness or self-focused happiness instinctual, or are they both learned?

Milla Titova:  That is a good question. I am not sure if I have the answer to this question based on the data that we have and the studies that we particularly had. I know just more anecdotally, that oftentimes people are like, oh wow. Making others happy makes us happy, which made me think that people don't necessarily assume, or think that that's the best way. And I think again, people just tend to be more self-focused naturally, but again, I didn't necessarily ask people, what do you think is going to be better, this or that? So that would've been fun question to ask actually. Let me think about that.

Maya Hsu:  Are there situations where it makes more sense to be focused on achieving happiness for yourself over others, just in terms of comparing the amount of benefit?

Milla Titova:  Well, given that if you concentrate more and yourself, at least in our data, it shows that it's going to give you less of a benefit in the happiness. So in given that, I would say, no, you should just go for others, and then you will end up improving yourself more. So in that way, I would suggest at least, again, trying that out and see what happens. I think that again, I'm going to just sound like a broken record, but people often think that it's just, you need to fix yourself first. You need to think about yourself first. So just breaking out from this way of thinking would, I think, be helpful and potentially, that may be why the benefit is there.

I mean, in our studies, we do find that the main mechanism for this is relatedness-need satisfaction, which we want to be connected with other people, we want to have good connections, and people were getting this relatedness-need satisfaction, even in those studies where they didn't interact with a person. It still gave them this sense of being related to somebody else, even though they didn't talk to them, they didn't see them, they don't know how they look like, they know nothing about them, but just doing something for someone else feeds that relatedness.

Maya Hsu:  This conversation makes me think of self-care and how we're in an era of, I think, changing how we view self-care, because previously, I think we conceptualized that with pampering oneself and buying products to make oneself feel better. And now, I think we're shifting a little bit toward being more self-kind and self-compassionate. And so this just has me wondering how to balance the amount of self-care and self-kindness, when one isn't feeling the best, because the data, it suggests that most, if not, all of the focus and energy should be spent toward making other people feel happy and appreciated, because then you will indirectly feel that reward as well. How would you recommend balancing those two, because there must be some degree of self-care that's important?

Milla Titova:  Yeah. Of course. I'm not saying that people should always and forever just forget about yourself, do everything for others. No. Totally not. Self-care is super important and I think that you made a great point in terms of how self-care is not always taking a bubble bath or splurging on a purse, as we used to more think about it. It's more psychological self-care. It's really taking time off, not beating yourself up that you are, oh my God, you're not working on a Sunday. You're not being productive. That's fine. That's how it should be. So I think that a lot of self-care has to do with that, just accepting yourself, being kind to yourself. Self-compassion is a big, big thing.

Thinking of self-compassion, there are different components of self-compassion and some of them have to do with mindfulness, just being present in the moment, just enjoying the moment, not being judgmental towards your thoughts, acknowledging them, letting them go, which is not easy. It takes a lot to actually be good at being mindful. But I think it's important in any condition, when you think about, if you are doing something for yourself and you are in the moment of just self-compassion, self-care or whatever, or if you are in situations where you interact with others, being mindful is pretty important. You are present in the moment, you are not thinking about 100 things that you need to get done or whatever things that you or what it might be, you're just really present for this other person, which again, will improve your relationships and stuff.

But in terms of the specific prescribed balance, I don't think I have the specific number or any prescribed thing. And again, I also think it will depend on a person. Some people really need to be alone to recharge or to feel themselves. Other people need less of that, so you got to find what works for you.

Maya Hsu:  Awesome. Well, it was wonderful speaking with you. Is there anything else you'd like to share with the world about happiness or well-being or altruism?

Milla Titova:  What else do I want to share? Great question. I don't know. Just with the, especially now, the times are weird in the pandemic, it's really easy to concentrate on all the negative things. So I think that just taking a moment to be grateful for some good things that you have. We all have at least something good going on, small or big. Just thinking about it, switching perspective, thinking about the things that we can be grateful for versus the things that we are missing, not doing or want to have, really can give us some moments of peace and happiness and contentment. Just being nice and calm and enjoying the moment for at least every once in a while, because I think it's very easy to get carried away by all the worries that we have nowadays. So that would be my last thought or advice.

Maya Hsu:  Thank you so much, Dr. Titova. It was wonderful having you on our series today.

Milla Titova:  Thank you 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.

Journalist Florence Williams on Nature Therapy

An Interview with Journalist Florence Williams

Florence Williams is a journalist, author, podcaster; her work specializes in the interconnections of the environment, health and science.

Chris Russo:  Thank you for joining us today on our installment of The Seattle Psychiatrist Interview Series. I'm Chris Russo. I'm a clinician with Seattle Anxiety Specialists, and I'd like to welcome journalist, author, Florence Williams. Florence is a contributing editor for Outside Magazine, freelance writer for a dozen publications, including National Geographic, the New York Times. She's the writer-host of two award-winning Audible original series, a distinguished public speaker, has held fellowships and visiting scholar roles at different universities and centers, engaged and worked in nature and environmentalism. And you're known for work that focuses on environment, health and science. Before we jump into things, just want to start a little general, if you could maybe tell us a little bit about yourself and what led you into exploring nature's effect and relationship with humans.

Florence Williams:  Sure. Thanks so much for having me, Chris, I'm excited to be here and serving your good work and your clients. I am a journalist and most recently I'm the author of The Nature Fix: Why Being Outside Makes us Happier, Healthier, and more Creative. And also a brand new book that's coming out any second, it's actually available now called Heartbreak: A Personal and Scientific Journey. And I've long been interested in the relationships, or the relationship really, between humans and nature and the hidden relationships— so the ways that our environment can actually make us sick. I wrote a book that looked at women's reproduction and the effects of toxic chemicals on breast cancer, for example, and breastfeeding. And also now interested in how the environment can help us and make us feel better.

And so the reason I wrote The Nature Fix, well, it started as an article for Outside Magazine. And I had just moved from the Rocky Mountains to the heart of Washington DC, and I felt personally that my own nervous system really responded negatively to that move. And I started to think a lot about what journalist Richard Louv calls Nature Deficit Disorder. Was that a real thing? Was I experiencing increased anxiety, depression, a lot of just general stress because of what I'd lost in terms of my daily connection to the mountains? And I think that actually was a big part of it. And so for Outside Magazine I went to Japan. That was the first place I went, where researchers there were actually studying the physiology and stress hormones, heart rate variability, some brainwave patterns and people in different environments and how being in nature actually really helped calm a lot of people's nervous systems.

And then, I started finding out there was more science. I wrote an article for National Geographic called “The Power of Parks.” And I realized there was really a book there looking at doses of nature and different levels of research and studies, what were the benefits of being outside on a city block where there's some nice trees, where there are still benefits, all the way to the three-day effect of what our brains are like after three days in the wilderness.

Chris Russo:  Yeah. There's been such a journey through starting with an article to now having multiple books, podcast series that have come from this. When you started, did you anticipate that there was going to be such a hefty dive into all of this?

Florence Williams:  I really didn't. For me, I thought my premise was very obvious. "Nature makes us feel good. Like, duh, everybody knows that, nobody's going to buy this book. Nobody cares, we all know it. It's so intuitive." But in fact, a lot of people don't know it or don't know it consciously. And I was really amazed by how many emails I would get from people saying, "Wow, I read your book and now I go outside." And it really spoke to, I think the society wide and cultural wide level of disconnection that so many of us do feel from the non-human world. And of course then the pandemic hit and it turns out the lessons from the book were more relevant than ever. And I think a lot of people have found so much comfort in the natural world, have gotten to know their local nature better. And so the book turned out to actually be way more relevant than I could have ever anticipated.

Chris Russo:  Yeah. Really this resource and tool that possibly was in people's backyards and right around them, that they weren't sure how to access and engage with and know that it could be really helpful and supportive and beneficial. Curious for us to maybe dive into a little bit of some of that science, we hear it's good for us. And I think what you touch on is a really important piece is that many folks intuitively maybe know that. I do want to acknowledge within the world of eco-psychology and a lot of nature-based stuff, they talk about traditional ecological knowledge. We use terms like indigenous wisdom and there's generations of people that have known this, that has been passed down through stories and culture. But the Western science wants to have the data, which is something that I think you really dive into, right?

Florence Williams:  Yeah.

Chris Russo:  So curious if we could maybe look at and talk about, what's some of the data, what's some of the science that tells us how we can benefit when engaging with nature?

Florence Williams:  Yeah. I was so interested to learn that there are so many neuroscientists and psychologists and immunologists and physicists who are really captivated by this topic. And I think it's because there is a recognition that we live in an increasingly urbanized world, where not only our children, so cut off from nature and disconnected, but we are ourselves because of our phones and because of our increasing time indoors, there's this increased anxiety that's I think driving a lot of the research. And so there is a lot of really interesting research going on. As I mentioned, I started in Japan and what researchers there were finding, there's this popular practice there called forest bathing, or shinrin-yoku, it's now been popularized here in the United States, there are guides all over the place.

But in Japan, what they were finding out was that even after just 15 minutes of people just strolling around or sitting in a forest that their blood pressure dropped, their heart rate variability shifted to a profile that was more consistent with stress reduction, their brainwave patterns changed a little bit. Additional studies since then have shown that their immune cells, their killer T cells increase in the presence of these forests, their blood sugar improves, it's just this big list. So that's just looking at an individual. And there are also these really large scale epidemiological studies, especially in Western Europe where there's great socialized medicine, like big public health databases and really good maps of where people live, like how close to green space do people live? And when they put these data sets together, what they see is that people are just a lot healthier who live closer to green space and that's after adjusting for income and education.

So there are just lower rates of all these illnesses, including a lot of cardiovascular, stroke-related… There's less anxiety medication prescribed, and in fact, better learning outcomes even in schools that don't have so much urban noise, that may be closer to green space. Lower mortality rates overall, pretty statistically significant drops in mortality and especially true in people who are underprivileged, so who may not have access to a lot of the other stress reducing things that wealthier people have. And so it turns out that if you live close to a green space, it's this social equalizer or leveler a little bit in terms of health. And then there have been a lot of other studies looking at, even in cities, the density of trees on your block, for example, once you hit a certain threshold of trees, it's the equivalent of a $20,000 boost in income in terms of health outcomes.

And in communities that have lost trees, for example, to the various blights like the Elm blight, that cardiovascular rates go up, risk goes up, and disease goes up. And then there have been some research in places like Finland, looking at depression specifically, and finding that people can prevent mild depression if they spend a couple of hours a week in nature. Really again, well, that was in medium scale studies, but in the UK, that was replicated in a really large scale study looking at I think 10,000 people, showing that two hours a week in green space was the optimal for wellbeing, both physical and mental.

Chris Russo:  Yeah. So a lot of these physical markers that are, you said, indicating a profile that would resonate with reduced stress, reduced anxiety, increased mood.

Florence Williams:  Yeah, exactly. And now there have been some interesting brain studies as well showing actually that blood flow to the brain is different when you are in nature. If you're out for a 90 minute walk, for example, there's reduced activation in a part of the brain associated with depression. And they think that's because there— the psychologist who was at Stanford at the time of the study, Greg Bratman, he's actually now in Seattle, found that rumination is associated, sort of negative thought cycling, associated with depression. And that there's a part of the prefrontal cortex called the subgenual prefrontal cortex, that was really reduced in activation after walking in nature, but not after walking in a city.

Chris Russo:  I was hoping we would touch specifically on rumination, so I’m glad you brought that up. Because I think that's, whether anxiety, depression, I work a lot with folks with obsessive compulsive disorder and rumination. It really impacts us, distraction, our attention, mood, right?

Florence Williams:  Yeah, it does. That voice in our heads is a brilliant mechanism of evolution. It helps us do so much. It helps us form priorities and articulate our thoughts and have some self concept, all that good stuff, but it can also run away with us. And sometimes it's good to quiet that voice or to give ourselves some distancing and some perspective, that that voice isn't really the most important thing all the time and we need to quiet it down. And it turns out that being in nature looks like it's one tool among many for just being more in the moment, waking up our senses. And that's what forest bathing is actually, as practiced by the Japanese and as practiced here now, increasingly.

It's a series of cues that are very simple, that just, you know, go outside for a little while and take some deep breaths and focus on your senses. What are you hearing? What bird song is out there? Are there some interesting patterns of light that you see in the trees? What is the breeze? What does the temperature of the air feel like on your face? Just some really basic elemental cues that are so easily grounded in nature. And when our sensory sort of animal brains wake up, our thinking brains dial down a little bit in a really healthy way.

Chris Russo:  Yeah. I want to, I think on that note but steering us a little bit, if we could touch a little bit on the role awe plays. That came up through some of your work. I was wondering if you could maybe speak a bit more about that?

Florence Williams:  Yeah. I talk a lot about this emerging science of awe in The Nature Fix. It's really interesting to me, as a positive emotion, it's been late to the psychology game. People weren't studying it until quite recently. Of course, philosophers have talked about it and poets have talked about it for a long time. Typically the way awe is described or defined is that it's receiving vast input from a view or looking at the Milky Way or something like that. Looking at the sky, looking at the sunset, looking at the ocean. So something vast that also in a way may surprise us or be unexpected. It makes us open our mouths, drop our jaw, raise our eyebrows like, "Oh my God, look at that moon." And it's really interesting what that sensation does to us. And what the brain studies have shown is that when we see something arrestingly beautiful and overpowering, it shuts down our brain in a way, because we need to take that in.

We don't necessarily fully understand it. It may challenge our expected schema of what we think we're seeing. For example, an eclipse or something like that. It's like, "What is going on? My brain is not used to taking that in, I need to understand that." And so our thinking brains, again, shut down for a moment. And suddenly we feel deeply moved, we feel connected to the world around us in a powerful way. We actually feel diminished in terms of ourselves, our ego takes a backseat for a minute. And in fact, in studies, when people go look at views in Yosemite, for example, and another group goes to look at a view of Fisherman's Wharf in San Francisco, which is a cityscape, the subjects are asked to draw a picture of themselves in the landscape.

