Psychologist Larry Rosen on Technology & Parkinson's

An Interview with Psychologist Larry Rosen

Dr. Rosen is past Chair and Professor Emeritus of Psychology at California State University. He is a research psychologist and recognized as an international expert in the psychology of technology. Upon his diagnosis of Parkinson’s Disease, Larry Rosen has sought to educate, mentor and guide others utilizing both a humanistic and scientific approach.

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 Psychologist Larry Rosen. Dr. Rosen is past chair and professor emeritus of psychology at California State University. He is a research psychologist and recognized as an international expert in the psychology of technology.

He has given keynote speeches to Fortune 500 companies and nonprofit organizations in the US and internationally. Larry has been featured extensively in national television, print, and radio media. Before we get started today, can you let our listeners know a little bit more about you as well as your current research endeavors?

Larry Rosen:  Sure. Thanks for having me, and I'm looking forward to chatting with you. I've been studying what I now call the psychology of technology since the early 1980s when there were no laptops, no smartphones, no nothing. You wanted to use the computer, you punched cards. You handed them to somebody who went into a very cold room, and they ran them. If you were lucky, you got to print-out this thick. If you weren't, you got a print-out that thin, and it meant there was an error, and you had to do it all over again.

What I was interested in way back then was something called computer phobia. And this is when computers were coming out. People were trying to use them. People were a little scared of them, a little frightened, a little weirded by them. Then we just kept changing what we were studying as life changed.

So, we went from computer phobia to technophobia, and we then went to tech and stress. Back I can't remember how long ago, I wrote a book called TechnoStress, which is funny because I reread it the other day. Most of what we said in my book was true, and yet it's probably 15 years old, if not more. We were looking at TechnoStress that you had at work, at home, and at play. So, it was invading everything.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  Then, since then, I've just kind of gone with the flow, whatever's interesting. I always tell people that whatever my kids are doing and my grandkids are doing is what I want to study.

Jennifer Ghahari:  Nice.

Larry Rosen:  I have a very low boredom threshold. So I'll study something for a while, and then I'll think I've got it. Then I'll move on and study something else. So I have worked my way to what I'm working on now. By the way, I'm retired, although retired just means I'm retired from teaching. I still do research, and I'm still very active on boards of directors for a lot of these groups.

One of the areas that I'm very interested in, I can only do this now that we've got newer technology, is what are people doing on their smartphones. As a corollary to that, what are teenagers doing? What are millennials doing? What are adults doing? We haven't really had the tools to do this until now, really till the iPhone got screen time and Android got digital wellbeing, I think they call it.

We were able to actually in the background have something track what people are doing, and what we get is an assortment of really valuable information. What I've done is had groups of teenagers and millennials at the end of their week when it pops up on screen time and says, "You've used 18 hours a day this week," or whatever the hour is, and then they can go back and get seven days' worth of data.

Because Apple doesn't allow them to download it, they take screenshots, they send us the screenshots. We then analyze them. What we're able to get from screen time is really quite a good picture of what people are doing. First of all, we get the gross amount of hours per week, hours per day. That sometimes can be telling if they're spending a lot, a lot of time on, particularly kids, perhaps video gamers, a variety of people who spend time on their phone.

We also get information on what apps they spent most time on. We get information on when they unlock their phone... Whether they have a face ID or a number ID or whatever or none, when they unlock their phone, what is the first app they tap? We also get how many times a day they unlock their phone, and we also get how many notifications they got each day and where they came from.

So, you can imagine we're compiling this set of data to be able to look at what everybody's doing out there because it's very clear. People are on their phones all the time. I mean, that's undeniable. I can't tell you how many times during the day I'll be at a stoplight, and there'll be a car in front of me. Light will turn green and be waiting and waiting. Oh, yeah. They're looking at their phone. Honk. "Oh, yeah. Sorry. I'll move on."

We take those 45 seconds and think we have to do something. We have to look at our phones, and we have to keep up. Otherwise, we think we're missing out on something, which is, by the way, why FOMO, fear of missing out, has developed because we have this sense that we're missing out on something.

Another attack that we tried to do, which, by the way, was a dismal failure, was to see if we could give teens and millennials strategies of how to treat their phone in a way that they might use less time on their phone. They might pick it up less often. We first tried giving them all sorts of choices. Some of them were take your icons for your social medias, put them in folders, scatter the folders all over the place so you don't know where they are thinking, "Well, they have to keep scrolling, and find the folders, and put the folders inside the folders, and whatever." That didn't work.

We tried to teach them how to meditate in order to be a little more calm when they approached their phone. That didn't work. We tried to teach them how to integrate technology into their work, such that instead of taking work breaks, they were taking tech breaks. That didn't work. I won't say it didn't work. It worked for the three weeks that we did it, and then as soon as we stopped, they went right back to where they were before. So then we tried it with fewer choices, but six weeks, and the same exact thing happened. They just went right back to where they were.

So, who's to blame for this? Because that's really what people are asking us. Who do we blame? Where do we point the finger at people who can maybe make changes? Obviously, one place to point your finger is at yourself. I think that's the first choice is you got here yourself. You didn't just stumble on it. You developed this habit, this way of treating your phone and in such a way that even if your phone is not in your pocket and you feel a little itch down there, you think that your phone is vibrating, which by the way is called pocket vibration syndrome, and is real. We experience it all the time.

The other thing we noticed is that when people walk around, say, from class to class at a campus or just walking around the campus, they are always carrying their phone in their hand because it is close. There is a point where women, girls used to put it in their bra, tuck it in there so that they really felt that vibration immediately, and then take a look, and see who's there.

Jennifer Ghahari:  Wow.

Larry Rosen:  The feeling is... It's when someone beckons you, whether it's instant message or whatever. When they beckon you, you feel compelled to go. I use that word, compelled, as part of the phrase, OCD, obsessive-compulsive, compelled, compulsive, behavior because a lot of what's going on is we are acting based on anxiety.

What are we anxious about? Well, we're anxious about missing out on things. We're anxious about not being Johnny on the spot when somebody texts you and texting them right back. We're anxious about a lot of things that take place on our device. Usually, it's the smartphone. Some people, it's the iPad, but in general, it's a smartphone, and in general, it's an iPhone. I will use iPhone as the whole generic category of Android and all those.

What we find is that we have lost control. What I mean by losing control is that we really don't understand why we're doing what we're doing. We just feel compelled, and that's the anxiety part. For example, take a typical teenager. They unlock their phone. They tap on an icon. We even have them take a picture of what icons are on the front screen. They're almost all the connection, text messaging, other kinds of messaging, instant messaging, lots of icons for social media. They're all there. They're all sitting there, waiting.

So, of course, you open your phone, the first thing you do is tap. The one you tap first may very well be the one you use the most, or it's the one that stands out the most, or it's the one that notified you. We have a compulsion to do that because if we don't, then chemicals in our brain and body start to build up and make us more, and more, and more anxious. So when we can't do it, we get anxious.

One of my colleagues, Dr. Nancy Cheever, did a really interesting study. You can actually see the study in action. If you go on my website and look at the very top where it says, "Anderson Cooper. Watch Anderson Cooper on 60 Minutes." So Anderson Cooper came into our lab and, Jenn, really nice guy. Came into our lab. Nancy sat him down at a desktop and said, "Okay, what we're going to do is show you a video and have you answer some questions later. We just want to put a couple of little things on your fingers," which now most people recognize one's an oximeter. Because of COVID, they know that.

The other one is more important. It's called galvanic skin response, which is the sweat on your skin. The sweat on your skin is equated to arousal, and arousal can be either positive arousal or a negative arousal. I mean, if I'm going to give a speech, my hands get very sweaty. It's not that I'm anxious about it. It's I'm excited. I'm excited to do it. But if I'm facing a really difficult thing that I have to do that's very uncomfortable, my hands might sweat, and that's anxiety.

So told Anderson, "Just put your phone upside down next to you," and then Dr. Cheever gave him about a minute or so of starting. She said, "Wait, wait, wait. We have to stop. That phone that you put down to the side is interacting with the two little clips, and so we're just going to need to move it behind you." She put it on a table behind him, and then she started texting him, but he could not answer.

She texted him four times. Every single time, galvanic skin response... spikes.... spikes... spikes four times in a row. We've done this with a lot of people, famous people, news, media, whatever. The interesting thing is it's always the same, except for one case, and I'll tell you the one case. What Anderson Cooper told us very clearly is, yeah, as soon as that beep went off, he felt a little rush in his body, which is galvanic skin response, and he felt like he was missing out on something, and he had to-

Jennifer Ghahari:  Wow.

Larry Rosen:  He felt like he had to check it right now, but he couldn't because we wouldn't let them. Now, interesting enough, people have very different ideas of why they need to check it. couldn't because we wouldn't let him now. Katie Couric, for example, felt like when her daughter was texting, she needed to pick it up quicker.

Steve Aoki, who I don't know if you know who he is, but he's a very famous DJ, and he travels with an army of people, all who monitor his social media, so he showed nothing because he didn't need to. His social media was being monitored by all of his team, and so he didn't show anything.

Two teenage girls, however, were brought in, and they showed not just spikes, but spikes. It was like, "Oh my God. What am I missing out on?" Part of it is because you know that if you get a text, for example, from someone, and you don't respond immediately, they'll text you back and say, "Are you mad at me," or, "Why aren't you answering my text," or something.

This is part of the problem, and I think this is the main part of the problem, by the way, is anxiety. We simply build up this anxiety over, and over, and over again, and the chemicals build up. Then our job is to do whatever we're anxious about so that the chemicals get reabsorbed.

For most people, cortisol is a pretty well-known chemical in our body and our brain. And we know that cortisol is the fight or flight chemical, but it's also in little amounts, not fight or flight at all. It wakes you up. Cortisol is what wakes you up in the morning. You get a little drip of cortisol. During the day, you get cortisol, and it kind of keeps your level of intensity at a pretty good state.

Another interesting study, not by our lab, but another interesting one is that somebody took... They recruited families with a mother, a father, and a teenager. Then what they did is beforehand, they had them fill out all sorts of questionnaires. How many times a day do you check your social media? How much time do you spend on social media? How much time do you spend on email and all sorts of various questions?

They went to sleep. As soon as they woke up, they took a Q-tip, took a swab, saliva swab, put it in a jar, sealed it, put it in the refrigerator, and then eventually sent it into a lab that records how much cortisol, right? They did it right when they woke up, and they did it 30 minutes later. Then they did it other times during the day, but that's not the point.

The interesting point is they were looking at what would cause your cortisol to jump from when you wake up to 30 minutes later. Now, nothing with moms, nothing. No use in general. No use of technology specifically predicted an increase. The dads' email did. Those dads that used more emails showed a bigger response in 30 minutes, which makes sense because they're working, and they get a lot of emails, and first thing in the morning, they got to check them to make sure what's going on.

For teenagers, the only thing that predicted an increase was those who use more social media. So you can already see this building up. You wake up, and you're already anxious. Even the first 30 minutes, you get more and more anxious. You just get more and more anxious. So the anxiety can be very debilitated, and particularly because, I mean, this is not an unknown fact, you can't have a lot of anxiety in you all the time. I mean, it would make you crazy. I mean, if you're always anxious all the time, they'd probably lock you up someplace because anxiety's reached a big peak.

And so, what I have always been interested in is trying to figure out ways to help people be aware of this, first of all, and then figure out a way for them to reduce their anxiety because the anxiety gets in the way of everything. It gets in the way of your thinking, your choice of attention, your multitasking ability, pretty much everything. It all takes place, by the way, right here in the prefrontal cortex, but the anxiety chemicals are buried in the brain and in the body. And in the brain, they're typically right behind here in the amygdala, which then measures your emotions and a bunch of other things.

So, my interest has really moved over the years to trying to figure out what is going on and what can we do to fix it. The first part's easy. The second part's not easy because as I said before, we tried to fix it, tried our hardest. Couldn't do it. We tried. Now, that's not to say that there aren't strategies to do it. I have a lot of strategies that I recommend to people, not a lot, but that we know work. But we're still facing this anxiety reaction all the time.

Jennifer Ghahari:  For, I think, a delight for our listeners, we actually are going to hear about two topics from you because it seems that you're kind of budding into a specialist into another field as well. Unfortunately, you were diagnosed with Parkinson's disease a few years ago, and you have started researching this and writing about your own experiences through a blog.

So, I was wondering if you could talk and share with our listeners a little bit about that. What are some of the first signs that you experienced? Especially as a researcher, you're going to have, I think, a different take on this type of diagnosis than someone without your skills.

Larry Rosen:  Right. And Parkinson's is a disease. It is a confusing disease because you can exhibit myriad symptoms, and no two people exhibit the same symptoms at all.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I noticed, for example, that when I walked, my left arm did not swing. When we walk, our arms swing back and forth, back and forth. Yeah, they swing. My left arm did not swing, which, I mean, it's a little strange. I also noticed when I was brushing my teeth that my arm was rigid. My left, my other arm was rigid and not moving also.

Jennifer Ghahari:  Wow.

Larry Rosen:  And didn't really know what it was, but I knew I'd better have an MRI to figure it out. Had an MRI done, and the MRI came up pretty clean in the sense that it really didn't show the Parkinson's because it's hard to do that, but Parkinson's is a biochemical issue. The chemical there, which is interesting, is dopamine.

Now, when we talk about kids being addicted to technology, for example, being addicted, dopamine is the main chemical we talk about. It's also the main chemical that those... part and parcel of Parkinson's. So one of the nice things is they can measure... Technology's so amazing. They can measure with a device sort of like a CAT scan or an MRI, but a simpler one, how much dopamine you have in your brain. They print you a nice, pretty picture, and the pretty picture has this orange-ish stuff showing the active dopamine. It usually looks like two little circles with commas coming out. If you have the requisite amount of dopamine, that's what you'll see. Mine had no commas-

Jennifer Ghahari:  Oh, interesting.

Larry Rosen:  ... just two circles. So that was pretty interesting. I am a scientist as you can tell from the science t-shirt. I am a scientist. This one says, "Science doesn't care what you believe, by the way," which I think is a good model for people to understand.

I had been looking at dopamine anyway, particularly with video gamers, because it's such an important part of what happens when you're addicted to video games, is this drive for more dopamine, this drive for more dopamine. You got to have it. You got to have it. You got to have it.

Well, so Parkinson's is a dopamine-related problem, and I started thinking about what to do about it. Now, you have to know that I'm a very open person, so I tell everybody everything, and so what I decided to do is to blog about it. I've been writing a blog for Psychology Today for years and years, and not very often, just maybe... Well, they yell at me if I don't do it every 90 days, so try to do it three or four times a year.

I like writing about technology because that's what I do. It's been writing about new generations, and kids, and video games, and all that stuff. All of a sudden, I'm sitting here looking at Parkinson's, and I go, "Well, why don't I write about Parkinson's?" So the first one I wrote called was called something like A Scientist Grapples with Parkinson's Disease because that's what I was grappling with.

I laid out in there some of the symptoms I have. I mean, for example, one's called micrographia. You write very tiny. Your writing gets tinier, and tinier, and tinier. There are other symptomologies that show up. Different people have different ones. Tremors. I have tremors in my left hand, but not my right, which was interesting, but that's not uncommon. Most people just have them on one side or the other to start. Sometimes they migrate.

So, I'm sitting here with a person sitting on my shoulder on this side, being the scientist, looking into it, and the person on this side being the person experiencing it. I thought I'm kind of in a unique place to be able to talk to people about what I'm feeling, and so I wrote that one. I wrote one the second year, and I just posted one for the third year a little late, mostly because I'm doing it kind of for me, my family, my kids, people I know.

I've seen symptoms come and go, more come than go, unfortunately. As you get deeper into Parkinson's and you start reading the research on Parkinson's, there are no two people who have the same Parkinson's. It just isn't. It isn't. Once it's diagnosed, you've can look at things. My neurologist has me always walk down the hall, watches my arm, whether it swings or not, but also watches how I turn to come back. Parkinson's people turn like this in little steps to turn around. I turn... I literally swivel like a ballet dancer. These are some common symptoms that you can see.

One of the interesting things is Parkinson's is a balance issue to people. People who have Parkinson's often fall, and that's really one of the major problems with... And people, by the way, do not die of Parkinson's. They die of something else that Parkinson's brought on, often Alzheimer's, often some form of dementia, often some other neurological problem, fall, hurt themselves. At the very end, you have trouble swallowing.

I just kept thinking, "What can I do to help myself?" Because part of the reading I found was, well, there's this boxing class, and boxing is good for your balance. I went to this boxing class. I joined a boxing class called Rock Steady Boxing. It's made for Parkinson's patients.

Jennifer Ghahari:  Wow.

Larry Rosen:  It's a franchise. People open their own little gyms or use other gyms. Couple times a week, I was going to this boxing class. It was great fun, by the way, hitting a bag, bam. Just a picture of somebody you don't like, bam.

What happened out of that is... First, the pandemic started, and so you can't be in a closed gym with a bunch of people, but there were a group of us. At that point, there was a group of four of us who'd kind of gotten to know each other, just chatting here and there. We decided to form our own little support group. Now, this is the pandemic, so every week, we met on Zoom. For a year-plus, we met on Zoom.

Then we decided to branch out and meet out in the open where we had lots of fresh air coming and everything. That was an important step, I think, because what that said to me is support is really important. Now, obviously, I get support from my family. I get support from my wife, soon to be my wife. We've been together for 18 years. We're finally getting married.

Jennifer Ghahari:  Oh, congratulations.

Larry Rosen:  Don't ask me why because I have no idea why we decided to do it, but 18 years seems fine. So they lend support, but it's a different kind of support when you get it from somebody who's experiencing the same thing. We talk about medications. We're all on different medications. We all have different symptomologies. One of the people walked in like this all the time. Why? Because he wasn't taking these meds.

