Psychologist George Bonanno on Trauma, PTSD & Resilience

* Note: Video is unavailable for this interview.

An Interview with Psychologist George Bonanno

George Bonanno, Ph.D. is a professor of clinical psychology at Columbia University's Teacher College. His research specializes in human resilience in the face of loss and potential trauma.

Tori Steffen:  Hi, everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Tori Steffan, research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today psychologist George Bonanno. Dr. Bonanno is a professor of clinical psychology at Columbia University's Teacher College. Dr. Bonanno is recognized for his pioneering research on human resilience in the face of loss and potential trauma. In addition to the books, The End of Trauma and The Other Side of Sadness, he's published hundreds of peer reviewed scientific articles, many appearing in leading journals. So before we get started today, could you please let us know a little bit more about yourself and what made you interested in studying trauma and resilience?

George Bonanno:  Oh, that's a good question. I have a long and a short answer to that question. The shorter answer I guess is I had the opportunity when I finished my doctoral program. I was trained, I think, pretty well in experimental research and in this general research methodology part of my clinical psychology degree. And the first position I took was in San Francisco, the bereavement project when I was given basically free range to design this massive study with the resources there. And so we just basically used methods that hadn't been used before with this kind of phenomenon. A lot of the work is mostly clinical and with people who were suffering. So the assumption at the time was that most people were suffering greatly with disease of the brain. Same thing with the trauma one. And when we used a different approach, more of a I think... we would get a broader... Okay, I was going to say epidemiological.

We did a broad swatch of people, anyone who had gone through a loss and then eventually did that in the trauma too. Anyone who'd gone through a particular event, we were interested in, and we would interview them and do experimental work with them and questionnaires as soon as we could after the event, and then following them. Right away, we began to see that so many, many people were showing, they had a difficult time talking about it when they had to, but they were basically functioning really well in their lives. And we found that right away and so we began to document that. And then I thought, "Well, this is kind of remarkable." So I was interested in this and we just kept pursuing it. And before I even realized it, I've now been studying that for 30 years. I didn't really intend that, but that's what we've been doing.

Tori Steffen:  Right. Yeah, it's funny how one study can kind of lead you down a road that way.

George Bonanno:  Exactly, yeah.

Tori Steffen:  Yeah. Well, I ended up reading your book, The End of Trauma, which was very interesting and investigates why some people might develop PTSD after traumatic events and then some might not. So could you kind of explain that for the audience a little bit?

George Bonanno:  Well, as I mentioned, we were finding these patterns for years. We called one the resilience pattern or the resilience trajectory, and those are people who they go through an event, everybody is distressed and disturbed by a major stressor or a major, I use the word 'potential trauma', but everybody has those reactions. And I'd say just about everybody and maybe 85% of the people exposed by a major life-threatening event or a major loss, or something like that. But for most people, it seems to abate within a few weeks, sometimes a little bit longer, sometimes a little bit less. And so we've replicated this now so many times and other people have now as well, dozens maybe. I think the last count it was something like 80 or 90 studies showing this. So of course over time, I was busy just simply verifying this and looking at it from this way and that way to make sure we were correct in this assumption, that these people were really resilient, they're not just telling us. So we had alternative methods. We usually talk to multiple people.

So then of course, naturally we began to ask, “What causes this? Why is it that these people are so resilient and other people not?” And that's a question I'm still trying to understand today. There's a longer answer to that one and also a shorter answer. The shorter answer if I can give you it quickly is that, so there are many factors that can be identified that correlate with resilience, and we've identified these factors and other people have too. And there's a widespread assumption that there's sort of several key factors that make people resilient and resilient people have these. And after really thinking about this and studying this for years, I think they've come to the realization that there aren't key factors. There's so many correlatives, so many predictors that they're just a multitude, well over 50 and counting.

And so how do we make sense of that? But it turns out all these things also are pretty small effects. In other words, they only really explain a little bit. There isn't any one factor that really makes you resilient or not. In fact, people aren't resilient. And that led that people have to become resilient. Resilience I think of as an outcome. So all those, I'm flying a lot of this past everybody. But the answer becomes what I call regulatory flexibility. Every time we're confronted with an event, we'd have to work it out. We'd have to embrace the event and find out for ourselves what works in this situation. And we do that through a process of trial and error. And that's very much the way humans cope, very much the way humans do the world. We are equipped for that. We try things, if it doesn't work, we try something else. So that's really the answer. We've studied flexibility now in detail, we have many different components of flexibility. We identified the pieces of us and we try to keep it simple, but life is not always simple.

Tori Steffen:  There's so many aspects and variables that kind of go into resilience. And I remember reading about the resilience paradox, and I think you listed, like you were saying, about 50 variables that could go into why somebody might be resilient after experiencing trauma. One variable that I remember being pretty significant is having a support group or people around you to support you after experiencing trauma. How significant would you say that particular variable is?

George Bonanno:  Well, I think there are some factors, social support, emotional support, instrumental support. If you break down social support or what we call interpersonal support, it's actually not one thing, it's many things. And people need different things at different times. So sometimes they need help with the daily aspects of living, instrumental support. Sometimes they need the emotional support. Sometimes they just simply need the group to belong to, it's about identity. So there are lots of different pieces of that. And we tend to assume that social support, anyone of this broader umbrella of support is really the "that's always good". But the research shows pretty clearly, it's not always good. It comes with a cost. Everything comes with a cost. Benefits and cost. And the cost of support have been studied research wise, and people have told me different costs that sometimes people just aren't able to engage in the kind of reciprocity that's required for support.

Sometimes the support is well intended, but not very helpful. Sometimes the support might undermine a person's sense of efficacy and sometimes it's just not what people need. Sometimes people need to be isolated, they need to be alone and work something out for themselves. Sometimes people don't want to be around other people because of whatever the event was that they experienced. And so in particular moments, it's not always the answer. And another piece of that is that when we cope with something major, it doesn't go away, as every good therapist... No, it doesn't go away and when you say, "Here's what I need you to do," bing - now it's gone. It takes time. And so what we do at any one time is different to what we do at another time. And so being around other people and just hanging out with other people, just enjoying their company and not thinking about the event is what we need maybe a little bit later down the road.

Maybe what we need immediately is just to be comforted by someone. Maybe we need help, as I mentioned, instrumental support and that comes somewhere in the middle. It all depends. And sometimes, as I said, we just want to be alone for some point of it. So it's really a matter of, we're not talking about, if your social supports always good, this is what we've been... What's good at this moment? And that's really what we see as being helpful.

Tori Steffen:  Right. Yeah, I can see that it would definitely vary between participants that you've interviewed. One situation might work out a little bit better. So it definitely just varies across the population. And the flexibility sequence that you had mentioned earlier, I remember in your book it stated somebody asking themselves after a traumatic event, what am I able to do versus what do I need to do. How might that distinction help one be more flexible?

George Bonanno:  Well, that distinction that's when we break it down and move to different components. So part of being flexibly adapting, which you'd say, is reading the situation first. A lot of people... We assess what's happening and ask, "Well, what do I need to do here?" We've grown up doing that, but we do this normally without thinking. Part of what I think is important clinically is bringing that to people's awareness, that we do that and that that's how they get through an event. They have to think about it, kind of embrace it even for a short time and ask those questions. The question about what am I able to do comes next. And we sense that what I need to do here is I'm ruminating, I need to stop myself from ruminating, or I'm thinking about this all the time, or I'm afraid to go back to this place. I'm even afraid to go out. Or I can't sleep, what do I need to do?

I need to find a way to sleep tonight or sleep for the next few days. I need to consult people. I need to ask people, I need to figure out what do I have... But then we get to the question of what am I able to do? And that comes to our repertoire. What do we have at our disposal? What do we already know how to do? And I'm a big fan of having people think about this when they're not in a terrible bad shape. Because once we're really upset about something and we amidst of a crisis, it's really hard to think clearly. It's really hard to even think, what am I able to do? I'm not able to do anything right now. And that's a real fact of life.

When people are really upset, we don't think very clearly. So it's a good idea to think about these things in advance. And so we ask ourselves, what do I need to do here? What can I do? What are the tools I have? And then we try something. And we get to the last step, which is, did this work? Do I feel better? Did the situation change? If not, then we try something else. And I find this last step is where a lot of people stumble also. They stumble and they can stumble at any one of these steps, but the last step is when we ask ourselves, is this working? Because people often find out, "Well, no, I still feel terrible. It didn't work."

And they give up because their assumption is, "Well, I'm not good at this. I can't cope. I'm not a resilient person." But nobody can do everything every time exactly the right way. It's how we learn, it's how we become healthy people. Even the healthiest people don't always have an answer. They try things. It doesn't work, you try something else, especially if it's a major event, especially if you're in bad shape, you try something else. And that's just really how we do get through things. So I think that's also another important thing, clinical teaching moment for people to realize that.

Tori Steffen:  Right.

George Bonanno:  It's how it works.

Tori Steffen:  Yeah, absolutely. I remember a case in your book about a girl named Maren who suffered a spinal cord injury from a horse incident.

George Bonanno:  Yes, yes.

Tori Steffen:  And I remember the key part of her recovery was her own optimism and motivation.

George Bonanno:  Yes.

Tori Steffen:  Do you think that those two things, motivation and optimism led her towards recovering so well?

George Bonanno:  Sure. I think Maren's optimism, if I can speak colloquially, was off the charts. It was really extreme. And they told her she was paralyzed for the rest of her life and not only did she say I'm going to walk again, she believed she would walk again. But optimism, few other pieces like that, maybe confidence, our ability to cope, a sense of I'll get through things, I'll get through this, I'll work it out. And even if the goal is just to accept what's happened, I will work this out somehow. I'll find a way to live with this and be happy again.

And that motivation is really important for all the things that I've just said up until now. Because it's not easy when you're hurting, last thing you want to do is think about it and embrace it. What we really want to do is just push it away, cover our face in a pillow, feel lousy and just hate the world. Those are much easier, but we have to actually face what's happened and think about it enough to work out what do I need to do then and what's going to get me through this? And you need to be motivated to do that. So Maren was super motivated, but a lot of people are. I think none of these are that extreme. Maren is a great person, but she's not a superhero. She just had the will to do this.

Tori Steffen:  Right. Yeah, I think that's a large part of it, your own personal mindset and believing that you can recover. But I mean, in a situation like that, it's just really interesting that that would have such a significant impact on her healing journey. So that's a great case to study. Well, Dr. Bonanno, I really appreciate your time. Are there any final words of advice that you'd like to share with the listeners today?

George Bonanno:  Yeah, I would. Another thing that I mentioned in the book is what I call coping arguments, that we sometimes need to do something that doesn't quite seem like it's healthy. It's something we maybe never thought about doing. It's something that we're told is not a healthy thing to do. But in this moment, it may be, and I'm not going to mention too many examples, but I think things like, sometimes people, I hope the listeners don't mind me saying this, sometimes people get drunk and just for the evening. And we wouldn't think of it as a healthy coping behavior. But for one night, and it doesn't... The next day you feel lousy. It's not gone. But people feel like, okay, but I decided to do that and I'm in control. Now what do I need to do here? And they get through the morning to make themselves feel a little bit better.

Then they still have the question. I did something last night, it didn't work, but I did something. What do I need to do now? And it does seem to sometimes give people just a little break. So the other thing, I won't name any other examples, but I'm sure people can think of them, they just get us through that moment and then we take the next step. So John Lennon has a song called Whatever Gets You Thru The Night. And I think I mentioned that in the book, but it's like the song because it's really kind of what it's about. When we're coping with really difficult things, we just want to get through it. It doesn't need to be pretty, it doesn't need to make us super healthy people. We just need to get through it. So I think that's an important thing also to keep in mind.

Tori Steffen:  Awesome. Yeah, that's great advice. And yeah, there's plenty of great information in the book too. I definitely recommend everybody checks out The End of Trauma by Dr. Bonanno. So yeah, thank you so much for sharing your knowledge with us today. And thank you everybody for tuning in and we'll see everybody next time. Thank you.

George Bonanno:  Okay, thank you. Thank you, Tori, nice to meet you.

Tori Steffen:  Thank you, you 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.

Psychotherapy Intern Debora de Souza on Grief Support

An Interview with Psychotherapy Intern Debora de Souza

Debora de Souza is a clinical intern at Seattle Anxiety Specialists for 2022-2023, providing care to those in need within our low-cost therapy program. She is finalizing her Master's degree in Clinical Mental Health Counseling at Seattle University and specializes in helping clients work through grief, loss and trauma.

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

I like to welcome with us today, Clinical Mental Health Counselor, Deb de Souza. Deb is a clinical psychotherapy intern at Seattle Anxiety Specialists and she is currently earning her master's degree in clinical mental health counseling at Seattle University. She works with parents experiencing perinatal mood and anxiety disorder, known as PMAD. And she also worked as a grief hike guide, helping those grieving the death of a loved one to process their loss. So before we get started today, Deb, could you let us know a little bit more about yourself and what made you interested in studying mental health counseling and grief?

Debora de Souza:  Hi Tori. Thank you so much for having me.

Sure, absolutely. This is a second career for me. I have been in the business world for quite some time locally here in Seattle in corporate settings. I always had an interest in the psychology when I first started college, that was definitely one of the careers I was... one of the schools that I was hoping to go into. Just life happens, it didn't happen. I ended up being program management and business operations for most part of my adult life. But when the opportunity came with COVID and things happened, I got laid off and I decided that it was the right time to go into counseling given that was something that I really wanted to do. And I had a lot of interest and passions, like you said, in the area of grief and PMAD and anxiety disorders, as well.

So I said, no time like the present. I had already applied to Seattle University and got accepted prior to COVID and I decided let's just make this a new career path for me. And it's been really enjoyable. I really am glad that I took the leap. It's a little bit threatening, but it was fun.

Tori Steffen:  Yeah, that's amazing. It sounds like it just worked out time wise and you got to love that smooth transition.

Debora de Souza:  Yeah, it was great. Meant to be.

Tori Steffen:  Yeah, exactly. Well, can you describe for us how your time at SAS as a clinical intern has been so far for you?

Debora de Souza:  I started in September and I have to say it's been really, really good for me. I feel very supported at SAS, that's one thing I really wanted. I applied to several sites and I actually had already accepted another site. And when I got an email from SAS to interview. And it just clicked, it really clicked with the folks that I talked to on my interview, the approach that they had to internship and also I like the low-fee model that was offered, that interns participate, where we provide service to folks that may be in that gap where they can't qualify for insurance, and they don't have private insurance or state insurance, and we can provide a service to that population. That otherwise may not even have access to care. So it's been really, really nice. It's a small group of interns, a lot of support from great supervisors and also from the staff. So I feel ... again, I think as a new person, as an intern, new person on the field learning how to become a counselor, the support is critical.

Tori Steffen:  Absolutely. I would definitely agree with that. It's a lot of stuff to learn and I feel like you really learn it from experience. So having supervisors help you through a little bit is crucial.

Debora de Souza:  It's vulnerable work.

Tori Steffen:  Absolutely. What would you say has been the most challenging about being a clinical intern?

Debora de Souza:  Well, I think the truth that come to mind right away is that I kind of expected, but experiencing it is a little bit different, is how vulnerable it is for me as a person sometimes, and how I can get flooded and overwhelmed, emotions when people share things that might be triggering for me and trying to differentiate what is mine, what is the client? So that's been a learning. And I knew from a scholastic standpoint, but it's different when you feel it, when you're in the room with someone. So that has been something.

Also how imposter syndrome is real. Sometimes you sit with somebody explaining their circumstances and you're like, "I deal with that too and I'm still finding my way. How can I support you?" So that is real. I think just learning how to be a counselor or a therapist and sit with someone. One thing that I did not expect, I've always worked long hours and being tired. And I remember telling Case (Lovell), who is my supervisor, in the first week how completely exhausted I was after a full day. I think it was my first day with four or five people.

Tori Steffen:  Wow.

Debora de Souza:  And I was very emotionally and physically tired. I just wanted to come home and go to bed. That was surprising for me because it takes a lot of effort to really focus and listen. It's a different way of engaging with people that I wasn't used to. Because that's not how we do it in our lives.

Tori Steffen:  Right. Yeah, that's something I wouldn't have expected either. But knowing that, it does make sense that it'd probably be drained, especially emotionally and need a good day of rest after your first week probably.

Debora de Souza:  It's a learned skill I hope, it gets better over time as you-

Tori Steffen:  Yeah. Yeah. I think it's one of those things that the more you practice, the more that you learn how to do it better. And-

Debora de Souza:  Absolutely.

Tori Steffen:  Deal with the feelings that come with it. Well, what would you say has been the most rewarding about being a clinical intern? Any specific moments come to mind for you?

Debora de Souza:  Yeah, I keep going back to the... I guess, I'm surprised and touched a lot how vulnerable people get with you. And it sounds like cliche, but really genuinely honored that sometimes without not knowing much, two or three sessions maybe, people really share deep things that they may not have other spaces in their life outside of session to talk about. And I'm very honored by that. And I think that is one thing that I keep it in mind a lot, is that I get to do this job. I get to sit with folks and support them and how intimate it can be, the relationship in one way. When you are really vulnerable, and also how much trust they have on us to be themselves and not being judged.