And people actually draw themselves as being much smaller when they're looking at powerful nature. So there's this like literal diminishing of self. And again, that's powerful in terms of wellbeing, where we feel like maybe other people and other things in the world are worthy of our attention, not just our own problems all the time. It makes us actually more empathetic and can also make us more creative, again, wakes up different parts of our brains in these really interesting ways.

Chris Russo:  Yeah. Many folks that have maybe spent a lot of time in nature, we've had some of those really powerful awe moments that seems so unique that there's a novelty to it, right?

Florence Williams:  Yeah.

Chris Russo:  I'm wondering for folks that maybe are a bit more stuck in the city, you mentioned Fisherman's Wharf in San Francisco. Can we experience awe in the everyday?

Florence Williams:  Yeah. I'm glad you brought that up. So one thing I learned through the course of writing The Nature Fix was how to cultivate a sense of beauty and awe in a city. And I actually participated in a study, I think it's called the North Bay Awe study. And there's some preliminary data from it already. And what it was is we were asked by the researchers to go out a couple times a day, just even walking around the block— this was in the middle of the lockdowns— and find something beautiful, like a flower or a sunset or the moon, they called it “micro-dosing awe,” to just stop for a moment and just be with this beautiful object or thing or feeling, could be even a food that you were eating or a house plant that you could look at, and take three breaths, just take three breaths while being with this point of beauty.

And then write about... there were a lot of questionnaires about, "Well, how do you feel today? How does your body feel? How does your mood feel? What's your sense of yourself? Are you liking your job? How is waking up this morning?" And what they found was that people who had engaged in this practice of micro-dosing awe for a period of weeks actually had a much stronger sense of wellbeing by the end of it. So I think we're used to awe being the Grand Canyon but it doesn't have to be, and we can in fact become better at savoring these moments of small beauty that can be very effective for mental health.

Chris Russo:  Thanks for that. You have spent time rafting with veterans down Western rivers, hiking through super, super cold weather with women who have been trafficked and faced abuse and experiencing PTSD, have hung out with researchers in Utah and learning what they're doing. Curious what you found most surprising through all the work you've done so far.

Florence Williams:  Yeah, good question. As you say, I knew intuitively that nature makes us feel better. But what I was surprised about was I think the cognitive piece, that even these quick walks outside could actually really make us feel more awake and more alert and more productive, and so that was a surprise. It can actually make us feel more creative. So that was really nice to learn. And then also in terms of how it makes us better members of society. The studies show that people who can feel awe on a pretty regular basis, those people in studies, they become more altruistic, they have a stronger sense of community and less a sense of self-driven ambition. So they want to make their communities better, not just themselves.

And this has been shown in various psychology studies where you give away more money or more lottery tickets, or you fold more paper cranes for earthquake survivors or things like that, that there are these acts of generosity that we're more likely to engage in after we've had these de-stressing moments of beauty and connection outside, and that really surprised me. So in this way, nature, it turns out is really good for civilization. And I hadn't really ever thought of it that way. I really thought it was separate from civilization or something different.

Chris Russo:  Takes it out of the individual and brings it more to a larger collective, right?

Florence Williams:  Right. And we know that that sense of community is profoundly impactful for mental health. And so many of us are combating loneliness right now. And of course loneliness is bad for your health, not just your mental health, but it's bad for your physical health. And so, we are as human animals, we are really wired of course, to be not only social, but hyper social and our bodies feel pretty threatened in this very subconscious way if we spend too much time alone or feeling alone. It's a subjective feeling. You can be in a marriage, but still feel alone. And so being in nature is one of the ways we can really feel less alone.

Chris Russo:  So it's been five plus years since you started diving into The Nature Fix stuff. Where is your journey taking you? You have this upcoming book, Heartbreak, A Scientific and Personal Journey?

Florence Williams:  Yeah. Heartbreak. So after I wrote The Nature Fix, which by the way I said, I looked at doses of nature and I really only got up to the three-day effect in The Nature Fix. But I then went through my own personal emotional trauma which was a divorce of a 25 year marriage. And couldn't believe how much that hurt and also seemed to be affecting my physical health. And so I thought, "Well, maybe I need a much bigger dose of nature now." And so at the core of the book is actually a 30 day river trip, including some of it alone. And I was really trying to see if that would help me feel better. And it did in a lot of ways, and in some ways it wasn't enough.

And so I talk a lot about the science of that in the book. And I talk a lot about the science of the immune system. I worked with an immunogeneticist at UCLA, and we actually tested my blood samples for genetic markers of stress and threat and loneliness at various time points after the divorce. But there's also a lot of, like in The Nature Fix, I think pretty user friendly ideas and tools for feeling better.

Chris Russo:  Yeah. It sounds like you kind of... You talk about Attention Restoration Theory and Stress Reduction Theory and I think Nature Fix maybe focused a bit on that, whereas this sounds like it really dives into grief, right?

Florence Williams:  Yeah. It dives into, so specifically trauma and grief and loneliness. So I sort of pick apart the pieces of heartbreak and talk about how to feel better and the urgency to feel better, because really of the significant health effects associated with loneliness, and the adverse effects, not just for yourself but for your family and for your community. If you can learn to really have a sense of purpose and extract meaning from your experience, then that does help you feel more connected to other people. But to do that, you also have to figure out how to calm down, how to calm your nervous system, and that's where nature can be super helpful. So I think it's a piece of the recovery puzzle, it's not the whole thing.

Chris Russo:  Yeah. So as someone who has spent some in-depth time researching, writing personal experiences through all of this, curious if there's any recommendation or advice for folks that might listen or watch this.

Florence Williams:  Yeah. I have this like really simple little coda, which is go outside, go often, bring someone with you or not and breathe. And beyond that coda, I would say if there are people listening who aren't necessarily really comfortable with spending a lot of time outside, start small. Just have your cup of tea in a place where you can see some clouds and really think about your senses, cue into your senses. And it's great to work with professionals and clinicians like yourself who can help people do that and understand the power of it. So thanks for the work that you're doing, Chris.

Chris Russo:  Well, thanks for bringing so much attention to it.

Florence Williams:  You bet.

Chris Russo:  And thank you for taking time to meet with me and chat about some of this work. It's exciting stuff and cool to learn about what's so immediately available. It doesn't have to be a 30-day back packing trip somewhere. Here in Seattle, we're so fortunate that we have so many green spaces. I know even in Washington, DC, you've got Rock Creek park that runs through. It's like there's a lot of stuff that is nearby that-

Florence Williams:  There really is.

Chris Russo:  We see some great benefits from as well.

Florence Williams:  Yeah. And even when the weather is crummy, by the way, the benefits are still there scientifically. So you still feel a little bit revived, a little more alert, a little more energetic.

Chris Russo:  So for a gray rainy Saturday... or Seattle days. Yeah.

Florence Williams:  Yeah. Just go anyway. The first 15 minutes are kind of miserable, but then it's great.

Chris Russo:  Well, thank you again for sharing all of your insights and reflections on this work.

Florence Williams:  My pleasure. Thanks so much for having me.

For more information, click here to access our article in “The Seattle Psychiatrist” Magazine: The Need for Ecotherapy in Our Overstimulated, Over-Industrialized World.

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

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

Psychologist Norman Cotterell on utilizing CBT

An Interview with Psychologist Norman Cotterell

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

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

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

Jennifer Ghahari:  Yes.

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

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

Jennifer Ghahari:  Wow.

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

Jennifer Ghahari:  Oh, wow.

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

Jennifer Ghahari:  Wow.

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

Jennifer Ghahari:  It was the right fit. Yeah.

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

Jennifer Ghahari:  Oh, wow.

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

Jennifer Ghahari:  Nice.

Norman Cotterell:  But we're basically sister clinics.

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

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

Jennifer Ghahari:  Exactly.

Norman Cotterell:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Ghahari:  Oh wow.

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

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

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

Jennifer Ghahari:  Yeah, exactly.

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

Jennifer Ghahari:  That'll work.

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

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

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

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

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

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

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

Jennifer Ghahari:  Wow.

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

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

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

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

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

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

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

Jennifer Ghahari:  Right. Yeah.

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

Jennifer Ghahari:  Nice.

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

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

Jennifer Ghahari:  Definitely makes sense, yeah.

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

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

Jennifer Ghahari:  Oh, okay.

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

Jennifer Ghahari:  Oh, wow, okay.

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

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

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

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

Jennifer Ghahari:  Oh!

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

Jennifer Ghahari:  No, not at this point.

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

Jennifer Ghahari:  Exactly.

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

Jennifer Ghahari:  Right.

Norman Cotterell:  Yeah.

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

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

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

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

Jennifer Ghahari:  Yeah.

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

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

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

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

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

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

Jennifer Ghahari:  I'm not. No.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Norman Cotterell:  Okay. Okay. Yes.

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

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

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

Jennifer Ghahari:  Yeah.

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

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

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

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

Norman Cotterell:  Advice?

Jennifer Ghahari:  Any words of wisdom or…

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

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

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

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

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

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

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

Jennifer Ghahari:  Oh, that's amazing.

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

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

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

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

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

Norman Cotterell:  It's certainly my pleasure.

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

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

Psychologist Kevin Chapman on Panic & Social Anxiety

An Interview with Psychologist Kevin Chapman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Ghahari: Thank you.

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

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

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

Professor Donna Davis on healthcare & Virtual Reality

An Interview with Professor Donna Davis

Donna Davis, Ph.D. is an Associate Professor and Director of both the Oregon Reality Lab and the Strategic Communication Master’s Program at the University of Oregon (Portland) and is an expert in psycho-social virtual reality (VR) utilization.

Stephen Alexanian:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Stephen Alexanian, research intern at Seattle Anxiety Specialists. I'd like to welcome with us Dr. Davis, who is Associate Professor and Director of the Strategic Communication Master's Program at University of Oregon, and also the head of the Oregon Reality Lab in Portland. Her work has encompassed potential uses of immersive media, virtual reality, with special interests and marginalized and vulnerable people. Her newest publication she co-authored is, “Virtually Real, But Not Quite There: Social and Economic Barriers to Meeting Virtual Reality’s True Potential for Mental Health.”

Great to have you here and helping us understand these interesting, complex issues. First of all, would you like to introduce yourself a little bit more, and tell us what made you interested in VR research?

Donna Davis:  Sure. I am Donna Davis and, as you just said, direct the Oregon Reality Lab and Strategic Communication. The work I've done is at that intersection of how we think about communication, how we think about creating communities, and how we create identities in virtual worlds, and the effect that that ultimately has on us and others.

And I got interested in this space because, working on my PhD at the university of Florida in 2008, I took a class in virtual worlds and it blew my mind. I had no idea this technology was out there at the level that it was. You figure game spaces in that moment in time were still pretty primitive. And the course that I took was actually using the platform of Second Life to explore the potential uses of virtual worlds. And Second Life was just three or four years old at the time also, really in a primitive state, both graphically and technologically.

But when I saw what was happening in that environment, I just thought, "This is crazy. It's the Wild West, and there is so much potential here. I need to try to figure out what's going on in this space."

And so, I wrote a dissertation on the efficacy of social capital that's formed with between people in virtual worlds when they only know each other virtually. Avatar to avatar, people fall in love, they build communities, they create support that's very, very real. And of course, it also has sometimes some very real, sometimes very positive, and sometimes very negative consequences. It got me on that path where I basically started the PhD program with an expectation to focus on family media literacy. I identified a medium that had even more potential to be both, there was promise and peril. And I just took that hard right and never looked back. Came to the University of Oregon from there, and I have stayed in that space as a researcher since then.

Stephen Alexanian:  Thank you for that. For our audience who may not know what virtual reality is, can you explain what it is? What makes VR very immersive or effective?

Donna Davis:  Sure. Well, and it's interesting because the term virtual reality is so often misused and misunderstood, because you read anything right now, and they talk about the future of work is in reality. They're talking about zoom as virtual reality. And in its literal sense, this is our virtual reality. We're experiencing real time, synchronous interaction face-to-face, but it's entirely remotely and digital. It is virtual.

But virtual reality also, among people that are in the field, typically they're talking about virtual reality as the experience that we have in a virtual reality headset, that really immerses a person in that virtual space. Because with a headset on you, don't see the world around you anymore. And if you've got earphones on, you don't hear the world around you anymore, and your brain actually takes you there, and you feel completely immersed in this built and virtual environment, and in an embodied way.

The virtual reality that I've been working in for now almost 14 years, is screen-based, so these are screen-based virtual worlds, again, that are entirely computer-generated, animated. And what makes them work, and so powerful, are a couple of different things. One of the key pieces of that is the concept of presence, feeling like you are actually present in that space, that there's a social presence where it's, I am socially present with others. There is an environmental presence where I feel like I am present in that space, in that moment in time. And feeling physically present that it's my body, and that I'm interacting with an environment that affects me in an embodied way. So, the self-presence, that you feel present in that space and that you're interacting in that space in a way that also, part two, is immersiveness. And that, like I said, with a headset on, you're even that much more immersed. And you feel completely immersed and present in that environment, where you don't necessarily feel present in your physical environment anymore.

So, there's almost a spectrum of both presence and immersion, based on which hardware or platform you're operating in, and at what level of built environment versus a camera, video environment. And the other part that is really important to the work I do is that sense of embodiment. That is where you have a digital body in that virtual space, that built environment, typically known as an avatar. And even as we think about avatars, I always ask in class, or when I'm presenting around the world, if people have an avatar, and a couple of people might raise their hands. The audience is, the more they do, because the younger audiences are gamers and are in many platforms such as Roblox or Animal Crossing or Fortnite, the big ones right now that are virtual environments.