Other people would talk about varying their meds. Their neurologist would let them take maybe a pill in the morning and another half if they felt uncomfortable. The medication, by the way, is exactly the same medication they've been using forever. It's called levodopa, which they always talked about that with Muhammad Ali and various other people who had Parkinson's. Levodopa is the drug of choice. It's actually called Sinemet because it's combined with another drug so you don't get nauseous and constipated, I think, are the two bad things for that.

I started on a very low dose, and my hands shook like this. Also, interestingly enough, my thumb would often stick to my finger, and I would have to pry it off. I've never met anybody with that symptom, by the way. It'd just stick.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I go, "That's weird." Well, I pry it off, and then it's fine.

I have had to increase my Sinemet, my medication quite a bit. The maximum you're supposed to take is 2,000 milligrams. I take 900. My doctor swears that's fine. I'm in a great range. Don't worry about it. We're really good. That took away all my tremors. I rarely have tremors, unless I get stressed. If I get stressed, the tremors come right back.

Jennifer Ghahari:  Oh.

Larry Rosen:  Yeah. Because stress-

Jennifer Ghahari:  Even with medication?

Larry Rosen:  Yeah. Stress exacerbates the symptomology that we ha, particularly the tremors. Stress just knocks the tremors back in. Along the way, I mean, I've experienced it. I've written what I've experienced. There's cognitive deficits that I have. There's physical deficits that I have.

The interesting thing is the cognitive deficits are hard to deal with now because I'm 72. How many of the cognitive things that happen to me, like not being able to remember names, happen because I'm 72, not because I have Parkinson's? So, trying to disentangle those is very difficult. You just have to kind of accept that they're either/or and talk to your neurologist about what they may be.

Then over time, I mean, the symptoms come and go. I have some interesting new ones. One's called REM behavioral disorder, which is when your REM sleep, we have movements. When we sleep, Parkinson's patients, those who have this disorder, will act out their dreams. I will pound things. My wife told me last night that she woke me up because she said I was just pounding and talking.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I was just literally acting it out. That's all again caused by the dopamine.

Jennifer Ghahari:  Wow. So in addition to these physical and cognitive implications, what about comorbid mental health conditions? Are anxiety and depression common or any other...

Larry Rosen:  Yeah, all of them. Anxiety and depression are common. In fact, when I was prescribed my first Sinemet, I was also prescribed an antidepressant-

Jennifer Ghahari:  Right off the bat?

Larry Rosen:  Right. Because my neurologist said, "You're going to be depressed for a while. Sorry." Then as things went on, I also was prescribed an antianxiety because certain things were making me anxious. So you have to balance the mental health aspects, but they're always going to be there. There's just no way you can skate through this and just go, "Ugh, I'm not feeling bad at all." It's depressing.

It's depressing particularly because the way they show Parkinson's is more end-state Parkinson's Michael J. Fox is not the Parkinson's norm. He's trembling all over the place, and his speech is problematic, and his throat closes up a bit. Yeah, he's not the norm. The norm are people who are like me. They have some symptoms. They try to get rid of the symptoms.

Part of what I'm trying to do in my life is give back because I taught for 45 years, a college profession, and I've done research, and I've participated out there, and given speeches, and all sorts of stuff. I felt like I needed to give back what I knew. Part of it came from our little support group.

I live in San Diego County. There's an organization here called Parkinson's Association of San Diego. There's Parkinson's associations everywhere. One of the things they did is open a mentor program, and so I immediately put my name in to be a mentor. I suggested that I'd rather mentor newly diagnosed people. Interestingly enough, I haven't really mentored any newly diagnosed people, but I've mentored a bunch of people who are really like me, kind of older, scared, concerned, everybody with different symptoms.

I talk to this one guy every week or so on the phone now. When I started talking to him, his mouth movements were not very good. He was a very slow speaker because of it. Over time, it's been interesting because he's now developing speech better, and so he and I can have a conversation where I'm not just sitting there waiting for the next word to come out.

Everybody's different. That's what's so interesting. Everybody's different. I feel like coming from a scientific tradition, I was really raised as a statistician, what that allows me to do is to look at the research and decide whether the research is good or maybe only suggestive. That's an important thing, I think, because research is tricky. Over the 40-some-odd years, plus graduate school, that I was doing research, there are tricks of the trade. There are ways to make a study good. There are ways to make a study bad. There's ways to make conclusions that shouldn't be there.

So, I read those things voraciously. People send them to me, and I read them. I don't talk about them on my blog because I don't want to shame anybody. But I do talk about with new people, here's some new things that are coming up, and I do talk in interviews like this about here's some of the things that might expect.

By and large, it is being diagnosed more, which I think is very interesting. Part of the reason why, by the way, it's diagnosed more is because now we have the testing, the DAT scan to really test it, and we have MRIs that are better. We have tests of fives or something the MRI takes, which is really great stuff, the fine brain stuff.

I will keep writing about it, and I will keep letting people know the symptomology that I have. By the way, because of my cognition problems, I did take a whole neuro workup. I just got the report, and I read part of the report. There are some neurological deficiencies, not horrible ones, but there are some neurological deficiencies, which is helpful for me to understand.

Interestingly enough, attention is one of the major ones right now, and I have a lot of trouble attending. I used to be a great multitasker. Don't do it. Can't do it. I used to think quickly. Sometimes my thoughts get a little muddled, and I have to kind of hold them inside until I get them out. I miss things. I see something on TV, for example, and somebody will say, "What did that person say?" Oh, I don't know. I don't know because my attention waned. So I'm able to say all those things, and I hope people who need it will read it.

Jennifer Ghahari:  So those issues that you just spoke of, how do you know what the difference is between a symptom of Parkinson's versus just normal aging-

Larry Rosen:  That's the million-dollar-

Jennifer Ghahari:  Or there's no real way to know, right?

Larry Rosen:  Million-dollar question. No, there's no real way to know. The interesting thing is I think it's good that there's no real way to know because as we get older, those aging symptoms will be there as well as the Parkinson's. Who cares whether it's aging or not? It's still interacting with your Parkinson's.

If I have trouble attending things, it's going to interact with my Parkinson's. If I have trouble remembering names because I can't pull them out of my hippocampus or whatever, it's going to be... Whether it's old age or Parkinson's, it doesn't really matter quite honestly. I mean, most of the people who get Parkinson's are older, so it's all mushed together. How can you tell?

But one of the things I do talk to people about is that they should be very careful to have someone watching over them because part of what happens and because this is dopamine... By the way, we always think of dopamine as the pleasure chemical, but it controls motor motions. And so if you have less dopamine in your body, you have poorer motor motion. One of the first questions the neurologist will ask, "Have you fallen in the last X amount of time?" Because that's a real strong indicator of potential Parkinson's problems.

So, I try to walk more. I try to make sure my balance is there. I also have a spiral staircase in my house, and I'll hold on. At times, I'll take two feet on one step, make sure that I'm not going to fall. I've not fallen yet, but I've definitely stumbled a lot and just been able to grab myself, but I've missed the bottom stair of our stairwell before a couple times. I stumble. Luckily, there's a wall right up there, so I put my hands against the wall. Saved my life.

Those are kind of all things that are individual. The anxiety, by the way, is pretty common. The depression is very common. And so from a psychological point of view, those are the kind of things. Yeah, am I depressed because I'm older? Am I anxious because whatever? Those things are also all tied up in one.

Interestingly enough, because of my work with technology, I'm able to talk about the biochemistry of it because of all the stuff that I've done with the biochemistry of the brain with technology. It's a pretty natural step, I found, to go from looking at that kind of biochemistry to looking at the biochemistry of Parkinson's.

Jennifer Ghahari:  Talking about social support and how important that is, you mentioned family, friends. You're part of this boxing group, which morphed into just a social support group. You're also mentoring people. In one of your blogs, you said something like, "I'm not complaining. I'm just reporting." I'm wondering, especially when you're trying to be in a supportive type of setting, whether you're talking to family or in a group, how many people feel like they are actually complaining and they might want to hold back what they're feeling? Is that common or are people more comfortable to talk about things?

Larry Rosen:  From my experience with Parkinson's patients, they are embarrassed. In our little group of four... ended up being five. Now, one passed away, so it's four of them.

Jennifer Ghahari:  Sorry.

Larry Rosen:  We don't meet anymore in the boxing because the person running the boxing program is not vaccinated. I mean, none of us... Even with Parkinson's, you don't want to be anywhere near that stuff that might have an effect on you. There's not been proven a link, but it's still there.

I think that the support you get is the way that you're able to judge aging versus not aging. In our group, there are people in their 60s, 70s, and one is in his 80s. We all reacted differently. I told everybody because that's me. One person only told her husband. That was it. Hadn't told her whole family that she has it. Another person told selective people. I think it's important to be able to see people in a similar situation as you are. I don't know if you know this, but Alan Alda has Parkinson's.

Jennifer Ghahari:  Oh, I didn't know.

Larry Rosen:  It's funny. He's actually done a lot, and I like what he's been working on. He was in a movie. The movie was the one where Scarlett Johansson and Adam Driver were getting divorced. He was playing Adam's attorney, and so they're sitting at a round table, and you see his right arm is down to the side, and his left arm is here. Then every once in a while, he brings his right arm up, and it's shaking a little, so he put it down. It's a little bit more... That wasn't maybe part of the script, and so they made it as innocuous as possible, but if you go on his Twitter, he talks about it a lot.

Having people do that helps normalize it. I think that's going to be real important for people. I mean, Parkinson's sounds like a really crazy, bad disease, which, I mean, on the whole, it is, but it's not as scary as we always thought it was. We're not going to be Michael J. Foxes. I mean, because he literally has a bad case of the tremors on both sides, as well as speech problems, and all sorts of things. He's at the end, and some of the people I know are spread out in there. I would consider myself maybe not at the other end, but sort of third of the way in because I don't tremor much.

Jennifer Ghahari:  And you were diagnosed how long ago?

Larry Rosen:  August 2019.

Jennifer Ghahari:  Okay. So you have had the disease for a few years now.

Larry Rosen:  Okay. So what's interesting is, yes, most people have Parkinson's for a lot longer than they know. One of the first symptoms is loss of sense of smell, and not everybody again, but it's a pretty common symptom. I lost my sense of smell, most of it, 10 years ago, which they would say is because you have Parkinson's.

Jennifer Ghahari:  Wow.

Larry Rosen:  I don't know how long my left arm wasn't moving because I wasn't paying attention to it. My guess is it was a long time before I was diagnosed. The only reason I was diagnosed is because I felt like there were some things that were just different that I didn't understand neurologically.

Jennifer Ghahari:  Wow. That's great. And I appreciate that you're coming on here, and speaking with us, and showing, as you're saying, a more normalized version of Parkinson's, that not everybody's going to have the absolute extreme version, especially right off the bat. So, if anything, this is going to be a really huge help, I think.

Larry Rosen:  Michael J. Fox has had it for like 30 years and-

Jennifer Ghahari:  Right. Yeah, it's been a long time.

Larry Rosen:  Yeah. What I think in the long run is the diagnosis is going to be made more often. By the way, there's all sorts of sub-varieties of Parkinson's, essential tremors. There's a Lewy bodies part. There's a whole bunch of little subcategories. We can have those or full-out Parkinson's. They have different symptoms and different effects.

I think because of our technology now, and because we're just more aware of it... I mean, Michael J. Fox is out there. Other people are out there talking about Parkinson's. Because of that awareness, I think more people then go to the doctor and will be diagnosed. We'll get better ways of diagnosing them, and we'll get better ways of treating them.

There are a tremendous number of research studies going on right now on other treatments other than drug treatments. For example, there's something called DBS, direct brain stimulation, where you literally have a little thing here, and it stimulates... It's like a nine-volt battery and stimulates the prefrontal cortex, which has been shown to help with your thinking and your attention abilities if one of the symptoms is you're losing your attention.

I mean, I have high hopes that the more we see out there, the more we'll understand out there, but it's scary. I mean, I would tell anybody that has Parkinson's. The first thing I would say is, "I bet you're scared." The answer is always, "Yeah, I'm scared to death." They have a reason to be. I mean, it's not a death sentence, but in general, people who get Parkinson's, they live maybe 20, 30 years with Parkinson's, or it can go really quickly. You just don't know.

Again, the medications are much better. The medications are better. There's lots of other meds besides the one I'm taking. The one I'm taking just is the base one you start on. If that doesn't work, they can give you other meds on top of it, or interestingly enough, the meds stop working typically after... I think Sinemet, they say, in general, stops working maybe every about five years with that. You have to find something else.

Jennifer Ghahari:  Yeah. I think, as you said, it's almost the fear of the unknown. That's the biggest drive of anxiety for people, and so I think things like this where you're helping disseminate information and just experiences is a really huge help for people.

Larry Rosen:  And one of the things that I would recommend is... The Parkinson's Association of San Diego has done a really nice service for people, and what they've done is they've had professionals record very short videos, we know our attention span is way too short these days, eight, 10-min videos on different symptoms and different kind of things that happen. It's just pasd.org, I think. They're free. You can go look at the videos. There's probably 30 or 40 of them, maybe even more.

Jennifer Ghahari:  Wow.

Larry Rosen:  The PA for my doctor does a few, and other people who know what they're doing do a few. Then my doctor, my neurologist is involved in lots of research too along with it. So I get to kind of eavesdrop and hear what she's finding. She talks on there about her research. People talk about the REM behavioral disorder and what it means. People talk about how to know when your medication's not working. So they're just little blurbs. I encourage people... I think it's a really great idea to just go there and harvest what we can.

Now, having said that, when I was diagnosed, I did no reading. In retrospect, I was scared to death and I didn't want to know. Everybody else read for me. My kids reported. My wife reported. Everybody read for me. Then at some point after about six months, I found that I was able to dive in and see what's there. Also, I mean, I encourage people to not be afraid to say, "I'm afraid."

Jennifer Ghahari:  Wow. Thank you. So psychologist, who's an expert in technology, someone who's battling Parkinson's, do you have any parting words of advice or anything else that you'd like to share with our listeners?

Larry Rosen:  Well, on both sides, I can share a lot about the technologist stuff, but I think keep track of what you're feeling. If you need to, take a diary. Keep track of it in a diary. Mark down when something odd happens, something weird happens. It may be Parkinson's. It may be not. At least, it's noted.

Don't spend a lot of time reading research because it's in its infancy. We're talking about really the last 10 years maybe that there's been this new emphasis on Parkinson's, even though Michael J. Fox had his foundation for quite a while, but it's pretty much a new phenomenon. When you say to somebody, "Oh, I have Parkinson's," say, "Oh, my uncle had Parkinson's, and my mother's sister had Parkinson's." Everybody knows somebody that had Parkinson's.

And to just realize it's not a death sentence, but you also need to kind of be aware of your body and your mind because you can just go on gleefully unaware, and then the symptoms will definitely get worse left untreated. What you want to do is try to get the best treatment possible and really trust that...

You're not doing this through your family doctor or your internist. You're doing this through a neurologist who knows Parkinson's, whether it takes... Even if you have some of these symptoms, and you try to get an appointment and you can't get an appointment for four months, don't worry about it. Nothing's going to much change in four months maybe.

Keep track of your symptoms. Keep track of everything. Don't study the research on it. Go look at how you can diagnose Parkinson's. There's lots of things that talk about how you walk or do this. (Moves his hands) My right is faster than my left.

Jennifer Ghahari:  Oh.

Larry Rosen:  Typing, my right is better than my left. I can't type anymore. I mean, I can type. It's just I make lots of mistakes. Keep track of your symptoms. Keep track of them, and write them down. Make sure that you are being as dispassionate as you can, but yet accept the support of other people. Don't ever let somebody tell you you're going to die of Parkinson's because they will. They'll say, "Oh, my uncle had it for 20 years and then died."

Jennifer Ghahari:  Right. Well, thank you so much. If anybody wants to read more about Dr. Rosen's research or read more about his blog, you can do so at www.drlarryrosen.com, and we'll have that link on our site.

Larry Rosen:  And the doctor is just D-R. Mention that maybe.

Jennifer Ghahari:  Oh, perfect. Thank you. Yeah.

Larry Rosen:  Please feel free to message me too. I mean, I enjoy talking to people about this because I think I can maybe not... Don't I'm a great helper, but I'm a pretty good listener.

Jennifer Ghahari:  Aw.

Larry Rosen:  And I think that's important.

Jennifer Ghahari:  It does make all the difference, definitely.

Larry Rosen:  Yeah.

Jennifer Ghahari:  Thank you so much, Dr. Rosen, and we wish you all the best.

Larry Rosen:  Thanks. Thanks for having me on.

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 Priyanka Shokeen on Psych assessments

To learn more about Psychological Assessments, click here.

To request an appointment for a psychological evaluation with our practice, click here.

An Interview with Psychologist Priyanka Shokeen

Dr. Priyanka Shokeen is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists. She manages the diagnostic evaluations and assessments sector of our practice and has extensive experience in working with trauma and personality disorders.

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, Priyanka Shokeen. Priyanka is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists.

Her clinical work is focused on providing comprehensive psychological evaluations, primarily for diagnostic clarification. Before joining our practice, Priyanka was the clinical fellow at Columbia University. Can you tell our listeners a bit about yourself?

Priyanka Shokeen:  Oh, yeah. It's always difficult to think about where to start on a question like that, especially after the introduction you gave me. So, thank you for that.

Jennifer Ghahari:  Sure.

Priyanka Shokeen:  Well, let's see, I've been studying Psychology since the age of 16, and it never fails to amaze me each year as to how little I know, for the fact that I'm still interested in learning more. I'm originally from India, and for the better part of the last decade I was working in New York City.