And as for an example, one that I have a client that we have sessions where the camera's off. My camera's on, but the client's camera is off. I got used to it, that's how this client prefers to engage. And I remember the first time he turned the camera on and in the middle of a conversation and it was to show his dog, he was talking about his dog. And he kind of came into frame very briefly, but he turned the camera to himself and said “hi.” It was the first time I actually saw his face and I was almost a little bit emotional. It was so meaningful to me that he... because he trust me enough to be a little bit more vulnerable and just say hello. So we've been seeing each other for some time and he still keeps the camera off most of the time. But every once in a while he'll turn it on and say hi or bye.

Tori Steffen:  Ah, that's amazing. Yeah, that's, I'd say, such a wonderful moment to have with the client and kind of just know that you've built that trust with them. So that's amazing.

Debora de Souza:  It felt really good.

Tori Steffen:  And it must have been amazing to see his dog, too.

Debora de Souza:  Yes. He has a very close connection with his pet. We always talk about the dog. He always comes to the session with us.

Tori Steffen:  Really? Ah. That's amazing. Well, kind of moving over to the outdoor grief groups that you work with. Can you explain how those work for the audience and maybe what activities you guys usually do?

Debora de Souza:  Yes, I do, I do. I love ... it's a volunteer position with the local... not company, but with the local group called Wild Griefs in Olympia, Washington, it's a small group, they're expanding now. We are volunteer hike guides. And basically it's to partner the power of nature to process grief. It started off as initiative to support teens that were grieving. A lot of times the loss of a parent or a caretaker or maybe a sibling, and provide them opportunity in nature to bond with each other, to share their experiences. And that was how it first started.

Wild Grief has several programs, all nature related, all outdoors throughout the entire year. So it's not a summer/spring only. We go out in December, the day before Christmas sometimes.

Tori Steffen:  Wow.

Debora de Souza:  And they offer programs that are day programs, like hikes. Some are more nature walks, some are more hikes, like five hours or so. Also overnight programs, which is a four day backpack with teenagers and a group of us take teenagers out backpacking in mountains around Washington. And each day is framed, there is some process. Each day is framed to go... they use the four tasks of grief as a baseline, basically accepting grief, feeling your feels, adjusting to a life without the person that you lost, and then making a new relationship with that person. So we try to frame all... even if it's a short hike or if it's a four day camp, we try to do that.

We also have a camping program that I usually participate on, that I really like. It's with the family. So it's a family camp, everything's provided, literally from shoes to food to pants. The family just comes. So a parent or a caretaker and children that experience a loss within that family unit. And we spent three days together camping somewhere around Washington. And it's beautiful to see not only the parents relating and connecting, but how the kids really find support on finding another child that has lost their dad, for instance. And be able to just talk about it, which they don't have a lot of space, maybe, in their life outside, in school and other friends.

So both the family camp and the hikes are the longer programs. The other programs are day hikes. And they say something else like nature does the heavy lifting and we just really provide the safe space to share, it's optional. And it has been really beautiful to see. We don't know who's coming, they sign up and we meet up in the trailhead. And usually there's two, maybe three guides, depending on the number of people. And we start hikes and then we stop in some places we usually kind of case out hikes and spaces before. Because we have two or three stops where we do little small processing groups.

And we talk about our person and we share memories of that person, the impact of that person in their life. And we compare with nature sometimes the changes of seasons. How does that reflect on the changes that grief does throughout time. And the rebirth when we see a log and there's a whole bunch of new growth in that dead tree. And the same thing with our grief, after the loss, we adjust and we move forward, and we bring that person with us in a different capacity. And just being with other people. So you can talk about your feelings with no judgment.

Tori Steffen:  Right. Yeah, it sounds like kind of the perfect safe space to provide people who are grieving. And you're right, you just have to get away from everyday life sometimes. Because work and school and all these responsibilities get in the way of processing the heavy emotions. So that's amazing. Yeah, it sounds good.

Debora de Souza:  Being outdoors really helped.

Tori Steffen:  Great program.

Debora de Souza:  Yeah, it's very nice because being outdoors, I even feel myself just with the trees and the sounds of nature. You are walking, you're also moving. We do have strategic stop times, but they're brief. I think it's a great idea, I'm glad that the board, the founders, the couple people that found that decided to expand and move forward and be more inclusive.

Tori Steffen:  Yeah, it sounds like they're doing a great job with being inclusive for all types of experiences, so that's amazing.

Debora de Souza:  Absolutely.

Tori Steffen:  What are the main benefits that you see the participants gaining from their experience in the hiking program?

Debora de Souza:  I think it's community. We talk a lot about acceptance, just have a space. Grief can still be a taboo topic in a lot of places at work or people, maybe people rush you like, "Oh, it's been already six months or a year." You hear a lot of those terms so people feel like, oh, I should ... it's not okay for me to talk about it or to bring it up. So people push it down their emotions, so that's a space that they can do. And it's amazing that we were all strangers in the beginning of the hike, it's oftentimes by the end, people exchange numbers or want to keep in touch. Or people come to several, we have hikes once a month, at least. So we'll see people coming again and again and them bringing children or bringing a friend. So definitely community and acceptance. And being outdoors. Yeah, being outdoors is always good.

Tori Steffen:  Right. Yeah, it sounds like just the perfect mixture of things to help you along that healing journey. Yeah. And that's amazing.

Well, if we could discuss the topic of grieving parents, specifically. There's a specific topic around it. So how it's become more acceptable for men to grieve where it was previously not really as accepted. Would you mind going into that a little bit?

Debora de Souza:  Yeah, absolutely. I think it's even harder for men. I think sometimes men get forgotten. And especially around parenting, I think we're talking about specifically about... there's another volunteer position that I have with the Perinatal Support Washington. I'm a warm line for answering the phone on certain shifts during the day. And most of the callers are women who are experiencing PMAD, Perinatal Mental Anxiety Disorders. So postpartum depression, postpartum anxiety, some miscarriages, sometimes stillbirth or birth trauma is very common. So we do a lot of talking to them, just trying to assess their situation, how we can provide support.

Sometimes every once in a while we get a dad or a grandfather calling to support someone that they love in their lives, who they're concerned about. So there's a lot of psycho-education, a little bit, like “Where do I go with this? How can I help my daughter or my wife?” And eventually, as you get to work with them, we have extended peer support. So if the person... until they get connected with some sort of therapist or service, they have the option to keep working with us and we can call them once a week. We can set up a cadence and we have brief calls with them. And I found that with fathers or with males, eventually it comes to their grief and their experience with, in the case of a miscarriage or stillbirth. And being able to express that because they think it's all around the woman, the mother, the expecting person.

Which makes sense and they feel a little bit lost or they say, "Oh, my wife just had a baby. And all the attention goes to her and I'm not feeling safe to say that because that's not cool. What kind of dad are you? What about me?" Or, "I'm grieving my wife because it used to be just me and her, and now there's this baby who's a newborn is very demanding." So we end up supporting and doing a lot of psycho-ed and just help and listening to both parents, to both caretakers. And grandparents do it the same and call and say, "I don't know how to help more or how to be present to my daughter, to my family member."

As far as personal experience with a male, a coworker, I did suffer a pregnancy loss and I was far along enough that people in my work knew. So I was away for recovery. And when I come back to the office a few weeks later, one of my coworkers, another gentleman that was in my team and asked me out to lunch, he wanted us to talk. And I think in the beginning, just to support me, “Welcome back, how can we be there for you?” But more in a private setting. And he got really emotional during that meeting with me and start crying and openly grieving a son that he lost, I believe it was like 30 years earlier. Because we talked about how weird was talking about pregnancy. But because I was so evidently pregnant, there was no way around it. And he just shared his own story that back when his wife lost their first child, he had nobody... men do not participate. They never talked about it. It was like they did the medical procedures, she came home. That wasn't even their first child, the second child was.

So it was just culturally different. I'm sure at the time, things were difficult. We have come a long way of normalizing not only perinatal mental health, but miscarriages and birth losses and challenges with IVF, challenges with fail adoption, the journey to become a parent can be riddled with challenges. And fathers feel it, too. And that gentleman really touched my heart, I will never forget because it end up kind of me making space for him and listening about his boy and how much that hurt him. That pregnancy wasn't viable and he didn't get to hold him. So it was a very powerful, and beautiful moment. And I'm very thankful that he felt safe to share with me.

Tori Steffen:  Yeah. And it really brings to light that men experience the same grief. And it is more evidently the mother is physically going through it and that's definitely significant. But the father is in there just as much. It's their child, as well.

Debora de Souza:  Absolutely. A lot of anxiety for dads when the first baby comes.

Tori Steffen:  Oh yeah, I bet.

Debora de Souza:  They're adjusting too. So it's nice to have a service like Perinatal Support Washington. So we have fathers volunteers, as well. So if you want to, you don't have to talk to a mom, you can also talk to a dad who has been through postpartum depression with their wives and whatnot. And it's really nice. It's a really great service.

Tori Steffen:  It sounds like just such a great resource for new parents, anybody who's gone through it.

Debora de Souza:  Oh, the landscape has changed. Even from my time of my losses, I really struggled to find someone, a therapist that was familiar with perinatal mental health, how that could support me. And I'm glad there's a lot more resources, I think, right now, nowadays.

Tori Steffen:  Yeah, that's amazing. It's not something that I have seen be super common out there. But it's absolutely needed, I would think. So, that's amazing. So what are some good resources that you know of that grieving parents can look into maybe after losing a child or losing a loved one? Are there any good go-to resources that you know of?

Debora de Souza:  There's several, like I said, the landscape did change. I will share the Wild Grief link and page, as well as the Perinatal Support Washington for Washington only. But there's also Perinatal Support International. A lot of resources, a lot of support groups are ran by those organizations and they're usually free of cost. And now since COVID, especially, they're online. They also list other ones, sometimes with churches or with community centers that people can find locally and connect. And they're a lot of support groups, which is wonderful. Because the safe spaces and the peer-to-peer support can be vital.

One that I like a lot myself and they offer trainings and they're very laid out website, it's called the Return to Zero. And they made a movie, they have a book. It's a couple talking about the experience when they lost their son, their first child. And from there, it kind of sprout into this beautiful website, where you can go in there as a parent grieving. And they really go the gamut, like I said, in fertility, IVF, anything in the Journey to Parenthood. Beautiful site, a lovely work, very well done and well set up. So you can get from referral to therapists, training classes. They have a lot of training classes for volunteers and people that work with parents and people in experiencing PMADs.

And it's just something that I wish I had access to back in the day because you just feel it can be very lonely. You go through very... and nobody wants to talk to you because people think that it's a baby and it's going to make you sad. Or they don't know what to say. I get it. It get all that. And when all you want to do is talk about it. And that's the funny part, all you want to do is ... especially when a baby. A baby is a baby and has a whole life already, the minute that you realize you're expecting.

Tori Steffen:  Yeah.

Debora de Souza:  It's amazing how you're already think the weddings, it's sounds silly. But a whole life become concrete. So that's another thing, as well. We used to have a miscarriage early on, sometimes people say, oh, at least try to do those kind of modifiers. “Well at least it was early enough. Or at least you can get pregnant again.” And for a parent, I think that life has already happened from conception on. So those are great support that folks can go to and get all kinds. And very cultural responsive too, and inclusive because different cultures... and I think I can speak from my culture, as well. It's very unique sometimes how you deal with the topic, how you deal with grief itself. So they do a very good job of having a multicultural approach and training and language that is inclusive to all parents. So Return to Zero, I will share the link, as well. They're excellent.

Tori Steffen:  Perfect. Yeah, we'll make sure to link those in the notes later, but that's so helpful. Thank you for sharing the resources. I'm sure it'll be really helpful to hopefully some of our audience.

Debora de Souza:  I hope so. Yeah.

Tori Steffen:  Awesome. Well, are there any final words of advice or anything else you'd like to share with the listeners today?

Debora de Souza:  No, it's been really a pleasure. I think I said my thing is about normalizing grief, normalizing sharing feelings. And even if we don't know what to say, sometimes not saying anything, just being there. Just letting the person know that you are there to say... and it sounds cliche again, but it's so important so you don't feel so lonely. You feel like it's okay, people understand. Because that's one common experience that we’re all going to have. At some point, we're going to lose someone.

But also other griefs, as well. It doesn't have to be a death of a person, ending of relationships. I mean, through COVID there were so many changes. And I always like to think about positive changes. Some people say positive changes, happy changes bring grief. And I'm like, oh, it's true. In order for something new to happen, something had to die or change. And I didn't think of that. I said, well, think about a wedding, there's a different life that you're entering now. But things are changing... sometimes and a lot of times bring grief with it. And I think it's uncomfortable, we don't like to talk about it.

Tori Steffen:  Right and it's like-

Debora de Souza:  We all feel it.

Tori Steffen:  Exactly. And those big positive changes are great. You're having-

Debora de Souza:  New jobs, moving to another country. I mean, there's so much that you can think, "Oh, this is so fun and exciting." But there's always some... the other side, that you're leaving something, there's a cycle ending in some way. And just honoring that and taking time to feel the feels just like the best... it's beautiful. Doesn't apply only to death, physical death.

Tori Steffen:  Right. Yeah, just taking the time to process the change, I think will help you, lead you into the future and make it easier on you emotionally.

Debora de Souza:  And be a kinder human being. Understand when other people go through their change, it promotes kindness. It's definitely a positive in my book.

Tori Steffen:  Yeah, absolutely. Well, thank you so much for sharing your knowledge with us today, Deb. It was great talking to you.

Debora de Souza:  Thank you so much. It's my pleasure.

Tori Steffen:  All right. And thank you everybody for tuning in and we'll see you next 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.

Post-Doctoral Fellow Kristy Cuthbert on Panic Disorder & Agoraphobia

An Interview with Post-Doctoral Fellow Kristy Cuthbert

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

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

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

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

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

Kristy Cuthbert:  Yeah.

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

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

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

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

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

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

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

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

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

Kristy Cuthbert:  Sure.

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

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

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

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

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

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

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

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

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

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

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

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

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

Kristy Cuthbert:  Yeah.

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

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

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

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

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

Kristy Cuthbert:  Exactly. Yep.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kristy Cuthbert:  Thanks, you too.

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

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

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

Consultant Leon Seltzer on the Effects of Childhood Self-Shame

An Interview with Consultant Leon Seltzer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Social Worker Elizabeth McIngvale on treating OCD & Anxiety with erp

An Interview with Clinical Social Worker Elizabeth McIngvale

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tori Steffen:  Awesome. Great advice.

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

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

Elizabeth McIngvale:  You as well. Thank you.

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

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

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

Psychologist Katherine Walukevich-Dienst on Substance Abuse & Social Anxiety

An Interview with Psychologist Katherine Walukevich-Dienst

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

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

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

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

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

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

Katherine Walukevich-Dienst:  Absolutely.

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

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

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

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

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

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

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

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

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

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

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

Tori Steffen:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

Tori Steffen:  Yeah.

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

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

Katherine Walukevich-Dienst:  Absolutely.

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

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

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

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

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

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

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

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

Katherine Walukevich-Dienst:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

Psychologist Andres De Los Reyes on Adolescent Social Anxiety & ADHD

An Interview with Psychologist Andres De Los Reyes

Andres De Los Reyes, Ph.D. is a Professor of Psychology at the University of Maryland. He's an expert in the field of adolescent psychology, social anxiety and ADHD.

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

I liked to welcome with us today, Psychologist Andres De Los Reyes. Dr. De Los Reyes is a professor of psychology at the University of Maryland in College Park, as well as the Director of the Comprehensive Assessment and Intervention Program. Dr. De Los Reyes is an expert in the field of clinical psychology. He's published over 100 articles, including “When Adolescents Experience Co-occurring Social Anxiety and ADHD Symptoms,” “Links with Social Skills when Interacting with Unfamiliar Peer Confederates,” and “Multi Informant Reports of Depressive Symptoms and Suicidal Ideation Among Adolescent Inpatients.”

Before we get started today, Dr. De Los Reyes, could you please let us know a little bit more about yourself and what made you interested in studying social anxiety, ADHD, and other mental health issues among adolescents?

Andres De Los Reyes:  As you mentioned, I've been at the University of Maryland for some time now, about 15 years. In that work, I spent a lot of time thinking about the most accurate ways of assessing various kinds of mental health concerns with a particular emphasis on those concerns, where when we try to get a sense of symptoms and associated impairments... Obviously, because we're often assessing children and adolescents, we're seeking input from not only the clients themselves but also significant others in their lives, like parents and teachers and sometimes peers. We focus our attention a great deal on those domains, where when we ask these questions, we oftentimes get very different responses depending on who we ask. That's a common byproduct of assessments of social anxiety, of ADHD.

The work our group has conducted, and the work of many other labs all over the world, really have led us to believe that although there may be some circumstances where these assessments are telling us different things because perhaps one or more of the informants aren't nearly as useful reporters as they might be, under the grand majority of circumstances, when we administer assessments to understand things like ADHD and social anxiety, we're often using well-established instruments, and we're also often asking people, informants, who mental health professionals have relied on for decades to assess behaviors. So under a variety of circumstances, there may very well be reason to believe that rather than these differences in results reflecting something artifactual about the measures we administer and the scores we obtain from these informants, it might be actually something really important. In particular, the specific contexts where adolescents, children might be experiencing concerns like social anxiety and ADHD.