And so, they all have avatars and they’re like, “Yeah, I do.” But if you also create a Memoji for your phone, or on Facebook, or on any other virtual platform where you have a digital representation of yourself, that is your avatar. That’s the other real important piece of this that I have found one of the most important parts of the work I do, because that sense of identity that comes through your virtual body can also be incredibly powerful in good, bad and ugly ways.

Stephen Alexanian:  Very interesting. One of the questions I was most interested in talking to you is, I know some people may have just heard of virtual reality. I heard about it a couple years ago. For you, how has research in VR changed over time since you first started exploring these areas?

Donna Davis:  The research is exploding right now because the spaces are so much more accessible. Early virtual reality research was done, and even if you were to Google the historical development of virtual reality, you'll see the Sensorama, these huge machines, or these headsets that were connected, that looked almost like you were in a Jules Verne undersea adventure, where the technology was very big, bulky, clunky, uncomfortable. And, just as early computers, what would be the size of my building we can now operate with my cellphone. Similarly, the technology is changing now in a way that you can buy a very good quality of virtual reality headset for $299 or $399, as in $399, $400, and have access to multiple experiences in virtual reality.

And while much of that has been driven by the game space, there are other people now recognizing its potential and its power, and really beginning to explore the uses of virtual reality that go way beyond gaming and entertainment, where that is still the primary driver. There are now multiple use cases of virtual reality in healthcare, especially as we look at pain management, and some work that's been done with burn victims, where you can put them in a VR headset and they're in a snow cave and playing a snowball game. And they find that the brain takes over and thinks they're in the snow. And the body responds physiologically to what the brain is thinking. So, they're able to change the bandages of burn victims with much less pain medication because the brain is so preoccupied with what they think they're doing that they are not paying as much attention to the pain.

Similarly, work in PTSD, in physical therapy, and now there's a much bigger, bigger recognition of the potential as well in dealing with people with isolation or other emotional issues, where they can see that virtual reality can be a really safe space and an accessible space to potentially explore alternatives to things like pharmaceuticals. Or it's just even practicing. There's been research done for more than a decade now with people with autism in virtual environments, where they can actually practice and experience virtually, similarly, agoraphobia or arachnophobia, and multiple phobias.

I was familiar with research that was being done with people who were afraid of water, and wouldn't go in the water. And they had their avatar just stand at the edge of the water. All the physiological fear issues kicked right up, sweat, heart rate increase, terror, terror, and they weren't even touching virtual water, much less real water. And it's like, all right, let's get you through this process of it's not even real. Why are you so terrified of it? Until they could put their toes in it, till they could put their feet in it, till they could go ankle deep. Now let's try that in real water. And they've been able to practice working through the response. Similarly, people with autism. Similarly, people with PTSD.

So, there's been a lot of research in that space for well over a decade now. But now, with the access that we have with more commercially available headsets and experiences, there's research that's really starting to take off, especially with the elderly, who often live in isolation. And people with dementia, where they can put them in a headset and they can remember a dance or a song or an experience incredibly explicitly. It's like everything lights up. There are just so many possibilities. If you can think it, you can build it, and you can test it right now. You can do that now.

Stephen Alexanian:  Thank you. You brought up the idea about pharmaceuticals, people are trying to avoid it. I know depression is a huge issue with that as well. Where is the development with helping people with their depression?

Donna Davis:  I think that I'm not as familiar with people that have been doing experimental studies with depression in VR yet. However, I can also point to some of the work that I've done that is... Again, when you're talking about social capital, it's how do you create connection in social spaces, especially in immersive virtual social spaces? And some of the early work I did was with the Parkinson's community, where an 84-year-old woman with Parkinson's discovered that she could... her son introduced her to Second Life. And because she was living in isolation, he and his sister were in opposite corners of the country. And he said, "Mom, let me help you to create avatars, and we could log in at night and hang out together and do things." And one of the things she loved to do was go ballroom dancing. So, she could log in, her avatar could put on a ballgown. Her son, on the opposite corner of the country, could log in and put on a tux, and take his mother ballroom dancing.

And the next morning when she would get up, she would've just experienced, to her, the night before, she'd gone ballroom dancing with her son. The experience was incredibly real. And that connection, and joy that she experienced, she felt, "I should share this." So, she actually started a Parkinson's support group in Second Life. And I worked with that group for over nine years, and I watched the level of support that those people were able to create from anywhere in the world. They could log in, and every Thursday morning at 10:00, we would have a Parkinson's support group in Second Life. And consistently these people reported how important it was to them to be able to have that connection with people that actually understood their situation, which, in the physical world, especially one of the women in the group was a woman that had early onset Parkinson's. She did not want to go to a Parkinson's support group in the physical world because, overwhelmingly, she would go and find that they were older than she was, further along in Parkinson's than she was, and it terrified her.

So, in the virtual world, she could log in with her very healthy, vibrant, beautiful avatar, and do amazing things, and connect with other people with Parkinson's, and have fun and do joyful things, and become friends. And people shared things in that community that they said nowhere in their physical world would they ever have felt comfortable enough to share. It's almost like people who are in any of the “As”, like AA or NA or those organizations where people may have a fear of going to one of those meetings because, even though it's anonymous, you see each other's faces, and you might bump into each other in the grocery store or at an event. It's your avatar. You could be anywhere in the world. Whether or not you share anything about your physical world identity is entirely up to you.

And people really open up in ways that they said they would never have done in the physical world because they felt it was a safer place to do that. But the mental health industry has been slower to adopt that because there are also risks, like if you're working with someone, especially who suffers from depression, or is at risk in any way of harming themselves, if something were to trigger them, and they live on the other side of the world, and you have no way to protect them, there are issues there. It's complicated legally, it's complicated clinically. But, after working with the people with Parkinson's, I got a National Science Foundation grant to work with people with broader disabilities.

And we found a community of people, again in Second Life, who were part of an organization called Virtual Ability. Many people with disabilities also are often addressing depression, and based often by their isolation, or by the circumstances of their disability. And we would host events, and one of the people in our community also started a depression organization in the virtual world, and they have thousands of members of that support group in the virtual world. Again, because they have a sense of anonymity and support where they feel like they can express themselves more openly than in any other situation they've ever been.

And they can express their emotions in really interesting ways. Sometimes it's by the way their avatar appears. I know many people have multiple avatars, and they say, "Well, this is my joyful avatar. This is the avatar I use when I'm feeling really dark. Or this is the avatar where I just want to let loose. Or this is my work avatar." They pick an avatar for the moment that they're in. Again, some people might think that comes with big risk, and that's where more research is needed. Are you creating greater potential for people who might suffer from multiple personalities? There's so many ways to approach this, and we're just at the very tip of the iceberg, I think right now, as a field, and in research, and in the technology.

Stephen Alexanian:  Just for our audience that doesn't know Second Life, is it easy for them to sign up free? Anyone can use it. Can you explain a little bit about that just for our audience who doesn't know about Second Life?

Donna Davis:  Sure, sure. And it's really funny because anytime I mention it, I will have people go, inevitably, there'll be at least one person in the room that'll say, "It's still around?" Second Life has been around for 18 years. And it's a 3D virtual environment, graphically created environment, that you can download for free on any computer at secondlife.com, and create an account at no cost.

There's different viewers you can download, but the Second Life viewer works just fine. And any computer with a graphics card and an internet connection, that's a contemporary computer, is pretty much going to operate Second Life. I've actually found that it were works on a Microsoft surface, but it does not work on a phone or an iPad, or most tablets will not run it. So, it's got to have enough beef to the graphics card, and your engine, that it'll run the graphics. But any laptop, any PC, for the most part, if it's been built in the last five years, is absolutely, probably even 10 years, is going to be able to run Second Life. You just need an internet connection and a decent graphics card, and it'll go.

Stephen Alexanian:  Okay. Thank you. Like I mentioned to you, your last published article that you did was about certain barriers to having VR reach true potential. It seems like the pandemic is really speeding up the need for telehealth solutions like VR. Can you talk about the main challenges for implementing VR in healthcare? Any social, technology or cultural issues?

Donna Davis:  Sure. One of the pieces that we wrote, that I co-authored with colleagues here in Eugene, we're talking specifically about the barriers to adoption of VR. Part of that is that the technology has been slow to market, and the pandemic actually exacerbated that with supply chain issues. But at the same time, things started to really grow during the pandemic because people were all, instead of... In working with people with disabilities, my colleague, Tom Boellstorff, from UC Irvine, who worked with me on the National Science Foundation grant, he and I always refer to people as, there are people with disabilities, and then there are tabs. And we're tabs. That means we are temporarily able-bodied, because as we age, some things about our body will... increasingly, you'll need glasses, you might need hearing aids, you might need a walker. But all of us will experience different levels of ability and disability as we age.

So, during the pandemic, we found that all people were living with the same level of isolation as people that had traditionally only been marginalized had experienced. So, they were finding new ways to connect, and all of that was digital. It's also driven a lot of the innovation in what's coming in VR in terms of headsets, and through which technologies. Everybody's scrambling to try to figure out how can we access these things on tablets and phones, because everybody has a phone in their pocket almost entirely today. We're not all walking around with a PC. And part of the obstacle is that headsets are still expensive as the globe thinks about the economy. I say, oh, they're just $400. $400 is a lot to a lot of people, and it requires a higher end computer to run it. So, there's an economic barrier.

There is to a certain extent, a technology barrier, although those barriers are coming down rapidly. Part of the technological barrier is even, some people will find, certainly the people that I worked with in the disability community, couldn't wear a headset. And it might be that they had a muscular-skeletal issue where their head couldn't support the weight of a headset. For some, it was a claustrophobia. For many, it was motion sickness. And while they're doing lots of things to remedy all of those things, it's still a barrier to a lot of people.

And the final barrier has been one of content. So, building the content is an issue in terms of... The primary content creation to date has been in the game space. And although there are many companies blossoming that are creating content in other ways now, we're starting to see it being more widely adopted across industries, so people are using VR and AR in lots of creative ways right now that... Pre-pandemic and at the beginning of the pandemic, it was just really hard to find content that was easily accessible. At the same time, we're in this moment where, any minute now, we should be hearing that Facebook is about to get a new name because, famously, a couple of weeks ago, Mark Zuckerberg said they're moving away from an internet or a social media company to a metaverse company. And the metaverse is entirely about virtual reality. When you have the biggest social networking site in the western hemisphere saying, "We're moving away from social and into metaverse," I think it says a lot about the direction that technology is going.

Stephen Alexanian:  Right. That seems like they're trying to get toward the, if you've ever seen the movie Ready Player One...

Donna Davis:  Of course.

Stephen Alexanian:  Quick question. How close are we to, how many years would you say till we get to that point of everyone being Ready Player One? Not the chaotic outside, but within the virtual reality world.

Donna Davis:  It's hard to know. And Ready Player One, and a lot of reporting about virtual reality, is very dystopic. And this is one of the things that I, this is the drumbeat that I am always banging on, and that is one, virtual reality should be an augment to our physical world, not a replacement of. And we know that game addiction is now officially recognized by the world health organization. So, there are other questions about, how do we create a balance, a healthy balance, of digital and physical in a way that we don't ignore the world around us that needs us, including our families, our children, the environment, all of those other things that we need as a healthy culture, we can't abandon because the virtual world is more fun, more entertaining, more loving, more all of the things that we think of that makes it utopic, creates a dystopia.

I think we're very close to the potential of just about anybody being able to log in. And I see, if some people have their way, that that would be the preferred method of work, of communication, of relationships, of many of the ways that we as human beings connect and communicate. That this wonderful technology is going to open the world up to us and connect us in incredibly more powerful and supportive ways. And where some of that is true, the dark side is also true. If we want to go down Ready Player One, it's not far off.

Stephen Alexanian:  Okay. Gotcha. My last question is a two-parter. You mentioned some people experience cyber sickness, other issues, problems. What would be your main advice, as a researcher, to clinicians who are wanting to work with VR therapy or getting involved with it, and talk about their reservations for getting them involved with this kind of research, because not a lot of clinicians are actually trained in this area. And then what would you say to patients who are interested in this, but have reservations?

Donna Davis:  Okay. Couple of things there. And let me start with the clinicians who would be interested, and how do they go about it. Very interesting is that, in our NSF work with the disability community, many of these people, and we didn't specifically say that people had to have any type of particular disability, so we had people with both physical and invisible disabilities. We had people in our community that had bipolar disorder, or who had PTSD or depression. And we had several people who were in therapy due to their condition, and one of them in particular was diagnosed with bipolar disorder and PTSD. Her issues were very psychological, and that she had a therapist who worked with her, but independent of what she was doing in Second Life, her therapist had never been in Second Life.

And she went to her therapist and said, "I've created an avatar that is my young child self, my young teen self, my young adult self, and my current self." I think she actually had five different ages. And what she wanted to do was try to experience where her trauma occurred, to be able to work through it in and embodied way. And found that her youngest self was so triggered instantly that she had to log out, and she couldn't log back in for a month, so those are the risk parts of it. But she was doing it entirely on her own, not with professional therapy. But she'd go to her therapist and say, "This is what I did." And her therapist said, "If I weren't about to retire, I'd totally be about trying to figure out how to do this with you."

I think that, again, as we think about telehealth and the future of telehealth, and we think about the future of these technologies as therapies, that we have to look at the legal implications. What are we allowed to do and not allowed to do, legally, when it comes to therapy? And when I say we, I think of it as a researcher, and I have to go through IRB approvals. Anytime I'm working with people, we have to make sure that we do no harm. In the same vein that people that are offering professional counsel to these people obviously want to do no harm. They need to be exploring, what are the technologies that are already available, where their clients might even be? And how do we meet them there in a way that informs everybody in a really productive, safe way, and potentially very innovative and supportive.