I'm somebody who's always been interested in advocacy, and throughout my life that's looked different depending on where I am personally and geographically. Then, I'm an avid reader. I don't get as much time to read anymore, but that's a lifelong habit I plan on keep trying to be better at. So, that's a bit about me.

Jennifer Ghahari:  What types of books do you read?

Priyanka Shokeen:  Oh, mostly fiction. I used to read a lot more theoretical texts, old texts, based in Psychology, back in grad school, even starting as early as undergrad, but right now I think fiction is a good way to detach from work.

Jennifer Ghahari:  Yeah. Nice. So, what is it that got you interested in becoming a therapist?

Priyanka Shokeen:  Funny enough, fiction.

Jennifer Ghahari:  Really?

Priyanka Shokeen:  Yeah. This is why I like fiction, the ability to engage with it is so transformative in that it allows you to really flex your imagination. It teaches you to how to imagine the mind of a character, how to experience strong emotions in a safe enough manner.

So, I initially thought this interest would translate into a career in literature and writing. And that was a quick lesson in the fact that hobbies are not necessarily things you're good at, and they probably shouldn't be. It's a good thing that hobbies are not things you're good at.

So, I kept following my interest, not just in the experience of emotions, but also with regards to my curiosity in terms of the confidence that make people behave in the way they do. And those include race and gender and class and culture, apart from, say, biology and family environments. So, I followed a story.

Jennifer Ghahari:  Great. I'm going to put you on the spot. Who is your favorite fictional character?

Priyanka Shokeen:  Ooh. You know what, I'm not sure if this is a popular book, but it is definitely my most quoted book. It's this book called Shantaram. It's about this convict who escapes from Australia and reaches Mumbai, I think back in the '80s. And it's him getting involved with the underworld there. So, the main character for that is my favorite fictional character.

Jennifer Ghahari:  Awesome. Great.

Priyanka Shokeen:  Yeah.

Jennifer Ghahari:  Thanks for sharing. So, in clinical practice, are there any areas or disorders that you specialize in treating?

Priyanka Shokeen:  Well, let's put it this way, my professional areas of interests are the areas I continue to build specialization in. So, with that in mind, I have a lot of experience with personality disorders and trauma, and that's where my primary interest and work lies. I, in the past, enjoyed doing group work a lot. I've run inpatient groups, I've run outpatient groups, I've run groups in counseling centers. I think they have a lot more power than we give group therapy credit for.

Then, like you mentioned in my introduction, I do specialize in differential diagnosis, which again, the personality disorders or the trauma work, for me, remains an area of knowledge that I keep growing in.

Jennifer Ghahari:  Great. For our listeners, can you explain a bit about personality disorders, maybe which are the most common, just a bit about them?

Priyanka Shokeen:  Yeah, I think if we were to look at personalities as somebody's unique signature in that it is their way of relating to themselves, to other people and to the world around them, that's what we call personality, ideally. Personality disorder is when your characteristic ways of being either with yourself or with people or with the world, they become problematic, they start causing you harm or they start causing people around you harm.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  So, in the past, personality disorders have been, according to diagnosis, certain axes. So, the kinds that we see a lot, or that gets talked about a lot, even though it's not that common, is "borderline personality disorder", because that is one of the hardest to deal with. It comes with a lot of emotional dysregulation, a lot of identity instability, risk factors.

But just as common is, more common than BPD, is "avoidant personality disorder" (AVPD) or OCPD, which is different from OCD. So, OCPD is "obsessive compulsive personality disorder", different from "obsessive compulsive disorder".

Jennifer Ghahari:  Great. So, if anybody thinks that they may have one of these, reaching out to someone you would be good, to talk about and possibly get an evaluation-

Priyanka Shokeen:  Absolutely.

Jennifer Ghahari:  ... as an example. Great.

Priyanka Shokeen:  I think one of the first points of entry into getting help is if you have started noticing that your characteristic ways of acting are not bringing you what you want or that people around you have started noticing something before you have. So, they're giving you consistent feedback about certain ways in which you act, say, for people who have really explosive anger.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  People around them are the first to notice that, "Hey, I think you need to get help." So, yeah, absolutely, I would be very happy to help. And if I feel that I'm not the most competent person to help, I would absolutely provide a good referral.

Jennifer Ghahari:  Great. So, aside from something like explosive anger that people are telling you may have a problem with, what are some other signs or symptoms that people should be on the lookout for?

Priyanka Shokeen:  Well, it depends on different things. It depends on your priorities. So, let's say if you have avoidant personality disorder, the characteristics of life where we measure functionality, where you're functioning well, is what is generally agreed upon as health. Different degrees is, self-care, it is your relationships, it is occupation, student, whatever job you're doing.

So, if you start noticing something going wrong in either of these areas, that's important for you to know. So, if you, as I was mentioning with avoiding personality disorder, you do want to form relationships, but just the task of it, the fear of it is so much you avoid them to the extent that it starts affecting you, that you end up being self-isolated. And again, the last three years have taught us, self-isolation is especially punishing.

So, that can be one of the signs to look out for. For "narcissistic personality disorder", it's very hard. Self-reflection is not the first criteria for it. So, people around can start saying, "Hey, you take a front to seemingly small things." They feel very personal to you. And as somebody who's going through it, you may think, initially, that they're saying it to hurt you or they don't value you, but depending on the number of contexts you're getting that feedback in, it becomes harder and harder to deny.

So, people may come in for complaints of depression or anxiety, which, once resolved, you might realize, once those symptoms are done, there are still lingering symptoms in these areas of occupational functioning, your relationships, your self-care. And that's generally when personality disorders initially start getting addressed, unless there's something as dramatic or as explosive as, say, BPD.

Jennifer Ghahari:  Wow. Great. Thank you. That's really helpful. So, let's say someone contacts you and makes an appointment and goes to see you for X, Y, or Z, how can you explain your treatment approach? What can someone expect to experience if they're going to therapy with you?

Priyanka Shokeen:  Okay. So, I'm going to try and break it down into my overall clinical approach, and then say what an initial couple of sessions with me can look like and what the purpose of asking certain questions is. My approach to clinical work is largely integrative. Most therapists out there, you'll ask, that's what they end up following, because we've been taught so many things and we know how to draw on different things, depending on what the client is presenting with.

With regards to case conceptualization, which is an overarching view of what I think the nature of someone's presenting problem is, I have a psychodynamic approach. So, I use my training in, say, diagnostic tools in psychological tests, and I put a focus on developmental history. I keep an eye out for differential diagnosis. I try and understand, what is the larger family context or the cultural context in which someone's presenting complaints operate?

So, the psychodynamic framework, it allows me to start building a coherent narrative of someone's life with the data that I've gathered from different perspectives. That said, I also use a lot of CBT and DBT techniques in session, depending upon, again, what the presenting problem is and what the client needs. So, that's more my approach, overall, throughout the course of treatment.

With initial sessions, intake with me can take anywhere from two to three sessions. Those three sessions are a good place for me to decide if I have the clinical competence to provide you the best care with what you're coming to me with, and that's a good way for you to assess if you would want to, keep coming to me, if you like my style, if you feel comfortable talking to me, even if not about everything, just initially.

So, the goal of that initial exploration is to get an understanding of what the client is coming to therapy for, they're presenting complaints, the history of that complaint, and then the circumstances in which the client is, as well as their own personal characteristic that keep those situations that they have a problem with or those symptoms operational.

I say this often enough to most all my clients that you're not reacting in a vacuum. There's two parts to this. There's the internal and there's the external. So, as part of this initial exploration, there's a lot of attention that I pay to developmental history, so trying to gather data about someone's attachment patterns.

I try to attend to the mention of key figures or key moments in somebody's life, specifically in early development, but also crucial details or crucial figures clients either forget to talk about or avoid talking about, because for me, that's the beginning of trying to understand somebody's presentation.

So, in this manner, guided by this dynamic framework, the goal is to start bringing what feels nonintegrated parts of the client self in order to provide them with greater access to their own internal world.

Jennifer Ghahari:  Great. So, talking about all these different diagnoses that people may have, and you run our practice’s psychological evaluation program. Can you explain what that is that you're running and what people can expect to experience if they reach out for an evaluation?

Priyanka Shokeen:  So, generally speaking, psychological evaluation or assessment, it's an evidence-based approach which makes use of information from a number of different sources to arrive at a holistic picture of how a person's mind functions and the ways in which they experience the world.

So, psychological evaluation or assessment, it makes use of clinical interviews, it makes use of behavioral observations, and then standardized psychological tests to understand a more comprehensive profile of what your strengths and weaknesses are, and what are the next steps for your mental health journey. I think you asked me another question as part of this, but I seem to have forgotten.

Jennifer Ghahari:  No, that's okay. So, if I'm going for a test, what can I expect to do? Am I going to fill out one of those old-time Scantron sheets where you pick A, B, C or D? Is it going to be, do people actually take the Rorschach tests, things like that? What do you do?

Priyanka Shokeen:  So, yes to the Rorschach, absolutely yes to the Rorschach. It's one of my favorite instruments to use. When used well and in a standardized setting, it can be one of the biggest sources of information about somebody's personality. But let's, again, start from the beginning.

So, an assessment would involve either question coming from the client, their loved one, their psychiatrist, their therapist. They don't need to be in therapy with me for us to go through evaluation. So, the process begins with, what is the referral question? What are you looking to get assessed? Once we've had a referral question, we'll set you up.

The first point of contact is a clinical interview. And the purpose of this interview is to gather detailed information about what is your current functioning and how you were functioning at a previous time. After the clinical interview is done, comes the process of the assessment. So, yes, there are forms to fill out, there are Rorschachs to do, but these are all different standardized tests.

And they can be part of a whole battery of tests. So, it might just be you end up doing one big test, like the Rorschach or the MMPI, which is also a personality measure, or you end up doing a bunch of different tests, like we do with our ADHD assessment, to understand different aspects of the functioning and how best to answer the referring question.

Once testing is done, we score it, we explain the results to you, we compile everything into a detailed report. And the final part of the assessment is a debriefing session where we go over with the client about what we found, what test was meant to do what… And it carries actionable recommendations on what to do with this information that we've learned, where to go next.

So, a lot of the times, this assessment in and off itself is enough to answer the referral questions. Sometimes we might feel we haven't gathered enough information or you need some other kind of assessment that we're not yet providing. And in that case, we make those referrals in addition to the recommendations that we're providing.

Jennifer Ghahari:  Great. So, I think we're in a society where people want instant gratification, so I'm presuming that this whole process is not an instant thing. Like you said, there's a debriefing and a full report. In general, let's say I came to you for some tests and we did the test today, when could I expect to get my results and the debriefing and all that? How long does it usually take?

Priyanka Shokeen:  Yeah, again, I wish I had more of a straightforward answer to that, but it really does depend on the referral question. On average, you can think of budgeting anywhere between five to 10 hours for the entire assessment process. That includes the clinical interview and the debriefing session. So, the hours-

Jennifer Ghahari:  Is that at one time?

Priyanka Shokeen:  I'm sorry?

Jennifer Ghahari:  It all happens...

Priyanka Shokeen:  Oh, my God, I would never. I think it would defeat the purpose because exhaustion and fatigue are a thing that affect performance. No, it definitely happens over, again, depending on the test battery. So, let's say a particular test is supposed to take anywhere between two to three hours. For a particular client it ends up taking to four hours. So, that would be one. But that's all we're doing that day.

Then, the rest of the things that we need to get done, we'll do it over 2-3 hour sessions over the next couple of days. So, definitely not putting anyone through that in one go.

Jennifer Ghahari:  They don't have to bring pajamas or a pillow or anything?

Priyanka Shokeen:  If it comes to that, we will provide the sleeping bags. (laughing) But you also mentioned when you can get the results? So, oftentimes it takes a lot of hours to score the tests in a particular way, to consult norms, to make sure you're doing the right thing, and then compiling them into a report. So, if you think assessment is time-taking on the administration, and believe me, it's double that on the report end.

So, I generally give anywhere between three to four weeks from the last testing session for me to compile reports because I don't want to do it in a way that misses out on any detail or skims on any part of the report. So, 3-4 weeks for you to get the report, and that's when we'll have the debriefing session and we'll go over the report together.

Jennifer Ghahari:  Perfect. And I think what sounds really nice about this process is, there are surveys online that people could take for this or that, and you hit a button and that's instant gratification, especially put in your email address, for so many websites.

But with this, like you said, it's really customized. You're a trained psychologist who, again, knows what you're doing to be able to look at the nuances of what a specific answer means, especially in conjunction with other tests and other answers.

So, I think the fact that we can provide these detailed reports for people, even though it is slightly more time consuming, the quality of what you walk away with is so much better than more of the quicker, instant gratification type of things that people can do on their own. So, I think this is great what you're doing.

Priyanka Shokeen:  I'm glad. I don't begrudge people on what makes them reach out for the instant gratification of doing an online quiz. It is the most accessible thing. Going through an assessment requires a lot of time and resource, commitment as well, but it isn't just about our report being most tailored to your question, it's that it's accurate. The reason why I say that is oftentimes people can get versions of tests online, but they don't know how to read the report.

You can assign a numerical value, but people might not know how to read that numerical value. Does that numerical value mean a different thing for a clinical population versus research subjects? And psychologists are the only profession that are trained to do this kind of testing. Not to give that example, but do you remember when this part of the previous president's cognitive test, some part of it got leaked online and people thought it was very easy.

It was one question in a neuropsych battery, and people were making assumptions about easy or difficult, but that had nothing to do with what that test represents. So, misinformation is vast and very easily accessible also.

Jennifer Ghahari:  That's a great point. And I think too, if people walk away with not really having the right diagnoses, they're potentially going to take a wrong path then, which would hinder their mental health recovery even longer. If I am actually presenting with diagnosis B, but I think I have diagnosis A, I might follow the wrong path and, actually, potentially get worse.

So, by going through something this, you're able to get the treatment that you need or at least the guidance that you need in order to have a better recovery and get the outcome that you're looking for, right?

Priyanka Shokeen:  Yeah, absolutely. And the thing with diagnosis is also, there's a lot of emotion attached to it. It can be hard to get a particular diagnosis because of how it's perceived. For some people it can be very relieving to get a diagnosis. For most people, the diagnostic categories don't represent a 100% of what they're experiencing. So, even the nuance of why we're saying this is a diagnosis versus that, even that is an important part of treatment.

Jennifer Ghahari:  Great. Before our last question, I'm going to change directions a bit here. What's your favorite part of Seattle? It could be anything.

Priyanka Shokeen:  Oh, my God. It's the proximity to my niece. She just turned two, and, oh, my God. I used to think it was the summers here, which also, beautiful, but tiny, cute baby learning words…

Jennifer Ghahari:  Nice answer. Do you have any final words of advice or is there anything else you'd to share with our listeners?

Priyanka Shokeen:  Oh, I hope somebody, whoever's listening, to whatever extent, that they can derive meaning out of it. The idea of comparison is so extremely prevalent, be it you comparing yourselves to coworkers, to family members, to people on social media. It's very easy to think that somehow everybody else can do things that somehow are very difficult for you or they're getting to places that you're not getting to.

They look a certain way, they do a certain thing. And I think the weight of those comparisons can really run you ragged. Or the thing that I find a lot of clients doing and have over the past several years of working has been when people in extremely hard conditions finally seek help, and it is very hard for them to give themselves the space to be tired, to be exhausted, because somehow everybody else is going through it too, how come they get rest?

Or somehow other people have it more difficult than them. And I always tell them, we're not playing the “Misery Olympics”. So, we don't know what goes into making somebody function. We don't know if what we're looking at is the real picture. We don't know the kinds of support they have or the resources they have, the protective factors, or on the flip side, we don't know what they're hiding or how close they are to a break.

So, it's okay to look at those things and think of them as either places you'd want to be or things you'd want to do, but that does not need to be a determinant in how you should feel about yourself when you should seek help, when you should seek rest. So, I hope some somebody listening can find some meaning in it.

Jennifer Ghahari:  Well, I've found meaning in it, so thank you.

Priyanka Shokeen:  I'm glad.

Jennifer Ghahari:  Now, this has been great. Thank you so much, Priyanka, Dr. Shokeen, for joining us today for this installment of “The Seattle Psychiatrist” Interview Series. And if anybody would to reach out to Dr. Shokeen or perhaps schedule an appointment at some time or some type of evaluation, you're welcome to do so by contacting info@seattleanxiety.com, and we'll get back to you shortly. Again, Priyanka, thank you so much, and we wish you all the best.

Priyanka Shokeen:  Thank you so much. Have a good one.

Jennifer Ghahari:  You too.

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

Psychologist Joshua Miller on Narcissism

An Interview with Psychologist Joshua Miller

Dr. Joshua Miller is a Professor of Psychology and Director of Clinical Training at the University of Georgia. His research focuses on the connection between personality and personality disorders, with specific interest in narcissism and psychopathy.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Dr. Joshua Miller. Dr. Miller is a professor of Psychology and director of Clinical Training at the University of Georgia. His research focuses on the connection between personality and personality disorders, with specific interest in narcissism and psychopathy. He has numerous publications on narcissism, including one of his most recent publications on the topic, “Narcissism Today: What We Know and What We Need to Learn.” Before we get started, Dr. Miller, can you please let us know a little more about yourself and what made you interested in studying narcissism?