It turns out that in both of these circumstances, in both of these domains, social anxiety and ADHD, the symptoms and associated impairments can move around considerably across various social environments that impact the lives of those we assess, the peers with whom they interact, the teachers who are serving as instructors in their classes, the parents who look after them and in fact are often initiating their services. So, I tend to choose domains like ADHD, like social anxiety because I think not only are they places where these discrepancies and results happen often, but if we learn more about these discrepant results, then we also learn more about the actual domains themselves.

Tori Steffen:  Right. Wow. That's really profound. I can definitely agree with you there how it's important to understand the differences, especially when assessing for the two of those domains. So, thank you for explaining that for us.

Well, getting down into basics about our topic, what age range describes an adolescent?

Andres De Los Reyes:  A very wide one. Even just a definition of what counts as an adolescent is a topic of considerable debate among mental health professionals, among developmental scientists. Adolescence can begin within some definitions as early as 12 or 11, and can stretch out as far as, within some definitions, the early adulthood years. There may be various factors that one might consider when thinking about where adolescence as a developmental period begins and ends.

But germane to the work that we do, we tend to focus on what some scholars might consider the mid- to late-adolescence period, so that period between the ages of about 14, 15, 16, 17, where developmental research and theory would posit that the people we're trying to assess are undergoing significant amount of changes in their biology, in their social environments. They see a lot of new environments, novel environments they oftentimes are not necessarily accustomed to encountering earlier on in development, like the development of romantic attachments, the development of time spent outside the home, outside of the immediate observation of caregivers who, as I mentioned previously, are often initiating care.

So we think of, like I mentioned before, social anxiety and ADHD as a great place where the assessment issues we care about happen. On top of that, the developmental peer that we focus these assessments on will oftentimes create additional complexities that require further elaboration and interpretation. That's where a lot of our work essentially seeps from, is trying to figure out within the traditional approaches we use to measure domains like social anxiety and ADHD, what additional things must we think about and be developmentally sensitive to when we're trying to apply our traditional assessment tools to assessing these specific domains in this particularly complex period of development?

Tori Steffen:  Right. Yeah. Definitely a lot to consider when defining an adolescent. So, that all is very important. Could you explain for our audience what social anxiety is?

Andres De Los Reyes:  The typical definitions of social anxiety revolve around several different kinds of core features of the condition. One of the big core features is an intense fear or apprehension. Under some circumstances, when the fears are really high in avoidance of social situations of various kinds, interacting one-on-one with somebody, even just going up to somebody and asking them for information or directions, like if you're going somewhere you don't really know where to go, giving presentations in a structured setting like a classroom or an adulthood in a workplace... But one of the common, core denominators that cut across all those situations is that among individuals who experience social anxiety, there tends to be a particular fear, apprehension, avoidance, of unfamiliar scenarios, scenarios that appear novel that haven't been encountered all that frequently, and where people might not have a lot of practice in navigating those situations effectively.

That's one of the big things that we think about when it comes to assessing and understanding social anxiety within adolescence, because like I mentioned before, you have these situations, these scenarios that as you enter the adolescence period you don't have a lot of practice in. One of the big ones that we focus on is in those scenarios where adolescents feel like it's one of their tasks to engage with people they don't know very well, particularly their own age, and try to develop bonds of some kind: friendships, romantic attachments, and then in both those places that unfamiliarity is something new to them, especially when you consider the fact that a lot of these unfamiliar interactions with people your own age are happening where your caregiver, somebody older than you isn't looking over your shoulder to see how things are going. You're doing a lot of this by yourself.

Tori Steffen:  Mm-hmm. Right. Okay. That definitely makes sense, that a lot of uncertainty and fear might be present.

Could you explain for us how adolescents typically experience social anxiety, and would you say that there's any big differences in symptoms among adolescents compared to adults with social anxiety?

Andres De Los Reyes:  This is something we've struggled with a great deal, and it bears some relation or implication to how we diagnose the condition among adolescents, children, and adults. I can focus specifically on the sort of diagnostic considerations you have within one of our predominant systems, the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition.

In the current edition, there's a distinction between the kind of social anxiety that manifests consistently across situations across contexts. So, for many clients there's this sense that the symptoms and their impairments: fears, the avoidance, the apprehensions, are there when you are ordering food at a restaurant and interacting with coworkers and trying to meet new people. You see it everywhere. That can be contracted with at least one other form of social anxiety that we tend to see in clients, and that is those scenarios, those instances in which clients appear to be experiencing symptoms and impairments that manifest in a specific kind of context.

In the Diagnostic and Statistical Manual of Mental Disorders, the DM, that context is typically characterized as a performance-based context, some kind of place where there's a lot of structure and you have a sense of what it's like to give a presentation in front of a group, you know what the rules of engagement are: You have to make eye contact; you have to enunciate; you have to be able to answer questions effectively. What we've been learning in our work is that although adolescents can experience that kind of context specificity that has a look and feel of what you see in adults, we also see at least one other kind of specific form of impairment and where symptoms arise. And that's when adolescents are engaging in the social scenario where the rules of engagement are kind of stripped away. There's no manual to figure out how to navigate parties effectively. There's no how-to guide on the right thing to say when you sit down next to someone on the first day of school. You probably think that you should be friendly, maybe say hi, but what else do you do after that?

So, that lack of structure in our work leads us to believe that although adolescents can experience those kinds of patterns that we tend to see in adults, the symptoms and impairments can manifest in lots of places or in one specific place, we have reason to believe that maybe it's worth considering the notion that because of the novelty inherent in the social experiences that adolescents often have, that even just being placed in a situation where you don't know the rules of engagement can produce the same kinds of symptoms and impairments that we see in that context-specific subcategory that you said that we already have in our diagnostic manuals.

Tori Steffen:  Right. Okay. That's good information to know, the importance of novelty, especially for adolescents. So, that's really interesting.

How are the issues of social anxiety and ADHD and adolescence connected? If the two issues, let's say, that they're co-occurring in an adolescent, does that have more of a negative impact?

Andres De Los Reyes:  In our work, we tend to see that it does. It's a phenomenon that fascinates us. The reason why is because there are a lot of different kinds of features of all of our disorders, all of our diagnostic categories. They all have their own lists of symptoms. What they also have are what we call associated features, or there could even be risk factors depending on whether or not their presence brings about the condition. But many times, when we're thinking about treatment, we're thinking about those aspects of functioning that might not be symptoms, but they could be implicated in how conditions are maintained. It's kind of like whatever started the engine, an associated feature might might keep it going.

One of those features that cuts across many conditions, but in particular social anxiety and ADHD, is a concept or domain that we call social skills: those behaviors, those elements of how you engage in social situations and make a difference in whether or not you're able to make friends and influence people, and not only make friends, but also maintain those friendships over time. We know that in both ADHD and in social anxiety, one of the key areas of impairment is in friendships, in how many friendships you've initiated or developed, and the maintenance of those relationships over time.

The key distinction that many of us encounter when it comes to social anxiety and ADHD is that although there's those associated features of social skills and friendships in both of the conditions, there's reason to believe that those features might arise in these conditions for very different reasons. So, for adolescents who experience social anxiety, they might experience social skills issues in part because of the avoidance. They experience apprehension, fears about engaging situations. They might not engage in situations where they could get opportunities to make friends nearly as much as other kids who don't experience social anxiety. The consequence of that might be kind of the same thing as you missing out on going to the gym for a few months, a muscle here or there atrophies, and then you get back to the gym and you say to yourself, "I can't lift nearly as much as I used to."

That avoidance might have the effect of perhaps overall reducing fears, so if you don't enter into a situation that you find stressful, you're going to experience less stress maybe, but at the cost of not being able to have opportunities to do positive things that might actually even help the anxiety down the line. So, that avoidance makes a big deal when it comes to social skills and associated impairments in developing and maintaining friendships.

With ADHD, there's reason to believe that within that condition, the social skills issues associated impairments of friendships have less to do with avoidance and perhaps a bit more to do with the fact that among many children and adolescents who experience ADHD, the hyperactivity they might experience might be seen by peers as aversive and perhaps make it less likely that they might want to engage with them in the future.

Now, if it's the case that someone's experiencing both social anxiety and ADHD, are perhaps experiencing social skills issues and associated impairments with building and maintaining friendships for different reasons, and those two different reasons are encapsulated in the same individual, so not just the avoidance, but on occasion, the hyperactivity kicks in; you create some kind of aversive interaction with somebody, maybe they don't want to associate with you as a friend. That might be one of the reasons why we're seeing what we're seeing, at least in our own data, that when adolescents experience heightened levels of both of these conditions at the same time, they tend to be experiencing more of these social skills issues in direct observations of how they interact with same-age adolescents.

That's the neat feature of the work that we do. We collect the symptom data the old-fashioned way by asking a bunch of people about what's going on with the adolescent or how they are thinking, feeling, and behaving, and whether or not those symptoms tell us that somebody's elevated in social anxiety and ADHD. But we're looking at those combinations in relation to how the adolescent actually behaves in our laboratory when we create scenarios that have the look and feel of everyday social interactions between themselves and somebody that we lead them to believe is a same-age peer.

Tori Steffen:  Okay. Yeah. That definitely makes sense. It sounds like really interesting work that you guys are doing to figure that out.

Well, one of your articles mentions that the presence of social anxiety and ADHD can have a negative impact on adolescent social skills. I know that you kind of explained how they might show up symptom-wise. Could you explain for us the impact on social skills in an adolescent?

Andres De Los Reyes:  Going back to this notion that adolescents experience social anxiety might have fewer opportunities to engage socially with people, typically their own age or other people. If they avoid those scenarios, then by construction, they're going to get less practice building the kinds of competencies that we know are instrumental in being able to have healthy relationships with other people. When's it appropriate to make eye contact? When is it appropriate to avert your eye contact? When is it appropriate to initiate a conversation? Is it okay to say hello to somebody when you're having a very deep conversation with somebody else? When is it appropriate to end the conversation and maybe go somewhere else, interact with somebody else? All these kinds of skills, we develop them whether we know it or not, oftentimes through trial and error. Most of us don't read a guide about how to be socially skilled before we go to a party. That's just not what we typically do.

Over time, we figure out what's worked and hasn't, and in that respect, among many of us who can be considered as socially skilled, those kinds of skills are kind of like a really good app on your phone. They fit into the background after they all make sense. So oftentimes, in our interventions for both social anxiety and ADHD, although the approaches we might take to improving social skills might differ, the outcomes have the similar kind of look and feel. We're trying to build up your competencies to be able to make friends and influence people, but the routes you might get there might be quite different.

Tori Steffen:  Okay. Yeah. That definitely makes sense, how it could have an impact there.

Have any significant differences been found in your lab work for prevalence of social anxiety and/or ADHD among girls versus boys?

Andres De Los Reyes:  We don't tend to see too many big differences in our work as a function of gender, but it is just one sample. One thing I can say is that some of the gender and the gender-related issues and how we diagnose these two conditions, depending on the condition, reflect either variations in rates as a function of gender or in features. So as an example, when you assess ADHD in the general population, so outside of a clinic, you tend to see a bit higher rate, 2-to-1 in children, maybe 1.5-to-1 in adults in the direction of males tend to be diagnosed more often than females. But in ADHD, you also tend to see that females are more likely than males to experience symptoms that have more to do with inattention, so difficulty in maintaining attention relative to males. Again, big average differences that we tend to see in research.

In social anxiety, historically what we've tended to see is a gender difference that might manifest in the general population, but once you get into the clinical circumstance, it doesn't tend to be much of a difference, much of a gender difference at all. But what you do see is a kind of variation in the other diagnosis, somebody might meet criteria with as a function of gender. Among females who are diagnosed with social anxiety, they tend to experience a greater number of depressive, bipolar, and anxiety sort diagnoses, whereas males who are diagnosed with social anxiety tend to experience diagnosable conditions that are more externalizing sort of in nature, so oppositional-defiant disorder, conflict disorder, alcohol dependence and abuse or dependence and abuse of illicit drugs.

That latter group, people have been interested in that group for a long time, that combination of social anxiety and substance use disorders. One of the hypotheses people have is what they call a self-medicating hypothesis, this notion that perhaps one of the reasons why people might use substances in the context of something like social anxiety is as a coping mechanism, like a means to reduce your arousal or apprehension to then enter situations and manage them more effectively.

Tori Steffen:  Okay. Yeah. That's definitely interesting to know, and sounds like maybe there's a few gender differences, but overall as far as diagnoses go, not super significant in the differences.

Well, another area of your study classified participants in groups of low social anxiety or ADHD and then high social anxiety. What might the main differences in the severity of symptoms be between the two groups?

Andres De Los Reyes:  The interesting thing about the groups that we observed in our own data is that the group that could be characterized as high social anxiety symptoms, high ADHD symptoms, differed from that other group that could be characterized as low social anxiety, high ADHD, and specifically in those social anxiety symptoms. But where they didn't differ much at all is in the level of ADHD symptoms.

The same is true for that other group that was high social anxiety, high ADHD, and high social anxiety, low ADHD. That group as well might have differed on the level of ADHD symptoms, but not in the level or severity of social anxiety symptoms, which made us pretty excited in that one of the problems or one of the limitations you have to overcome when you do this kind of work is sort of ask yourself, when I think about grouping individuals this way, is the group that's showing concerns on two different domains simply just a more severe form of clinical presentation, or are they just a more severe client when it comes to the symptoms? Is that all I'm looking at that? That it's a 10 to 5 difference on one versus the other? If so, what's the point?

But what made us really excited was that, at least from a symptom severity standpoint, we didn't see differences in those groups that are elevated on one versus another versus elevated on both. What it looked like to us was that these groups are different from each other, from something other than raw symptom count. There's something else going on here, and it might have implications for understanding the phenomenology of the actual clinical presentation.

Tori Steffen:  Wow. Yeah. That's a great finding to come by. Yeah. Thanks for explaining that for us. That's definitely an interesting finding.

Well, actually another finding in your study linked social anxiety in ADHD through impairments or behaviors in adolescents. Can you explain that finding for us a bit?

Andres De Los Reyes:  Yeah. We thought it was important to do. In a lot of our studies, we make an observation, we might find it interesting, but we want to scrutinize it a little bit more and probe it. One of the things we wanted to probe with regards to the findings of this particular study was this notion that maybe the social skills issues that we're seeing, the differences among these groups, are isolated to just this kind of interaction. Do we have any data that sort of speaks to the possibility that these differences might have implications for impairment issues we might see outside of the peer context?

It turns out that we had a survey, the work and social adjustment scale for youth, that provides us with a broad sort of index of psychosocial impairments germane to mental health functioning or at least behaviors that might be indicative of mental health concerns. We were able to essentially replicate the finding we observed with the behavioral data, that when you look at overall indices of psychosocial impairments, that same group, that high ADHD, a high social anxiety group, tends experience overall more psychosocial impairments than the other groups in our sample.

Tori Steffen:  Okay. Definitely good to know as far as what to expect in the experience.

Well, clinically speaking, what psychotherapeutic treatment methods might work best for an adolescent with, let's say, co-occurring social anxiety and ADHD?

Andres De Los Reyes:  The good news with regards to both social anxiety and ADHD is that there are well-established interventions for addressing social skills issues in both of these for these conditions. So, social effectiveness therapy, a form of social anxiety behavioral treatment developed by Deborah Beidell and Sam Turner and colleagues, seeks to focus on improving social competence within children and adolescents experiencing social anxiety and for that matter, adults as well. There's a version of social effectiveness therapy that is developmentally modified or tailored for adults experiencing social skills concerns stemming from social anxiety.

There's a variant of that kind of intervention that's broadly thought of or referred to as social skills training that has been tested for many years among children and adolescents experiencing ADHD. My sense, and this is not something that that's been tested formally in a controlled trial or treatment study, is that addressing these co-occurring issues might involve trying to first assess the associated impairments within a client experiencing both of these concerns at once, prioritizing figuring out which one might be more impairing, and then on the basis of understanding where the priorities lie, which of these might be getting in the way of building social skills competencies in most, starting with one of these two intervention protocols, and then moving on to the next protocol if it looks like further addressing these needs is warranted.

The interesting thing, and this is another thing that hasn't been tested yet, what we tend to see in the treatment literature goes like this: If you try to address anxiety or you try to address ADHD and you're successful in doing it, you'll see reductions in the thing you're targeting, reductions in anxiety, reductions in ADHD, but you'll also tend to see reductions in mental health conditions that are related but conceptualized as distinct from those conditions. So, we tend to see that if we see a reduction in anxiety and we targeted anxiety, we also tend to see a reduction in depression; try to address ADHD and successful reducing ADHD, you're also likely to see reductions in oppositional-defiant disorder or conduct problems or what have you.

The interesting thing here that I don't think has been tested is this idea of if you treat social skills in one of these domains, both lying, by the way, in very different spectra ADHD being a more externalizing-related condition versus than a more internalizing condition like anxiety, might in those circumstances, you see the rare occurrence of seeing a reduction in social anxiety and a concomitant reduction in ADHD, specifically because the core feature that cuts across both of them is social skills.

Well, might this be one of those rare circumstances where you would see a reduction in two distinctly conceptualized diagnostic conditions? That's a question that I'd be intrigued to see somebody probe, and maybe they have the data to probe it in one a large-scale data set of sorts. But suffice to say, that the good news is there are these two classes of interventions available to address both of these conditions, and what might be required in a clinical scenario is figuring out which one to target first and then monitor symptom response to intervention across sessions and then figure out at what point might it make sense to transition over to addressing social skills in their domain versus continuing on with that same one.