Obviously, it won't be for everybody. When I was working on my PhD, so this is almost 14 years ago, one of the people that I met, one of the first people and friends that I met in Second Life, was a therapist who worked with the criminally insane. He was working with people who were hospitalized by virtue of the crimes they had committed. And many of them had suffered from pretty severe addiction issues with pretty severe drugs. And he said that he was working with some of them in game spaces, whether it was Second Life or in a game environment, and he found that they really were drawn to it in a way that potentially could be addicting or addictive. And at the same time, he said, "But if I can addict them to a game instead of heroin, I consider it a win." And this is 14 years ago. So much has changed since that time.

Similarly, one of the women in our community who was also getting therapeutic support, said that her therapist was concerned that she would get lost in the digital environment, that she would spend too much time there and be addicted. So, we have certain biases already built into our minds about the way we look at some of these technologies, especially from the dystopic perspective. And her therapist is basically scolding her about the amount of time she was spending in the virtual world. The woman in our community said she doesn't have a social life in the physical world. It's not like she's going to a restaurant and sitting on her phone during dinner. When she's at dinner, she actually is having real face-to-face conversations with people. Then, in the virtual world, they might go to work for that, or they might go to other events for that. This is where she would go for that.

I think that, for people that are looking at this space, that they need to really open their minds to its potential, rather than automatically discount it as a bad or evil space, which often happens. Understand where the patients are, and where you can think about these platforms as ways to augment experiences in productive, safe, and positive ways. And to also look at them with really critical eye, in ways that we protect the people that are there, so we don't become that dystopic Ready Player One, and we are replacing our physical relationships and world with the digital.

And I think it has immense potential, both in positive and negative ways. The more we all are looking at that with a critical eye to look for what are the goods, and then what do I need to do to protect the people so they can experience that good, is going to be really important.

I live in Oregon. It's well known as a wine country. And this is one of those things, that I've had people actually yell at me after presentations in conferences about the evils of these platforms. And my response has always been, "I live in wine country, and I do really enjoy a fine glass of wine with a good meal. It doesn't mean that when I open the bottle, it's the beginning of a three-bottle night every night." Some people are going to be prone to go that way. How do we put protections in place? Other people find it as a really fine experience on an occasion that can augment their life in really positive and wonderful ways.

Stephen Alexanian:  Gotcha. Do you think more researchers, last question, researchers should build their own company, like Oculus or something, to have more safeguards? Because we're basically trusting a lot of Facebook, these other big tech companies. Is there a way, do you think, that researchers can get more into this, that are independent from these companies? So, people don't feel as worried about the evils of Facebook.

Donna Davis:  Of course. And Oculus is the number one VR headset out there, owned by Facebook. And beginning this year, you have to actually set up an Oculus with a Facebook account, so they have locked you in. And a lot of people have pushed back against that and say, "Well, I'll use a different headset." And there are options out there. And there are other world builders out there. And there are experienced builders out there. There are companies today that new positions in the companies are Chief Metaverse Officer. They're saying, "We've got to be in this space." Especially as we look at Gen Z. The millennials, plenty, but Gen Z totally are growing up in these environments. We're way behind if we're not already thinking about those things. And there are big companies, like the biggest gaming companies, that are creating platforms for multiple uses.

I think that you'll have plenty options in the future. And I think it's really important to know who's hosting where you are. Are you creating your own space? And you certainly can do that. And I think, ultimately, it'll be much like subscription services as we experience them now, where you can pay to have a private environment, and keep it very exclusive to your space. But if you want people that are able to experience a blend of both the native what's already out there, and create a safe space, I think that finding a blend is going to be probably optimal, depending on your use and your audience.

And that's the other drumbeat that I'm always talking about, is what is the use and who is your audience? And so, the answer is going to be different in every single one of those cases. But any option is available.

Stephen Alexanian:  Thank you, Dr. Davis, for being with us, spending all this time. I'm sure our audience and myself are very interested in all of this and learned a lot. Thank you so much for being on this installment of the Interview Series at The Seattle Psychiatrist. Thank you.

Donna Davis:  My pleasure. Thank 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.

Psychologist Mark Leary on Self-Compassion

An Interview with Psychologist Mark Leary

Dr. Mark Leary is a Professor Emeritus of Psychology and Neuroscience at Duke University, and specializes in social and personality psychology.

Maya Hsu: Hi, my name is Maya, and I'm a research intern here at Seattle Anxiety Specialists. Today I am joined by Dr. Mark Leary, who is a professor emeritus of psychology and neuroscience at Duke University. He has made significant contributions to the fields of social and personality psychology, and he has also authored an article titled Self-Compassion and Reactions to Unpleasant Self-Relevant Events: the Implications of Treating Oneself Kindly, which is how I found Dr. Leary. Dr. Leary, would you like to introduce yourself and share how you became interested in social psychology and self-compassion?

Mark Leary: I've been interested in topics involving self-reflection, that is thinking about yourself, for a long time because the quality of our lives and our emotions and our behavior are affected by how we think of ourselves. And traditionally, psychologists have thought of that in terms of self-esteem. But more recently, in the last 20 years, the topic of self-compassion has become hot. And I just sort of tagged onto it and began to do work with my research team on self-compassion.

The difference is that self-esteem has to do with how you evaluate yourself. Do you evaluate yourself positively or negatively? How good do you feel about yourself? So everybody's familiar with the topic of self-esteem. Self-compassion is not a self-evaluation. It's how you treat yourself. Do you treat yourself well, with kindness and caring and understanding, when you have problems in life? I often like to describe it as compassion directed toward yourself.

Think about how you treat other people you care about when they're having problems and they're struggling and they're unhappy and they're anxious and they're depressed. You treat them with care and empathy and concern. The irony is that many of us, when we hit problems, we treat ourselves very badly. We're really mean to ourselves and critical to ourselves. We beat ourselves up in our own heads. And so self-compassion is an attempt to try to lower the degree to which people are mean to themselves and increase the degree to which they treat themselves better, treat themselves kindly and with concern.

Maya Hsu:  Great. Thank you so much. You answered my first two questions of what is self-compassion. It's self-kindness. And how does it differ from self-esteem, which is more of a self-evaluation. Which got me thinking, is it possible to have one without the other? Is it possible to have self-compassion without self-esteem?

Mark Leary: Absolutely. Think about it in terms of having compassion for another person. You can have a lot of care and compassion for somebody that you don't evaluate positively. Right? You might even dislike them, but you might be compassionate and try to help them and make them feel better and reduce their problems. A person with low self-esteem can do that to themselves. For the time being, maybe they don't evaluate themselves all that well, but that doesn't mean they have to be mean to themselves. They can treat themselves kindly. I also think there are some people with high self-esteem who treat themselves horribly in their own heads. They're very self-critical. They beat themselves up a lot. They evaluate themselves positively. They have high self-esteem. But they're not very self-compassionate. So these are two very distinct things. They are correlated because the more favorably people perceive themselves, the better they tend to treat themselves. But there's no necessary relationship there. You can have one without the other.

Maya Hsu: Okay. And I know this is true for me and a lot of people that I talk to in my life. Why is it easier to access compassion for others than ourselves?

Mark Leary: That is a really good question. I've been puzzled with that in my own life. It's occurred to me sometimes that if I talked to other people as meanly as I talk to myself in my own head, if I was as critical to them as I am to myself, I'd probably be arrested. I'd be sued for harassment. We harass ourselves in our own heads. And it is a puzzle because in many ways the average person cuts themselves a lot of breaks. There's a lot of research showing that we are nice to ourselves in some ways. But when it comes to self-criticism and catastrophizing and beating ourselves up, some of us are just not very nice to ourselves, and I don't have a good answer for exactly why that is. My hunch is it's because if we treated other people the way we treat ourselves in our own mind, we wouldn't have any friends. Our romantic partners would leave us. Nobody would want to interact with us. They'd say, "You're horrible. You treat me awfully." Some of us treat ourselves in exactly that way, but we can't leave ourselves. We're stuck with the person who is mistreating us, which is us.

Maya Hsu: Yeah. I wonder if part of the advantage of being self-critical is that it can act as a motivator for us to improve or work on certain qualities within ourselves. Is it possible to have that self-motivation without the self-criticism? Is it possible to have self-compassion and still be driven to work on oneself?

Mark Leary: I absolutely think so. And I want to make a distinction because you ask a question I've been asked many, many times, because the idea of self-compassion suggests to some people that we just should always be nice to ourselves, only say pleasant things to ourselves, never be negative, never be self-critical. That is not true. There are times that we have to evaluate ourselves negatively. That helps us regulate our behavior. So there's nothing, truly nothing wrong with negative self-evaluations, as long as they're accurate. If I mess up, if I fail or I make a mistake or I engage in a bad behavior or hurt somebody, it makes sense that I have to say, "I was wrong about that. I shouldn't have done that."

So negative self-evaluations are okay. Where they're not okay is when they are inaccurate. And so many people have self-judgments that are just far more negative than they really should be. So you want to have an accurate self-judgment. But the worst thing is that when you have a self-judgment, the question is, how hard do you need to be on yourself? How hard do you need to beat yourself up? And again, if you think about applying judgment to other people, if someone else has done something wrong... Let's say you're a parent and you're interacting with a child. It's perfectly okay to say, "You shouldn't have done that. That was a bad thing to do." But how badly do you need to scream at the child?

Well, the same question can be raised in your own head. Yes, it's okay to say, "Boy, I messed that up," or "I've got this problem I have to solve," "I lose my temper too much," whatever it happens to be. But how mean do I need to be to myself? And my guess is that most of us don't need to be nearly as critical and nearly as mean to ourselves as we are in order to stay motivated, because that negative evaluation is motivating at times. I've talked to many highly achieving people who just insist that their success is based on how badly they treat themselves when they fail. And I can see the truth in that to an extent. But I always ask them, "Okay, I agree with that. But how bad do you have to treat yourself? Isn't it enough just to know that you messed up and that you need to do better, or do you need to lie awake at night and feel badly about it?"

Maya Hsu: Yeah. It sounds like you're making a very clear distinction here between negative self-evaluation and meanness, because you can have one without the other.

Mark Leary: Yes. That's right. That's exactly right.

Maya Hsu: And you can acknowledge that you might have done something imperfectly or you might have harmed somebody without reprimanding yourself to the point where you feel awful.

Mark Leary:  Yes. And there's a couple of other considerations there. When you do something badly or something's going wrong or you're afraid of something that's going to happen, it's okay to think about that in a very concrete and specific way that focuses on the actual problem, the failure, the mistake, the bad behavior, the threatening event, to think about that very narrowly about, "Well, what can I do about this? What's going on here? How do I solve this problem?" The problem is many of us over-generalize from that thing, from that failure. Yes, I failed this test. But the thing I say to myself is, "God, I'm stupid. I'm always going to be a failure. I'll never amount to anything." You've taken one specific thing and you've blown it up, or you're rejected.

Yeah, we all have rejections. And yeah, that hurts, and it's a problem to be solved. But it's one thing to say “I was rejected.” It's even one thing to say, "I didn't behave as I should have in this relationship." It's another thing to say, "I am a horrible person who will never be loved by anybody." We over-generalize. So as we evaluate ourselves negatively, it's very helpful to keep those evaluations really focused and specific.

It's also important just to be able to solve the problem. I can solve the problem of doing badly on this particular test or taking care of one bad habit. I don't know how I would solve the problem of just being a loser or a failure in all areas of life or a horrible person. Those are just so global, there's no way to begin to solve the difficulty that started the whole problem.

So I think people need to be very attentive to how they talk to themselves in their minds because it makes their life worse. It creates negative emotions in ways that aren't beneficial. It's okay to have unfavorable evaluations if it helps you correct a problem, it helps motivate you. That's fine. But so much of this is not helpful. It just makes us miserable.

Maya Hsu: Yeah. I think you touched on a really important piece there, which is the accuracy of that self-evaluation and self-reflection. And I definitely have engaged in that globalized, fatalistic thinking where you do one thing imperfectly, and it's like, "Well, I suck at everything now."

Mark Leary:  And we all do. The challenges are the people who just get stuck in that mode of reacting to their problems, and those are the ones that really need to think about how do we deal with this in the long run.

Maya Hsu:  Right, because it can be very cyclical. And you can then enter into confirmation bias where then you expect yourself to do that in the next situation, and then it's just a self-perpetuating cycle.

Mark Leary:  Yes. Let me add one other thing. So far we've been talking about not being mean to yourself when you have problems, when you've done bad things or bad things have happened, to be less mean. But the other part of self-compassion is to actually be nice to yourself, do pleasant things for yourself. So often when we have problems, particularly if we feel like we have caused the problems, it's almost like we feel like we ought to punish ourselves and push ourselves harder and hold our feet to the fire. But that might be the time to be nice to yourself. And again, if you think of a friend who's really struggling, sometimes we'll say something like, "Hey, let's take the evening and go have dinner. Hey, let's talk. What do you want to do that would be fun? You had a bad day." We don't do that. When we have a bad day, that's when we push ourselves the most sometimes.

 This really dawned on me. I had a graduate student who was working on this. In fact, she's one of the co-authors on that article that you mentioned at the beginning. She went away one weekend to visit her grandparents. They were in their 80s, I think. And like all older people, they were starting to suffer some cognitive issues. Their memories weren't as good. They were clearly physically more frail and had health problems. But she came back very impressed by the difference in how her grandfather and her grandmother coped with those problems.

Her grandfather was a poster child for low self-compassion. He fussed and ranted about his memory is getting so bad, and he would criticize himself and, "I'm not strong enough to go out and mow the yard without stopping now. I just hate getting old, and I can't do anything anymore. I'm worthless." Her grandmother was a poster child for high self-compassion. What she said was, "Yeah, I've got good days and bad days. But when I'm having problems and my joints are hurting and I can't get around much, that's when I treat myself particularly well. I'll fix myself a cup of tea and watch the birds in the yard, and I won't try to push myself to get the housework done." And it was such a striking difference. And it wasn't just that the grandmother wasn't being mean to herself. She was actually treating herself more nicely.