Joshua Miller:  Sure. I've been a professor at UGA since 2005. I did my graduate work at University of Kentucky and then an internship in post-doctoral scholarship at Western Psychiatric Institute at Department of Psychiatry at University of Pittsburgh. In terms of studying narcissism, it was really sort of just happenstance to some degree. I was studying psychopathy, which is sort of like a fraternal twin of narcissism in a lot of ways, coming out of grad school, and then doing cluster B personalities sort of in general in my post-doctoral fellowship. And then, when I moved to the University of Kentucky, we had one of the foremost experts in narcissism from a social psychology perspective, Keith Campbell, and we just sort of hit it off and just started collaborating and talking about the differences in how I, as a clinical psychologist, thought of narcissism and how he, as a social psychologist, and it just sort of led to a fruitful collaboration and sort of kickstarted this whole line of research I've pursued really for the last almost 20 years.

Amelia Worley:  So to begin, can you define what narcissism is?

Joshua Miller:  Yeah, I mean, I just think of it as a suite of traits organized around an individual who values sort of a sense of superiority, status, recognition over almost anything else in their lives. That means even the willingness to denigrate, devalue those around them so as to maintain themselves in a higher position. So, narcissistic people tend to be grandiose, entitled, require others admire them, feel upset and angry when they don't receive those from others, while simultaneously being sort of callous and non-empathetic towards others. They expect particularly good treatment from others while providing very little of the same to those around them.

Amelia Worley:  What are the different types of narcissism?

Joshua Miller:  Yeah. And I think of the sort of two main dimensions we talk about, and they're not really types as in a narcissistic person has to be one or the other. Rather, they're modestly related dimensions. So, you could be mostly one, mostly the other, or you could have features of both. We talk about grandiose narcissism, and that's the one that most people will think of. The person that is explicitly outgoing, assertive, domineering, grandiose, entitled. And then, the vulnerable one is sort of sometimes harder to recognize because the person tends to actually have lower self-esteem. It's sort of this weird paradox of oftentimes these individuals dislike themselves, can have intense self-loathing, while also feeling quite entitled and having sort of grandiose fantasies, believing that others should treat them better, should recognize within them their special talents to some degree. These are the ones that sometimes in the literature they were called covert narcissists. The idea that it was more hidden, it would take longer to recognize some of those traits.

Amelia Worley:  That's really interesting. I know you briefly covered this, but what are some of the most common signs that someone may be a narcissist?

Joshua Miller:  For what we think about, the most defining features to me are things like grandiosity, a strong sense of entitlement that you deserve better things than others, that the rules shouldn't apply to you, that you shouldn't be treated like the average Joe. When we see those things, those are probably the clearest signs that someone is narcissistic. Tend to be egocentric, self-absorbed. Even the more vulnerable individuals who don't always have as much grandiosity, they tend to be quite self-absorbed. They believe the world should focus on them, should revolve around them. And even that self-absorption can sometimes revolve around their sense of sort of fallibility, and distress even. It's not like, "I deserve better things because I'm the best." It can be, "I deserve special treatment because of how wounded, how fragile I am." This is the sort of dimension we may see more in outpatients oftentimes.

The grandiose individuals may not be coming in to therapy very often. In fact, they're not likely to come in. And if they do, it may be later in life when they sort of have failed, they're starting to recognize that they can't maintain this grandiose sort of belief system. But, we're going to see lots of sort of more vulnerably narcissistic individuals who believe the world, their significant others, their clinician should accord them special treatment in part because of maybe past trauma, past difficulties, the amount of distress they're experiencing.

Amelia Worley:  Is there such a thing as a healthy amount of narcissism?

Joshua Miller:  It's hard to say, right? I mean, I think within some reason, some degree of believing that you're good at things, that kind of stuff, believing that you're entitled to fair treatments, right? The higher you are, the more impairment we're going to see. The more difficulty you're going to cause in other people's lives, the more difficulty you're probably going to cause in your own life, the more impairment. So, any degree further like lower we can help someone get is probably better. I think when people say healthy narcissism, they're really just thinking about self-esteem really. Self-esteem is almost entirely healthy. It's actually not that correlated with grandiose narcissism. It's negatively correlated with vulnerable narcissism. It's positively correlated with grandiose narcissism, but at a correlation about 0.3. That's pretty small. The reality is that most people who have high self-esteem aren't that narcissistic, and many people that are narcissistic don't actually have that much high self-esteem.

This one study we did in my lab that really compared them over about 5000 individuals, and multiple studies, they're similar in that high self-esteemed people and grandiosely narcissistic individuals are outgoing, they're approach-oriented. They sort of go out and attack the world. They go for what they want. They believe in themselves. They're assertive. They take on leadership roles. The difference is that high self-esteemed people are more communal. They're more other people-oriented than narcissistic individuals. The way I would describe it is if I'm a high self-esteemed person, I can feel good about myself without having to denigrate you.

Let's say we're both clinicians. We both could be good clinicians. We both could be good parents. We both could be good spouses. Whereas, the grandiose narcissistic person views the world more hierarchically. There isn't room for both of us to be good. If I'm going to say I'm the best clinician, that means I need to denigrate you. They view the world almost like a ladder. You can either be above someone or below someone. Not equal. And I think high self-esteemed individuals can allow the space for others to feel good about themselves without being threatened by that. Does that make sense?

Amelia Worley:  Yeah, definitely. And digging into that further then, where do you draw the line between someone who is just highly confident versus someone who's a narcissist?

Joshua Miller:  Again, it comes down to these more disagreeable traits. Is the person callous? Do they have a sense of entitlement that they expect treatment that other people wouldn't get? Are they constantly talking about themselves as being better than others? I think people who are just high self-esteem have a quiet self-confidence about themselves. They don't need to trumpet it everywhere. They don't need that kind of persistent, nonstop validation from others. They don't need that admiration because within themselves, there is just a general sense that, "I'm a good person." And self-esteem is usually built on a sort of a broader base. If you think about it, good self-esteem is built like a house with multiple sort of parts of the foundation.

I might think, "I'm a good researcher, but I also value that I'm a good husband and a good parent and a good friend. So even if my work isn't going well, let's say I get multiple papers rejected, I don't feel terrible about myself because I still know my kids love me and my spouse loves me. And that I have friends and a supportive social network." But, a narcissistic person builds themselves up, their foundation, on a much smaller, narrower set of things. They tend to be agentic things. Narcissistic individuals don't tend to think they're better than others in all things. They tend to think they're better in agentic things, like smarter, better-looking, more athletic, better leader.

They don't tend to actually report that they're better people. They know that they're not necessarily as nice as other people, as kind. And they don't value that as much. These interpersonal things. So, for a narcissistic individual, if my whole sense of who I am is built on being a great researcher, well, if I start getting negative feedback on my papers, that's going to be really threatening to me because I have nothing else to build my sense of self on. That's one of the differences that makes self-esteem largely quite a healthy, psychological construct. And narcissism, a more mixed bag in some ways, for sure, with more maladaptivity.

Amelia Worley:  Can narcissistic personality disorder be treated? Can a narcissist ever change?

Joshua Miller:  It's a great question. There's been remarkably little funding from NIMH about treatments on narcissism. I don't know if there's ever actually been like an RCT on narcissistic personality disorder specifically. There has been some work from more like sort of psychodynamic perspective, looking if short term psychodynamic therapy can make changes in these individuals. And I think they've shown some positive results. I certainly don't know that there's a panacea or an easy cure for someone with really persistent, longstanding narcissism. I believe with kind of constant, consistent feedback in a supportive way of the ways in which a person's narcissism is negatively affecting others, even the clinician, the clinician giving that in the moment feedback, that you know, "Hey John, when you say that, it makes me feel devalued," like that kind of consistent feedback, but you'd have to have a patient that's really motivated to get treatment, to improve, to recognize that their narcissism is standing in the way of a fuller, healthier sort of life.

Without that, I'd be much more sort of pessimistic that you would see much change. There's got to be some insight into the problem. There's got to be motivation to make those changes first. And then, it's probably going to take some substantial time with a supportive, trained therapist to make some gains, I think.

Amelia Worley:  Is there a link between being around someone with narcissistic tendencies and anxiety and depression?

Joshua Miller:  I don't know specifically of empirical study and looked at that exactly. We published a paper in 2007 where we did find that people who were rated as, these are community participants and patients, those who had more narcissistic personality disorder were rated by our research group as causing their significant others more distress. So, to the extent that we could think that people being distressed probably means having anxiety, depressive symptoms, marital instability, it probably is likely that really severe narcissistic individuals probably can cause those in close proximity, spouses, parents, children, friends, coworkers, some of those kind of symptoms, for sure, if they're not able to sort of remove themselves from the situation. Which, of course, if you have a narcissistic parent or a child, it's not so easy to remove yourself. If it's a coworker, you might be able to find ways to psychologically or even physically distance yourself from that person such that they can't do as much damage.

Amelia Worley:  So, digging into that further, at what point should someone consider cutting ties with a narcissist? What can someone do if the narcissist is a coworker or superior at work?

Joshua Miller:  Yeah, I wish I had really clear cut answer to, "Oh, at this point, you should do..." I think whenever a person recognizes that someone is really bad for their psychological wellbeing, then it's reasonable for them to start thinking about how they can take steps to mitigate that harm, whether that's ending a relationship, like if it's a friendship, but I don't like to be too glib about the idea of ending a relationship because of course that's not always that easy. It's not that easy to, say, cut off a parent or cut off a child, or decide to end a romantic relationship. With a coworker, I think, again, we can do whatever we can to mitigate the time we spend dealing with that individual. If it's a coworker, potentially talking to those higher up. If they're trusted about working less with that person, not being assigned to those same kind of teams, being asked to move off of a team.

If it's a narcissistic boss, it's hard to know what exactly are your mechanisms to exert change. If you have someone even higher up, you could consider talking with them. It could be that if it's bad enough, you look to move within your job or move to a different job. Again, I would never want to speak for someone without knowing the circumstances. Sometimes, working with someone narcissistic is mostly just annoying. You feel frustrated, you feel put down, but it may not be something that you're willing to, say, change a job or ruffle feathers. I trust someone's autonomy to make that decision. If it's much worse where you come home feeling beleaguered every day, put down, denigrated, dismissed, then I think we're talking about things where if it's starting to really adversely affect your mental health, then thinking about bigger changes is certainly worthwhile. And if the person is in therapy that's doing this, that's the perfect thing to talk to a therapist about.

One of the cool studies that this guy, Drew Westen at Emory did was look at countertransference with narcissistic patients. So, that is like, what are the feelings that a therapist has towards a narcissistic patient? They're really noteworthy like dreading those sessions, not feeling like they're going to make much change, feeling put down, feeling dismissed. If therapists who are trained to deal with patients and try to put their own feelings aside feel that way, then certainly it's reasonable for us to expect people with less psychological training to struggle even more to deal with people in their lives that show these kinds of traits.

Amelia Worley:  That's fascinating. Lastly, do you have any advice or anything you would like to say to someone who may be involved with a narcissist?

Joshua Miller:  Again, there's no easy glib answer to that. If it's, again, persistently, negatively impacting your wellbeing, their traits, their grandiosity, their need to put themselves before others, if they're showing a lack of concern, if the relationship doesn't feel bidirectional, if it's like, "Wait, I'm only here for this person as a sounding board. I'm here to support them and validate them. But when I need a chance to talk about this trouble I'm having, they're disinterested," then I think rethinking, again, the parameters of that relationship are reasonable.

But, again, relationships are really complicated, and I get that. If you're in a relationship with someone and have children with them, I don't want to say quickly, "Oh, well, just end that relationship." And it depends on the severity of the person's narcissism. If the person seems narcissistic but it is unaware of it and that they might be willing to seek treatment, then it might be something where the couple can have meaningful discussions about whether or not that's something that could be dealt with in couples counseling and individual therapy, things like that. Each case is so specific. It's really hard to give an overarching answer to that.

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

Joshua Miller:  You're welcome. Yeah. Thanks for having me.

To learn about gaslighting, click here to access our article.

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

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

Therapist Amanda Ann Gregory on Trauma & Roe v. Wade

An Interview with Therapist Amanda Ann Gregory

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

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

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

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

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

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

Amanda Ann Gregory:  And can you say that again?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To read more about Amanda Ann Gregory, click here.

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

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

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

Therapist Terrence Real on Relationships

An Interview with Therapist Terrence Real

Terry Real, LICSW is a family psychotherapist, best-selling author, internationally-recognized speaker. He is a senior faculty member of the Family Institute of Cambridge, MA and the founder of the Relational Life Institute (RLI), which offers workshops for couples, individuals, and parents who wish to develop deeper connections in their relationships.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Mr. Terry Real. Mr. Real is the family psychotherapist, best-selling author, and teacher. He is also the founder of the Relational Life Institute, which offers workshops for couples, individuals, and parents who wish to develop deeper connections in their relationships. Mr. Real has numerous publications on relationships, depression, and psychological issues that men face, including his upcoming publication, “Us: Getting Past You and Me to Build a More Loving Relationship.” Before we get started, Mr. Real, can you please let us know a little more about yourself and what made you interested in studying relationships?

Terry Real:  Oh gosh, there's an old saying, a psychotherapist are people who need to be in therapy 40 hours a week. I first became an individual therapist 40 years ago, and I think I did in order to gather the skills I needed to have the conversation with my depressed, violent, loving father that I needed to have in order to free myself from the legacy and not become him. And I did. I learned how to be an individual therapist and I healed a lot of my trauma. I then went on to family therapy and couples therapy, literally in order to learn how to have a relationship. I come from a really dysfunctional family, we all come from a really dysfunctional culture, and I didn't know how to do it. So, I became a professional, and then in 1995, I published a book called, “I Don't Want to Talk About It,” which was the first book ever written about male depression. And it did real well to a lot of depressed men in America. And I was getting calls all over the country, "Can you help me with blah, blah, blah, blah, blah, blah?"

And what I began to realize was that moving men out of depression was synonymous, in my mind, with opening their hearts and reconnecting them. The way we turn boys into men traditionally in this culture is through disconnection. Feminism has worked for 50 years on girls and women's disempowerment. The womb for boys is disconnection. We teach them to cut off from vulnerability, from their emotion, from others. And I began to believe that the healing move for boys and men is reconnection, connecting them to their hearts and to others. And so my work was grounded in the restoration of relationality with men. And I began to feel like the best way to do that is in their current relationships. So, I began to invite partners and, in some cases children, into the therapy room to teach these guys how to live relational lives, how to live lives of authentic connection to themselves and to others. And so the work naturally gravitated away from doing individual therapy to working to transform people individually, but through their relationships and the restoration of relational capacities.

Amelia Worley:  So to begin, can you describe what relational life therapy is and what methods it uses to help couples in therapy? Additionally, how is it different from regular couples therapy?

Terry Real:  We break a lot of rules. Let's see if I can name some. The relational life therapy, first of all, we're not neutral. And when I was a couples therapists, the corner rule was thou shall not take sides. If you took sides, you had to go to your supervisor and talk about your mother for a while. We're not neutral. Some issues are 50/50, but some are not. Some are 70/30, some are 99/1. And specifically, I came out of it through my work with men and through a feminist perspective. Women across the West are asking for more emotional intimacy from us guys, then traditional masculinity raises us to deliver. The essence of traditional masculinity is invulnerability. The more invulnerable you are, the more manly you are. And women are asking men to move into vulnerability, to move into their emotions, to open their hearts, to be less defensive, to be more sharing. In other words, to have a broader, a repertoire of relational skills.

So we agree with that. We take sides. We side with the person who is asking for more intimacy in the relationship, and the way you're going about asking for it may not be very skilled. I'm not saying women are angels, but the demand for increased intimacy is good for us. And so we're not neutral. We're perfectly capable of saying, "Mrs. Jones, you're a nut and Mr. Jones, you're an even bigger nut, and here's why, let me tell you what's going on." The other thing is that we're lovingly confrontational. There are three phases to relational life work. The first, I call: waking up the client. This is where you hold the mirror up to the client about what their maladaptive responses may be born of childhood trauma and adaptation that are blowing their own foot off. This is what you're doing that will never get you more of what you want.

And the confrontation is, I call it: joining through the truth. Anybody can club somebody with the truth, but this confrontation is so loving, so empathic, so on the side of the person you're talking to, that they feel closer to the therapist through the confrontation rather than more resistant and distant. So the first phase is waking up the client. The second phase is trauma work. This is where that adaptation came from. You were adapting to something. So I do deep trauma work in the presence of the partner, another rule we break. We don't find trauma work out to an individual therapist, we do deep trauma work, inner child work while the other partner is sitting there. There's some contraindications, but if there're going to be vicious or whatever, but by and large... Excuse me. Sorry. But by and large, it's much more powerful to have the partner who's been on the receiving end of the person's immature adaptations, see where the whole story comes from. It opens their heart.

And then the third phase is: teaching. This is what you've done wrong, this is where that maladaption comes from, and this is what right would look like. And I think it's the combination of all three of these, confrontation, deep trauma work, and skill building that produces transformational change quickly. So that's what we do. We are not neutral, we judiciously self-disclose. We're not a blank screen. This is not transference-based therapy. And another thing is that we're at least as interested in grandiosity as we are in shame. For 50 years, psychotherapy has dwelled on helping people come up from the one down of shame. In RLT, we're also interested in helping people come down from the superiority contempt entitlement of grandiosity. And I believe as a couple's therapists, you must be able to help people come up from the one down and also down from the one up. Doing one without the other is insufficient. So there are a lot of things that are very distinct about relational life work.

Amelia Worley:  I really like that. Can you identify any common myths society believes about relationships?

Terry Real:  Well, my new book, if I can do this, “Us”, being released June 7th, it is all about taking on what I call the toxic culture of individualism. And what we know from interpersonal neurobiology these days is that the idea of a free standing individual is mythic. We don't self-regulate, we co-regulate one another all day long. Our central nervous system is not designed to be alone and self-cystic. We are designed to be in relationship. And this whole book is about shifting from an individualistic patriarchal model that says we're above nature and in control of it, whether the nature we're above and in control of is our bodies, “I've got to lose 10 pounds",” our thinking, “I've got to be less negative,” our partners, our kids, society, the world at large. And the whole book is about trading in that mythic idea of power over dominion, for a much more realistic idea of collaboration and cooperation.