Tori Steffen:  Right. Okay. Yeah. That's really good to know, good information, especially to know that treating one issue might actually help the symptoms of another, which is really good information for a researcher.

Well, while all these treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things that adolescents can do on their own to potentially reduce or lessen some of those symptoms of social anxiety or ADHD?

Andres De Los Reyes:  It's important when you're experiencing these kinds of issues to become a good detective of how you're thinking, feeling, behaving. If you start noticing that it's kind of hard to build the kinds of relationships that you really want to have because it is true, and this is the interesting thing about social anxiety and ADHD for that matter, is that when you avoid these situations or you have difficulty maintaining friends, that doesn't mean that you don't want to be in those situations; you don't want to make friends. Quite the contrary. I mean, the research on social anxiety suggests that avoidance doesn't equal, "I don't care." There's that weird push and pull where you don't want to go into that situation, but you actually do really want to have friends. You actually do really want to maintain a healthy relationship, which is a universal feature. It's the rare person that doesn't want to build these kinds of relationships, because they're healthy and they feel good, and being able to have fun conversations and lean on people when times get tough, those are all things that the majority of us value.

So, if I was experiencing these kinds of concerns, I would sort of start asking myself, “What might be getting in the way? What are the things that I notice about myself when I know I want to go meet that person? I know I want to go. I know I really would love to be friends with that person, but I just can't get there.” What seems to happen before I get there? That isn't to say that you need to become your own therapist, far from it. But I think the interesting thing is to think about what information can I start gathering about myself, that once I get there, once I think I have the information I need, I can reach out to somebody who can help me: my parents, a counselor at school, someone who can guide you towards the people who have the experience, the expertise to help you make a meaningful change in your life.

Tori Steffen:  Right. Awesome. Yeah. That's really good advice. So, thank you so much for sharing that.

Do you have any final words of advice for us or maybe anything else that you'd like to share with the listeners today?

Andres De Los Reyes:  Do you have any questions about our work or are interested in learning more? I can be reached on Twitter with the handle @JCCAP_Editor, and feel free to reach out to me at my email address adlr@umd.edu. Thanks so much for finding this work interesting enough to listen all the way to the end.

Tori Steffen:  Perfect. Yeah. Thank you so much for sharing your knowledge. Definitely a lot of good advice and just good things to know about social anxiety and ADHD in adolescents, so we really appreciate you taking the time to enlighten us.

Andres De Los Reyes:  Happy to do it. It was a lot of fun.

Tori Steffen:  Yes, definitely. Well, thank you so much again, and thanks everybody for tuning in, and we will see you guys next 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.

Ecologist Lance Risley on Mitigating the Phobia of Bats

An Interview with Ecologist Lance Risley

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Great.

Lance Risley: If we have time.

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

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

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

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

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

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

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

Lance Risley: Yeah.

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

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

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

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

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

Lance Risley: Yes.

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

Lance Risley: In that sense. Yes.

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

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

Jennifer Smith: Okay.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lance Risley: Really?

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Absolutely. Yeah.

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

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

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

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

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

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

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

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

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

Jennifer Smith: Right.

Lance Risley: Enjoy them. Yeah.

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

Lance Risley: All right. Thank you.

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

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

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

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

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

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

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

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

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

Psychologist Pam Jarvis on Attachment & Trauma Awareness in Schools

An Interview with Psychologist Pam Jarvis

Pam Jarvis, Ph.D. recently retired as an Honorary Visiting Research Fellow at Leeds Trinity University in Leeds, England. Dr. Jarvis specializes in psychological wellbeing in childhood, adolescence, families and education.

Tori Steffen:  Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today chartered psychologist Pam Jarvis. Dr. Jarvis is a professor at Leeds Trinity University in Leeds, England. Dr. Jarvis specializes in a multi-disciplinary research perspective, including psychological, biological, social, and historical perspectives. She's written several publications including the book Perspectives on Play, which looks at play-based learning in four to six year olds, and the article Attachment theory, cortisol and care for the under-threes in the twenty-first century: constructing evidence-informed policy. Before we get started today, could you let us know a little bit more about yourself, Dr. Jarvis, and what made you interested in studying attachment and trauma awareness in education?

Pam Jarvis:  Okay, so I should correct that. First of all, I'm retired from Leeds Trinity University now.

Tori Steffen:  Okay.

Pam Jarvis:  And I was a Reader, which is a particularly British term for academics in various, so just to put that on record.

Tori Steffen:  Okay.

Pam Jarvis:  And you asked how I got started, well that's an awful long time ago because I studied as a young mature student when my own children were very small and they're all in their late thirties now. And I had an idea that I wanted to sign on for a degree because I hadn't done that at the so-called right time. And I was interested in psychology and I ended up working as sort of playgroup volunteer and doing my psychology degree at the same time, so it was just a perfect kind of environment to get interested into that kind of arena. And I followed that through really throughout my career with all the other things I've done.

I've also got quite a strong interest in history, but my major thesis in that was written on a pioneer, a nursery pioneer here in Great Britain, although she was actually born in New York State, I think in America, but she grew up and practiced in London. Margaret McMillan actually grew up in Scotland and practiced in London, so it's been a thread, if you like, all the way through my career that, that is the part of psychology that I was always interested in. I would do other things because I'd be encouraged to do that, but then I'd always come back to it. My PhD was on children in early years education, but it was more focused towards their learning on play-based learning. But emotion played a big part in that too, so really it's been a sort of thread that's gone all the way through whatever I've done.

Tori Steffen:  Right. That's great. Yeah, it's nice to have so many different perspectives in your practice. And then I'm sure studying child development with kids of your own might have helped a little bit or given you some knowledge.

Pam Jarvis:  Well, yes. Because you had the theoretical and the practical going on at the same time, so yeah.

Tori Steffen:  Right.

Pam Jarvis:  In action.

Tori Steffen:  All righty. Well, getting down to basics, could you explain for the audience what currently exists in the educational environment for student wellbeing?

Pam Jarvis:  Oh, that's a big question. I think it depends on the nation. The Scandinavian nations are much better at this then we are in Britain, and unfortunately you are in the United States. A lot of it revolves around the importance really that the society accords to that period of life and the interest that lawmakers have in early years development. And in my own country it's not much and hardly any, so I think I worked with a lady for quite some time who was a professor of early years child development education at Salem State University in Massachusetts. And the way she described your childcare provision was a patchwork quilt in terms of what was available in various states. Massachusetts did quite well, I think California does reasonably well, but not quite so well.

I'm not an expert on that, but I think where you can make the judgment on Britain in terms of, well, in England, what we do in England, Scotland is slightly better and the politicians are more interested in early years education and in what I'm going to talk about later, adverse childhood experiences, particularly. The politicians at Westminster in England are not interested at all. They have a very much a kind of attitude to, well, how cheaply can you do it?

Tori Steffen:  Yeah.

Pam Jarvis:  And I think some American states have that kind of attitude when you get a, I don't want to be political here, but when you get a Democratic president, I think you get a bit more interest and when you get a Republican president, you get a bit less interest. And the same thing goes for us that when you get a Labor government, you get more interest. When you get Conservative government, you get less interest. And at the moment, we're under one of the worst Conservative governments we've ever had.

Tori Steffen:  Yeah.

Pam Jarvis:  It's a difficult situation really, but we have hoped that it might get better. Things have turned around before, so I think that we are very dependent in England on the Westminster government, where in America it's the education and it's evolved status now. And it's much more about what state you are living in, but where money's coming from the top, there is a hit on that. Sorry, the trouble with this subject is it so quickly gets into politics.

Tori Steffen:  Yeah.

Pam Jarvis:  We know what good practice is, but it's whether we can provide the lawmakers to actually do it.

Tori Steffen:  Right. Yeah. I think what's important is kind of bringing awareness to just how significant it is to provide the resources for students, so that's what we're going to get into today.

Pam Jarvis:  The Scottish government have done particularly well over the last, I suppose five years. And they've moved in a really big way to a very informed practice. But I wrote a chapter for a document that went forward to Scottish Parliament and it was very receptive.

Tori Steffen:  Wow.

Pam Jarvis:  But not in England, unfortunately.

Tori Steffen:  Yeah. Well, hopefully America and England can learn from others that have a good system in place.

Pam Jarvis:  The Scandinavians. And I think Scotland did draw a lot of its ideas from Scandinavia, although they have their faults as well, nobody's perfect.

Tori Steffen:  Right. All right. Well getting to the topic of attachment theory, could you explain the relevance of attachment theory in education for our listeners?

Pam Jarvis:  I mean the relevance for attachment theory for human beings in every walk of life is enormous. Attachment theory has gone through several stages. And the original one with John Bowlby, who was the creator of the term, had lots of faults, but there's a central core in it, which is the internal working model. And what that means is that when the child is born, it will learn from the adults who look after it how human beings act in their relationships. And where a child gets an upbringing or an environment where they feel that their cared for, that they can call for help when they want, when they feel that their needs will be addressed, they become secure and that then will develop an adult who will feel secure in society. I mean, none of us feel secure all the time. I know I've taught this for years and years to many students and a lot of them actually were parents at the time, and they would sort of come up with this idea, “Oh I'm a bad parent because I'm not perfect. I don't make my child secure all the time.”

I might have actually told them off when I shouldn't have done this type of thing. And I think the first thing to say is, none of us are perfect but we can be good enough, effectively. And it's how the child perceives really whether they're loved and whether they will get support. And then as they grow older, they will apply that model to the rest of society. They will apply it to teachers, to peers, they will apply it to romantic relationships. There are things along the way that can happen that will make things better or worse. It's not just all with, this was one of the thoughts of the original Bowlbyian theory because it was everything with the parents and after the three years, well then that's it. And that's not true, but it is important. What can happen if a child gets the message that other people are not kind and I am not lovable. This is the model of both society and themselves that they will go out with that the self is not worthy of love.

And the society is not going to help you if you ask for help, they're not going to be kind to you. And then all else transpires from that. Most of us go out with it's not an either/or. Most of us go out with something that's somewhere on a scale. This is another thing with Bowlby because it was a 1950s theory. It was very either/or, it's not really like that. But if we're just too far away from the not good enough, what we are doing with those children, you are not only creating that model but also creating an internal stress, it's much easier to stress someone who is not secure because they haven't got any help coming, so we are going to get very stressed very quickly. This is the model of the world in your mind, nobody's going to help me and this is all going wrong. Whereas somebody who is more secure is much happier to go to a colleague and say, “I'm running into trouble here, can you help?” And think that, “Yes, they're going to help me.”

Tori Steffen:  Right. Yeah, that definitely makes sense. How it would have an impact on a child's perspective on if they can reach out for help. And you brought up the stress piece.

Pam Jarvis:  Yes.

Tori Steffen:  So definitely important and very interesting topic to study, and moving kind of over to trauma. How is the topic of trauma connected to wellbeing in education?

Pam Jarvis:  Basically we'll start off with this model of the child of, basically what happened in the 21st century was that there was a lot of work done actually on stress, how stress works within the body. And then this was taken to early years in terms of some children tend to get more stressed more quickly. And what then, because the setting up of the cortisol system is done in the very early years, if that makes sense, so therefore I always cite it to my students like a central heating system that if you've got the thermostat turned up too high, you're going to make the boiler work too hard, so effectively what's going to happen if you continually work the boiler too hard is either it's just going to go poof and die or it's going to blow up. And this is the type of emotion that you've got in these children.

And in education, this does obviously impact on behavior because those children are going to be on a much sort of tighter spring in terms of behavior, they'll do things that seem unreasonable and expect things from adults that seem unreasonable. But the other issue in education is that if you've got these stress patterns running in your head all the time, you are not going to learn as well or as quickly. Because again, the way I describe this to my students is rather like you've got a computer with a finite ability to pay attention to something. And if you are always looking on the horizon for the next bad thing that's going to happen to you, then you don't have that attention or concentration to apply to learning.

Tori Steffen:  Wow.

Pam Jarvis:  So for children who are at the really far end of this scale, it's a really difficult situation. Now here in the UK, one of the issues that is a problem is poverty because this stresses a family, which stresses the child, which creates arguments, which creates insecure attachment, which creates sort of too high reactivity stress reactions. And then this is how disadvantaged children are then disadvantaged as they go along and along and along because when they start education, they're not really set up to learn. And because of the stress that they're carrying, the adverse childhood experiences, which originates in America around about the two thousands also adds some information to this.

I don't know if you're familiar with that, you could probably do a whole piece on adverse childhood experiences, ACEs. Felitti et al, that actually I think was principally studied in California and it's rather simplistic, but it sets up a series of life events that are likely to give a child high adverse childhood experiences, which creates this excess stress. And yeah, it's all related. That's what my article is about. The one that read from early years international is how we put all this together. The work that Bowlby did in the 1950s, the work that's been done in this century on the cortisol reactions and the adverse childhood experiences idea that has come from Felitti. Which is somewhat problematic because again, it rather oversimplifies, you can't just give someone an ACEs score and kind of walk away and say, “Oh, well, that's it.”

This is always the problem with this. And in school in particular, there was a school or an area I think in Scotland that started actually assessing children for ACEs and putting that on a permanent record, but where it can be used to help children and provide help for the family, it can also be used to stereotype, so teachers could go back to it and say, well, this child hasn't achieved because look at their ACEs score, so basically they stopped doing it because it was causing argument. It's something very, very difficult in education because I think in education often there is this problem, which is if we're going to diagnose something, we need to know how to treat it. And if we're going to diagnose it and not treat it, we maybe are going to cause more harm than good because child will be stereotyped, so this is where we are at the moment.

Tori Steffen:  That's a great point. Yeah, there's so many different areas that kind of go into the attachment, and education, and trauma, and the biological perspective that you mentioned, so that's great that you know, were able to take it a step further and kind of fill in some of those gaps by putting all of this information and knowledge together, so it's definitely important to know.

Pam Jarvis:  That was the purpose of the article. Yeah, it was effectively a literature review that said, there's this area of theory, there's this area of theory, there's this area of theory, but they all go together to make this picture.

Tori Steffen:  Right.

Pam Jarvis:  And then of course you are setting the scene for a lot more research.

Tori Steffen:  Yeah, and it just gives us so much more information that's really crucial to providing for those students that have insecure attachments, or trauma, or low stress management, which we're going to get into here soon as well.

Pam Jarvis:  I mean, this is something that, what I worked when I was a teacher, principally with children in the secondary phase, junior high and high school, and I ended up basically going to work to train early years professionals here. And the reason I decided to do that, well, there were so many teenagers that I would deal with who I in the end would think, well, most of the problem with you is something that probably happened before you arrive, but now I'm looking at you at 15 and our options are limited, there are options, but they're limited. Whereas if I go and work with people who work with children in early years, that will be training people to understand this so we can do better at the period where we should be doing better and have more impact, if that makes sense.

Tori Steffen:  Right. Oh, absolutely. Yeah, it's important to kind of reach these children early because a lot of the development is happening at those very young ages, so that's a great point as well.

Pam Jarvis:  There's not nothing we can do at 15, but it's so much better if we did it at three or four.

Tori Steffen:  Right.

Pam Jarvis:  Or even before birth if we work with the parents.

Tori Steffen:  Yeah, exactly, exactly. Well, why do you think is it beneficial for schools to be more aware around the topics of trauma and attachment?

Pam Jarvis:  Well, here in Britain or in England I should say, and in America there's been a sort of fad over the last 10 years for this zero tolerance idea with teenagers that if they do something very small wrong, then you come down on them really hard and sort of make them mind if you like put them in isolation. But the trouble is, if you've got children who are basically on edge all the time, if you apply a zero tolerance regime to that child, you're going to make them much, much worse because the model of themselves they're carrying in their head is, I'm not worthy. And the model of other people they're carrying in their head is they are not going to help me.

All you're doing is justifying both of those beliefs if you're going to apply a zero tolerance technique to them, so where we have trauma-informed practice instead of immediately saying, well, a punishment is going to work here. I think the lady who works in California, sorry, whose name I've forgotten, I always do this in interviews, I should have looked this up, but I've got on her says, do not say what is wrong with you to a child, say what happened to you. They may not know in fact, but that's the question the adult should ask first. If you've got a child who's always creating problems, it's not what's wrong with them, it's what happened to them to make them do that. Obviously all teenagers misbehave at some points and sometimes the reasons aren't very deep, it's just trying their luck because that's the way they are.

But if you are a reasonable teacher or if you are a reasonable school counselor or whatever, you ought to be able to tell the difference. And this is to me where the importance of training comes in. I don't think we need to train teachers to be social workers, but we do need to train them to spot the problems. And I'm honestly not sure about teacher training in the US. I think, again, it is different in different states, but in England, I can tell you for a fact, we don't train teachers like this and it's just not appropriate. They need to be trained in this, in child development effectively.

Tori Steffen:  Right. Yeah, that is a really good point. As you mentioned, maybe teachers aren't exactly social workers, but they do have a large impact on children, on their wellbeing, and it is important for them to have those tools to address issues that come up, so that's a really good one.

Pam Jarvis:  Well, they're a first line practitioner, aren't they?

Tori Steffen:  Correct.

Pam Jarvis:  They're the ones who will flag this up. No one's saying that they have to deal with really difficult cases on their own, but they know enough to flag this up. I mean, all the time I was teaching teenagers because I was a psychologist, obviously I did, but I would go to higher up to various people who would clearly have no idea, and it was so frustrating.