And this student went on... they gave her the idea for her dissertation. She did three studies of self-compassion in older people, people 65 to 95 years old that we recruited as participants. And consistently, the ones who treated themselves more nicely, who were higher in self-compassion, were psychologically doing better. They were less anxious. They were less depressed. They were more healthy. It's the same kind of finding we find anytime we study self-compassion. You get positive psychological and physical outcomes. But it was particularly striking when I thought about it in terms of aging. And that was 20 years ago. I'm kind of more conscious about the psychology of aging now than I was 20 years ago when we first did that research. But I can understand the importance of self-compassion in that context.

Maya Hsu:  Yeah. That's an important point that it's not the absence of meanness, but it is the presence, the addition of self-kindness. And I like the anecdote. Thank you for sharing that. It reminds me of family members who berate themselves when they gain weight and that kind of thing, when they could access self-compassion and do something kind for themselves, which ties into the previous point of not having that motivator. I think that self-criticism is like, "Well, if I'm kind to myself after I've gained weight, then I'll just gain more weight."

Mark Leary:  Yes. But then again, that person who's gained weight and is unhappy with it knows they don't want to be overweight. They already have a motivator. They know they'll feel better and they'll look better and be happier. Do they need to go through their entire life until they lose weight beating themselves up? And the answer is no, probably not.

Maya Hsu:  Right. You touched on some of the positive effects that can accompany self-compassion, like better health and psychological well-being. How does that work? How does it moderate the effects of more negative events?

Mark Leary:  It does a couple of things. One is that it takes away that extra layer of negative self-evaluation and self-criticism. The average person thinks that their reactions to events are reactions to the events themselves in the world. So I have an experience or I do something and I feel bad about it, but that's sort of like a natural reaction. That's partly true. But so much of our reaction has to do with how we think about it and perceive it and think about ourselves and talk to ourselves. So self-compassion takes away that extra layer of negative emotion that occurs when you berate yourself, when you don't treat yourself nicely.

The way I often explain it to people is when you have a problem, you really do have a problem. Whatever that problem is, whether it's your weight or a bad habit or you failed or you were rejected, you have a problem. Why make that any worse than it already is? But we all do that. I do that. I don't want anybody to get the idea that I'm always self-compassionate. I'm not. I'm more self-compassionate than I was before I started studying this. I absolutely am. But still I have a problem, and now I'm going to make that problem worse just by how I talk to myself about it. So self-compassion takes away that extra layer of negative emotion, and I think that's why people high in self-compassion are happier. They are more satisfied with their lives. They rate themselves higher in serenity, even. Why? They don't pile the extra stuff on there. It doesn't make their problems go away, but it changes their reaction.

In one study we did with university students, at the end of the semester, we asked them, "What was the worst thing that happened to you this semester?" And we got a whole range of things, from very trivial things like "I lost my chemistry book" or something, to very serious, traumatic, life-changing events. But regardless of what we asked them— this worst thing that happened to you, how upsetting was it and how disruptive to your life was it?— And what we found is the students higher in self-compassion said that the worst thing that happened to them was less upsetting and less disruptive to their life. And they had the same kinds of problems. We thought maybe people high in self-compassion somehow have fewer problems. But we analyzed the content of the problems. That wasn't it. It was the fact they were not adding the extra emotional baggage on top of the original problem. Whether it was a lost book or a traumatic event, they weren't adding to the trauma of the situation through how they were talking to themselves.

So the big thing that self-compassion does is it takes away that extra layer of stuff. And then to the extent that you can treat yourself more nicely, it can actually make you feel better. When we're having a problem and a friend treats us nicely and takes us out to dinner, it doesn't solve our problem, but it does enhance our positive feelings because now we're doing something nice. So self-compassion just corrects for the fact that we don't treat ourselves as nicely as we should.

Maya Hsu:  So to clarify, it strips away the globalization thinking and the self-judgment and just kind of the inaccurate thoughts and the meanness. And that is what leads to improved health and improved cognition and better physiological benefits.

Mark Leary:  As a very general statement, that's true. I wouldn't quite say it strips them away because that sounds like they're never there anymore, but it reduces them to where they're not as much of a problem.

When it comes to health, there's some interesting research trying to understand why it is that people higher in self-compassion do show better physical health. They have fewer symptoms, and they just seem to be better... They have fewer stress reactions physiologically. We know that stress makes people unhealthy. There seem to be two processes by which self-compassion improves physical health. One is it reduces the negative emotions and stress. And we know that negative emotions and stress undermine health, interferes with the immune system, so it reduces the stress and unhappiness. But also, people higher in self-compassion take better care of themselves. If you think about that, when you care about somebody, when you're concerned with their wellbeing, you treat them better. And you would tell a loved one if they're doing something unhealthy, "Maybe you need to stop eating all that junk food, or, "Maybe you need to go and get a flu shot," or whatever it is. I think people higher in self-compassion are more likely to do that.

In the study of the older people I mentioned a moment ago, we found that participants higher in self-compassion were more likely to take daily multivitamins, even, which is really interesting. If you care about yourself and your own wellbeing enough, it not only leads you to treat yourself well and not beat yourself up, but you take better care of yourself physically.

Maya Hsu:  That's so interesting. It sounds like there's a certain sense of empowerment that you have to embody. You have to kind of step up to the plate and take ownership of yourself and be willing to treat yourself kindly, which takes effort if you've been treating yourself poorly your whole life, to take your multivitamins.

Mark Leary:  I've never thought of it that way, but that sounds accurate. For those of us, myself included, who were never particularly self-compassionate, it does take effort. It takes a change of habits to do that. I think some people somehow grew up just naturally being nicer to themselves, and I envy those people because they don't quite have these struggles. I have talked to people who just are kind of puzzled. They say, "Why would anybody be meaner to themselves than they need to be? I've never done that." And that amazes me. That's great though.

Maya Hsu:  In your years of studying this, what have you seen are the biggest barriers to people sort of shifting into a more self-compassionate mindset?

Mark Leary:  I think the biggest one is something we've sort of talked about indirectly, and that is, people are afraid that if they're too nice to themselves, they'll turn into slackers. Because it does sound like if you're not careful that self-compassion is something where no matter what happens, you go, "Well, that's okay. No, I'm fine. Oh, I did this horrible thing. Well, that's okay. Everybody does horrible things." But that's not what it is. You still take your behavior seriously. You just don't add that extra layer.

And there are some studies that show among university students, higher self-compassion students take more responsibility for their bad behaviors. Like after failing a test, students higher in self-compassion take more personal responsibility and then work harder before the next test. And that might seem counterintuitive because it sort of sounds like if you're nice to yourself after you fail, that's sort of like you're taking yourself off the hook. Why would you go ahead and work really hard? And I think it's because if I don't beat myself up, I'm not adding a lot more negative emotion to the whole situation of failing that would lead me to avoid the whole thing. If I'm really, really mean to myself, my life is a wreck when I fail, and I just sort of tune out. And I say, "Well, there's nothing I can do about this." And I pull back, and I over-globalize and I can't fix this problem. But if I can accurately say, "No, I didn't do very well on this, and I'm not going to make a big deal out of it, but I'm going to do better in the future," it actually increases students' motivation.

So I want to encourage anybody who says, "I'm afraid to be self-compassionate because I'll turn into a loser or a bad person, who just will do anything and not worry about it.” That is not what happens. When you're compassionate towards someone else, and they have done something bad or they have failed, you don't tell them, "Hey, that's okay that you failed. Don't worry about it. Don't try to improve." You would never say that. Or if they did a bad moral behavior, you don’t say, "Well, that's fine. That's okay. You stole the money. Who cares?" You don't do that. And we don't do that to ourselves. We know how we're supposed to act. We don't cut ourselves that much slack.

Maya Hsu:  Yeah. It does seem a bit surprising at first that people with self-compassion after failing a test would work harder and achieve higher the next time. But it does make sense when you break it down because when you do layer on all the judgments and it becomes this insurmountable task, then it would definitely make sense that people would just give up.

Mark Leary:  Yeah. That's right.

Maya Hsu:  Yeah. Let's see. How might someone journal self-compassionately for anxiety management, or just use self-compassion for anxiety specifically?

Mark Leary:  There are writing exercises out there, including journaling exercises that help promote self-compassion. And I think what those kinds of exercises are useful for are two things. One is,  if a person wants to change unhealthy habits... And low self-compassion is just an unhealthy habit. It's changeable. It's just a pattern that we get into in how we think about ourselves and think about the bad things that happen to us. The only way to change a bad habit is to begin to really monitor yourself for cases in which you do it to understand, when do I do this thing? Why do I do it? What form does it take? And journaling, in which you analyze your day in terms of how you talk to yourself about the things that happened, particularly after a bad event, I think is really beneficial in terms of just opening people's eyes to how much they really do this. And that's the first step. So journaling is beneficial just in terms of alerting people, putting them in touch with how they're talking to themselves.

The second thing then is you can begin to journal in ways that promote your own self-compassion, or do writing exercises of other kinds. There are exercises out there, for example, where people are told to give themselves advice about a problem the way they would give that advice to somebody they really cared about, with kindness and concern and compassion. In fact, write it in the third person. You're writing it to yourself as if you were somebody else. And that's often eye-opening to people to realize that “the advice that I would give somebody else for how to deal with this is very different than the advice I've been giving myself in my own mind that's making me so miserable.”

So there are ways to begin to give yourself advice. If there are personal characteristics that a person has, they dislike a lot, and that's making them beat themselves up for whether it's academic or intellectual or personality problems or social problems, you can do the same sort of thing. What would you say to someone else who had these characteristics, somebody you cared about? How would you talk to them about these shortcomings that you think you have? And again, you wouldn't deny them to somebody you cared about when they realize they're having problems in school or something like that. But you would talk to them about it in a proactive, healthy, somewhat positive way.

I would recommend to any listeners who want to try different kinds of exercises, whether they're writing exercises or exercises that you do just in the course of everyday life, there's a website, self-compassion.org, self-compassion hyphenated.org. This is the website of Kristin Neff, N-E-F-F, who started the study of self-compassion in psychological research about 20 years ago. If you go back through the research literature on self-compassion, you can't find the term in psychology until Kristin's groundbreaking work. She developed the idea, developed a scale to measure it. And she's got a fantastic website at self-compassion.org that has, last time I looked, a couple of dozen exercises and lectures, little lectures, five minutes up to 20 minutes, along with a number of different exercises for people who want to begin to explore, how do they promote their own self-compassion a little bit more. Kristen's great at doing this stuff. She's been doing self-compassion workshops around the country for years now, and she can give you a lot better advice about how to deal with low self-compassion than I can. Self-compassion.org.

Maya Hsu:  Awesome. Thank you. Okay. And can people acquire trait self-compassion, or is it only possible to acquire state self-compassion over time?

Mark Leary:  Okay. Let me define those terms for your listeners first. When psychologists talk about people's characteristics, they often make a distinction between a trait. And a trait is a general tendency. So there are some people who have a general tendency to be low in self-compassion. We would say that's trait low self-compassion. There are other people who have a tendency to be high in self-compassion, high in trait self-compassion. It doesn't mean they're always that way, but if you look at them over a period of time, across different situations, yeah, we lean in one direction or the other. State self-compassion refers to how self-compassionate am I behaving at this moment. In this particular situation at this particular time, am I treating myself with self-compassion?

And there's obviously a relationship. People high in trait self-compassion are people who engage in state self-compassion more frequently. But there are some people... And I would put myself here. I think I have emerged as a person high in trait self-compassion after working on this, but I still can be really low in state self-compassion. Sometimes I just lose it over that stupid thing I did because I'm an idiot and a loser, and I don't know that I'll ever amount to anything. The thoughts just start running.

So the question is, can you change? In a state way, it's not all that difficult now and then to catch ourselves. In that moment, we can say, "I'm not going to engage in this low self-compassion stuff. I'm going to treat myself nicely." That is not all that difficult to do from time to time. The bigger question is, can a person who generally does not treat themselves well, a person low in trait self-compassion, ever become high? The answer is absolutely yes.

People just need to realize, again, this is a habit. We all have habits, and we can change habits, including unhealthy and bad habits. This is a way of thinking that some of us have developed— who knows how. There's not much research on this. By the way our parents talked to us, perhaps, the way people taught us to think about our problems and mistakes and bad behaviors along the way. Maybe some of us just drifted into it, started not being very nice to ourselves. But regardless of where it came from, we can always change bad habits by beginning to monitor them, by doing exercises, by accepting the fact that we're going to fail at this from time to time.

You're never going to be always high in self-compassion. There's nobody on the face of the earth who never criticizes themselves unnecessarily or beats themselves up. That's fine. What I tell people is what you really want to do is just reduce this a little bit. It takes the edge off of life if you can just reduce your negative self views, your beating yourself up, not being nice to yourself, by even 15 or 20%, for example, your life will improve.

So yes, this is changeable. And again, I'll refer people to Kristin's website as a good way to start to really understand self-compassion, to monitor how they're treating themselves, and then to start taking steps through exercises to try to become more self-compassionate.

Maya Hsu: I think that's very encouraging to think of it as a habit that can be changed and worked on through practice. Is there anything else that you would recommend for our listeners about self-compassion just broadly?

Mark Leary:  There are probably some people listening who right now are beating themselves up for not being sufficiently self-compassionate, because I do that sometimes. It creeps in through the back door, low self-compassion and this meanness that we have for ourselves sometimes. So just cut yourself a break. Accept the problem a little bit more. It doesn't mean they're not problems.

I always want to make the point as well, sometimes if you're not careful, what sounds like high self-compassion is trying to tell yourself you don't have problems. It's like it's positive thinking. Self-compassion is not positive thinking. I'm not a big fan of positive thinking, in fact. I am a fan of accurate thinking because being too positive can create almost as many problems as being too negative. So it's not just telling yourself happy stories. It's not just being optimistic about the future for no reason. It's not building up your self-esteem artificially. It's not telling yourself that you can do anything you put your mind to, because that's not true. All it is, is not making your life worse by treating yourself badly. It's not just positive thinking. It's accurate thinking and not being mean to yourself. And when you look at it that way, it shouldn't be that hard. We're nice to other people. We have a lot of experience being nice to people. Why can't we be that nice to ourselves? That's what self-compassion is about.