When we move out of you and me, win, lose adversarial thinking into the prefrontal cortex, the part of the brain that can remember that we're a team, that this is a relationship that we are in a whole, all of the terms that we live with shift. For example, from a relational perspective, the question who's right and who's wrong is: who cares? What matters is how are we going to work in a way that's going to work for both of us? And so the first order of business is shifting out of what I call you and me consciousness, which is subcortical, triggered by trauma about survival into what I call the wise adult part of us, prefrontal cortex, the part of us that can remember the gestalt, the whole, that we are not striving above our marriage, for example, but we're in it. I call this replacing the hubris of power and control with ecological wisdom and humility.

Our relationships are our biospheres. We're not above them, we're in them. You can choose to pollute your biosphere by having a temper tantrum over here, but you'll breathe in that pollution by your partner's withdrawal or lack of generosity over there. You and they are connected in an ecosystem. And once we wake up to an ecological systemic consciousness, this isn't about you versus me in some power struggle. This is about how we are going to operate together in a way that works for both of us, then a whole range of new skills and new ways of thinking open up to us.

Amelia Worley:  So, going off of that further, how does that shift from individualistic thinking to relational thinking. How does that heal problems in relationships then?

Terry Real:  Well, it is the difference between, for example, "You're a reckless driver." "No, I'm not." "Yes, you are." "No, I'm not." "Yes, you are." "No, I'm not." I call this objectivity battles. Who's right and who's wrong? And instead, think of this, "Honey, you may be a fine aggressive driver. I'm not arguing that, but I want you to know that when you tailgate and change lanes and speed, none of which you deny, I get myself very nervous sitting next to you. I know you love me. It would be the world to me if as a favor to me, you could tone down your driving so that I could feel safer in the car. Would you do that for me?" And the person next to them goes, "Sure, I'll do that for you." Problem solved. Are you an aggressive driver or not? That could go on for 50 years. “Could you tone down your driving for my sake so I could feel safer?” “Sure, I’ll do that for you, Honey.” Problem solved in 10 minutes. That's the difference between approaching an interactional problem individualistically and relationally.

Amelia Worley:  Okay. So also in your book, “Us: Getting Past You and Me to Build a More Loving Relationship”, you talk about how healing of the self can occur in relationships. You mentioned that this is not done by controlling our partner, but rather by coming to terms with the ignored parts of ourselves. Can you expand on that idea more?

Terry Real:  Well, we all marry our unfinished business, we all marry our mothers and fathers. Falling in love is the conviction that this person is going to heal me, or at the very least, I'm going to avoid all that nastiness that I grew up in. The real relationship comes when you realize that your partner is precisely designed to throw you into the soup. Now, that doesn't mean you're in a bad relationship, it means you're in a truly intimate relationship. What matters is what do you do once you're in the soup? Now, most of us in this culture will try and heal ourselves by getting from that partner what we didn't get, and by often retaliating when we don't get it.

The new news comes when we deal with our own inner wounding and our own adaptation. We stop asking the partner to heal us, but as we move from these triggered automatic adaptive responses to a more thoughtful adult response, we do something different in the moment and they do something different in the moment, and that heals our trauma. Not that they get it to us, but that something different happens between us because I have done something different inside my mind. Can I give you an example?

Amelia Worley:  Yeah, definitely.

Terry Real:  The essence here is understanding what I call the adaptive child part of us. Subcortical automatic response fight, flight, fix about survival. And when we feel unsafe, the autonomic nervous system scans our bodies four times a second, am I safe? Am I safe? Am I safe? If the answer is yes, we say seated in the prefrontal cortex, we're here and now we can be thoughtful. If the answer is no, I feel I'm in danger, which has everything to do with being trauma triggered. Then I will click into whatever I use as a kid to adapt to that danger. And I will repetitively do that in my relationship, even though it never gets me what I want. The essence of this book is about how to cultivate the skill, the wisdom of in the heated moment, shifting from that automatic response, what Dan Siegel calls the reactive brain, to the wise adult prefrontal cortex, the integrated brain.

So let me give you an example. A guy comes to me on the brink of divorce. I specialized in couples on the brink of divorce. He's a chronic liar. He's the kind of guy I say to him, "The sky is blue," he says, "t's aquamarine." He won't give it to me. So quickly, I identify what we call in relational life therapies, his relational stance. His stance is evasion. This guy has a black belt in evasion. So when you think relationally, you can figure this out. It seems brilliant when you're not thinking relationally, but I have a saying, show me the thumbprint and I'll tell you about the thumb. If he's evading, the question is as a child, who did he have to evade? And so, I ask him, "Whatever the adaptation is, what were you adapting to?"

So I say to him, "Who tried to control you growing up?" Brilliant. His father. "Tell me about it." Military man, how he ate, how he drank, how he dressed, everything. I said, "How did you deal with this controlling father?" He says, with a smile, that's the smile of resistance, he says, "I lied." Brilliant, brilliant little boy. I teach my students, always be respectful of the exquisite intelligence of the adaptive child. You did exactly what you needed to do back then to preserve your integrity and grow, lying. Brilliant. Only I have another saying, adaptive then, maladaptive now. You're not that four year old boy, your wife is not your father. So we surface all of those.

They come back two weeks later, it's an absolutely true story, and they're holding hands, "We're cured." "Okay, tell me." She sent him to the grocery store for 12 things, true to form, he comes back with 11. She says to him, "Where's the pumpernickel?" He says, "Every muscle and nerve in my body was screaming to say they were out of it. And on this day, in this moment, I took a breath, I looked my wife in the eye and I said, I forgot. And she burst into tears, true story, and said, 'I've been waiting for this moment for 25 years." That's what we're after. That's recovering.

Amelia Worley:  Wow. That's incredible, honestly. So in your opinion, what is the best way to transition out of being an adaptive child?

Terry Real:  Well, I speak about what I call relational mindfulness, take a break. I'm a big fan of breaks. Take a walk around the block. Go to my website, if I can say, terryreal.com is a one pager on the 10 Commandments on how to take a time out. Physically remove yourself for a while, but get centered, re-regulate back in the part of you that can remember what you are about. Remember that the person you're speaking to you care about, and the reason why you're speaking is to make things better. Until you're in that place, shut up, don't try and resolve anything you won't. So the first skill, I call it the ER skill, is getting re-centered in the part of you that can use skills to begin with. Then from that place, open up your mouth and speak to your partner. But the first order of business is you tending to those triggered early child states inside your self.

Another one of my sayings is maturity comes when we deal with our inner children and don't foist them off on our partners to deal with. You deal with your triggering, you get centered, then you go back to your partner and say, "What are we going to do to make this work?"

Amelia Worley:  So, on the other hand, what are some signs that it is time to leave a relationship? Where is the line between relationship problems and relationship toxicity?

Terry Real:  You can get on my website, I have an article that I wrote for the psychotherapy networker called, “Rowing to Nowhere: When Enough is Enough”, in which I tackle this issue, when's enough enough? They're obvious, if there's drug addiction or alcoholism or acting out either sexual aggressive and the person doesn't want to do anything about it, if there's a serious psychiatric disorder and the person refuses to do anything about it, if one of the two partners wants to be a thoughtful relational accountable partner and the other one doesn't, just wants to be a big baby. One of the deal breakers is if there is a distinct discrepancy in the emotional maturity of the two partners and the immature partner doesn't want to do anything about it, then the more mature partner feels pain in living with the other person, and I would help them get out. But it mostly has to do with not what the difficult partner is struggling with, but whether they're motivated to do anything about it or not.

Amelia Worley:  So how can staying in a toxic relationship affect mental health and hinder self growth?

Terry Real:  I talked to people about, I wrote this in the book, about what I call becoming relational champions. That means that you get centered in a place in your soul in which you say, "I deserve, it is my birthright to be in a relationship that is essentially cherishing, a relationship in which I can cherish my partner, they'll let me, and I feel cherished by my partner. And if I am in a relationship that is essentially uncherishing, first, let me do something about it, then we go get help. And then we get help that really helps. A lot of couples therapy doesn't do much, so let me get help that really helps. And two, if all bets are off and there's nothing I can do about, it's bad for me to be in an uncherishing relationship, it's bad for our kids to see me in an uncherishing relationship, it's bad for the uncherishing partner, it's bad for all of us. It's time to pull the plug."

Amelia Worley:  So some people seem anxious or afraid to leave a relationship they know isn't healthy or good for them because they're worried about being alone or they're nervous to try and find someone else. What type of advice would you say to someone feeling that way?

Terry Real:  Well, that person is what I would call a love dependent or a love addict. They are filtering their sense of self-worth and well-being through connection to the other. They're using other base to seem the other person's warm regard for them as a prosthetic to supplement their own faulty warm regard for themselves. So that person needs to work on self-esteem, learning how to cherish themselves. And 9 out of 10 times that person's dealing with an abandonment wound. As a child, they were not aligned with, they were not met. Adults don't get abandoned, adults get left, children get abandoned. And that a childhood ego state of abandonment feels like I'm going to die. A child will die unless they're cared for. So I would say self-esteem work and prom work on an abandonment wound. That's at the core of their terror about being alone.

Amelia Worley:  So if someone is unhappy or in an unhealthy relationship, but they stay together for the sake of the kids, is this typically the right move for everyone involved? Or is it actually better and healthier for children to have their parents separate?

Terry Real:   It all depends, but that's really case by case. How old are the kids? How long you're going to have to tough it out? If you stay together for the sake of the kids for a year because they're about to graduate high school, fair enough. If you're staying together for the sake of the kids and they're three, well, that's quite a different matter. And what are you putting up with? What are you passing on to your children as a legacy? What are you teaching them about how you're going to be treated? It's a very personal decision. It's not for me to decide that for you, but I will say this, on the one hand, you have the damage of the divorce and what that does to children. On the other hand, you have the damage of raising your children in a loveless environment, and what that does to children. There's no easy answer to this one. Either way, your kids are going to be hurt.

Personally, I believe kids do best when either or both parents are happy and in loving relationships. And I would rather have the couple split up by and large and find other people to be happy with. I think that's better for the kids in the long run, but this is one of those questions you ask six therapists to get 33 different answers.

Amelia Worley:  So lastly, do you have any final advice or anything you want to share with our listeners currently in a struggling relationship?

Terry Real:  Well, I would invite you to my workshop starting in June. It's the first ever Us workshop online, go to my website and find out about it. I would invite you to find a relational life therapist. Of course, I believe in my method, in those I've trained, they're on my website as well. Get help and get a therapist who will really support you. I don't think the traditional, uh-huh, uh-huh, tell me more about it, oh, that's what you think, oh, tell me what you think, is going to work. You find the therapist who's going to deal with what you're dissatisfied with and take your partner on and see if they can render themselves more pleasing to you. And if you don't have that support, find a different therapist. So my first order is find help and my second is find help that will really support you, take the issues on, not be so nice, not be so passive, and deliver a better relationship for you.

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

Terry Real:  Thank you. It was a great joy. Be well.

*Cover photo credit: Dennis Breyt

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.

Internist Howard Schubiner on Mind-Body Connections

An Interview with Internist Howard Schubiner

Howard Schubiner, MD is an internist and both the founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. Dr. Schubiner is a clinical professor at the Michigan State University College of Human Medicine and is an expert in the mind-body connection, as it relates to one’s health.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Nicole Izquierdo, a research intern at Seattle Anxiety Specialists, and I'd like to welcome with us Dr. Howard Schubiner. Is that how you pronounce it? Is that correct?

Howard Schubiner:  It is.

Nicole Izquierdo:  Okay. So Dr. Schubiner is an internist and both a founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. He is a clinical professor at the Michigan State University College of Human Medicine and is a fellow in the American College of Physicians and the American Academy of Pediatrics. He has authored more than 100 publications in scientific journals and books, and lectures regionally, nationally, and internationally. So before we get started with the official questions, would you like to share a little bit more about yourself with our listeners, and what made you interested in becoming a physician?

Howard Schubiner:  Well, that's a great question. First of all, it was a long time ago. It just seemed like a good idea at the time, I guess. I wanted to do something that would be useful and meaningful. I wanted to work in a community. And I was in university at the time, and I don't know, I just thought I would see what it was like. I took a few science classes and I found them to be not too difficult, and it just kind of led from there. I started volunteering at a free clinic and learned more about healthcare and medicine and some of the problems in medicine, frankly. Even way back then in the 1970s, it was becoming very clear that the biotechnical approach to medical problems had tremendous potential and tremendous value, but it also left things lacking. And it turned out, as my career has meandered and wandered over the years, that I've come to a place now where my main work has to do with the failings of biotechnological medicine and the promise of more simple and more patient-centered approaches.

Nicole Izquierdo:  Thank you. Thank you for sharing that. So you specialize in the mind-body connection as it relates to one's health. Do you mind defining what that is to our listeners?

Howard Schubiner:  Sure. Everyone knows the brain and the body are connected. The mind and the body are connected. When you get embarrassed, your face turns red. When you have to give a speech, your stomach may flip into knots. Everyone knows that. But it turns out it goes much, much deeper. It goes deeper in the sense that we have learned, in the last couple decades or so, that our brains actually create all of what we experience. Which is really a revolutionary concept. And it's called predictive coding or predictive processing. And so when you touch a hot stove, it's not your finger causing pain. It's actually the brain. The nerve signals go up to the spinal cord into the brain, but the brain makes a decision. It sounds weird, but the brain makes a decision whether to turn on pain or not. And we know that, because a lot of times, people have injuries without any pain. And we also know that the brain can activate pain or anxiety or fatigue or depression or insomnia when it's under stress. It's like a warning signal.

And so pain is a protection. We need pain. The reason we have pain is that it warns us that there's something wrong, usually wrong physically in the body. But our brain can turn on pain, the same pain, exact same pain, when we feel trapped or emotionally in danger, and that pain is real. And so it's really important for people to understand that pain and anxiety and depression are actually generated in the brain, and they're generated in the brain as a warning signal, as an alarm, like a smoke alarm.

And so it's up to us to figure out what the message is, why that's happening. If you have pain in your back and it's a kidney stone, then that's the message. You need to deal with the kidney stone. But if you have pain in your neck because you're in a job that's untenable and harsh or you're in a relationship where you get betrayed, then that's the message. But the pain can be exactly the same. The anxiety can be exactly the same. So once you understand that the brain creates what we experience, now you have an inroads for understanding how we work, what makes us tick, and how to deal with it.

Nicole Izquierdo:  So would you say that those instances where it's more like a psychological stressor causing let's say neck pain or a headache or back pain, would that be, what's the term, psychophysiological disorder, or is that something else?

Howard Schubiner:  No, that's exactly right.

Nicole Izquierdo:  Okay.

Howard Schubiner:  In the old days, they used the term psychosomatic. They still use that term in Europe, but we don't use it here because it seems mean. But the fact is, since our brain controls what we experience, it's not mean. The fact is that we are psychological beings, we are emotional beings, we are social beings. And so the fact that we can get... If I have pain and I know it's from my brain as opposed to from my body, I'm happy. It shouldn't be stigmatizing, because the symptom is real. It's not imaginary. I tell people, anyone who says the pain or the anxiety or the depression or the fatigue or the insomnia is all in your head, it doesn't understand how things work. It's real. It's not your fault. It's not because you're crazy. It's not because you're weak. It's not because you're deficient. It's not because you want it. It's because your brain is sounding an alarm. There's something important that's going on in your body or in your life, and so it's up to us to figure that out.

Nicole Izquierdo:  Yeah. That's nice that the terminology is changing to capture that change of... Because it is invalidating, telling someone, "No, it's fake. It's not as bad as a 'real' injury or 'real' pain." And "real" in quotation. Are there any specific examples of these disorders? Like diagnostic names, diagnostic criteria?

Howard Schubiner:  Well, yeah. We have developed a lot of diagnostic criteria for these disorders. And, well, first of all, people who develop these mind-body conditions or what I sometimes call neurocircuit conditions are more likely to have stressful childhoods, more likely to have histories of trauma, more likely to feel like they have been criticized or feel they are not good enough or put other people first and not stand up for themselves. They're more likely to be in difficult situations currently in their life.

And the symptoms that they have are more likely to turn on and off, to shift or move. And we see, what's interesting is we see, because as we understand the brain creating these conditions, we frequently see that some people may have headaches for a while, and then the headaches go away, and then they get back pain, and then the back pain goes away, and then they get anxiety, and then the anxiety goes away, and they get fatigue, and then the fatigue goes away and they get irritable bowel, and the irritable bowel goes away and they get depression. And these can shift and move, sometimes within days or hours or weeks or months. And you can see the pattern where you can see that someone's been under stress and their brain has created a variety of different warning signals. And so we're looking very carefully at people's stories and listening to them. And, as you said, validating them, caring for them, being compassionate toward them, and helping to understand them and understand that their symptoms may be reversible, as opposed to being incurable.

Nicole Izquierdo:  How would you recommend that sometimes to get to that point, once you check everything else off the list that is let's say a kidney stone, for the back pain. How would you recommend going about it so that patients that do struggle with this aren't also struggling with the toll of going through a bunch of tests or the cost associated with those tests?

Howard Schubiner:  Yeah. That's a great question. We always recommend getting testing. If you have anxiety, you need to have your thyroid checked to make sure that you're not hyperthyroid. If you have anxiety, you need to have your heart checked to make sure you're not having a tachyarrhythmia or something like that. If you have depression, you need to have your thyroid checked, you need to have your hormones checked. These are obvious. If you have back pain, you need to get your back checked.