Tori Steffen:  Yeah, yeah, that's definitely important to have. I think that just that alone could make a really big difference.

Pam Jarvis:  It really could.

Tori Steffen:  Yeah. Well, something in your article noted that children who experience ongoing stress from an insecure relationship with adults, they can develop issues with stress management.

Pam Jarvis:  Yeah.

Tori Steffen:  How might that say a low stress management, how might that show up in an education environment?

Pam Jarvis:  It's children who are not focused on learning, sometimes they can act out, but often it's just a kind of just not focused that a teacher can tell this, that the mind is somewhere else. And also a child who's very on the edge, if they get some kind of mild admonishment from a teacher, will just flip out and create a huge amount of difficulty. And then obviously in some regimes, the punishment for that is very harsh. One of the things English schools do is often exclude children for either for a short time or if they really badly offended them permanently. But that doesn't answer our question, it just passes it on. And there's a term here in the UK, I'm not sure if it's familiar to you, which is the exclusion prison pipeline.

Tori Steffen:  I haven't heard of that.

Pam Jarvis:  Yeah, so the child is effectively back out of education and then they'll turn up in prison sometimes later.

Tori Steffen:  Right.

Pam Jarvis:  And still carrying whatever it was that happened when they were three, and nobody's tried to address it or two or whatever.

Tori Steffen:  Right, which could create issues down the road that could have been avoided from the start.

Pam Jarvis:  Well, the biggest sort of irritation to me is that is so expensive.

Tori Steffen:  Yeah.

Pam Jarvis:  It costs more to keep a child here in secure accommodation, child offenders, than it does to send a child to Eaton where Prince William and Prince Harry went, so what is the sensible thing to do? It's not just about being a woke liberal, it's about common sense.

Tori Steffen:  Right. Yeah, that's a really good point. Well, what can schools do to help students with higher stress and insecure attachment styles?

Pam Jarvis:  Well, we need trauma informed environments, so this is staff training so that all teachers are aware when to spot the signs of a child who is highly stressed. And we also need, there's endless arguments in England about exclusions that if a child is dangerous to other children, you can't keep them in the classroom. I mean obviously that's true, but the question is, is where are you then sending them? Are you sending them to an isolation booth and punishing them or are you sending them to an adult who is trained to work with them. And actually get to the bottom of what it is that's bothering them? Often, as I say, they can't say, but it's taking, if you like, I think what the adult has to keep in their mind is this child most likely has a model of themselves that is they're not lovable and they have a model of me that I'm not willing to help them, so it's starting to work on that.

Tori Steffen:  Yeah.

Pam Jarvis:  Wherever it is you are sending them. Teachers can do this too for children exhibiting sort of lower levels of stress, but that needs to run all the way through the school process. And we're really not very good at that in this country.

Tori Steffen:  Yeah.

Pam Jarvis:  With the fact Scotland has made a start on this.

Tori Steffen:  Okay, well it's good to hear that somebody out there is confronting the situation and hopefully we can learn from what works, what doesn't, so that we can kind of reap those benefits as well.

Pam Jarvis:  What we hear, the problem, I'm sorry, this is becoming a very policy oriented discussion, isn't it? But the thing is, you can't, what we hear is actually putting this kind of policy in place is very expensive, but the argument is that more children are going to come out the other end who are not going to go into prison, who are going to create family lives that are less fraught themselves for their own children. And it's that invisible saving. There was a project actually in the US called Headstart, I don't know if you've heard of this? Where children from projects and their parents were given a lot of help and care, they'd be about my age now in their sixties. And there was disappointment because it hadn't made them sort of hugely academically more able when they got to school than children that hadn't had been in the project.

But as they grew older, they were more likely to form secure partnerships, adult partnerships. Their own children were more likely to be secure, they were more likely to be employed, they were more likely to graduate high school. So all of that, even though it hadn't made them super clever or raised their IQ by a huge amount, that security in their lives had made them, if you like, better citizens, be because they had a good, we keep going back to the internal working model, don't we? Because they had a self-confidence in their own abilities, and they also had the belief that the society was a good place.

Tori Steffen:  Right.

Pam Jarvis:  Why would I contribute to a society where I think nobody much likes me, or is going to help me.

Tori Steffen:  Yeah, that's definitely important to understand how, it just sounds like it's very significant, the attachment style and the way that the child perceives themselves and others, which makes sense that, that alone can have such a big impact on educational success. And then later in life relationships, so many other areas in life.

Pam Jarvis:  And educational success doesn't just mean high grades and going to an Ivy League university.

Tori Steffen:  Right.

Pam Jarvis:  It means getting to the end of education, graduating, and maybe doing a very ordinary job, but that security to do that, to stick at it. And attachment is really, if you like, the melting pot for all this.

Tori Steffen:  Right.

Pam Jarvis:  That early part of life where we learn who we are and how other people will react to us, our expectation of ourselves and others.

Tori Steffen:  Absolutely. Well, if students are experiencing anxiety or other mental health issues, are schools able to provide any type of therapy or even just recommend that the caregivers seek out therapy?

Pam Jarvis:  Well, again, in England, and in America, I presume it again, depends on the states. In England, no, we are in terrible trouble with this. We've got huge amounts of teenage mental breakdown, which isn't only to do with the home, it's to do with social media, and to do with the experiences they went through in lockdown and COVID. Our mental health service is massively, massively overloaded. But really we could, as I say, train other professionals in the children's workforce to be able to do some of the work, but we don't.

Tori Steffen:  Right.

Pam Jarvis:  Every so often the prime minister, whoever it is this week, says, “Oh, well we are going to put more money into the mental health service.” But my kind of reaction to that is, well, that's like pushing somebody off a cliff because we've got so many families living in poverty here and sending an ambulance in the bottom. Why don't we help families at the beginning, so we don't have so many kids with mental health problems in the end?

Tori Steffen:  Right.

Pam Jarvis:  We can't really do much about social media or there are things we could do, and I have written about that. And again, we could do a lot more about family poverty, a lot more.

Tori Steffen:  Yeah, yeah.

Pam Jarvis:  We can't make all families secure.

Tori Steffen:  Right.

Pam Jarvis:  But we can raise the chances, and we just don't bother.

Tori Steffen:  Right. Yeah, why not start from the beginning versus trying to fix issues later down the road when it's going to be, you have limited options as how to help these individuals.

Pam Jarvis:  And their bigger issues.

Tori Steffen:  Yeah, and they already have that ingrained insecure attachment. Yeah, I think it would be more beneficial from the beginning, see what you can do to intervene there versus later on.

Pam Jarvis:  I mean, I haven't actually specifically written about this, but I mean logically, if you are insecurely attached, the type of trolling and bullying you get on social media is going to have a much bigger effect on you and so on.

Tori Steffen:  Yeah, yeah, because you just have less tools maybe to deal with that kind of stress.

Pam Jarvis:  Yeah.

Tori Steffen:  Yeah.

Pam Jarvis:  Well that's the thing with stress, isn't it? The actual term stress was taken from engineering, I believe originally and if you've got a bridge that's built with stress metal, you put a train on it that's too heavy and it goes pow, same thing for human beings.

Tori Steffen:  Yeah, I like the analogy.

Pam Jarvis:  If this is already cracked and you put a heavy load on it will give way.

Tori Steffen:  Yep. Yeah, that's a perfect analogy for kind of what you can expect from students. Well, what can families do on their own to help children develop a secure attachment? And if they are able to develop that secure attachment, do you think that, that would lead to a higher wellbeing in a school environment?

Pam Jarvis:  We have to recognize how hard it is for families to start with, I think, because I would hate to input family blaming because there are so many stresses on families now. But all things being equal, what the child needs in the first three years is a group of bonded adults. Bowlby said it just had to be the mother, this is not true. That's been shown again and again and again.

Tori Steffen:  Yeah.

Pam Jarvis:  What children need is a circle of adults, it could be three, five, but who take care of them and are bonded to them and what they will, who are emotionally available to them who have a focus on them. And what tends to happen is they create a main attachment and then these subsidiary attachments, so therefore it doesn't really matter. Your daily round could be to be with mom on one day, with dad on another day, with granny one on one day, granny two on the other day. That's fine, as long as that's familiar and you are bonded to those people. And out of that a main attachment will come, but the other people are acceptable substitutes. The big problem that you have with children is if they're sent particularly to daycare where the staff keep changing and then they don't have an adult in that environment who they have that bond with.

And there are ways, personally, and this is just my personal preference, I would prefer that families were at least given the option for parental and kin care within the first three years. But if there's a lady down the road who's a really experienced child minder and you're paying her to take care of the child and she's wonderful with the child, what's the problem with that? She just becomes another one of that bonded circle. Barbara Tizard who worked with Bowlby, I think she's still alive, but she'd be quite old by now. She said, well look, the way that children were cared for in the early industrial period in Britain, because women did have to go out to work when they worked in the field, obviously the children could often tail along behind them, but there was a tradition in England of paying one woman in an extended family to care for all the children, so it could be a sister, a cousin, it could even be a grandmother.

But this created, although they might have been poor or sometimes the kids didn't get enough attention, there would be a group, a kin group of children, and a bonded adult, so really, in many ways that's better than sending a child to faceless daycare. It's a really low, here across the UK and in America childcare is, the parents pay for it. If you're lucky, I think in America you are going to get a creche attached to your job, that doesn't happen in the UK, so parents pay for the daycare that they can afford, so if you've got parents in poverty, often they're paying the lowest price for daycare and that daycare is paying the practitioners the lowest possible money. And those practitioners are, they're moving in and out of those roles all the time because they're so badly paid and they'll get a better job. It really is setting up a child that, if you like, disadvantage leads to disadvantage, leads to disadvantage.

Our prime minister for 60, 30, I can't remember, about 45 days, wasn't it Liz Truss, she was children's minister of 10 years previously, and she was asked, would you send your child to this type of daycare? And she said, “Well, children do get care, obviously I'm not looking after them all the time.” And it came down to the fact she had a nanny. Well fine, they can bond with the nanny. With attachment, what I think this is something that's often missed, the disadvantage often breeds disadvantage all the way along the line because it's about how you fund your family.

Tori Steffen:  Yeah.

Pam Jarvis:  And that is often in direct sort of opposition to good attachment in that first three years.

Tori Steffen:  Right. Yeah, you can see how it could be a domino effect of sorts and it's going to have an impact on the development of the child, and especially around trauma and attachment, so yeah those are important things to think about when you're choosing care for your children. And a really great point about the bonding with a number of adults, I envision just the parents, but it really makes sense to have a larger group of adults that children can bond with.

Pam Jarvis:  Well, granny's are often very helpful in this respect, but as you know, society's getting poorer, then often the grandparents are having to go to work.

Tori Steffen:  Right.

Pam Jarvis:  It's quite worrying, I think what is happening in the current situation where we have rising fuel prices, rising inflation, and it's making families poorer and poorer. And at the bottom of all this, children are suffering.

Tori Steffen:  Yeah, yeah, absolutely. I can definitely see how that would have an impact. And let's say everything goes right and a child does develop that secure attachment. Do you think that a secure attachment leads to wellbeing in school for that child? They can accomplish it a little easier.

Pam Jarvis:  I think they have the best chance of being the best that they can be. If you send them to a really bad school, well then nobody is emotionally indestructible. You can't bank on it, but you've given them the best chance, I think.

Tori Steffen:  Yeah. Yeah, I would agree. I think you're setting them up for success in a way. Yeah, just providing a good development, so I definitely agree with that.

Pam Jarvis:  It's kind of how we see success and success in a life, well it doesn't necessarily mean you went to the best university or you had the highest paying job.

Tori Steffen:  Yeah, very true.

Pam Jarvis:  It's being comfortable to be yourself and you've got your best chance of that if you feel that people like you and that they will help you.

Tori Steffen:  Right. Yeah, just having a healthy perspective on the world, on yourself will have a big impact on what you choose to do in your life, no matter what it may be. All right. Well, Dr. Jarvis, do you have any final words of advice for our listeners or anything else you'd like to share with us today?

Pam Jarvis:  Yeah, I think we have to see children as much more important in neoliberal societies like the UK and the US than we do. They are almost pushed under the wheels of the economy and profit. And we exist in order to make money and to make profit. And in that culture, the children are the ones who suffer the most. I think particularly, we... Actually, today we've had a news article about a private company that we're responsible actually for looking after children in residential care who gave them the most appalling service because their motive was profit. Rather than the quality of the care for children. And I think we are in danger of pushing children under these wheels and just not worrying about the emotional setup we are building for their future, but the only future that any of us have is our children. And I think this is something that we just don't think about enough.

Tori Steffen:  Yep. Very good points there. Yeah, like you mentioned, it's important to just start early so that you're not spending, you have to create all these policies and put things in place for later down the line as far as social workers and wellbeing. It just makes more sense to put the emphasis on child wellbeing during development. It's going to do your children a favor and just kind of well roundly help everything else along the way.

Pam Jarvis:  The economy is for people, people are not for the economy. And I think that's especially relevant to childhood because of the development that they need and the human things that we have to give them to allow them to develop healthily. We pay a lot of attention to physical health, because we can see it. But we don't pay enough attention to emotional health.

Tori Steffen:  Yes.

Pam Jarvis:  And then very quickly, it's coming up to too late. You're going to have to do an awful lot of work to reclaim that child where if you've done it properly first off, then it wouldn't have been so difficult.

Tori Steffen:  Right. Yeah. Well, hopefully parents and teachers out there can kind of develop those tools and skills to help these young kids develop in a healthy way, so thank you so much for sharing all your knowledge today with us, Dr. Jarvis. I've definitely learned a lot and I'm guessing our listeners did as well, so thank you so much.

Pam Jarvis:  Thank you.

Tori Steffen:  Thank you so much, and thanks everybody for tuning in and we'll see you next 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 Travis Osborne on OCD & Hoarding

An Interview with Clinical Psychologist Travis Osborne

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

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

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

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

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

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

Travis Osborne:  Yeah, for sure.

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

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

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

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

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

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

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

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

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

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

Travis Osborne:  For sure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Travis Osborne:  Yeah, for sure.

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

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

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

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

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

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

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

Psychologist Sven Hroar Klempe on Music & Cognition

An Interview with Psychologist Sven Hroar Klempe

Sven Hroar Klempe, Ph.D. is a Professor of Psychology at Norwegian University of Science and Technology, in Trondheim, Norway. He's an expert in the field of psychology and musicology.

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

I'd like to welcome with us today psychologist Sven Hroar Klempe. Dr. Klempe is a Professor of Psychology at Norwegian University of Science and Technology, NTNU, in Trondheim, Norway. He's an expert in the field of psychology and musicology, and has written several publications on the topic, which includes the book Tracing the Emergence of Psychology, 1520-1750, as well as the book Sound and Reason, which focuses on the conceptualization of sound in a specific context or field.

So, before we get started, could you let us know a little bit more about yourself, Dr. Klempe, and what made you interested in studying both psychology and musicology?

Sven Hroar Klempe:  Yeah, that's a good question. The background is, I'm a very interdisciplinary person. When I was young, I was very into mathematics and physics, but also in music during my whole growing up. I think that the main question that I posed myself was, “How come that rational people are doing music? Why do we do music? Why do we sing, when we can talk?” That's the core question.

And therefore, I have since 1970s tried to figure out, to what extent do music communicate? And with this background, I went to Paris in the late '70s, just to investigate semiology and the French philosophy of structuralism, which very much focused on a kind of abstraction of language, by means of defining language in terms of science instead.

Tori Steffen:  Great. Yeah, that seems like it would be really interesting to study the French perspective on music.

Sven Hroar Klempe:  Yeah, absolutely. Absolutely. And of course, you have an American tradition as well when it comes to Charles Sanders Peirce and his pragmatics, which is also concentrated on semiotics, where he understand logic in terms of semiotics. So, there are two different traditions, in a way, but they merged very much, I would say, in the '80s, '90s.

Tori Steffen:  Very interesting. Well, getting down to basics, could you explain for us how music is related to psychology?

Sven Hroar Klempe:  Yeah. This is a very intriguing question, especially because we have almost forgotten how interwoven they actually were in the late 19th century. But the best example would be Gestalt psychology.

When Gestalt psychology was established, especially Gestalt qualities from Christian von Ehrenfels, who published in 1890 his answer to that core question in the late 19th century Germany, especially, what is a melody?

And so, they had a lot of discussions about this. They focused very much on the musical aspects, and the answer that Christian von Ehrenfels came up with is very important. He says that if you transpose a melody from one key to another, as from C Major to D Major, then you replace every single pitch with a new one. That means that it cannot be the elements, the tones, that make the melody, because the sounds are the same melody, although you have replaced all the elements. So, what is the answer?

The answer is, quite simply, it is the relation between each tone that form the melody. And in musicology, we have names for this. We call this intervals. But on the other hand, an interval, what is it? It's a kind of empty space between the two tones. So, we fill the space with a relation, also the relation with one with the other. And this is the Gestalt thing. Not only the whole melody, but especially the relationship between each element.

And this is hard to grasp, because we are thinking about the elements all the time, and we think that everything is built up by elements, and we get a whole out of it. But, as a matter of fact, and this is also an important part of the perception and understanding that we are focusing on how they are placed in relation to each other. And this is the important thing, and that is also why the relationship is the most crucial aspect of the experience of things.

Tori Steffen:  Right. Yeah, it's definitely learning about the intervals with music. Music is almost its own language.