Maya Hsu:  That made me think of one last question I want to ask you. With failing a test and with gaining weight, those kinds of measures are more objective. But with the situations that are a bit more ambiguous, maybe social situations where people might feel like they failed, but it's hard to know for sure, how does one access accuracy in those situations?

Mark Leary:  Wow. That is a really, really, really good question because we all know that there are times in which we misinterpret what has just happened in the situation, whether it's a social situation or a romantic situation, or it's just me working in my yard and I mess up something and cut down the wrong tree. What happened there? And I don't know. I think the best thing is just to be aware of the fact that the beliefs we have about ourselves and our behaviors and the causes of what happens to us are partial and sometimes incorrect. They certainly don't feel that way. We believe that we understand what has happened to us and why it's happened. And we have to go on those beliefs. We just can't sit and say, "I don't know why anything happens."

We do infer things correctly sometimes. I just encourage people not to take their judgments and their beliefs about themselves too seriously as if they're completely accurate, because everybody knows they're not. Everybody could think of times in which they misjudged a situation or they misjudged themselves. One question you could ask yourself is, “how sure am I that this was my fault?” And there's often a little bit of ambiguity there. So there's no good answer to your question in terms of how do we increase our accuracy except to be open to the possibility that we're sometimes inaccurate and be able to live with that.

Some people would be paralyzed by uncertainty. How do I know what to do? I don't know who I am or why I did this or what happened to me. That's not it. You have to go ahead and make behavioral decisions, but just don't be too certain that you think that this social event went badly and everybody thought you were an idiot. Was that true? Maybe not. We know that people sometimes overestimate negative situations. Our threat detection system is on high alert. And all animals are made that way. They're more likely to treat something that's not dangerous as something that's threatening and risky than they are to treat something that's dangerous as safe. And we do that throughout life, throughout our jobs and our social lives and our family lives and our academic lives. We put a negative reading on things. And that's adaptive because it makes sure we don't miss anything bad, but it also is a downside because it makes us react to things as if they're bad that aren't really.

Maya Hsu:  Yeah. So there are some situations where it's kind of ambiguous and unclear, and that's something we have to accept. And it sounds like what you're saying is that in those situations, the best thing we can do is just be on alert for inaccurate thoughts and judgments and just to not engage in those. And then what's left is kind of the more accurate ambiguous truth.

Mark Leary:  You said that better and more concisely than I did. Very good.

Maya Hsu:  Collaboration. A collaborative effort. Well, thank you so much for joining us today, Dr. Mark Leary.

Mark Leary:  Well Maya, thank you very much. I've enjoyed it. I hope it's been helpful.

Maya Hsu:  Definitely. It was wonderful to have you.

Mark Leary:  Thanks.

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.

Rev. Tim Burnett on Mindfulness-Based Stress Reduction

An interview with Reverend Tim Burnett

Rev. Tim Burnett is Executive Director, Founder, and guiding teacher at Mindfulness Northwest.

Jennifer Ghahari:  Thanks for joining us today. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I'd like to welcome with us, Reverend Tim Burnett, executive director, founder, and guiding teacher at Mindfulness Northwest. Tim has been a teacher of mindfulness-based stress reduction since 2010 and a mediator since 1986. Before we get started, can you let us know a little bit more about yourself and what made you interested in mindfulness?

Tim Burnett:  Sure. Yeah. I stumbled into Buddhist meditation as a young man, and I found it helpful. I didn't really have language for it. I was a bit shy about it. I didn't really tell my friends. I was going quietly off to the Zen center early in the morning on my way to college classes and so on. And then, I relocated and just by happenstance ended up helping to form a group that became a Buddhist center. And meanwhile... The practice of it, somehow it met some need that I couldn't meet any other way, stabilizing, soothing, provided some sense of purpose and meaning that I needed. But I always saw it as specialized unusual thing and a little weird that not that many people would be into this kind of thing. But I was. So, okay, what the heck? In the meantime, my career was just going left and right and center and not really landing anywhere. I was a field scientist for a while. I became an elementary school teacher. I worked in technology. And nothing was really quite landing.

And then I started in about... I don't know... 2007 or 2008 to notice mindfulness starting to show up on the media more. And of course, now, it's a lot more than then. And a friend of mine was involved in a project at the Seattle VA Hospital to bring mindfulness-based stress reduction training to veterans with PTSD, Gulf War Syndrome and some pretty serious conditions. And I somehow got involved in that for a little while and started teaching these classes and found a lot of resonance with what I had personally been experiencing in Zen Buddhism, but delivered in contemporary language, really accessible to people who probably would never walk through the doors of the Zen Center.

And, I was amazed just how much it seemed to help people and starting with this group of vets. A few of them were actually Vietnam veterans and suffering from the effects of PTSD and the trauma of the wars for 40, 50 years. And here they were in the second or third class that I was somehow facilitating and reporting lots of shifts and changes and feeling excited, feeling positive, understanding emotions a little differently, and sleeping better. Yeah. So, I was hooked from there. And then I got curious, could I do more than just one project?

So I started an institute like the Paul Simon song says. It was the right place, the right time and the right level of persistence, started getting institutional interests from county government and medical schools and university, and then started offering community classes. And it just unfolded from there. So, now there is 11 people on staff, some of them part-time. And we are about a half a million-dollar organization, non-profit, fee-for-service, with some donor support. And we've been offering these trainings to thousands of people up and down the Puget Sound region, and now, of course, online. So yeah, that's how that came to be.

On a good day, I take a little step back and I'm amazed. Like wow, how could this even be happening? It's such a new field, but it's been increasingly accepted. One thing I've noticed over the years is the people who come have shifted from an earlier attitude, which was like, "Well, this is a little weird. But maybe, okay, I'll try it. Ya know, I'm stressed." Now people are like, "I know I need this. How do you do it? I don't know how to meditate. How do you do this?"

So it's interesting, at least within some segments of American society now, it's just understood in a way it wasn't before that stress is harmful and we can't just push through all the time. We need some other tools, other attitudes, other ways of being. So, yeah, it's been really exciting. Yeah.

Jennifer Ghahari:  Great! So, can you explain what the mindfulness space is and how is mindfulness important to one's life?

Tim Burnett:  Well, mindfulness is a term that just helps to point at an ordinary thing that we do all the time, but we do it pretty automatically, which is that we're navigating in a really complex, perceptual, biophysical, psychological field all the time, right? And moments are happening. Moment after moment is happening. And somehow, we're selecting which moments to pay attention to, which is attention itself. We're responding to them in certain ways. We're influenced by our history, conditioning and culture in certain ways. But, we're so busy often, and often lost in some conceptual stuff that we add to everything, kind of lost in our heads, that we miss a lot of opportunities to see things a little more clearly, to respond to things a little more creatively, to be more aware of the felt sense of what's happening moment to moment, and whether we're adding to our own stress with habituated patterns or whether we're finding different ways to cope that are more adaptive to the current situation.

Like one quotation we like that describes the space as it was a good question, is a quotation attributed to Viktor Frankl. And the quote is, "Between stimulus and response, there's a space. In that space is our power to choose our response. And in our choice is our growth and our freedom." So, it's dialing it way down, and we're... Of course, that's where we are. We're always happening now. But our mind is about, "How am I going to deal with it this time? Do I have time to get the kids after work? Oh my God, did I remember that?" Right? So, there's a way that our incredible minds, which can construct past and future, useful, but also, we get lost there, and we lose track of what's happening now. And we live in an autopilot mostly by habit.

And so, yeah, we talk a lot in our mindfulness courses about how all these things are useful; I’m not saying otherwise. We need habits. That's how we assemble a bunch of tasks and do things without thinking about it too much, right? But, when life becomes all habit and becomes all anxiety and depression, what are we missing, and the mindfulness trainings help us feel that space that he's talking about in that quotation. "Oh, maybe it's not, maybe it's this? Oh, wait. Okay. I can do it this way. Wow." And often there's quite a bit of relief from stress, from anxiety, from certain conditions that lead to depression through just being more present. And there's some interesting science around how people when their minds wander less, they tend to be happier. They tend to be more resilient, more engaged.

So, yeah. It's just like putting some more of the focus on the process of living because we have so much training and education in the content and skills and stuff to do, and then all this societal pressure to buy more stuff and do more trainings and get more-busy, right?

Jennifer Ghahari:  Right.

Tim Burnett:  So, mindfulness involves remembering that there's a brake pedal down there too. And even though the gas pedal gets stuck down, we can tap the brakes and say, "Oh." So that's what we mean by space in mindfulness.

Jennifer Ghahari:  You had mentioned that you're trained in Zen Buddhism. And, a few weeks ago, I had a chance to interview the Venerable Thubten Chodron of Sravasti Abbey in Washington state. And we spoke about meditation, anxiety. And, I see that there seems to be some type of connection between Buddhism and stress reduction. And can you explain what that connection is?

Tim Burnett:  Sure. And that's great that you got to speak with her. She's a real leader in that world.

Jennifer Ghahari:  Yeah. She's great.

Tim Burnett:  Yeah, amazing person. Well, what we're now calling mindfulness is a coming together of several different strands. And one of those strands are the understandings from traditional Buddhist meditation about the value of this present-centered awareness and a whole set of tools that help people to park that busy mind and reengage with what's happening now. And so that's modern mindfulness has married that with positive psychology, looked for support for it from neuroscience, sprinkled in some poetry to soften and connect people in the way that great literature and arts can do. Some philosophy. And so, yeah, it's just that Buddhism is one of the deep roots of it.

What's nice is that Buddhism actually is a religion in addition to having all the elements that we're speaking about here. And so, mindfulness is presented in a contemporary non-religious way so you don't have to worry about what you think about Buddhas or bodhisattva or rebirth or anything like that. It's about, yeah, well, there's some support from a deep tradition. People have been trying stuff like this for thousands of years. And we're doing it in a way that we feel is applicable and relevant to modern society. So, yeah, we use language like attention, stress, planning, worrying, returning to the present, just ordinary language for an ordinary thing. But, it's also in a way not ordinary because when we really engage more fully in our lives, we remember in a deep way how amazing it is to be alive.

How amazing that this organism can do all the things it can do. So, Buddhism has that enthusiasm for the incredible potential of human life. But Buddhism expresses it in a certain socio-religious context and we express it in a more everyday context. Like, “Yeah, life can be hard.” We got to really recognize that and feel that, which is really coaching with what Buddhism calls the first noble truth, that condition life has this element of suffering and stress. But then, where we go with that in modern mindfulness is, and we can really feel and understand and experience that it's also wonderful to be alive - even with pain, even with anxiety, or even with depression. There's a joy there that we can access.

So, yeah. I don't know. I feel like they're roommates from different cultures or something like that.

Jennifer Ghahari:  Yeah. That's definitely. So, at Mindfulness Northwest, you teach mindfulness-based stress reduction. So, what is that exactly? And how is it practiced?

Tim Burnett:  Sure. Yeah. We offer mindfulness-based stress reduction and then a whole suite of classes that are in that same kind of modality. So, mindfulness-based stress reduction and the acronym often gets used MBSR, that pops up a lot, it's an eight-week course on mindful awareness and stress resilience with everyday components like bringing mindfulness to perception, bringing mindfulness to communication, bringing mindfulness to understanding of stress reactivity works, and bringing some of the science of stress reactivity forward in a way that we can use for ourselves. And what mindfulness... Excuse me. There we go. I failed to silence my phone. The first thing I told people to do in mindfulness class. (laughs)

So anyway, that class was actually created by one of the pioneers in this work, a fellow named Jon Kabat-Zinn in the late 1970s, really early. And, it's remained pretty consistent from his original vision. But what I've done and with my colleagues at Mindfulness Northwest is that's a wonderful course we offered multiple times a quarter to the communities... When there's not a pandemic... in communities from Bellingham to Olympia, and also online. But we realized that that's a pretty big commitment. It's an eight-week course. It's a long evening, eight weeks in a row, and there's a Saturday session too. So, we really have a lot of hands-on time to do these practices deeply. And not everyone has time for that. So, we also have a shorter five-week version of that that's oriented towards healthcare professionals called Mindfulness for Healthcare Professionals.

We have two-week introductory workshops. We have two- and four-hour topical workshops. So, we started with that framework and brought out different pieces of it to make it more accessible. And we also offer a second eight-week course called Mindful Self-Compassion, which builds on that sense of the power of present-centered awareness to also cultivate more kindness and more emotional understanding. So that's also a wonderful course. We offer that every quarter as well. So, it's a whole suite of programming and it's... The MBSR, mindfulness-based stress reduction course is like the granddaddy of the program, but we have gone beyond that.

Jennifer Ghahari:  Oh. So, can you tell the audience what's something that they might learn in an MBSR course?

Tim Burnett:  Mm-hmm (affirmative). Yeah. You might be surprised to learn that even though the things that are happening in life can be stressful, there's all kind of little ways that we can take a stressful thing and make it worse. And that, we can actually notice that with some simple mindfulness tools and switch it and turn that down and respond differently. And actually, here's another area of little bit of Buddhist crossover, I often quote as Buddhist story, which is worth telling, it's pretty brief.

Jennifer Ghahari:  Yeah!

Tim Burnett:  Yeah, great, which has the Buddha recommended and we do too in mindfulness that life does include inevitably difficulties and trying to pretend it doesn't serve us, right? There's a certain kind of approach orientation we needed to show up in life. And the Buddha told the students that when life hits you with one of those difficult moments, it's like you're hit by a dart or an arrow. And it’s painful, right? Whether you stub your toe or your boss yells at you, or somebody cuts you off, these are painful moments. Or you feel really anxious and worried, these are painful moment.