But we don't want to over-interpret things and we don't want to make people think that just because their symptoms are chronic that means that they're incurable. There has been a lot of research showing that, for example, in neck and back pain, that most people have abnormal MRIs. The MRIs are going to be abnormal. They're going to have degenerative disc disease, spinal stenosis, things like this. But those things are common in people who have no pain at all. So you shouldn't be saying, "Oh, that's the cause of your pain, because you have these mild abnormalities that everybody else has."

Similarly, with anxiety and depression, I feel strongly that we shouldn't be telling people that... And I know this is controversial and some people in your groups may disagree with me, but when we tell people that the problem is inflammation of the brain or it's genetic problem, what we're telling them is that it's not fixable. What we're telling them is that they're doomed and that they'll just have to cope with it. And that's the same thing doctors tell people with back pain when they see an abnormal MRI. And so we're trying to break out of that rigid biotechnical model to embrace this mind-body model or this predictive processing model, because it's much more optimistic and much more hopeful about making changes and getting better.

Nicole Izquierdo:  So one of your books is titled Unlearn Your Pain, and we actually have several clients that come to us seeking relief for chronic health issues, many of which included chronic pain. So without giving the entirety of the book away, can you explain how this could be possible?

Howard Schubiner:  Sure. Well, it starts with what we've been talking about. It starts with understanding predictive processing. It starts with understand how the brain works. And then it's an assessment, so it's making an assessment to make sure that there's nothing actually structurally wrong. And most people with chronic pain do not have a structural condition. Most people with headaches, fibromyalgia, irritable bowel, chronic abdominal pain, chronic pelvic pain, chronic neck and back pain, do not have a structural problem in their body, and I would assert the same is true for people with chronic fatigue, insomnia, anxiety, and depression. So the first part is that assessment. And then after that, there's three types of things that we help people to work with. One is we call pain reprocessing therapy. The second, we call emotional awareness and expression therapy. And the third is making changes in someone's life and dealing with their current issues in their life.

Pain reprocessing therapy can also be used for anxiety and depression, and what it is, it's a process of changing your relationship to the sensations you have in your body. Instead of fearing them and focusing on them and trying to figure them out and trying to fight them, it's actually being with them and tolerating them and knowing that they're not serious, that they can't hurt you, that you're going to be okay, and it's practicing graded exposure to gradually do more and more and tolerate the sensations of these uncomfortable, unpleasant physical sensations, and by changing your relationship to them, you're calming that danger alarm mechanism in the brain, which will then turn down the symptoms. That's the first step, the first treatment.

The second treatment is emotional awareness and expression therapy, which I developed with my colleague, Mark Lumley, and that involves dealing with the emotional issues that people have been through. Dealing with the emotions of anger and fear and grief and sadness and guilt, and moving through those to compassion for one's self. And it's a process instead of trying to just moderate the emotions to actually feel them, identify them, feel them, and express them in safe and healthy ways.

And then the third step is what do you have to do in your life? Sometimes, people need to make a change in their life. You need to set boundaries or make changes in their relationships in order to free their danger signal from continuing to create the pain or the fatigue or the anxiety or whatever.

Nicole Izquierdo:  Thank you for sharing that. Would you say that there is an evolutionary reason for something like the brain turning on those pain signals when there is no physical or structural issue?

Howard Schubiner:  Yeah. It's speculative, of course. We can't really go back in time and understand. But the way I think of it is that pain is a protector. Anxiety, depression, fatigue, they're protectors. Our brain is turning them on as a message to protect us from something, to alert us to something. When we get a broken ankle, our brain turns on pain in order to tell us to stop walking on that ankle, get rest, get help. So way back in hundreds of thousands of years ago, Neanderthals lived on the earth and homo sapiens did. Neanderthals were bigger, smarter, faster, they had bigger brains, they were better hunters. Why didn't they survive? Homo sapiens survived because they worked in clans. They got together in groups and they communicated and they hunted together and they looked out for each other. And that's, we think, why we, so to speak, survived.

And so if you were back in those days and you got bit by a tiger, obviously, your brain, you want pain. You break an ankle, you want pain. But why would you want pain or other symptoms in an emotional situation? Well, if you survive because of your clan, if you get kicked out of the clan, you might die. That's a life-threatening thing, to get kicked out. Why would you get kicked out? Because of shame, because of guilt, because you did something wrong, but you beat up somebody or you betrayed somebody. And then the group would enforce the rule by shaming you or yelling at you or criticizing you, or whatever. And then you would be in danger of ostracism, which could mean death. So from my point of view, it makes sense that our brain would turn on a very strong reaction not only to a physical injury but also to an emotional injury. And I think that's why that occurred, but it's a bit of speculation, of course.

Nicole Izquierdo:  So you were featured in a new documentary titled This Might Hurt, which follows three chronic pain sufferers and offers solutions to such suffering. So your paradigm for diagnosis and treatment was found to be effective in several randomized trials, and it was actually listed as a best practice by the HHS's taskforce to combat the opioid epidemic. Can you speak a little bit more about this film and what has led to the ongoing opioid epidemic in the US?

Howard Schubiner:  Sure. The film is This Might Hurt. It was directed and produced by Kent Bassett and Marianne Cunningham, two young people. Kent himself had chronic pain and cured himself by changing his mind, changing how he related to it, changing his understanding of it, without any medical intervention. He had very severe chronic pain that it was incapacitating for quite a while. So he wanted to make this movie, and the movie kind of shows the real-life issues that people with pain have. One of the women in the movie was bedridden for eight years with chronic abdominal pain. And after going through this program, she got up, she got out of bed, she could work. She went back and got a job. I mean, it's amazing what can happen when you have this different way of looking at it, as I was describing, this whole different way of looking at it and different way of treating it.

Because the main paradigm for treating chronic symptoms in our medical world, chronic pain, is that you're going to have to cope with it. We'll give you medications, injections, physical therapy, acupuncture, meditation, all these things to help you cope with it better, but they're not offering, actually, to make it better. And the research shows that the coping method doesn't work all that well with chronic pain. And similarly, I would argue, with anxiety and depression and chronic fatigue, we're finding that the coping model of doing a little bit of this and a little bit of that doesn't... It has kind of a ceiling effect. You're saying, "Well, you can get better, but you can't get all the way better." And so you're stuck in this danger signal in your brain. And so we're trying to think of these things in a different way, which I think is actually scientifically valid. It's not pie in the sky or just rose-colored glasses. It's actually based on the neuroscience of how the brain works.

And so the opioid epidemic was a response, but it was a kind of neurobiotechnical response. You have pain. There must be something wrong in your body. We have to treat the pain. We'll have to give you medication because there's nothing else we can do. And so over time, more and more people got more and more medications. Of course, the drug companies were complicit in this, in trying to tell doctors that these medications weren't addicting or weren't as addicting as people were concerned. And in addition to that, our society has basically been falling apart in a lot of ways. And so that clearly weighs on people's minds and makes people much more likely to turn to pain relievers, because their lives are so difficult.

Nicole Izquierdo:  Thank you. So our practice specializes in treating anxiety and anxiety-related disorders, and so we were particularly interested to see you have another book titled Unlearn Your Anxiety and Depression. Do you mind elaborating on how this might be possible, and whether this is something that someone can do by themselves, or whether it has to be under the care of a mental healthcare provider like a therapist or a psychiatrist?

Howard Schubiner:  Yeah. Good question. When I started working in the field of pain, and so I saw a lot of people with pain and I learned a lot. I've been doing this for almost 20 years now. So I just learned a lot about pain, and what I saw over time was that frequently, the people who had chronic pain also had anxiety or depression. If you're in a counseling center and you're seeing people with anxiety and depression, about 50% of your patients are going to have a chronic painful condition. So there's a tremendous overlap in these conditions, number one. Number two, there's tremendous interchangeability of these conditions, as I mentioned before, where you see people where symptoms will kind of come and go, and anxiety may be replaced with pain and pain may be replaced with fatigue and fatigue may be replaced with insomnia and then depression. And so when you see that in people, you can see, well, gee, the brain may be turning on one set of symptoms and then may be turning on another set of symptoms.

And what I've found over the years is that if you apply the similar diagnostic assessment tool mechanism to people with anxiety and depression as I did with people with chronic pain. Again, really not a structural problem, and looking for the clues that suggest that it is a neural circuit problem, number one. And then number two, using the changing your relationship to the symptoms. For example, if someone has anxiety... What I'm doing is not rocket science, not super complicated, but it's very optimistic, and it's saying that you can change.

And so if someone is having anxiety in a certain situation, in elevators or in work meetings or in family situations, the first step would be to have them imagine that situation in their mind. And when you imagine that situation in your mind, what happens in your body? What response do you get? And so if you're imagining being in a work meeting and your stomach starts to flip into knots and you feel a little bit trembly, then that's your brain turning that on. You're not actually in the situation. You're just imagining it. And that's a low-level exposure. And then we help people to smile at that, to calm their brain, to soothe the brain, to treat the brain like a scared child lying in bed, fearful of a monster in the closet, and to give themselves love and compassion and caring, give their brain love and compassion and caring. Recognizing their brain is not the enemy, it's just afraid. It's just afraid of the situation.

And then we use these techniques to help calm those symptoms, calm the stomach, calm the trembling. And then go back and imagine the situation again, and then calm the sensations. And then imagine the situation again. And you keep doing that, and then it's just like the old classic way of treating a phobia of snakes. Desensitization. And then you gradually get people to go into those situations with this calmness, with these techniques. And the techniques are not all that brilliant. They're just the normal calming techniques. But it's knowing that you can do it. It's knowing you're going to be okay. Knowing it's just your brain that's afraid. And that's the key that can really help people to propel themselves to changing their symptoms. And then, of course, certain people may also need to deal with some of the traumas in their life, some of the emotional situations. And that's what we talked about with the emotional awareness and expression therapy part of it, as well.

Nicole Izquierdo:  So you would say it's ideal for this to happen under the care of a practitioner, developing the exposure hierarchy? Or even having someone there when you're experiencing those stressful situations to make sure they're not in danger?

Howard Schubiner:  Yeah. I mean, some people clearly need help and need a therapist. But there's not enough therapists in the world to deal with all the people who have chronic pain and have chronic anxiety and depression. There's nowhere near enough therapists in the world. So my view is that a lot of people can do this on their own. A lot of people can learn these techniques. And that's why I've written these books into a self-help guided recovery program that people can use. And I get emails all the time from people who are using these on their own.

And so it's really a question of what level of worry and concern and what level help people need, and what level of underlying trauma people have, what the severity of their situation is. So I think it's kind of a mixture. When I work with people, I work with them individually, but then I give them lots of homework, and I say, "Here's how you can start to practice this on your own. Here's how you can do this on your own." Because ultimately, we want people to be in charge of their own health, as much as possible.

Nicole Izquierdo:  Thank you. Yeah, I see something similar with that and what we're trying to do with our website with interviews and writing articles. Because some people can't afford to start treatment or continue treatment forever, so.

Howard Schubiner:  Absolutely.

Nicole Izquierdo: Nice that that was your goal with those books. I appreciate that. So we're approaching our final question. As a doctor specializing in the mind-body connection, do you have any other words of advice or parting words for our listeners?

Howard Schubiner:  No. I really think that the most important thing is compassion. So many people who have been brought up in difficult situations have learned that it's much easier for them to be compassionate to others than to be compassionate to themselves. We see this all the time. And if they can begin to do that, if they can begin to look out for themselves, stand up for themselves, speak up for themselves. If they can recognize that they are, it sounds silly, but, worthy and deserving and worthy of being loved, just as everyone else is, that is just such an important step for people to take. And there's ways to do that, and there's books written about self-compassion, for example, that people can follow and learn to take care of themselves. Because what's happening is that their brain is reacting out of fear and worry, and some of the fear and worry they're actually putting on themselves because they're feeling inadequate. And so, to me, it really starts with compassion.

Nicole Izquierdo:  Thank you. So to wrap things up, we just wanted to let our listeners know that Dr. Schubiner has a series of animations on YouTube that are very insightful, so we will be linking those on our website. And I just wanted to say thank you so much for joining us and sharing your knowledge, Dr. Schubiner. We really appreciate you taking the time to speak with us, and we wish you the best.

Howard Schubiner:  Thank you. It's a pleasure. Thank you for doing what you're doing. I appreciate it.

Nicole Izquierdo:  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.

Psychologist Bethany Brand on PTSD & Dissociation

An Interview with Psychologist Bethany Brand

Dr. Bethany Brand is a Clinical Psychologist and Professor of Psychology at Towson University. She is an expert in trauma and specializes in the assessment and treatment of trauma-related disorders, including PTSD and dissociative disorders.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialist. I'd like to welcome Dr. Bethany Brand. Dr. Brand is a professor in the Department of Psychology at Towson University. She also maintains an independent practice in clinical psychology, specializing in the treatment of trauma disorders, including dissociative disorders and post-traumatic stress disorders. She has numerous publications on trauma and dissociative disorders, including one of her most recent publications on the topic, “An Examination of the Relations Between Emotional Dysregulation, Dissociation and Non-suicidal Self-injury Among Dissociative Disorder Patients.” Before we get started Dr. Brand, can you please let us know a little more about yourself and what made you interested in studying trauma?

Bethany Brand:  Yes. Thanks for having me. Well, if we go way back, I had a friend in high school and she had been traumatized, and so had her sisters, and they had very different responses, and it just intrigued me trying to figure out how could people go through similar traumas and have very different outcomes? So then when I was in graduate school, I started pursuing it more seriously and asking supervisors if I could treat trauma. Then, I did my master’s and my dissertation on trauma. When I looked for my first position after grad school, I found a postdoc at Sheppard Pratt, and at that point they had a trauma disorders unit that was just opening. So, in that case, I was at the right place at the right time, and I got to work on their unit, which had mostly people with serious dissociative disorders, so I got great training early on.

Amelia Worley:  Wow. So, to begin, would you mind defining what dissociation is?

Bethany Brand:  Sure. Dissociation is a disconnection of what are normally integrated psychological constructs or functions. So, for example, a person may feel disconnected from their body. They may literally see themselves at a distance and be looking down on themselves, or they may feel very numb when they should have emotion. It's an emotional time. They're talking about something with that they might normally feel terrified about or ashamed about, and they feel nothing. So, that's that kind of disconnection. You can also have disconnection from your environment. So, it may be they're in a place that's familiar or with somebody they know well, and suddenly they don't look familiar or they don't recognize fully who that person is. They have some sense that they know them, but they can't really place them. They may have a disconnection in their memory where they feel like there's gaps in their memory.

They can't recall, it might be hours, days, or even potentially, from childhood. There might be years that they really don't recall. Within their identity, they may have a sense of being kind of fragmented where they feel like, more than people who are non-dissociative because we all have parts, but they may feel like they act so differently, seem so differently, behave so differently that at different times they feel as if they're almost different people, although nobody can have more than one person inside them. It's states, dissociative-self states. They also may have disconnection from behavior. So, they may find themselves doing something, see themselves doing it, and they literally can't stop what they're doing. Those are just some of the examples.

Amelia Worley:  How is dissociation linked to trauma? Are some traumatic experiences more likely to cause dissociative disorders?

Bethany Brand:  Yes, they are. So, we know that if it's particularly life-threatening, you might be more prone to dissociation. We know that children are more likely to dissociate, and they lose that ability a little bit over time. So, for example, if there's ongoing childhood abuse, and especially if it's done by a caretaker, somebody who's in charge of the child, should be protecting them, and instead they're betraying them, we know from betrayal trauma theory that they're more likely in those situations to dissociate. So, it's particularly severe, ongoing trauma, but it can even happen for a one-time really serious car accident. Like I know somebody who, when they were in a car accident, they were actually seriously injured, but they didn't feel any of the injury. It wasn't, they hadn't had nerve damage. It was that they were at for a little while having what's called very traumatic dissociation, which is dissociation during the actual trauma itself.

Amelia Worley:  Wow. How might someone know whether or not they're suffering from trauma-related dissociation? What does it feel like?

Bethany Brand:  It's a good question, but it feels very different according to which one of those constructs is, they're disconnected from. So, do they, generally speaking, have emotions? Do they generally feel like the body is theirs or do they sometimes feel like that's not my body? It's not like, it's not a person getting older and looking at themselves thinking, that's not how I look. It's more profound than that. Like they might look child-like, or they may feel like they look at themselves and suddenly they look decades older, and it just, it's a strange sensation. They may look in a mirror and not recognize themselves. If a person is, has experienced or is experiencing a number of the things I've talked about, problems with feeling connected to their body, connected to their emotions, connected and oriented and aware of their surroundings, that probably means that they don't dissociate much.

But if sometimes their surroundings look far away, even though let's say, if they're hand looks like it's a mile away, like their arm has suddenly grown, there's really a huge distance, that's a type of depersonalization. Or if, let's say they're talking to a therapist and suddenly the room looks foggy, that's derealization. The world around them looks different. Or they can't hear their therapist speaking, even though there's nothing wrong with their hearing, that's a type of derealization. So, if somebody's experiencing any of these things, that might give them some indication that they possibly have trauma-related dissociation, and of course, have they been exposed to some kind of trauma? That's a prerequisite for trauma-related dissociation.

Amelia Worley:  So, what can trigger dissociation in an individual after the traumatic event has occurred?

Bethany Brand:  It may be that they're just hearing a sound that reminds them, a trigger. It could be a sound, an image of the light being a certain way. They might hear, they might smell a certain smell. Smells are very, very likely to trigger traumatic associations. So, it's when they feel triggered that then they may also start to dissociate. So, I'm careful, I'm a little cautious that some listeners might be a little triggered about what I'm going to say. So, I'm going to advise them if they want to just tune me out for a minute, but let's go with the example of smells. So, if somebody was traumatized by somebody who'd been drinking alcohol, if later, they smell alcohol, they can be triggered by that, and start to have their heart race, feel terribly vulnerable, like something dreadful is going to happen, or they may do that for a bit, and then disassociate, start feeling numbed out, kind of like things around them looking surreal in some way, or they might just really rapidly go to a dissociative state.