Sven Hroar Klempe:  Definitely. Its own language. Another system, and quite different from language as well. But then, there is more when it comes to the relationship between music and psychology. So, if you take the whole German experimental psychology and look at that, they are focusing on music as main stimuli in their experiments.

Wundt for instance, Wilhelm Wundt, the one that is primarily related to experimental psychology, he had two laboratories, one acoustical and one visual. But in his papers, he primarily refers to the acoustical. And in this acoustical laboratory, he had about 300, 400 tune forks, like you tune the instruments with. And the reason is exactly that he wanted to investigate exactly the relationship between the different tones.

But this tradition goes further back. It was Fechner that started up and introduced the term music as the direct factor. With this, he means that also what experimental psychology wanted to focus on was exactly the relationship between what is out there, what do we perceive, and our ideas about what we perceive. Because those two things are quite different, very often.

And for instance, if I take this pencil, and I do it like this, I don't know if you see that it's both, but it's hard. So, the experience of the pencil was that it is soft, but it is, from a physical perspective, it is hard.

So, there is a difference between how the nature is out there, the physics, also the physical nature, is out there, and how we perceive it. So, in experimental psychology, the aim was justify the relationship between this.

And when it comes to this pencil, I have a term for it. And also, if I look at pictures and other things, I have terms for this. But what I want to focus on was, how they experience things without putting things into terms. And that is why music is the direct factor, the most important and most interesting, esteemly, because you cannot put music into words.

Tori Steffen:  Right. Yeah. And what you said definitely seems to be related to one's cognition. Have you found any connections in your studies between music and cognition?

Sven Hroar Klempe:  Yes, absolutely. And we are back to this problem that psychology is maybe focusing too much on language. And especially after the Second World War. Almost all cognitive investigations have focused on language as the bottom line, so to speak, of rationality.

But by focusing on music, we will go beyond language. And what we find immediately, when it comes to music, is that polyphony is a very basic aspect of music. Polyphony means that different tones are sounding at the same time. And this is a quite crucial thing, because in language, there is a kind of mutual exclusion between the words. If I choose one word, I cannot at the same time articulate another word. But if I take the guitar, for instance, I can very easily play two tones at the same time. And the music is based on this. The chords presuppose, so to speak, that I articulate different tones at the same time.

So, we have the capacity of putting things together at the same time. And there are some psychologists that have focused on this. And one is especially Vygotsky, the Russian, Lev Vygotsky. In his thesis on speech and thinking, he demonstrates, very convincingly, how separated thinking and language actually are. In the sense that, well, that the egocentric speech of the child is a kind of preparation for thinking.

It is the same kind of speech that goes into the thinking process. But the thinking process goes in further, in the sense that it focuses on thinking without words, so to speak. So, in our heads, when I'm talking now, I'm trying to take one word at a time and have one point at a time, the one after the other. Whereas in music, we have the capacity of putting things much more together.

Tori Steffen:  Yeah. It sounds almost like a subjective point of view. And I was reading your book, Sound and Reason, and you noted that music can have sort of a subjective impact on the listener. Could you explain a little bit about that for our audience?

Sven Hroar Klempe:  Yeah, sure. Yeah. And what you are focusing on now is the privacy of music and aesthetic experiences in general.

And it's the same when it comes to music as it is with sexuality, for instance. It is very intimate, private, but also directed towards something different from yourself, also pointing towards the other. And especially when it comes to sound, it goes so deep. So, when you have heard some certain melodies in crucial parts of your life, for instance, when you are a small child, or in the teens, when you are a teenager, you remember these melodies very intensely.

And I remember when David Bowie died six years ago, I think it was, about, and the newspapers in Norway were full of people that wrote about how they mourned so much. But I'm a bit older, so for me, David Bowie was not a big issue for me. So, in my perspective, it was a bit funny to see how a whole generation of journalists and also mourned about this, about David Bowie who passed away.

So, this is for all of us. I have other things in my background that comes up with very intense feelings, back to the early teenager, and also when I was a small child.

And some sound goes so deeply into our memories that this is the core aspect, so to speak, when it comes to memories. But it's not only sound. Also, smell and taste and colors, all the statical impressions that we get, they go so deep into us that we have to deal with this later on during life.

Tori Steffen:  Yeah, it makes sense, definitely, that it would have a lasting impact on your memory/cognition, especially from a young age, listening to music.

Sven Hroar Klempe:  And this is also an important aspect of... When you look at psychoanalysis, for instance, as Freud started up focusing very much on concepts, the bird representation should reflect a kind of content that was related to your experiences in childhood.

But this is something that Jacques Lacan, for instance, brings a step further, as he makes a very clear distinction between the sound of the word and the content of the word. And this is part of this French structuralistic way of thinking based on Ferdinand De Saussure's, thesis of the arbitrary sign, in the sense that content is completely separated from the sound, so to speak. So, when it comes to how to deal with a neurosis, or also Lacan is more focusing on psychosis, and things like that, the sound of the terms are more important than the content.

Tori Steffen:  Yeah. So, we've covered how it could impact one's cognition. Do you think that there's a connection there with music and mental health, and if it might have a role, music in therapy?

Sven Hroar Klempe:  Yeah. Absolutely. And I think this is a very important thing to pursue, in a sense, especially from this perspective. When focusing on the sum of the word is not just related to mental disorders, but also a part of our everyday use of language. Whenever we talk, we do not complete the sentences always. And the reason is, quite simply, that we want to express different things at the same time.

And, of course, sometimes this makes meaning. Especially when you read poetry, for instance. Also, poetry is characterized especially by exactly this echovocality, that you have the ambiguous aspect of the terms. So, the good poetry, they tell, very often, at least two stories, even three different stories at the same time, by the use of the terms. So, this is a part of our normal life, so to speak, and we enjoy it as well, like we enjoy music and the polyphony in music.

When it comes to different types of disorders, especially the psychosis, it is very much the same, specifically that they are expressing different things at the same time, but they are not able to see exactly the distinction between the different things. So, in that sense, I think it's very important to see how gradually the line between a disorder and an order actually is.

So, in that sense, I think it's very important to, and we have very good experiences, when it comes to how to use music, when it comes for aphasic person, for instance, in the upper CI, if they have a letter on the left hemisphere, for instance, where lose the language, then it's very easy to get in touch by music.

And of course, as the newer scientists say, that the brain is very flexible. You can build up something, but you had to start with something. And then it can build up also the functions in the left hemisphere by activating the right hemisphere by means of music.

So, in that sense, music, not only when it comes to aphasics and psychotics, but everywhere, we use music to get in touch with each other, and that's the point.

Tori Steffen:  Yeah, definitely. What you were saying about poetry and music, it's a way to bring different perspectives on topics, and that's very interesting that it might differ between cultures. Do you think music can impact cognition? How might it impact cognition on an intercultural level, would you say?

Sven Hroar Klempe:  Yeah, that's an intriguing question. And I think there are two answers that I can come up with. One is that it is very important. First time I was in China, I had a meeting with the Chinese, and we ended up singing folk tunes to each other, my Norwegian and their Chinese folk tunes.

But that was a situation where they knew Chinese folk tunes that followed more or less the same type of tonal systems as I'm familiar with from Norway. But when it comes to music around the world, we'll find very many different systems as well. And one example is for the Lappish people in Norway. So, the traditional music they are singing, when we go 100 years back... How it is today I don't know exactly, but transcriptions 100 years ago, they demonstrated very well how difficult it was to make phrases in this music.

And that is the difference between the western music, which is very exact when it comes to phrasing, that you have a phrase that stops, and it continues with a new one, and so forth. But in the Lappish music, all these phrases, they are going into each other, so to speak. So, they overlap. And that is a kind of implicit polyphony, that you have different phrases that are articulated at the same time.

Like we do in language, in abbreviations, for instance, when we shorten everything, but also blendings: edutainment. Education-entertainment. Edutainment, for instance. And that is exactly what also happens in music. And in music, it's much more natural to do this, that you have these overlaps. It's a part of the system, so to speak, especially because music is polyphonic.

And among the Inuits, for instance, they have a tendency to sing in one beat, let's say 60 beats per minute, or 100 beats per minute, and then they can drum in 91 beats per minute. Also a kind of polyphony that is impossible for me to perform.

So, we have a lot of old cultures that have very intricate musical systems. And this is also an important aspect of the African music, as well, which is very polyphonic.

Tori Steffen:  Right. Yeah. That reminds me of the idea of Structure of Sound. Your book actually pointed out an interesting perspective on that, so I'm going to quote you really quick. "An identifiable structure is a prerequisite for us to be able to experience sound as meaningful." So, how might that idea relate to our topic of cognition or psychology?

Sven Hroar Klempe:  This is at a core, in the sense that we have different systems, and that's the point. And we can operate with different systems as well, when it comes to both the way we use language, the way we use music, and whatever. But we have to be familiar with the systems.

So, I had a very interesting situation with my granddaughter, she is three years old, and her elder brother plays chess, and she wanted to play chess. But she wanted to define the system. She didn't know the rules, of course. So, she just put the pieces in a certain order that she found meaningful.

Tori Steffen:  Interesting.

Sven Hroar Klempe:  And it was very meaningful in that situation. So, we played chess on her premises in this way. I had to adapt.

So, the point is that we have to be very open to very many different types of systems. And this is a challenge for especially the western culture, because they think that our language system, musical system, and whatever, are at the top. The end of the development of human beings, so to speak. But it's not. It's not at all.

And when we look at this complicated ethnomusic, they are even more complex and subtle, I think. So, the point is, yes, as long as we understand the system, then there is a meaning.

Tori Steffen:  Right. Yeah. That's such an interesting story about your granddaughter, and creating her own meaning. That's very interesting.

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

Sven Hroar Klempe:  Yeah. Maybe this main message of trying to take a step back, to see how we focus on language as the core of rationality, because it's not there. Because if we say that language is the center of rationality, then we underestimate pre-verbal children and their personality. And I have to tell a story at the end, if I may.

Tori Steffen:  Absolutely. Yeah.

Sven Hroar Klempe:  Yeah. It's a book I heard about where the father let the small child write about their conflict in the family, so to speak. And one interesting thing was that the child blame her father to take the wrong toothpaste every day. The toothpaste. Because the little child... They obviously had different toothpaste for each one, and all the toothpaste, they have different colors, different pattern, and so forth.

The point is that this child was very rational when it comes to how to differentiate between the different toothpaste tubes, whereas the father didn't think too much about this. And this is the distinction between how the child categorize the world in terms of colors, sound, smell, taste, and so forth, before they have a language. And they know exactly where is what, and what belongs to who, and so on. So they categorize. They are very rational without language.

Tori Steffen:  Yeah. It's kind of like creating your own meaning, going back to the story about your granddaughter, and then this story seems to also kind of paint that picture of building your own structures and language, especially with the senses. So, yeah, that's very, very interesting stuff, Dr. Klempe. So, thank you so much for contributing to our interview series. It's been great speaking with you today.

Sven Hroar Klempe:  Thank you for inviting me.

Tori Steffen:  Absolutely. Well, I hope you have a great rest of your day, and thank you again.

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

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

Professor Chris Hackley on the Psychology of Advertising

An Interview with Professor Chris Hackley

Chris Hackley, Ph.D. is a Professor of Marketing in the School of Business and Management at Royal Holloway University of London. He's an expert in the field of marketing and business.

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

I like to welcome with us today Professor Chris Hackley. Dr. Hackley is a Professor of Marketing in the School of Business and Management at Royal Holloway University of London. He's an expert in the field of marketing and business and he has written several publications on the topic, including the article, Brand, Text, and Meaning, as well as the book, Rethinking Advertising as Paratexual Communication, which takes a literary theory perspective on advertising as text.

So before we get started today, could you please let us know just a little bit more about yourself and what made you interested in studying both marketing and psychology?

Chris Hackley:  Sure. Welcome to the talk, everybody, and thanks for asking me, Tori. Yeah, many, many years ago when I was teaching in two year colleges, I decided I was a little bored with marketing and I thought I'd change career track. So I studied for a second Bachelor's Degree in Psychology with the Open University, that's a part-time school in the UK. My plan was to change track to ed psych because I thought that was pretty interesting at the time.

So I completed the degree and completed the diploma so that I could get membership of the British Psychological Society. But just then I managed to develop my career into research universities where I was able to write my own courses and I found that I could integrate my fondness for psychology into my own teaching and research. So there wasn't any need really to change career track anymore.

And of course I had a young family at the time, so it would've been economically unrealistic to do that. So I was able to combine my interests, really, since I had more freedom to write courses I wanted to do and write books about the things I wanted to study.

So that's where that came from and how my career developed. And of course marketing is very much about psychology in many ways. And so the two interests combined quite neatly, I think.

Tori Steffen:  Right. I was thinking the exact same thing that both fields would kind of help with the other. So that must have been great to study both. Well, getting down to basics, could you explain for us how marketing is related to psychology?

Chris Hackley:  Yeah, some people would suggest that it's all psychology, really, the psychology of persuasion. And there are many people with cognitive psychology backgrounds who become marketing academics. And there are many sort of research streams based on cognitive psychology in the marketing literature.

I think it's also broader because marketing touches on many other subjects of course, and I approach some of it from a sociological perspective, well perhaps from the borders of sociology and psychology. So that's why I think it's broader than just psychology. And of course management is a very much a multidisciplinary subject to study as well.

So I think one can look at marketing very much through a psychology lens, but I think if one only does that, one does miss some important things. And I'm influenced by the psychology degree that I studied, which was a little bit unusual. It was at the time the course was led by a lady called Professor Margaret Weatherall, who is a very, very well known psychologist, but she specializes in qualitative psychology.

And the course was really leaning toward what some of the tutors called sociological social psychology. So in other words, they took a lot of perspectives that perhaps in a lot of psychology departments would be regarded as more of the sociologists remit rather than the psychologists. And that was what attracted me very much about that particular degree because they looked at the borders of sociology and psychology.

And I think that's where marketing does get very interesting because marketing phenomena are not just in people's heads, they're also in the culture, and the context around people. So I think it's really the borders of psychology and sociology that marketing does get really interesting.

Tori Steffen:  I would definitely agree with you there. How might you say psychological theories, maybe Abraham Maslow's Hierarchy of Needs, how might that be connected to marketing?

Chris Hackley:  Well, my simple answer would be that it isn't.

Tori Steffen:  Okay.

Chris Hackley:  It's enormously overused and it's marketing academics and consultants are very, very good at appropriating little bits of theory that sound kind of good and that they can use. And Maslow's, unfortunately, is one of those, I'm sure Maslow himself would be absolutely horrified at the uses to which his hierarchy is put by marketing people because of course he was a humanistic psychologist and he did not advocate that people could become self-fulfilled through consumption. And I'm sure the very idea would be anathema to his entire philosophy.

So the use of Maslow's, Hierarchy, is a piece of bare faced thievery by marketing academics and consultants. It can be... Quite a few theories in marketing, they're not really theories. They're more back of the envelope frameworks, which are useful discussion points. And they're use useful for bringing out particular topics. So their use really is as teaching devices, but I don't think there's necessarily a lot of integrity in that, intellectual integrity.

They're kind of useful in the classroom and marketers are very pragmatic in their use of theory from other disciplines. Pragmatic is probably a better word to use than thievery.

Tori Steffen:  That definitely makes sense. Well, thank you for explaining that for us. And how might ethics play a role between that relationship of psychology and marketing?

Chris Hackley:  Well, it's extremely important and it's extremely important, I think, for marketing academics to expose unethical practice that the problem comes in the very nature of marketing, which is essentially about persuasion. And a lot of the ethical issues arise in how precisely that is done.

And of course, Vance Packard back in 1957 when he wrote his book, Hidden Persuaders, was horrified when he found out how advertising agencies use psychology to persuade people as he saw it, in a rather sinister way, to persuade people in ways of which they were not aware.

And marketing, as a discipline, it's about the same age as psychology, about a 100, 120 years in its modern form. And it's persistently had this rather dual nature where it tries to present itself as being the discipline that makes life better by improving the allocation of resources in ways in which economists can't do because of the assumptions of their discipline.

So marketing brings to bear behavioral and psychological and other disciplines to try to understand human desire and human choice and decision making more accurately so that markets can be cleared more efficiently. But as Maslow, sorry, as Packard pointed out, this can get a little bit manipulative. And I suppose the modern day equivalent of that would be what they call neuromarketing, where a lot of big global brands do this.

They hire a bunch of out of work neuropsychologists, buy them an MRI scanner and put them to work, putting consumers through it and looking to see what their brains look like when they are looking at certain adverts or eating a certain brand of ice cream or something. And a lot of hope and money is invested in neuropsychology, neuropsychology for marketing or neuromarketing, as they sometimes call it. The results have been, I think, very limited so far.

But of course the aim is total controllable organizations over consumer behavior, which is not a nice, not a good thing, I don't think. And the dual nature of marketing I referred to earlier was referred to its public face as the science and the discipline of resource allocation that makes life better and makes people happier by giving them more stuff that they want, and as well as generating jobs and wealth and income and so forth.

But on the other hand, it's also has a reputation as being a rather dubious site of hucksterism, sinister manipulation, and downright dodgy dealing, which of course, which it fully deserves, as well. Some of the greatest marketers in history have been people like P.T. Barnham and Edward Benes, of course, and a lot of other very dodgy characters whose ethical standards were a little bit flexible, should we say?