So the Buddha recommended learning to just really show up and feel and experience those directly. Sometimes, you've experienced them directly and feel them. They just pass on again. They don't always stick in the same way we think they do. But then he said, and here's where I'm getting to the point is, "But then we have an incredible propensity as human beings to then throw a second dart at ourselves." Why did that happen? That shouldn't have happened. Whose fault, is it? Is it my fault? Is it their fault? They should know better. This should be set up differently. This should be organized better.

And what we're doing there is we're taking something that may be difficult, maybe it's a mild difficulty, and we amplify it, and we make it worse. So, we have a way that we generate our own stress. And, it's hard to be aware of that when we're just moving so fast. So, one of the things people experience in the MBSR course is, here's a framework and a lot of community support. We really work together as a group and a support from a teacher to slow down and notice what really happens. What really happens when I get a grouchy email from such and so. If I'm in next minute like “ahhhh!” writing an angry reply, what does that do to me? I already knew it didn't solve the problem with her, but what does it do to me?

And so we learned to take a breath. We learned some body awareness skills that help us to be more in touch with how I'm feeling, which is a little different thing from the story. “She sent me an angry email. She sucks” is different from, “My stomach's tight. My face is scrunched. I'm angry.” And that noticing of the experience below the storyline can be so liberating. It can help us get back into that space that the quotation is talking about. Here's a stimulus. That email I perceive as nasty and here's a moment to notice, "Okay. This got something. (breathes out) How do I respond? And here's my response." And maybe I do it differently this time or maybe they have it patterned so strong, I do it anyway. But at least I know I did it. So, it's that growth of awareness that really is, I think the mediator of the stress reduction of this work. It's just we notice better what we're doing.

Jennifer Ghahari:  Right. “Taking a pause,” it sounds like.

Tim Burnett:  Right. Exactly. We have a whole suite of ways that we strengthen our natural ability to take a pause that we forget how to do when we're so busy.

Jennifer Ghahari:  Great. So, what is mindful self-compassion?

Tim Burnett:  Mindful Self-Compassion is another eight-week course, very similar structure, eight evening or afternoon courses, and then a day session to practice the hands-on skills. It was created by a pair of psychologists named Kristin Neff and Christopher Germer. It's a more recent thing that created somewhere around 2000 or so. And they were really interested in how do people treat themselves that most of us are conditioned to be very good at serving others, helping others, paying attention to others, kind to others. But if we really tune in using these tools of mindfulness to our own self talk, our own behavior towards ourselves, we're often quite hard on ourselves. And so, they developed psychological measures of self-compassion, and found that it's pretty low. And that, based, again, on a mix of Buddhism and psychology, that they could devise practices, exercises, including psychodynamic and psychoeducational exercises to help us understand our emotions and our pattern that we can just learn to be nicer to ourselves. And that there are a lot of benefits from that. And they aren't just self-focused benefits.

Then, we're actually able to be kind and compassionate to others in a more sustainable way. There's a way that our helping is often exhausting because we're not really that aware of what we're doing. It's also another habituated thing. So yeah, in both classes, the MBSR and MSC, mindfulness-based stress reduction and mindfulness self-compassion, they involve a lot of reflection, a lot of conversations, a lot of exercises, where we're doing something a little differently with their mind. Some of them are rooted in meditation. Some of them are other modes. And they just help us take a fresh look at, “Who am I and how do I work?” And are there areas where I can make some little shifts. And oftentimes, people discover over time a little shift leads to a big change. I'm curious if that's been your experience supporting people with anxiety too?

Jennifer Ghahari:  Yeah, definitely. Like you said, just learning different habits and working on them, one habit leads to another. And then, there are vast improvements that happen over time.

Tim Burnett:  Yeah. Yeah. Exactly. Another thing that's neat about these courses is their group interventions. So, they're a little a more affordable, a little more accessible. And as I'm sure you do too, we're trying to provide skills and practices that people can continue well beyond the course, well beyond the intervention so that they really can have this as a lifelong support. And most people that we... We don't do very systematic follow up, but the bits of follow up we've managed to do, most people do continue. Most people, if they find it helpful, they keep doing this stuff and it helps them.

Jennifer Ghahari:  You had mentioned about how groups can be helpful. Are there any other benefits to doing this or any pros or cons to doing this type of class in a group as opposed to one-on-one?

Tim Burnett:  Well, yeah. The advantage of it and the disadvantage of it is you have to be pretty vulnerable because this work is inherently so personal so you have the wonderful safety when there's a strong therapeutic relationship in a one-on-one intervention. And so, we really work hard and I think do usually pretty well creating a little model learning community in our classes. We talk in the first weeks about ways to be safe together, how to hold confidentiality. We are especially careful about not giving people advice or trying to fix them, that each of us is here on our own journey. And then the incredible advantage there is if you're with a group of people who are able to be vulnerable and open about their situation, then there's so much learning from each other. And yeah, one example I will never forget as I was working with the veterans at the Seattle VA Hospital, and there were several with pretty extreme physical complaints. And so, they were talking about how painful every day was. But they were trying to apply mindfulness and it was helping them.

And four weeks in this, one fellow, but I don't think he really spoken before said, "You know, I've got severe depression. And I've been listening to you guys with all your back pain. I don't have back pain. And you know, if you can really get into this mindfulness thing, and if you can stick with it with all that pain, I can stick with it too with my heart, with my sad, my dark moods and my depression and how upset I am all the time. I can stick with this. And I can feel that it's helping me."

Jennifer Ghahari:  Wow.

Tim Burnett:  Yeah. So, there's a way people with different challenges and different conditions can offer each other a really genuine kind of modeling and organic support. And sometimes specific really helpful ideas like, "Oh, I'm not giving advice. But I've learned to navigate this aspect of my crazy mind in this way." And someone else say, "Oh! I never thought of that." So, yeah, there's a lot of lateral learning and community learning. But yeah, the challenge and the joy of that is that we have to be pretty open and create an environment where that's safe to do. And usually that works fine. Sometimes people realize it's too much for them and we try to be really graceful and supportive. And from the get-go we say, "This is not for everybody. This is not for everybody."

Many, many people have been benefited from this lots of different ways. And there's good scientific evidence as well. But, a few weeks in you might realize this is too much and that's fine. We give them a refund and some of them on their way with love. And, “Maybe later” right now. So yeah, it has been really a core thing from the beginning that it's not just a group, but also a heterogeneous group, people with lots of different backgrounds and conditions. And I'm happy in Seattle, especially we've got more and more diversity in our classes. So, I think we're also, in some small way, part of the bigger conversation about the tremendous diversity that we need to acknowledge and understand and own in a stratified society.

Jennifer Ghahari:  Well, the fact that it's heterogeneous, I think there are differences. But the fact that you feel that you're not suffering alone will help too, right? Like you said, especially for the veterans, they were all suffering in slightly different ways, but all feeling that they had some type of shared community, helps.

Tim Burnett:  Exactly. Exactly. That's well said. Yeah. But there's a way when we think, “It's just me” the stress and the fear and the anxiety, or whatever it is for us is so amplified like an echo chamber. And there's an aspect of self-compassion that they called common humanity, which is what you're saying is so powerful, the sense of common humanity. We all, even... And I try to be as straight and vulnerable as I can be. I mean, I'm overall pretty privileged and have had a pretty protected life. I had to work hard and everything. But, I suffer, you suffer, everybody suffers. And so, if we really can feel that in a genuine way where it's not just words, but it's like we're really sharing from the heart, then, yeah, it's such a relief.

And you can watch people in the room, their shoulders drop, their faces relax, they're, "Oh. It's okay to be this way, huh? Wow." Yeah. And you wouldn't think that because we're so programmed to think in terms of problems and solutions, right? That's not a solution exactly. But it changes the whole perception of the problem, which is a solution. So, it's funny.

Jennifer Ghahari:  Well, right. Great. So do you have any other advice or recommendations for our listeners or anything else that you'd like to share?

Tim Burnett:  Yeah. I mean, if this stuff interests you, I just really want to encourage you to try it. And there's so many different levels of trying it that are available now. There are all the meditation supporting apps out there. You can try there. And nobody has to know. I was so shy and private about this when I started. So, I relate to that, and wouldn't want to show up in a big center or a class until you know what it is. So yeah, you can try a meditation app. And Mindfulness Northwest and other groups, we offer introductory workshops. So, it's less of a commitment. Or maybe something about this just rings your bell and you want to jump in and go for it; we welcome that too. Even our eight-week classes are designed for people who are new to this. We walk you through step-by-step.

So, yeah. If you haven't tried it, it's just a little different way of being in your own skin. And it's still you. It's not like you're taking on some weird thing from somewhere else. But it's a support for... I don't know... remembering who you are in a certain way, pausing and reconnecting, rebooting if a computer metaphor works. So, yeah. I just recommend giving it a try. I always tell people, like I said before, it may not be for you. But how would you know, unless you tried it?

And it's very experiential. That's the other thing. This is not thinking our way out of our problems. It's about doing something different with body and mind, but then, opens up some new possibilities. So, it's, yeah, stuff you have to try. It's like just thinking about a restaurant menu doesn't taste like food, and watching ski videos doesn't make you a great skier, although it might help. You have to actually get out there and do it to find out what it is.

Jennifer Ghahari:  This is something that anybody can do, right? I think maybe some people might be hesitant to thinking that, "All right, if I'm Christian or Jewish or Hindu, maybe I shouldn't be doing this?" But it's something that anybody can do, right? Because mean you're prescribing to a certain religion.

Tim Burnett:  Yeah. There's no beliefs or anything like that required. Yeah. It's very... The word secular isn't quite right, but it's not hinged on any particular belief system. And it's all about like try this and see for yourself. But, since it's a little different than what we usually do, you need a little support and structure and guidance to actually even try it. So, you got to get in there and try it. But then, yeah. It's available to everybody. When we work with people sometimes who have some pretty challenging internal conditions, like social anxiety disorder or severe depression, they reach out to us and we support them in trying it out. If it doesn't work, it doesn't work. But, I've had people with those kinds of conditions, both find it incredibly helpful, like a whole new life. And also, tried it out and say, "You know what? Too much." That's fine too. Maybe it's just not the right time.

Jennifer Ghahari:  Mm-hmm (affirmative). You won't know until you try.

Tim Burnett:  Exactly. Exactly. Yeah.

Jennifer Ghahari:  Well, Tim, thank you so much for joining us and being part of this project. And we look forward to hopefully speaking with you again in the future. And, thank you again.

Tim Burnett:  Thanks a lot, Jennifer. What a pleasure to talk to you about this.

Jennifer Ghahari:  Great. Thank 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.

Psychiatrist David Neubauer on Insomnia & Anxiety

An Interview with Psychiatrist David Neubauer

Dr. David Neubauer is Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University and an expert in sleep medicine.

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 Psychiatrist David Neubauer. Dr. Neubauer is Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University. He's an expert in the field of sleep medicine and has written several articles on the topic, including: “Understanding Sleeplessness: Perspectives on Insomnia” and “Pharmacologic Approaches for the Treatment of Chronic Insomnia.” Before we get started, can you please let us know a little bit more about yourself and what made you interested in studying insomnia?

David Neubauer:  Sure. I guess going back to my brief history, I just always was interested in the brain and the mind as a teenager, even. And I used to cut out articles out of the magazines about all sorts of brain-related activities. And so, I came upon articles about sleep, and this was a long, long time ago. And so, I remember cutting these articles out of these young sleep researchers who decades later, I actually got to know later on. In any case, I guess my interest in sleep was sort of latent for a while. I went to college, got interested in lots of different things, anthropology in particular. So, I got a master's degree in anthropology down in Florida. Decided that I would work towards a PhD so I came up to the northwest. So, I went to Vancouver. I studied at University of British Columbia for a year.

And then despite the fact that it was heavenly and I was really interested in what I was doing, I sort of switched gears at that point and decided that I would go to medical school. And so, I learned a lot there. And when I was doing my psychiatry rotation, that just fit well with me considering my social science background. So, I did a psychiatry residency, and that was where my interest in sleep really blossomed more because there was interesting research going on about sleep architecture and how it related with mood disorders.

And so, that really captured my interest at that time. And I broadened that to a bigger interest in the mechanisms and regulation of sleep, and then onto the whole spectrum of sleep disorders and really finally into a sleep health for everybody. So, I'm become an evangelist for sleep in a lot of different settings, academic, writing, lecturing, but a lot of other activities, for instance through the National Sleep Foundation of which I'm on the Board of Directors. So, we do a lot of the public-oriented activities.

Jennifer Ghahari: Fantastic. Thank you. So, I presume that that most people, at some point in their life, have had difficulty sleeping. And what actually defines having insomnia as opposed to just having difficulty sleeping or trouble sleeping throughout one or two nights?

David Neubauer:  Well, you're exactly right. Everybody has trouble sleeping at some point. Fortunately, our sleep-wake cycle is very robust and works well for us. But sleep is sort of the final common pathway to all sorts of different types of disturbances. So, we're all vulnerable to a bad night here and there. When it goes on for a longer period of time, we may meet the criteria reaching a certain threshold to be diagnosed with an insomnia disorder. There are several different categorizations of sleep disorders. The two current main ones are in the DSM-5. There's also one in the sleep community which is the International Classification of Sleep Disorders, and that's the third edition of that. Unfortunately, the diagnostic criteria for insomnia disorder are very similar for both of those. So first, you have to have the sleep problem, and that needs to be the complaint of difficulty falling asleep, staying asleep, waking up too early.

But, in addition to that, there has to be some daytime consequences or impairment that might be associated with that. And so, that could be fatigue, irritability, complaints of cognitive difficulties, impairments in productivity, whether it's work or school or family life. For a lot of people, it just evolves into a worry about sleep, itself, that lingers throughout the daytime. So that may be part of it. So, you have the nighttime complaint, daytime consequences. Then, you have to have a good opportunity for sleep. So, it's not insomnia not getting enough sleep because you're staying up too late and getting up too early. Or if you're sleeping in an environment that is very unfriendly for sleep. So, you have to have adequate opportunity and circumstances. Then, you have to have frequency in terms of the criteria because they always do that.