Amelia Worley:  That's really interesting. In your publication I mentioned earlier, “An Examination of the Relations Between Emotional Dysregulation, Dissociation and Non-suicidal Self-injury Among Dissociative Disorder Patients”, you talk about how this idea of emotional dysregulation. Can you explain what emotional dysregulation is, and how it relates to trauma-related dissociation?

Bethany Brand:  Yes. So, you know how we like to have very big terms in our field? Emotion dysregulation is basically difficulty dealing with emotions. Okay? So, people who have got, who've experienced a lot of trauma, whether they're highly dissociative or not, they tend to feel too much or too little. So, for example, let me go back to that past trigger example I gave you. Maybe that person normally has normal feelings. They can feel some happiness, some sadness, some anxiety before a test, whatever. But when they get around, let's say they are abused by a man. When they get around men, then they start feeling really scared. Their heart starts to race. They feel like, oh, I've got to watch behind me. I've got to watch this guy. That's feeling too much. The opposite can also happen where they feel too little. The examples I gave where somebody is numbed out, they don't feel connected to their body.

So, emotion regulation is when you have the capacity to know what you're feeling. They can identify the emotions, and emotions, how do we know we're feeling emotions? It's in our bodies. So, if somebody's angry, they might feel I'm imitating it for anybody who's not watching the video. I'm clenching my hands. I'm kind of raising my shoulders. I'm tensing up muscles. A lot of people feel that kind of muscle tension and agitation energy in their body when they're angry. If you're feeling, if you go back and forth between too much feeling, too little, if somebody starts getting angry and they're very uncomfortable with that emotion, they may shut it down and disconnect from their body. Maybe anger is very scary, because maybe they were in a relationship that was physically abusive, and so they disconnect if there's anger. So, what happens when somebody's traumatized, trauma by its definition, it's overwhelming.

They may feel at risk for their life, and so the feelings are huge, way, way, way too big. Like that example I gave earlier with somebody who had peritraumatic dissociation, if you're so terrified, sometimes the brain, it's an automatic kind of a brain-based response, may start shutting down emotion. The person's not willing it to happen. It just starts to happen. Parts of our brain start kind of metaphorically going offline. They're not very active. So, later on, if that happened during trauma, that the person started dissociating when they felt too much, if later on after the trauma, they're starting to get overwhelmed with feeling too much, they may get scared of that, and at first, they may consciously, like, I don't want to feel this. I don't want to feel this. I don't want to think about this, and they kind of push it away.

That's normal PTSD is you try and push away emotions and remembrances and memories, images. But over time, if somebody's also disassociated or starts to learn to dissociate, they can numb out and disconnect. If they avoid thinking about something enough or it's so awful, they really just, they're, they don't go there in their minds. Over time, they may have less access to that memory, and so they start maybe having the memory problems I talked about earlier. So, emotion regulation is intricately tied in with dissociation, because dissociation is a way of dealing with emotion, and a terribly threatening situation.

So, what we've looked at in some of these studies is, can we teach people who have very high levels of trauma-related disassociation other ways to identify what they're feeling, to not be so afraid of emotions, help them learn how emotions are helpful, and how to healthfully manage them in a range that's tolerable, so they're not flooded. They're not numbed out. They don't have too much or too little emotion. We found in this treatment study we did with dissociative disorders, folks, that as you teach them emotion regulation skills, then dissociation began to decrease some. They weren't needing to dissociate so much. We also found that self-harm decreased, PTSD symptoms decreased. Helping people learn to regulate their emotions is a really fundamental, crucial skill, in other words.

Amelia Worley:  So, continuing on that idea, can you talk a little bit about the most effective treatment approaches for trauma-related disassociation?

Bethany Brand:  Yes. So, the study I was just referencing indirectly is one called “The Treatment of Patients With Dissociative Disorders.” It's TOP DD, and that's for people who have really serious dissociative symptoms. We're in the process of doing a randomized controlled trial treatment, where we're checking out the program I was just referencing. So, we get people who have very high levels of dissociation, plus their therapist, who agree to be in the study. We have a number of videos where we teach them what trauma does in general, various symptoms related to trauma, then we get to dissociation what it is and how that was helpful, but also how in adulthood, when you're safer, if you're safer now, how it can get in the way. So, somebody not always knowing what they're feeling, maybe they're tuning out some important clues from their body, from their mind that a relationship's not safe, but if they're not in touch with their emotions, they may not feel that.

So, we know from research that people with lots of dissociation have high rates of being re-traumatized in adulthood. So, it's really important to help them learn to identify their emotions, and to gradually use less dissociation. So, we're, in that program, that's some of things that we're teaching and that's in general, whether somebody's in that treatment study or whether they're working with a therapist. The therapist, generally speaking, teaches them what dissociation is, the symptoms of PTSD, because they often have both. Then there's a technique called a grounding technique. So, let me, and I'm talking this out loud, just in case somebody can't see the screen. Dissociation’s on a continuum. At one end of the continuum is somebody is grounded and oriented in present reality. They can feel their body. They know where they are. They know what the date is. They're really hooked into present reality.

The other end is profoundly dissociated, where they don't necessarily, they don't recognize where they are. They're not feeling their body. They're really severely dissociated. Then in between, there's this whole range. What a therapist can help a client learn to do is recognize the early signs that they're beginning to dissociate. So, they might feel spacey or tingly. Those are just examples. So, the client learns when they start recognizing that warning sign, then they use these grounding techniques, and I'll just explain a very basic one that lots of people know. You can use this with panic attacks, all kinds of things, not just disassociation. But you put your feet on the floor. I'm going to do it, because when I teach people, I always do it along with them. So, I'm pushing my feet into the floor, and trying to really notice what that feels like. That is using muscle movement, contractions, and trying to get them to feel that part of their body, assuming they're okay with feeling that.

Then I would also be having them look around where they are. If it's a Zoom therapy session, look around the room where they are. If we're meeting together, look around my office and find something that they can describe with all the senses. So, I've got a cup of water here. If they've got something to drink, can they feel the weight of the cup? Can they feel the coldness or the warmth, taste it, using all their senses? That actually helps wake up metaphorically, the parts of the brain that have shifted, and kind of gone offline while they're dissociating. So, you use the senses, all five senses to get the brain back online in the normal way that it should be. Those are grounding techniques. So, a therapist would be teaching them grounding techniques and having them practice that in session, and then also, out of session. Those are just some of the basic tools we use when folks have got a lot of trauma-related disassociation.

Amelia Worley:  Wow. Lastly, do you have any advice or anything you want to share with our listeners suffering from trauma-related disassociation?

Bethany Brand:  Yes. I would say one of the most important things you can do is to learn exactly what I was just talking about. Learn grounding techniques, and practice them, and learn healthy ways of taking care of yourself emotionally. So, many, many, many people who've been terribly traumatized feel ashamed of themselves, feel dirty. They feel like they're bad people. That's, those are symptoms of being traumatized. It's not the reality of who they are. It's a symptom. So, hopefully they can start thinking about that, looking into that. There are good books out there to read for trauma recovery. If somebody has a really serious, a lot of dissociative symptoms, if they have a therapist, if they want, and they can look into this treatment of patients with dissociative disorders study, TOPDDstudy.com, and we have that website. They can go there and look and see if we're still running the study.

There's also a professional website that has a lot of information for consumers and therapists. I'll say it slowly. It's ISSTD. It stands for the International Society for the Study of Trauma and Dissociation. That organization does a lot of training for therapists, and they have frequently asked questions on their website about disassociation. They have some questionnaires, people could even try and fill out and find out do they seem to be scoring fairly high, and learn a little bit about, do they have dissociative symptoms, where to go to get help. They have a Find a Therapist page on that website.

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

Bethany Brand:  Thank you so much. It's been an honor to be here.

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

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

Therapist Kate Willman on ACT & Writing Therapy

An Interview with Therapist Kate Willman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kate Willman:  Yeah. Thank you, Amelia.

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

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

Therapist and SAS ED Blake Thompson on Psychotherapy

An Interview with Therapist Blake Thompson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Blake Thompson:  Hey, thanks, Nicole.

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

Therapist Jim McDonnell on High-Stress Employment

An Interview with Therapist Jim McDonnell

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

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

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

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

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

Anna Kiesewetter:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jim McDonnell:  Thanks, Anna.

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

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

Psychologist Michele Bedard-Gilligan on Trauma & Recovery

An Interview with Psychologist Michele Bedard-Gilligan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Psychologist Sarah Gaither on race & Social Identity

An Interview with Psychologist Sarah Gaither

Dr. Gaither is an assistant professor of psychology and neuroscience at Duke University. She is a social psychologist specializing in diversity and inclusion.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Nicole Izquierdo, research intern at Seattle Anxiety Specialists, and I'd like to welcome with us Social Psychologist and Diversity and Inclusion Scholar, Dr. Sarah Gaither. Dr. Gaither is an Assistant Professor of Psychology and Neuroscience at Duke University, and she earned her PhD in Social Psychology from Tufts University, and is currently the Director of Duke's Identity and Diversity lab. She's an expert in social identities and inter-group contact, and her research focuses broadly on how a person's social identities and experiences across the lifespan motivate their social perceptions and behaviors in diverse settings.

So before we get started, do you want to add anything else? Can you tell us a little bit more about yourself?

Sarah Gaither:  Sure. Well, thanks for having me. I'm excited to be here. I think, you know, for me, it's really important for everyone to kind of know my framework of where I come from for why I study what I do.

So I'm Biracial, so I'm Biracial Black/White, but I look like a strange White person, and so it's kind of my lived experience, right, of having this invisible versus visible identities, that's really pushed me in wanting to understand how our group memberships can shift our behavior and identities in different ways. So for me, it's always been this lifelong question of growing up in a mixed-race household, constantly being questioned about why I don't match my dad, why my brother looks different than I do. Those kinds of identity-questioning experiences really what's fueled why I study what I do today.

So I think that's just an important thing for everyone to keep in mind as we discuss things today.

Nicole Izquierdo:  Thank you. So I guess you kind of answered this a little, but besides social psychology, growing up, did you play around with any other career paths or like you always knew from day one social psych-

Sarah Gaither:  I definitely did not think I'd ever be a Psychology professor. I was not even a Psychology major in undergrad; I was a Social Welfare major. So I thought I'd be a Social Worker. Turns out I'm not a strong enough person for that. After working on a case, it destroyed me, and I knew I really wanted to study people and behavior and understand, you know, why we make the decisions we do, why we interact with people in positive versus negative ways. So I've always just been a people person. I think for me, growing up kind of confused about my own mixed-race identity, my toys were all super multicultural and multiracial so I knew I was lots of things at the same time, but I didn't really have the words to explain those things.

So during my gap years after undergrad, that's when I realized doing literature reviews, as boring as that can sound to some of you listening to this right now, I discovered within the Psychology field, at least, there was very little published research with Biracial samples. So my group, my existence really just didn't exist within our current findings, and so that's what motivated me to want to apply to grad school. Try and give a voice to these populations and experiences while also using Biracial, bicultural experiences to help us understand more broadly how our identities kind of function, even if you aren't a member of one of those groups.

Nicole Izquierdo:  So for the people listening who don't know what social psychology is or what diversity and inclusion research is, do you want to go into a little bit more detail about that and even the specific questions that you aim to answer?

Sarah Gaither:  Yeah, yeah. So being a social psychologist, I think everyone in the world is a social psychologist, even if you have no training in it, basically because we all judge each other all the time. So social psychology is our social judgements of each other, our social judgements of ourselves. It's the psychology behind the decisions we make, the role that the context plays in shifting how we perceive things in our social world. So social psychology really shapes everything we do. It's also the lens that we process things that have already happened to us at the same time.

So in my work as a social psychologist, I look not only at the present day and sort of, "What are your current attitudes and how you feel about your own identities or other people or other groups?", but I also look developmentally, when you were little, when you were growing up. "What are the types of experiences you had with people from different diverse backgrounds?" that might actually predict whether you're more inclusive versus an exclusive person later on as an adult. So that's sort of how I see social psychology and why I think all of us are technically social psychologists deep down inside.

Nicole Izquierdo:  Yeah. So I wanted to ask you about, I don't know if this is the right term, but like implicit bias, and basically you said that it affects people in the future when interacting with others. Are people doomed when it comes to their implicit bias? Is there a certain limit or, like what can be done? Like what are some interventions or early childhood teachings?

Sarah Gaither:  Yeah. So implicit bias, for those of you who might not know what that is, that's kind of these internal automatic associations, stereotypes that you might have about someone you don't know, right? So that gut reaction, that gut response that you have when you see someone new for the first time, those are usually our implicit responses to that individual or to that group. So, lots of people ask me all the time, "Is there a critical age point where we should intervene and make everyone magically inclusive?" There's not one age point, right, where we say, "This is when change happens." Early on, early childhood is one of those critical periods. We know exposure to people from different races, cultures, ethnicities, if you can travel to different regions of a country that you live in, those are really prime opportunities when you're a young child, because you're learning what words mean and what these associations mean to different groups.

So if you're only exposed to people who look like you the whole time growing up, the first time you see someone from another group who looks a little different, you're only going to have those stereotypes you've maybe learned from the media or other sources of influence. So, diversity contact is super, super important early on in childhood. Adolescence is another time that we know is ripe for interventions, mainly because that's when kids are switching school environments, and so changes in context are always ripe for opportunities in people trying to reassess themselves or reassess their biases. Same thing goes for entering college. This is a very important identity period in particular, because when you move off to a four-year institution, if that is the type college you may have gone to, that's usually the first time people are moving away from their home, their family, their friends, and they're forced to navigate these social worlds for the first time, without any help from anyone that they've known.

So college is one of those identity-ripe periods where people are often experiencing new things for the first time. Maybe they lived in a context where they could never acknowledge an identity or an aspect of themselves until they got away from that home environment or that home context. So those are kind of main age points that I focus on a lot in my work, mainly because I am very interested in those moments of change. So to answer your original question, no one's doomed. Everyone can change, but some people might take a little more effort to change than others. The same thing goes for negative contact you might have. So if you have lots of positive diversity contact, that's going to change your attitudes in a positive direction, but you could have negative contact, and that's going to work against those attitude changes. It can actually reinforce those negative attitudes you might already have. So, contact can work in both positive and negative ways.

Nicole Izquierdo:  When you talk about college, I wanted to talk a little bit more about the kind of work you've done on Duke's campus. I'm familiar with your random roommate study, but I was hoping you can elaborate a little bit more on that as well.

Sarah Gaither:  Yeah. So Duke, a couple years ago, changed their roommate policy for incoming freshmen. So, they used to allow a freshman to either be randomly assigned to a roommate or they could choose their own roommate, and Duke decided to change that policy a couple years ago where all incoming freshmen are now randomly assigned. They did this because they wanted to see if it actually changed how inclusive the freshmen class felt, and they asked me if I wanted to study it. I had some work from grad school I had published that showed if you were a White freshman living with anyone but another White freshman, so a Black, Latino, or an Asian individual, that experience living with someone from another racial background your freshman year, by the end of that freshman year when I brought you into the lab to meet a Black student you had never met before, that interaction went way better. Way more positive eye contact. You smiled more. The Black students also felt better in those interactions as well. So this wasn't just a gain for White students, but for students of color as well.

So Tufts and I did that project during grad school in Boston, and then Duke knew that I had done that, and so they asked me to follow this cohort here at Duke. Really, what we're seeing is similar types of effects and changing some of our White students' social behavior in these future settings who have been randomly assigned a roommate from another racial or cultural background, but we're seeing that I think is even more interesting in a way as we also recruited minority students in the sample at Duke, and regardless of what your racial or ethnic background may be, everyone's friend networks are becoming significantly more diverse by the end of that freshman year.

So by forcing you to live with someone who's different just for that first year of college, we're seeing this expansion of one's sense of self, as we call it. Your in-groups become bigger, your social networks become more inclusive, and it's actually making Duke not seem as exclusive. Still has some issues to work out for sure, but that's one of our main positive findings right now, which I'm really excited about.

Nicole Izquierdo:  So the positive effects are happening for both the White racial majority and the minority groups. Okay.

Sarah Gaither:  Yeah, for both groups. So that's, you know, and that's rarely studied with students of color on different college campuses. It's tricky at Duke since we're still a predominantly White campus to kind of control for how much White contact versus minority contact students are getting, but the fact that everyone's friend networks are actually becoming more racially diverse, gender diverse, sexual orientation diverse, religiously diverse. The only one we're not moving, it seems, is politically diverse, but Duke's campus is also politically liberal, pretty biased in that direction so I think there's not quite enough room to move those friend aspects around, but all the other categories seem to be expanding.

Nicole Izquierdo:  And we all know the pandemic kind of messed up all our life goals, research, et cetera. So how would you say it impacted your research both like practically, and also, did it change the kind of research questions that you want to ask moving forward?

Sarah Gaither:  Yeah. COVID, you know, shifted a lot of things, and of course, millions of people around the world have died from COVID, and so that's really the real thing we should all be focusing on, on how COVID has impacted things. From a research standpoint, for me in particular, it ended all in-person research. So what I really love studying is the actual social behavior between people when they're talking to each other face-to-face, but when COVID hit, we couldn't run in-person studies, everyone was wearing masks. So if I'm wearing a mask, you can't see my face. You can't see my emotions. It makes coding whether these interactions are going positively or not pretty much impossible. So we had to stop all behavioral in-lab data collection.