So marketing is particularly interesting, to me, because it has this dual nature and it has this, perhaps you could call it a tension within it between these sort of the marketing appeals to people's rationality and its attempts to give people a greater range of choices from which they can make useful decisions to improve their welfare and their quality of life.

And on the other hand, just trying to manipulate people and obviously a part of marketing is stimulating desires that we didn't know we had for stuff that we don't need.

So it is a very complex field and it does both of these things. And ethics of course has many, many dimensions of application in marketing, and it's more important, I think, than ever.

Tori Steffen:  Absolutely. Yeah. You mentioned neuromarketing, which is really interesting topic to bring up in relation to ethics. How would you say the field of neuromarketing, particularly, is related to maybe mental health or one's personal psychology?

Chris Hackley:  Well, I'm not in any sense an expert on neuromarketing, and I know that a lot of proponents of it feel that it has great potential. I'm a little bit of a skeptic, mainly because I don't think psychology resides entirely in one's central nervous system. I think the borders of... I think a lot of psychology is relational, and it's to do with the context and the cultural situation of people, but I think its results have been very limited so far from what I've seen.

Obviously the idea of a golden bullet, as it were, for organizations to stimulate desires in us and action without just really being aware of that is extremely sinister and not something one would really wish for in a pluralistic liberal democracy. So I think the aims of it are a little bit dubious, but I was told not so long ago by somebody in the media industry that a lot of big brands won't allow the latest advertising campaign out of the door until the neuromarketers have shown it, put people through the scanners, and shown them the ads.

Tori Steffen:  Wow.

Chris Hackley:  So I guess for the marketing industry is very, very risk averse a lot of the time. And anything they think they can do to reduce a little risk a little bit, they do cling onto. And so ideas of marketing science are very, very attractive for that reason.

And so if they can reduce risk just a little bit by using neuro marketing, then they'll try to do that. And I guess it does have its uses, but I couldn't comment any further on it really, because I'm not up enough on neuromarketing, I'm afraid.

Tori Steffen:  Got you. Yeah, it's definitely one of those newer fields. So still a lot to learn. Well, in your article, Marketing Psychology and the Hidden Persuaders, you mentioned that psychology can enable a more critical engagement with marketing. Could you explain how that works for our audience?

Chris Hackley:  When I initially studied management and business, I found it intellectually kind of unsatisfying because there wasn't enough critical thinking in it. We've already mentioned a lot of marketing theories that don't really stand up to a proper critical analysis because they're really more consulting or teaching frameworks than theories as such. So, forgive me, I've lost my train of thought on your question?

Tori Steffen:  Yeah, so just how more critical engagement with marketing, or more the psychology, is related to that extra critical engagement?

Chris Hackley:  So later on when I started to study psychology, I found it extremely useful, firstly, in understanding methodologies more thoroughly because my business and management education was a little bit superficial on that, but also simply because the psychological approach is to appraise theories by their evidence and by their capability of predicting and explaining and so forth. So it's a much more systematic social science training in a psychology education, I think.

And I think that brings a great deal to the study of marketing and management, which is not necessarily present in marketing and management degrees because since the 1950s and 60s, the idea of management has become very much dominated by a toolkit for action for managers and the need to step back and really critically analyze the ideas and the theories and management has been relegated, a little bit, to some final year courses and to postgraduate research and so forth.

So yeah, I would say that I think in my institution we do this pretty well, but a lot of undergraduate management degrees, they don't really teach critical thinking rigorously enough, in my opinion. So I think psychology really does help a great deal with that because people are trained in critically evaluating competing claims and especially competing claims that are sort of justified by particular theories.

So, for example, so many management and marketing students are taught Maslow and goodness knows what they think of Abraham Maslow. The vast majority of them would not go to read about Abraham Maslow and his work. They would just say, "Oh, this guy understood the buying process very well." Or, "He understood how consumption works to make..." Goodness knows what they think because they're usually not given the context around that.

So that's where I think a psychology education can be extremely helpful.

Tori Steffen:  Okay. Yeah, that definitely makes sense that it could give you those extra tools to have a little bit more critical thinking when looking at advertising and media, so that's great.

How might you say that consumers engage with marketing on a more conscious or critical approach to avoid those hidden persuaders? Any advice on that front for us?

Chris Hackley:  I can give you one example, which is a generational divide. I've been involved in quite a bit of research on product placement in movies, which of course has been going on since the silent movies, but these days it's much more talked about and well known. And indeed movies now they put out press releases of their latest product placement brand agreement as part of the advanced publicity.

So there's a generational divide in the sense that older people tend to think that product placement and similar forms of sponsorship within entertainment vehicles is inherently deceptive because it's an advertisement that looks like an entertainment. And for an older generation people, who are really more used to a divide between editorial and advertising that used to be more rigorously imposed in media, that's a deceptive practice.

For younger people, it's not. That they assume that media is going to be completely suffused with brands, because that's what they've always seen and they're not used to a media where there is a rigorously imposed line between editorial and advertising. So for younger people, when they watch movies, they enjoy spotting the placements. They don't regard it as underhand or sinister. I think they kind of feel flattered that somebody would go to so much trouble in expense to try to manipulate them. And they quite enjoy playing the game and spotting the subtleties of these placements.

Especially when they're integrated into the plot or the scripts and so forth. So there's, for younger people, there's a much greater acceptance of that. Sorry, my doorbell just, I don't know if you can hear it, my doorbell just went and the dog is going crazy, But hopefully you can't hear that.

So I think consumers are aware of the potential for marketing to manipulate, but that they come at in different ways and younger consumers, in particular, they tend to talk about subliminal advertising. And for them that sort of manipulation is dark, but also kind of interesting, because the idea that we're being manipulated is quite an interesting theme.

So that theme does come up sometimes, although it doesn't really exist, subliminal advertising, it's a bit of a myth, but that's the level at which I think some people do feel that marketing can manipulate. So I think in general there is a lack of critical engagement by consumers with marketing. Where it is engaged, it's sometimes a little bit misdirected. So I think marketers are always a little bit of a step ahead.

Tori Steffen:  Makes sense. Yeah, that's very interesting about how it might differ among ages. I hadn't thought about that before. So thank you for sharing. And I know we mentioned Packard earlier.

Could you explain for the audience, Packard's vision of marketing manipulation, and in your opinion, do you think it's still relevant today?

Chris Hackley:  It's a long time since I read Packard's book. The particular incident I recall is his observation that advertising agencies were using, what they described as depth psychology, to understand people's deepest emotions and motivations. And in particular, he was shocked that they were using these techniques on children. He was shocked that he felt this was very, obviously, intrusive and potentially quite a sinister form of manipulation.

And nothing has changed. Advertising agencies still do. And in Britain, for example, where we're not very good at protecting children from marketing, our regulation in that area is quite weak. And it's not unusual for agencies to specialize in the marketing to children. Agencies will go into kindergartens and show logos to the kids and they'll put their hands up and say, "Oh yeah, I know that one. That's Marlboro."

Well, because the kids see these things all the time and advertisers are pretty cynical. They know very well that advertising on kids channels, cable channels, is a way of getting adult products talked about in the house.

So what Packard wanted to alert people to is still very much a reality today. Probably he'd be more horrified now when he learned about the way that digital platforms manipulate children, for example, through advert gaming and drawing children into all sorts of consumption.

So what he warned about has truly come to pass, I think. And the world of digital media is an absolute minefield for children today. It's pretty scary.

Tori Steffen:  It definitely can be scary. So yeah, it definitely sounds like his vision is still pretty relevant, and like you said, he might be quite surprised.

Well, your article also goes into the topic of TV product placement and how it can relate to a young consumer's sense of identity. Could you explain how that works for us?

Chris Hackley:  Yeah, I'll try. Well, marketing is very much about emotions and identity. So the idea now is quite commonplace, really, that we consume in order to fulfill our sense of our own identity and our sense of group membership. So in a sense, anthropologists would say all marketing and consumption is about displaying the right sort of tattoos or shells or whatever to signify one's status in the group and one's membership of particular groups, and marketing elaborates on this with brands.

And now today, we're very accustomed to seeing people walking around with brands prominently displayed on their clothes and so forth. And that's what marketing tries to do. It tries to create offers that chime with people's sense of their selves, and it also tries to create aspirational offers so that we can buy things because of a group, because we can appear to be a member of a group to which we'd like to be a member, even if we're not necessarily a genuine member of it.

So I think our identity is extremely important to marketing, and it is a way of really articulating our sense of ourselves and our sense of meaning in the world, but in a symbolic way rather than an actual way.

So to that extent, it's also potentially damaging, psychologically, if people, for example, are shut out of the market because they are disadvantaged in some way, because the market doesn't regard them as a useful target, if they are economically disadvantaged, so they can't take part, then there is the risk of a feeling of lack or unwillingness or something. And that's the unfortunate thing about the consumer society, that if you're not included, then you are excluded. And that can be very damaging to people's sense of identity.

Tori Steffen:  I would agree. I think that psychology is definitely relevant when it comes to the sense of identity in marketing.

Chris Hackley:  Absolutely.

Tori Steffen:  Thank you for sharing that. So there is some research out there regarding the ethical nature of subliminal promotion. Could you explain your thoughts on the topic of subliminal promotion for us, and if you think it may be related to anxiety in consumers at all?

Chris Hackley:  That's an interesting question. Well, I touched on subliminal advertising a little while ago. I think it does connect to anxiety in the sense people do feel that marketers are very powerful and probably manipulating us. But that sense is quite vague, I think.

Most people, most ordinary consumers wouldn't have heard of neuromarketing, for example, they wouldn't have heard of depth psychology and as regards subliminal advertising, that became a very popular sort of idea. But the original experiment on which that was based turned out to have been incorrect. I forget the precise year or the theater, but it was a movie theater where they were said to have projected images of ice cream at less than 1/16th of a second, which meant that one doesn't register it consciously, but unconsciously it's there. And then people were apparently got up, in unusual numbers, at the break to buy ice cream.

So from this, the word came about that subliminal advertising, literally meaning advertising that's flashed up on the screen more quickly than we can consciously register it, was a powerful thing. It turned out that was actually a fraud, that experiment. And there is no evidence, the subliminal advertising is banned and certainly in the UK by the regulators, but there's no evidence that it does work. No good evidence that it does work.

But what I found that young consumers tend to do now is the literal meaning of subliminal, as in an image that's flashed more quickly than the eye can process consciously, has been lost. And they tend to use the word subliminal as a general term to mean something that is sinister, underhand, and manipulative. So it tends to have morphed into a broader usage.

And this ties in a little bit with product placement. People do understand that that's an attempt to manipulate, but as I mentioned earlier, young people tend to be pretty blasé about that, and they quite enjoy the game of spotting these attempts to manipulate them.

So I think that the idea of subliminal advertising, which really reflects the idea that Packard spoke to all those years ago, reflects a general sense of anxiety that we are being manipulated by these technologies and by these images that marketers create. And people are never quite sure, people always say, "Oh, advertising doesn't influence me," but people are never really quite sure. And of course the market shares of the various brands tell us a completely different story that advertising does indeed influence us.

So I think there is a generalized anxiety about that, but we're probably not anxious enough about it because I think there is a lot of, I guess, complacency about marketing activities and not enough close examination of them probably.

Tori Steffen:  Yeah, absolutely. It would make sense that one might be more anxious if they're more aware of those hidden persuaders. So definitely takes a little bit of awareness to get there, but it can help.

Well, I came across another interesting project of yours. It's called Branded Consumption and Identification: Young People and Alcohol, that looked really interesting. Could you describe for us what was being studied in the project?

Chris Hackley:  Sure. This was a few years ago when what they called binge drinking was a big thing in the UK. So there was a lot in the media about young people, particularly students, drinking way too much and way too early. And we decided myself, the project was led by Professor Christine Griffin from Bath University, and so Christine's a psychologist. She got myself and another professor of marketing involved, and then there was a couple of other psychologists.

So we decided to interview young people to try to understand exactly what it was they got out of getting very drunk. And so this is probably quite culturally specific to the UK, I think. Not entirely. There were strong parallels with some aspects of American research and Australian research, but the idea was to get really smashed as quickly as possible. And one of the main reasons was because it cemented bonding in the group.

When we were interviewing these groups of young people, they became really animated when they would tell the terrible stories of what happened to them when they were really drunk. Sometimes with really bad stories, people ending up in hospital with broken limbs, or people getting beaten up or something.

But this all tied in with the idea that the nighttime economy was a sort of liminal zone in which anything could happen. And all you'd got was the togetherness with your friends and they had to look out for you. And people would get very, very drunk and if their friends didn't look out for them, something might happen, but that would still give them a drinking story.

So as the interviews went on and the focus groups went on, we realized this was all about group bonding. It was all about friendship and deepening the bonds of friendship. We did interview some people who didn't drink, but they were kind of out of it a little. They were kind of excluded. And some people would say that, "In my first year in university, I found it difficult to really get in the social scene because I don't drink.” And it was all about the drinking, you see?

So at the time, the British government put out some adverts ostensibly to persuade young people not to drink so much. And they showed young people getting terribly drunk with torn clothes and ending up upside down in a hedge or something. And the strap line would be something like, "Do you want to end up like this?" And this was the theme of the ads, and we realized that there is no embarrassment. This was the whole point. The whole point was to do something outrageous or to experience some risky event and then to be able to laugh about it for years afterwards with the group. It was a drinking story that cemented the bonds of friendship in the group. And you were kind of a hero if something awful happened to you when you were drunk because you could tell the stories forever with your friends.

And so we realized these government ads really did the opposite of what they were ostensibly intended to do because they glamorized drinking. They were depicting exactly what the young people got out of extreme drinking, you see.

So we put out a press release saying, "Actually this government campaign is going to make it worse. It's a catastrophically conceived campaign." And we were informed by... We wrote a string of articles about this. I wrote some based on literary theory such as Mikhail Bakhtin's, Theory of the Carnivalesque, the idea that on special occasions one can upturn the social order and reverse the normal order of things, and drink was intrinsically a part of this. And this sort of rebellion against the social order was a very powerful thing, and it kind of refreshed people and enabled them to have a rebirth the next day. And this was what the heavy drinking was partly about.

So that got covered in the press and stuff, and we had to do interviews and things. So that all became kind of fun and we carried it on. But that was the basic idea of it, that we wanted to understand exactly what people got out of getting very drunk. I have three sons who were teenage boys at the time, so I got a little mini experiment in front of me so I could understand how their drinking practices differed from mine a generation before.

So it was particularly fascinating to me. So, that was basically what we did and essentially what we found

Tori Steffen:  Great. Those are great findings to come by. A really interesting project there. I didn't think about how it could actually have a reverse effect than what the advertising was originally trying to accomplish. But it definitely makes sense, and it seems like you guys went about it in a very good way of coming by that information.

Chris Hackley:  Yeah, things have moved on now. Binge drinking so much in the news, but the idea of drinking to get drunk is still, of course, very, very prevalent. And the public health cost of excessive drinking is going up all the time in the UK, as it is in many other countries. So that the issue is still very much a live issue. And it's also bound up with the regulatory framework because in the 1980s, the government liberalized the sale of alcohol in the UK and now you can buy it from anywhere 24 hour hours a day as you can in a lot of states in the USA.

And that, of course, is all part of the whole frame that the entire regulatory context as well. So it remains a problem. But some research has shown that more younger people now are drinking less. One of the reasons being they can't afford it now because the cost is relatively much higher now.

Tori Steffen:  That's interesting. Well, I guess that's good that hopefully it's be going down, not as much binge drinking. Great. Well, Dr. Hackley, do you have any final words of advice for our audience or anything else that you'd like to share with us today?

Chris Hackley:  I guess, I don't know about advice. I'm don't think I'm very good at giving anybody any advice, but I think psychology and marketing are very, very mutually enriching subjects to study. And I think that there's really... I think on the one hand, social science does look down on management and business studies with some reason, I'd say. On the other hand, management and business studies exist in a little bit of a self-referential bubble and it needs more engagement with social sciences and social psychology.

So I would like to see much more mutual engagement between the various disciplines, the social science disciplines and management, especially in the construction of degrees and the construction of teaching. There is quite a lot of mutual engagement at the higher of levels of research. But I think younger students deserve a stronger social science background in their management and business. And that would give them a stronger critical appreciation of the techniques that marketers use in order to navigate their own way through those techniques.

So I would like to see a much stronger connections between social science, especially psychology, and marketing education.

Tori Steffen:  Great. Yeah, I could definitely see how that would just give the students a broader sense of the ethical nature of marketing and how it relates to personal wellbeing as well. So great. Thank you so much for sharing that, and it's been very nice chatting with you today and I really appreciate you joining us for our interview series and contributing. So thank you so much.

Chris Hackley:  My pleasure, Tori. Thank you for asking me. I hope people find it interesting.

Tori Steffen:  Absolutely, I think they will. Well, hope you have a great rest of your day, Dr. Hackley, and thank you again.

Chris Hackley:  You too. Thank you, Tori. Bye. Bye.

Tori Steffen:  Bye.

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

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

Professor Irina Zlatogorova-Shulman on Leadership Influence & Employee Wellness

An Interview with Professor Irina Zlatogorova-Shulman

Irina Zlatogorova-Shulman, Ph.D., MBA is a professor of business psychology and organizational leadership at Southern New Hampshire University and the Chicago School of Professional Psychology. She specializes in business psychology and organizational leadership.