So it has to be at least three nights a week. And the duration is this going on for at least three months. Now, the patients that we see, more likely three years or three decades in some cases, but, so it has to be a persistent problem. And it shouldn't obviously be due to some other disorder. For instance, sleep apnea may cause disruptions in sleep or some other medical conditions or a pain disorder or use of a substance or medication that might be causing it. Now, you might have co-morbid conditions. You might have insomnia disorder along with sleep apnea. But it shouldn't be obviously due to that.

All of that put together pretty much defines insomnia disorder. So that's what's setting it apart from the bad night here and there that any of us might feel when we have bad news or even excitement.

Jennifer Ghahari:  You had mentioned a pain disorder. And I recently read some research which regarded the link between poor sleep and the inflammatory response, inflammatory response chronic pain and depression. And can you explain what is exactly happening in that regard about that link and how someone with those symptoms could possibly break the cycle?

David Neubauer:  So, I'm not sure that we fully understand the relationships, but we know that the poor sleep often is associated with increased inflammatory markers that go along with a lot of other conditions. So, particularly with chronic pain, there's a very strong relationship with sleep. And it's rather interesting. Even for people who don't have pain conditions, if they are deprived of sleep, in experimental circumstance, their pain is worse the following day. So, there are particular standard measures of pain, you know how long somebody can be subjected to a certain amount of heat or how long they can have their hand in a bucket of ice water. And the people who are sleep-deprived, and again, this is any of us, have a greater pain response.

So imagine those people who have a pain disorder that interrupts their sleep, well, their pain experience can be even greater the next day. So, it can be really a downward spiral for their misery throughout the daytime and nighttime as well. And you mentioned depression. So huge amount of co-morbidity, it's very much a two-way street. People who are depressed very likely are going to have some disturbance in their sleep. And people with chronic insomnia have a greater risk than for developing a depressive disorder, actually anxiety disorders as well.

Jennifer Ghahari:  A lot of our clients come to us with co-morbid insomnia and depression. So, we do see that a lot.

David Neubauer:  I'm not at all surprised.

Jennifer Ghahari:  Unfortunately.

As your research touts, there are some pharmacologic approaches to treating insomnia. And generally, how effective are prescriptive medications against insomnia? And are they usually good for short-term or long-term use?

David Neubauer:  So the answer is all of the above. So, all of the medications, at least those that are approved by the FDA for treating insomnia of which there are quite a lot. There are: benzodiazepine receptor agonist hypnotics, there is a melatonin agonist, there is a histamine receptor antagonist, there are two orexin receptor antagonists, all specifically approved for treating insomnia. They have different characteristics, different pharmacology, different pharmacodynamics and pharmacokinetics, meaning, that you can customize what might work for somebody best and not somebody else. Some are good to help people fall asleep. Some are good to help them stay asleep after that. All have gone through a huge amount of testing. And so, under those circumstances compared with placebo medications, they're statistically better. And people report better results with them. Out in the real world, things vary quite a bit because people have different lives, different co-morbidity, other medications that they might be taking.

And so, any of these medications may be beneficial. Some of them are approved for short-term use and several of them really don't have any limitation on the duration of use. So, it's very customized. I think a lot of people coming in with severe insomnia may benefit from a medication for a short period of time, maybe transitioned to intermittent use under a period of time where there may be increased stress and maybe that can cut short the progression of insomnia so it's not going to get worse and worse. And there are some people who use these medications long term and for those people that may be appropriate, especially when they're being well-monitored, I mean, they certainly should be if they're getting continued prescriptions for a sleep promoting medication.

But as I say, it varies quite a lot. Fortunately, we have a wide variety of medications. I do want to say though, that we never turned to a sleep medication first. We always do it in a much broader context and want to make sure that people are following good sleep habits as a foundation of treatment. And of course, there's cognitive behavioral therapy as well, which is well supported for treating insomnia disorder. So, I don't want to suggest that this is the treatment for insomnia. But it can play an important role for some people.

Jennifer Ghahari:  Nice. In terms of other treatments, you mentioned cognitive behavioral therapy, are there other maybe natural ways that people can use to try to combat insomnia, other ways that can help restore sleep?

David Neubauer:  Absolutely. So, I'd like to emphasize the importance of the infrastructure that supports our sleep. I'm all for roads and bridges and ferries and all those other social supports that we need to function well about the society. But for our sleep-wake cycle, it's important to pay attention to the fundamentals to those processes that regulate sleep. We have a circadian system that under normal circumstances, is very effective in promoting sleep at nighttime and wakefulness during the daytime. It interacts with a homeostatic process. So, these two working together help us out. But we need to do our part as well. And so, people with insomnia disorder, this is really important, but really for the entire population and people who want to maximize the benefits of good sleep, should be following pretty basic rules.

So, the first one is going to bed, which is important because people tend not to. People stay up too late doing whatever, doing things on their phone or watching TV or other computer things. We can usually, we would be able to fall asleep a lot earlier than the time that we actually get into bed and turn out the lights with the intention of falling asleep. So, you got to go to bed and should be leaving sufficient time to get enough sleep. We should be active in the daytime outside if possible. Sunlight is a good thing to help with the robustness of our circadian system, exercise, other physical activity. But we should wind down in the evening. Part of the reason is that we should just have a relaxing routine to transition into sleep rather than scurrying about and turning out the light and instantly expected that they'll be able to fall asleep. But also, because we want our natural processes to work for us.

So melatonin is one example. So, melatonin plays a really important role in facilitating our ability to fall asleep. So normally, we produce melatonin from my pineal gland and our level is very low throughout the daytime, but it gradually rises in the evening for a period of two hours or so as our bedtime approaches. And then it plateaus during the night and then comes down by the next morning. And it's a cycle that repeats itself night after night after night. Well, in the evening, if we have a lot of light from our room lights, from our phones close to our eyes, or all of other sources, we're actually suppressing our melatonin. And therefore, we are depriving ourselves of that natural process, again, which facilitates our ability to fall asleep. What melatonin does is: when it's rising, it interacts with particular receptors in our suprachiasmatic nucleus. And those are the ones that really help us out in the evening.

So we typically are the most awake and alert in the early evening than any time throughout the whole 24-hour cycle which makes sense because otherwise, if we didn't have our circadian clock doing that, from the time we get up in the morning, we would be progressively sleepy right up until the time we fall asleep and then sleep and reverse that, and then do the same thing every day. But, it's not the case. We are able to be alert and functioning for 16 hours or so during the daytime and evening, and then sleep eight hours or so during the nighttime. But part of the reason that we're able to keep going through the evening is because our circadian system is promoting maximum arousal at that time. Now, the exact time depends on the individual and it might be 7:00 or 8:00 in the evening. But when melatonin is rising, it's interacting with those receptors and decreasing that arousal signal, leaving that background sleepiness from the homeostatic processes that's been building up from the time we woke up in the morning.

And so, that's why I emphasize that melatonin really has a permissive role. It facilitates sleep onset. It really doesn't it stops sedating in and of itself. It just allows sleep to occur. And so, I tell people if they're interested in using melatonin I say, "Try your own melatonin." Avoid lots of light in the evening, particularly the blue end of the spectrum. But even then, the apps and filters and glasses that people wear to block out the blue spectrum, that's really pretty limited. And I think, relatively dim light and going to bed relatively early, is the way to go to help maximize the ability to sleep.

Jennifer Ghahari:  You had mentioned eight hours is what people should receive in order to get a good night's sleep. Is that the standard that everybody should get, because I think everybody has heard that growing up throughout their lives, is that really the standard or is that been debunked or is everybody individual?

David Neubauer:  Well, there is a lot of individual variation, but most people who are on the lower end of that variation who are saying, "Oh, I'm fine getting five to six hours of sleep," really aren't. And, that “eight” hours is a good number. If you're not getting that much every night, shouldn't be too anxious about it. And it really depends on how you're feeling during the daytime as well. The guidelines from organizations like the National Sleep Foundation, also from the American Academy of Sleep Medicine, for adults are recommending seven to nine hours of sleep. And that's based upon review of just huge amount of research. So, we really don't want to cut ourselves short on sleep because there are so many health benefits of sleeping. People tend to think, "Well, I'll sleep later. I'll sleep when I die." Whatever.

Jennifer Ghahari:  We'll “catch up later.”

David Neubauer:  You want to age well and decrease your risk for chronic diseases that may go along with sleep deprivation. And you may be aware that there have been a lot of health headlines in recent years about discoveries of the role of sleep in helping to minimize the risk for Alzheimer's disease. So, it turns out that while the brain doesn't have a lymphatic system like the rest of the body, which helps to move fluids and sort of recycle fluids in the body, that's not in the brain. But there is something that's been called the glymphatic system. And so, while we are asleep, our cerebral spinal fluid is able to wash away the toxic byproducts of reactions in our brain. And brain is one of the most active organisms in the body, probably the most, and all of those neurotransmitters being recycled and other neurochemical reactions that are occurring, have byproducts that need to be washed away. That's happening best during sleep.

And there are both laboratory studies, as well as epidemiologic studies supporting this conclusion that sleep has an important role in helping to wash away things like beta amyloid and the tau proteins that are associated with Alzheimer's disease. So, it may not be the answer. It may not be the most important factor, but it is a factor. And for that reason, we shouldn't be trying to minimize our sleep so we can be doing other things because all the other things we want to do in our life are going to be better with a well-rested brain and body.

Jennifer Ghahari:  Right. Have you found that people are reporting worsening sleep patterns since the pandemic began? Or is this one area that COVID-19 actually has not had much impact?

David Neubauer:  Well, if you think about how people's lives have been affected by the pandemic, it's easy to think about how sleep is affected. But there are so many life trajectories that people have experienced as a result. So, on the one hand, you have those people who are the first responders on the front lines working in hospitals, working in ICUs, incredibly stressed, not just because of the patients that they're dealing with, but also with the hours that they have. So, those individuals clearly have a tremendous amount of stress and anxiety and sleep is worse for them.

On the other hand, I talked to people who tell me that the pandemic has been a blessing for them because they're getting more sleep if they are working remotely. They don't have that hour-commute in frustrating traffic. People working from home tell me that not only are they able to get more asleep, but they're able to get outside more, they can take a break, they can walk outside, they can exercise and more flexible with their schedules sometimes. And so, I'm just as likely to hear from people that they're sleeping better than as opposed to those people who are right in the middle of much more stress associated with the pandemic. So, there are so many different stories that people have and so many different ways that their at sleep has reacted.

Jennifer Ghahari:  In my own experience, because I think we all have a story to tell, I found that even minor hypoglycemia at night can lead to a type of anxious feeling and the subsequent inability to sleep. And this is usually mitigated by doing something as simple as eating our granola bar, which I found out the hard way, but I found it. So that was good. So, I'm curious how common is this phenomenon of hypoglycemia at night leading to insomnia or lack of sleep? And is there a better way to mitigate this and lessen the problem from happening?

David Neubauer:  Yeah. So, I'm not sure that I have the answer for you in terms of what pattern of sleeping and eating is going to work best for you. It does make sense of hypoglycemia can elicit a sympathetic response that's very alerting and could easily wake you up. And so, it's nice that you've found a solution for that. So clearly, that makes sense. And some people with diabetes, if their insulin levels and dosages are not prescribed optimally, may dip down and have very severe hypoglycemia during the night and rather dramatic awakenings associated with that. So, it is a phenomenon.

One thing that I do advocate for people is maximizing the robustness of their circadian clock. And so clearly the behaviors that we've talked about getting outside and being active and winding down early in the evening, all of that's really good. It turns out that it's further enhanced by the timing of eating. So, there's a lot of literature out now about time-restricted eating, usually meaning big breakfast, smaller lunch, smaller supper, and then stopping eating. So, you have just a zone of eating and then fasting during the rest of the evening and until the next morning. And, that's very potent in helping to reinforce our circadian system. And probably, although there's not much literature to support it yet, probably has a very positive effect on sleep as well. It does appear that not eating for a few hours prior to going to bed is a good thing that has a positive effect on sleep. And there's recent literature showing that there are metabolic reasons to avoid eating close to bedtime as well.

Traditionally, the sleep hygiene lists for all say, "Well, have a bedtime snack and maybe you'll fall asleep better." And so, I've taken that off my list because we have a more negative metabolic response as the evening goes on especially around the time that melatonin is starting to come up. And so, we know that people who have a particular meal in the morning, say 8:00 in the morning, if they have that identical food at 8:00 PM, they're going to respond differently and have a larger glucose response and a larger insulin response, which is what happens when people have pre-diabetes. So, we all get a little pre-diabetic in the evening and so it's good to avoid eating mid to late evening. So, cutting off meals early in the evening and not eating anything after that is probably optimal for our circadian system and probably for sleep as well. I don't know what that means for your cycle, but I think it's good advice for a lot of people.

Jennifer Ghahari:  Yeah. Thank you. So as a prominent psychiatrist specializing in sleep medicine, do you have any other advice or recommendations that you'd like to share with our listeners?

David Neubauer:  Well, I'll just go back to the concept of the infrastructure. Your own body has regulatory mechanisms that control the sleep-wake cycle. And as humans in our society, we tend to mess with all of that. We're up and doing things at all different hours. And we have lights, electric lights, and we have all these other electronics that can interfere with our sleep-wake cycle. We live in a 24-hour society and can go online, or even go out to stores, some, at all hours as well. So just trying to go back to our natural rhythms, it's really what I preach.

Jennifer Ghahari:  Perfect. Thank you, Dr. David Neubauer of Johns Hopkins. Thank you again for reaching out and helping us with the project, and hope to speak with you again in the future.

David Neubauer:  That'd be great. This has been a pleasure.

Jennifer Ghahari:  Thank 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.

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.