We also do work with young kids and families. Since kids under five still are not able to be vaccinated we're actually still running kids online even today, even though COVID is becoming less of a problem, just to keep all families and parents safe. So, that's the main way it's affected us really, is not being able to do any in-person data collection.

The other way is even online data collections since we can collect some of our work through online surveys. Those prices have also skyrocketed because everyone got moved to online platforms. So following classic economics, right, supply and demand, they can charge what they want when all of us were forced to collect our data online. So, grants became more necessary during COVID, and just thinking creatively about how to adapt some of the questions that I'm interested in into an online Zoom format, right? How can we still relate this to real world outcomes through these weird little black boxes we all exist on for the last two years?

Nicole Izquierdo:  Thank you. So now I want to move into a little bit more, most of our listeners are either interested in like therapy, mental health. So have you done or read up on any work about Biracial individuals in therapy, or anything related to like racial trauma and like Biracial people's role in the Black Lives Matter movement?

Sarah Gaither:  Yeah. So lots of responses there. So the bulk of my work focuses on Biracial and bicultural experiences because of my own lived experiences. The most common stressor we have for both of these groups is something we call "identity denial" or "identity questioning." So if someone's ever asked you, "What are you?", "Are you sure your dad's your dad?", these kinds of very direct identity-threatening situations, over time, they serve as small little microaggressions that science has now shown really add up to being strong mental health stressors. It develops people in an inability to form a positive sense of self. It's negatively impacting their self-esteem. So a lot of the multiracial and multicultural literatures actually cite higher cases of different types of mental health outcomes, such as depression and anxiety for these groups, and the reason they cite this sometimes in clinical work is because they have twice amount of the exclusion in their lives, right? If you're part White and part Black, you now have White people and Black people both excluding you for different reasons, right? So it's twice the amount of social exclusion.

So Biracial people aren't experiencing more discrimination than other racial or ethnic minority groups importantly; we know monoracial minorities tend to experience more direct discrimination and prejudice, but from a social exclusion standpoint, which is what's directly linked to a lot of negative and mental health outcomes is higher for our Biracial and bicultural populations compared to other racial and ethnic groups.

So that's something our lab's been trying to measure, and we actually have the first paper where we measured cortisol responses for this specific identity denial experience that Biracial and bicultural individuals face. So you see your cortisol, which is a biomarker, inside of your body that elevates when you have a stressful experience. We find that this increases for both bicultural and Biracial people, and if you live your life at higher rates of cortisol all the time being elevated, it can lead to early death, weight problems, sleep problems, things of that sort as well.

So, what I think is tricky from a therapy counseling angle is most of the research that exists has excluded multiracial and multicultural people from their demographics. They're difficult to categorize and to fit into boxes. So we don't know if you need a certain type of multicultural therapist to feel included in your sessions. We don't know what cues, right, and what to train people on since there's so much variability within the multiracial and multicultural demographic. It's hard to come up with a one-size-fits-all kind of training model on what to do in these therapy sessions.

I think what this all stems down to is just this notion of belonging, right? When anyone has an issue with belonging, they feel like they don't belong or they don't fit in, this is what leads to those negative mental health downstream consequences. That's what led to me writing my own piece on being involved in the Black Lives Matter movement, as someone who presents very White. Those are those particular contexts, right, where you question where you belong, what your space is, what your space is not, and to also question your privilege; if you're White-presenting, you clearly have privileges in our US society that other people do not, but knowing where you can still fight for those who are marginalized, fight for those who are having more difficulties in their life is still an internal stressor for many multicultural and multiracial people.

So I wrote that piece as a way to hopefully motivate others who maybe felt similarly as I did where we wanted to be involved, but weren't sure if that space was a space we were welcomed in or not, right. Making sure that we give the stage and the platforms to people whose voices have not been heard over time. So that's really what motivated that piece that I wrote earlier.

Nicole Izquierdo:  Do you see anything with children of, let's say, your Black father and your White mother, where they experience, I wouldn't say it's like secondhand, but like you witness the racial minority parent experiencing discrimination. So even though the child doesn't firsthand because they're White-presenting, they see someone they love experiencing that. Have you done or heard about any research that analyzes that?

Sarah Gaither:  Yeah. There's very little research in that direction—sorry. My dog is barking. There is clearly a delivery person outside. He's going to be very loud for a second, but he's a lovely dog, everyone. Yay for working at home. That's the other way COVID has impacted me.

To answer your question there, there isn't a ton of research looking at offspring of mixed-race parents and sort of, what are the instances of discrimination or prejudice they witness from their parents. That's a great thing that should be studied. I know from my own firsthand experiences, for me, that's what made me hyperaware of race relations growing up, right? Knowing that I was never targeted, but it was always my dad being targeted, right? He would be accosted when we were at the shopping mall. People saying, "Hey, are you kidnapping this little girl?" They would never come up to me; they would direct all of their accusations toward him. We had skinheads living down the street from us growing up and they would only throw rocks on his side of the car, but not my side of my car.

So there are these explicit exposures and that's how kids learn. Kids learn through these experiences, and I think that's what makes being multiracial a complicated thing to study developmentally. It depends on if you're in a two-parent versus a single-parent household, that also hasn't been studied a ton, which parent is doing the kind of racial or ethnic socialization. Also not studied a ton, but our lab is currently collecting some data on that, so stay tuned. So I think those inputs of how kids learn, particularly from multiracial and multicultural backgrounds when they're little, it's just not documented that well. Sociology has a couple papers on it, but there's hasn't been any large-scale psychology studies yet.

Nicole Izquierdo:  Thank you. That just came up when talking about this.

So you mentioned that inclusion, sense of belonging have been linked to mental health outcomes. Can you just elaborate a little bit more on that? Like how much sense of belonging is enough to prevent those things from developing or is just like one instance of ostracism detrimental?

Sarah Gaither:  Yeah, yeah. So needing to belong, it's this kind of core fundamental human desire to just want to fit in. You want to feel like you have a home. You want to feel like you have a family. You want to feel like people understand you and your experiences for who you are without any questions whatsoever, right? So this can be measured in lots of different ways in psychology research, but the way we know it affects mental health outcomes in particular is for people who really feel like they never belong anywhere, right, or if they're trying to get into certain groups, but then there's people that keep saying, "No, you're not enough of X to be in this group," or "No, you're not good enough to be in this group," it's those constant kind of combinations of wanting to be in a group but then having that identity denial experience of not being able to attain that group membership that ends up leading to these increased stress outcomes, increased anxiety outcomes, etc.

So, how much needing to belong people have, everyone varies on this. There's not a magical number. If you have too many friends and none of them are very close friends, you're going to have a lot harder time dealing with identity stressors and identity threat experiences. You really need a couple good core members within your social circle. These could be family members, these could be friends, these could be romantic partners, any of those things, but you really need more than one. I'd say somewhere between three and five good core people, and the question that I post to all of my classes, which Nicole here has actually heard me already say once is, you know, if your car broke down at 2 o’clock in the morning on a very dark highway in the middle of nowhere, do you have at least a couple people you could call who would come and pick you up, no questions asked? Right?

That's the level of belonging, that level of social bonds that people strive for, and if you don't have those social bonds to latch onto when you're feeling threatened by society, by a peer, by a colleague or an employee, that lack of a social bond connection is what causes us to have these drops within our self-esteem and leads to that increased depression and anxiety outcomes.

So that's really one of the number one reasons why we see people in therapy and counseling sessions because they feel like they just don't know where they fit in.

Nicole Izquierdo:  Something else we learned about in your class, which I guess is another avenue I say that negative mental health outcomes could result from is compartmentalization and conflicting identities. So you still belong, but you're not able to, let's say, express that other conflicting identity within that group. Can you like give an example or why compartmentalization is so detrimental versus being able to integrate all your identities?

Sarah Gaither:  Yeah, yeah. So, you know, a big area of research is called identity integration within this kind of identity circle, and so if you have lots of your identities, the more integrated they are, the more in harmony that they are, the more they get along together, usually the less negative mental health consequences you're going to face because you can navigate very flexibly between your different identities, but if you view your identities very separately or they're in conflict, or one's in secret, you can't claim that identity based on a given context you may be in, that ends up leading to more stress, right? And it's because you're constantly fighting this battle of who it is you really are with this kind of secret invisible identity perhaps versus who it is you think you should be, right?

So a way we frame this a lot in psychology is looking at these conflicts between your actual self versus your ideal versus your ought self, right? This ideal self of who you would ideally be in an ideal space. The ought is who you think you should be, right, maybe based on social pressures, family pressures, but the conflict that you have between your actual self and either of these ideals or ought selves, that's where we see this increase in mental health negative downstream consequences for individuals.

So, I always try and tell people, you know, if they're feeling down, they really should work on why it is this one identity or this one experience seems to be so separate from the rest of them because our identities are multifaceted. They are intertwined with each other, but sometimes one can get very detached, but figuring out a way to get that more encompassed with your other identities is the best way to try and lift yourself back up in those moments.

Nicole Izquierdo:  Thank you. So now we're going to switch back the spotlight onto you. So, you recently became a mother to twins. So has becoming a mother impacted the way you view the world and impacted the way you are as a researcher?

Sarah Gaither:  I think for me, I had twins last summer, so they're almost a year old. I've almost made it a year now with twins, which is a whole thing on its own. I think, A: being pregnant is a new identity, right, that people don't really talk about within the identity structure, and it's a temporary identity, right? You're not pregnant forever, but being a pregnant person is definitely an identity experience that I don't think is quite understood. And then you're not pregnant anymore randomly and these beings have come out of you. It's a totally weird transition, right? You go one day from being this, you know, wobbly person who can barely walk, and now you have this person, or in my case, two people who are completely dependent on you in every way, shape, and form.

So I think for me over the past year, what I've become hyperaware of is, A: how incredibly gendered our world is. I have boy/girl twins. We're trying not to gender them as much as possible, but it is everywhere and it's how people interact with them. It's even the language that people use with them, the toys that they choose to give them if they have choices of toys across a room. I think that's been a big kind of eye-opening experience for me, but for my own identity experiences, I think I didn't know how multifaceted I really was until I became a mom. I think being a mom makes everything else kind of click together. Now I know my experiences of cooking and liking food can now make them the food that they need. I know that my experience and the love for travel and exposure to diversity, the things I strive for in my own research are all the opportunities I look for to take my kids to, right, to make sure that they're getting that exposure at different cultural events here in Durham or whatever the case may be.

So, I think I am much more thoughtful now than I was before and where I go and what I do with my time, and making sure that each thing my kids are exposed to is hopefully going to lead to this positive identity change that I measure in my own research. So, it's kind of made me a double researcher in a way where I don't want my kids to not practice what I preach, right, is sort of my approach with them.

I think the other thing that it's made me really think about is how much we don't know how people are going to change, right? Identity is malleable across everyone's lives, and you asked earlier, right, "Is bias malleable?" Well, your identities are malleable too, right? So the experiences my kids are having right now is definitely going to shape some of their attitudes, some of their preferences, but that can also change drastically later on, right? There could be things that I'm doing, limiting certain things that they don't have a chance to experience, right, and trying to make sure that I'm open enough with letting them identify how they want to identify, right? Because identity is definitely malleable over the lifespan too.

So I think those are the things that keep me awake at night because they're actually pretty good sleepers. So I think about those things a lot.

Nicole Izquierdo:  And what advice would you give to parents of Biracial children, being one yourself, and like researching Biracial children?

Sarah Gaither:  I think it's, you know, exactly what I just said: let your kids, and even if your kids aren't Biracial, let your kids identify how they want to identify. What we know from so much research and psychology, sociology, education, health research is that when people feel their identity is forced on them in any way, taking away their autonomy, taking away their freedom to really identify for who they are, that's what leads to these negative mental health consequences. So, as much as you want to put your culture, your race, your background, your upbringing, your favorite foods, whatever it may be on your kid, if they don't like that favorite food, try to be nice about it, right? Because when things feel forced, that's when we know this identity conflict starts sort of arising between a parent and a child, and it can affect their overall identity development.

So let them be kids. Let them explore, let them learn, and realize that you too are going to make mistakes, right, in how you talk about things with them and you can learn from each other. So that would be my advice, I think, for anyone out there.

Nicole Izquierdo:  Is there a limit to what can be considered an identity?

Sarah Gaither:  Yeah. That's a good question. I'd say no. I'd say people can frame an identity in lots of different ways. Some people, being a runner really is a core component of who they are, right? If they lost their ability to run, they would lose their sense of self. I hate running, right? So for me, that would never be an identity, but for some people that's a very strong identity and that might be stronger than their gender identity or their racial or ethnic identity. I think when we think about identities broadly, we tend to think of race, gender, religion, sexual orientation. We don't always think about these other aspects: being a foodie, being a mom, being pregnant, right? There are lots of identities out there. What I think is important is knowing which identities are more important to you and why, right?

So that's what makes things shift your behavior and shift your judgment, is certain identities are going to cause you to change what it is you buy at the store, who it is you want to date, or what kind of graduate school program you might be considering, and not all of your identities are going to play as strong of roles in shaping those decisions down the road. So I think identities can be anything, but some of them are going to have more power over you than others.

Nicole Izquierdo:  And finally, another personal question, but where do you see yourself in the next five years, and how would you like your career to grow while at Duke?

Sarah Gaither:  Yeah. Well, hopefully I'll be tenured within the next five years. You listening, Duke? I hope that happens. I'll be submitting for tenure this summer. So we'll see what happens in the next year. So hopefully I'll be tenured. So I think for me, my biggest outstanding questions are really trying to figure out, what happens if you have negatively stereotyped identities? How does that function within a lot of these kind of multiple identities, flexible thinking kind of outcome spaces? I'd really love to understand more about that. I'd also really love to understand more developmentally with little kids when they really claim something as an identity. It's very hard to measure, but when does that young kid realize, "Hey, this is actually who I am," right? What are the different age points where race versus gender versus being a runner or whatever the case may be, when does that become important to kids, and what are the contexts or the pathways that lead to that strong, positive identification?

Those are things I'd love to still be studying going forward. I think the other thing I'd love to do is to also take this out into the real world. I think we do all these nerdy psychology studies in these controlled lab settings. That's why this roommate study was really interesting for me to do because it's real-world behavior, right? It's students living in the dorms with their roommates. So trying to extend some of this work into more naturalistic settings, I think, is absolutely key for us to truly understand the power that our identities have over our choices.

Nicole Izquierdo:  Do you see your work translating into the relationship between a therapist and their patient?

Sarah Gaither:  Yeah. I think identity always matters, right? I think there's lots of work out there; people are trying to measure identity matching, right? If that's something that helps within therapy sessions or not, or identity signaling, identity cues.

Another project we've been doing here on Duke's campus is called DukeLine, which is a peer texting program. So undergrads are helping other undergrads. I'm just a faculty member helping to fund it and run it, but I play no role in the peer coaching that happens, but what we've been trying to do within this peer coaching texting framework is to not necessarily tell you which anonymous peer coach you have if you happen to text in for help. You don't necessarily know what their individual identities are, but we have bios of all of our coaches we're putting on our website that show all the different identities that are represented within our coaching team, and our coaching team works really close together. We have a searchable database of the 600-700 most common stressors for Duke students that are actually curated by people from all of these different identity backgrounds, right, to make sure that when a student has a question, if you don't belong to that group or you haven't had that experience, we have people who have had those experiences, right, that we can pull from.

So I do think, from an identity matching angle, that type of connection is absolutely key. It's impossible, I think, to always match people based on certain identity qualities for therapy sessions, but it's not impossible to give people cultural tools and cultural knowledge, right, to make sure that the advice they're giving them, the help that they're giving them is culturally sensitive, and that's where I think we need to be improving.

Nicole Izquierdo:  Yeah, I wrote a, I forgot what class it was for, but I wrote an assignment about this, and yeah, like the same thing: there are so many barriers for those minority identity groups to even enter the field and become therapists. So obviously matching by those identities is like impossible. So the first step should be to equip these White majority, or not even White: any other majority group, whether it's religious or sexual orientation, with like these cultural tools to implement them, so-

Sarah Gaither:  Yeah. Not all identities are visible when someone walks into a therapy session also, right? Like no one would know walking into a therapy session with me that I have a Black parent, right? So I think these assumptions that we sometimes make as clinicians also should be checked, right? We should have, you know, thorough kind of demographic explorations with patients to make sure that we know their multifaceted selves are all of themselves that they bring to each session, right? It might be one identity that's being targeted in that moment, but I argue all the different identities, again, whether they're in harmony or not, are all contributing to the stressors that someone's facing and how they're processing them in that moment. So if you're only targeting one identity, you're probably not going to be that successful in healing the whole self, because it's all intertwined.

Nicole Izquierdo:  Thank you. So yeah, we'll just be wrapping up now. I guess the last thing is, is there anything you'd like to share or any advice you'd like to give to our listeners to close us off?

Sarah Gaither:  I think just be bold and brave and experience new things, right? This is the number one thing that when people ask me, "Well, what can I do for my kid?", or "What can I do for myself?" Go out and explore the world. We live in such a segregated society. We talk to people who think like we do all the time. Go make a new friend in a new group, go to a new cultural event. Go to a part of the state or the region you live in you've never gone to before and just feel it out. We know that even just temporarily vacationing somewhere different, right, can force you to think about the world in a different way, and these perspective-taking experiences I think are so key, not only for how you learn about your whole world and society, but how you learn about yourself.

So just, you know, get out there and do some new things, and even just taking a walk around your neighborhood if you don't even do that is a good start.

Nicole Izquierdo:  Well, thank you so much for joining us, Dr. Gaither. We really appreciate you taking the time to speak with us.

Sarah Gaither:  Yeah. Thanks for having me. I had a great 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.

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.

---

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.