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

I'd like to welcome with us today industrial organizational psychologist Irina Zlatogorova-Shulman. Dr. Z., as some students call her, is a professor of business psychology and organizational leadership at Southern New Hampshire University and the Chicago School of Professional Psychology. She's an expert in the field of business psychology and organizational leadership, and has written several publications on the topic, including the dissertation thesis, "Leaders' Influence on Employees' Participation and Wellness Programs and Organizational Productivity, Correlational Quantitative Case Study," as well as the book "Overcoming Mediocrity Resilient Women," which provides life lessons to overcome obstacles in a professional setting. So before we get started, can you let us know a little bit more about yourself, Dr. Z, and what made you interested in studying leadership influence in an organizational setting?

Irina Zlatogorova-Shulman:  Of course. Thank you, Tori. First of all, just want to thank you for the invitation to participate and contribute to the discussion on leadership influence and employee wellness in organizational settings. A little bit about me, I immigrated to the United States from Russia 30 years ago in 1992. I received my PhD in business administration specializing in industrial organizational psychology from North Central University and an MBA from Northern Illinois University. I'm also a writer, a public speaker, and a member of the American Association of University Women, AAUW. And as you mentioned, I'm also professor of business psychology and organizational leadership at Southern New Hampshire University and the Chicago School of Professional Psychology.

Because of my work ethic, willingness to learn and continuous pursuit of education, I progressed very quickly in my leadership career. I worked in a corporate environment for over 20 years. In one of my last roles, I was a senior executive for a large retail organization. I managed a department with over 100 business professionals and $4 billion in expenditures for purchasing retail-related services, at my workplace, which was a huge corporate facility, I saw many stressed, anxious, and burned-out people, and the overall environment in that organization would be considered toxic by many employees. So, when I decided to switch careers and become a college professor, I selected a dissertation topic related to the improvement of wellbeing of employees at their workplaces. I was also curious to find out through research how leaders impact employees' sense of wellbeing and why some people do not participate in the wellness programs offered at their places of employment. I hope this information answers what interests me in guiding leadership influence in organizational settings.

Tori Steffen:  Absolutely. Yeah, that sounds like really impressive background and experience to have in relation to those topics, so that's wonderful. Well, getting down to basics, could you explain for us how leadership influence presents itself in an organizational setting?

Irina Zlatogorova-Shulman:  Sure. When researching leadership influence in organizational settings, I used a theoretical framework consisting of the employee wellbeing theory and the authentic leadership theory. The stakeholders for that research were corporate employees and their employers. After finishing the study and publishing the findings, I met with individual leadership teams and shared my discoveries illustrating that their influence in organizational settings is significant. Would you like me to share some of that information, some of the findings?

Tori Steffen:  Yes, please.

Irina Zlatogorova-Shulman:  The results of my research showed that the perception by employees of their leaders' care about their wellbeing, including physical and mental health, influenced their work engagement and job satisfaction. In one company, leaders' care about workers' health will assess at 93% versus the national average of only 9.3%, which is low, so it was 10 times higher. That particular organization was voted as one of the best workplaces for 11 consecutive years. That was the main connection that I found, is that the more employees think or believe that their management cares about them, the more likely they will stay with the company and enjoy working there.

Tori Steffen:  Okay. Definitely some interesting findings there. That's great to know. What are some connections that you've found between leadership influence and employee mental health?

Irina Zlatogorova-Shulman:  Well, first of all, I want to talk about productivity and engagement. Because both productivity and engagement can be improved by positive leadership support. It can also reduce levels of absenteeism and presentism. As you know, absenteeism is the temporary absence of an employee from work due to personal reasons. But presentism is when an employee presents, attends the work, but performs sub optimally because of illness, emotional exhaustion, depression or burnout. And productivity-related discussions could be a sensitive topic among researchers and practitioners because productivity is affected by so many factors, and it could be hard to measure. Job-related stressors may include job role ambiguity, alienation, worklism, and workload. So, these issues influence productivity due to workers' illness and poor mental health. According to Statista, and I just pulled the statistics from today, in 2022, the following professions were found the most stressful jobs in the United States. First one is the enlisted military personnel, second: firefighter, third: airline pilot, fourth: police officer, and fifth: broadcaster. Fifth one surprised me, but it is what it is. So many organizations seek new solutions to mitigate work-related stressors, to improve productivity, and also now to survive in today's economy and remain profitable.

The situation got even more stressful for workers during the Covid-19 pandemic, and same thing related to engagement. Doing my research on engagement, the results of employees self-assessed levels of wellness were directly related to organizational engagement. For example, according to Gallup's research, about 26% to 30% of employees were actively engaged at work in the United States in 2018. In the United States alone, disengaged workers cost anywhere between $450 to $550 billion per year in lost productivity. Again, according to Gallup. However, in my research, those companies that invested in their employee's wellness through wellness programs and other health initiatives, they saw up to 90% engagement scores, which were three times higher than the national ratings. So again, employees' wellness level directly related to productivity and engagement.

Tori Steffen:  That's amazing. Thank you for sharing those statistics. It definitely helps paint a picture around how important the wellness programs can be for employee mental health, productivity, engagement. So thank you. Could you describe for us how employee wellness levels relate to organizational productivity and engagement from a research perspective?

Irina Zlatogorova-Shulman:  Yes. I just kind of covered those two topics related to productivity and engagement. I can also expand a little bit more on how wellness programs themselves also impact their mental health, engagement, and productivity. Is that okay?

Tori Steffen:  Absolutely.

Irina Zlatogorova-Shulman:  Okay. So, if implemented correctly, wellness programs can have a positive impact on employees' overall mental health and reduction of stress. It can also reduce their anxiety, depression, and mental burnout. However, the research unfortunately also shows that wellbeing initiatives will fail if they lack top level support, for instance. In some cases, employees may not be aware of workplace wellness program, or their leaders do not communicate available health benefits or promote awareness. Also, leaders' inability to handle their own stress at work can negatively affect the effectiveness of wellness programs implementation. I have seen that wellness programs adoption increases when employees see their leadership support of those initiatives. For example, when managers enroll and participate in company-sponsored programs, they lead by example and the employees follow. Therefore, wellness programs can produce a positive impact not only on employees' overall mental health, but also on the mental health of their leaders.

Tori Steffen:  Okay, perfect. Thank you so much for giving us that background.

Irina Zlatogorova-Shulman:  Sure.

Tori Steffen:  Okay. And how effective would you say are those wellness programs in producing a positive impact on an employee's overall mental health?

Irina Zlatogorova-Shulman:  Again, I kind of covered that information in my previous response. And I would also say that people in leadership positions can do above a lot more than just wellness programs. They can create a positive atmosphere and welcoming environment for their employees. So, as they participate in wellness programs, they also notice how their leaders behave and follow those examples. For instance, if they see that their managers participate in wellness programs, they can also more likely to enroll and participate in those initiatives, versus if they observe that their managers are reluctant to participate in programs and see it as a waste of time, they may also choose not to participate in those programs.

Tori Steffen:  Okay. Sounds great. Have you seen anything in the literature in regards to maybe anxiety or depression in relation to wellness programs?

Irina Zlatogorova-Shulman:  I have seen a lot of information related to authentic leadership styles that followers and mental health. Would you like me to cover the leadership style that is authentic leadership style for your listeners?

Tori Steffen:  Yes, please. If you could explain authentic leadership as a style for our listeners, that would be great.

Irina Zlatogorova-Shulman:  Okay. Well, authentic leadership is a specific style that leaders display based on their moral values, their beliefs, and their behaviors. Those leaders, authentic leaders, play a critical role in creating positive organizational cultures and ethical work environments. Authentic leaders are generally in tune with their emotions. They're passionate about their mission and adaptive to changes. Authentic leaders also convey self-confidence, self-discipline, self-knowledge. They clearly express their thoughts and they're able to choose and listen. So two years ago, I was invited to present information on authentic leadership style to the Society of Human Resources Management, SHRM, and many HR managers admitted that although this style sounds wonderful and is attractive, it is challenging to be authentic at some places of work due to their organizational culture.

Tori Steffen:  Okay. Yeah, that's interesting, bringing in the aspect of the company culture as far as leadership influence. Great. One thing that your research discusses is the ways that authentic leadership can impact individual sense of wellness and productivity. Could you describe for us how this might work in an organizational setting?

Irina Zlatogorova-Shulman:  Of course. So, leaders with authentic qualities can definitely promote positive relations and effective commitment. They can empower their employees. And in an organization that attempts to create a climate that promotes employees' involvement and engagement, authentic leaders serve as role models. They convey appropriate behavior based on their moral values, and overall individuals in leadership role greatly influence how they can demonstrate and share similar goals with their followers through leading by example. And in multiple studies, even outside of my research, the authenticity of a leader was found to be effective in preventing employees' burnout. Plus, since the authentic person can listen patiently with understanding and without judgment, employees feel much more compelled to approach them without feeling being judged or feeling retaliation. When followers identify themselves with authentic leaders, they are also more likely to develop self-advocacy, self-esteem, confidence, optimism, passion, hope, and resilience to job-related stressors. They can also become more engaged.

Tori Steffen:  Great. It sounds like authentic leaders would have a lot of great qualities and be able to lead by example in an organization. What are some of the different types of leadership styles and how might they impact employee wellbeing and productivity? Have you seen any negative ones out there that you might be able to speak about?

Irina Zlatogorova-Shulman:  Oh, thank you for asking this question, Tori. So, scientists and theorists are still arguing and trying to identify the best leadership style and practices that would eliminate the negative trends related to employees' health at work. Overall, since the beginning of research on leadership, the paradigm shifted and reflected significant changes in leadership progression from total dominance by leaders to group decisions, and from the power of leaders to values of groups, and from leaders' goals to group visions. So, if you look at leadership as a continuum, you would see autocratic style in one side and authentic servant leadership style on the other side. The leader's roles change from active to passive. And out of all leadership styles. I would say that the autocratic leadership styles could potentially negatively affect employees' morale, productivity, and wellbeing depending on the work environment. Autocratic leaders tend to make decisions quickly without input from others, and usually when they're pressed for time. This can lead to subordinates experiencing work stress, anxiety, lower wellbeing, and most of the research on autocratic leadership has shown that subordinates dislike managers use this leadership style they call the micromanagers. And they experience more job stress when being managed by such individuals. They also have lower levels of job satisfaction.

Tori Steffen:  Okay. Yeah, that's definitely important to know how the different styles might have an influence on those factors, so thank you.

Irina Zlatogorova-Shulman:  You're welcome.

Tori Steffen:  Your research was also investigating a correlation between leader involvement and employee enrollment in wellness programs. Could you explain for us your findings about that relationship?

Irina Zlatogorova-Shulman:  Sure. During my research, I collected data about employees' participation in the wellness program and compared it to their management enrollment statistics, and I found significant positive correlation between leaders and employees' enrollment in wellness programs. I think there are three factors that could explain that correlation. First one was transparency of a self-tracking and reporting system that companies use to monitor everyone's participation. In some cases, employees could see if their managers enrolled in the program or not, including their CEOs. The second one was positive correlations could also indicate that individuals had higher personal commitment toward their health and wellbeing if they saw that their leaders are also committed to their health. And finally, surprising finding was that employees and their managers were motivated by financial incentives to participate in wellness programs. For example, when one company introduced financial incentive of up to $560 per year for all employees, including top leaders, the wellness program's enrollment and participation rates went up from 17% to 57%.

Tori Steffen:  Wow.

Irina Zlatogorova-Shulman:  I hope these information examples answer your question, Tori.

Tori Steffen:  Okay. That's great to know. Definitely a big jump there in the enrollment, so that's great. What else might leaders be able to do to promote employee wellness and productivity levels, maybe besides the high involvement in those wellness program enrollment?

Irina Zlatogorova-Shulman:  Yeah, I touched a little bit on this before, but to promote employees' wellness and productivity leaders can also create a welcoming, inclusive, safe, and pleasant work environment. Several research studies that I reviewed during my dissertation confirmed that authentic leadership style influences the positive emotions of their followers and directly impacts employees' engagement and turnover rates. In those work settings where employees can voice their concerns without fearing retribution, they feel more secure and less likely to leave. Also, in my research on wellbeing, I found that flexible work arrangements can improve employees' morale, increase their engagement and lower turnover. For instance, more and more organizations are now considering creating flexible working arrangements for their employees, such as hybrid work, telecommuting, remote work, condensed work week, flex time, part-time, shift work, or even job sharing. So here are some additional ideas.

Tori Steffen:  Awesome. Those are great to know. We personally do remote work and flex time, and I definitely find that that helps with work-life balance, so that's great. Do you work on any other research projects or maybe activities that relate to the topics of our discussion today?

Irina Zlatogorova-Shulman:  Yes. I am currently researching data and findings related to mindfulness practice. Mindfulness refers to a mental state or focus on the present moment while noticing and accepting all feelings, thoughts, and bodily sensations. So, in the past two years, I've been participating in educational seminars and workshops on mindfulness. This topic is getting more and more interest because it can be applied to any field, any area, from businesses to schools, and from arts to sports. I was very grateful to lead one training session at Southern New Hampshire University and deliver a presentation to our faculty about how mindfulness can be integrated into the online learning environment for our students. I also did an educational zoom session on mindfulness related to financial health for one of the investment firms and their clients. And now, I'm working on an article for Silent Sports Magazine on how athletes could integrate mindfulness techniques into their training and improve endurance and performance. Finally, I'm teaching yoga and meditation classes. I'm a certified yoga instructor at the local park district, and I see more and more people becoming interested in these activities, mindfulness, meditation, yoga, and relaxation techniques because they find those helpful in enhancing their emotional wellbeing and building individual resilience to stress.

Tori Steffen:  Great. Those are all really nice topics to touch on as far as mindfulness, and I can see how it would be very helpful for students, athletes and teachers too.

Irina Zlatogorova-Shulman:  Yes.

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

Irina Zlatogorova-Shulman:  Yes, I would like to share some final thoughts. When employees are unhappy with their jobs or workplaces, they start searching for different opportunities. And with the COVID-19 pandemic, many people began reevaluating their life commitments and where and how they spend their time and talent. Now, many organizations struggle to attract and retain their most productive workers. However, they can stop employees from leaving by creating and promoting a healthy culture. It all starts at the top, at the senior management levels. And I know I'm repeating myself by saying this, but the leadership influence on employees mental and physical health is significant.

Tori Steffen:  Absolutely. Well, great. That is amazing, helpful information. So thank you so much for joining us today, Dr. Z., and contributing to our interview series. It was really great speaking-

Irina Zlatogorova-Shulman:  Thank you very much for participating, for inviting me to participate in the session. I appreciate.

Tori Steffen:  Absolutely. It was really great speaking with you today, Dr. Z.

Irina Zlatogorova-Shulman:  Thank you, Tori.

Tori Steffen:  And I hope you enjoy the rest of your day.

Irina Zlatogorova-Shulman:  Thank you, you too.

Tori Steffen:  Thank you.

Irina Zlatogorova-Shulman:  Bye-bye.

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

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

Psychologist David Rosmarin on Spirituality & Mental Health

An Interview with Psychologist David Rosmarin

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

David Rosmarin:  Thanks for having me on your series.

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

David Rosmarin:  You too.

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

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

Author John Purkiss on The Power of Letting Go

An Interview with Author John Purkiss

John Purkiss is the best-selling author of several books, including:“The Power of Letting Go: How to Drop Everything That’s Holding You Back” and “Brand You: Turn Your Unique Talents Into A Winning Formula.” He is an expert on the notion of “letting go” while utilizing mindfulness to improve performance and mental well-being.

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

I'd like to welcome with us author John Purkiss, who joins us from England today. Mr. Purkiss is the author of several books, including “The Power of Letting Go”, he began his career in banking and management consultancy. He now recruits senior executives and board members, he also invests in fast-growing companies. Before we get started today, can you let our listeners know a little bit more about you and what motivated you to write “The Power of Letting Go”?

John Purkiss:  Certainly. Well, thanks for inviting me. So what happened in my case was... like a lot of people, I got the message that if I was intelligent and hardworking, then everything would be fine, so I did that until I was 26, so I went through economics degree, banking, consulting, MBA and it all worked extremely well. And then, I was diagnosed with clinical depression, which nearly killed me, so that was my wake up. I now see it as a blessing, it was like the beginning of the destruction of the ego. But from a medical point of view, it was very bad news so that's when I realized. What I was offered, electroconvulsive therapy, Freudian psychoanalysis or pharmaceuticals. I didn't do the electrical thing but I did do the Freudian psychoanalysis and I did do the pharmaceuticals. And then, I just thought there has to be another way so I started searching for other options so that's how the journey began.

Preeti Kota:  Can you describe the Vedic tradition that inspired the concept of letting go?

John Purkiss:  Yeah, certainly. While I was searching around, I read lots of books. Everything from Californian self-help to Eastern philosophy. And what I found was pretty much everything points back to the Vedic tradition. So Veda simply means knowledge, it's a Sanskrit word which means knowledge. As you may know, science also means knowledge, scientia. The difference is that Western science is largely based on looking outwards, doing experiments in laboratories and social experiments. Whereas, the Vedic tradition is more of a download, so it's looking inwards. And people downloaded things thousands of years ago, which are now being tested in laboratories. So the Vedic tradition goes much faster because it doesn't have the empirical process, but it seems to be leading to very similar conclusions.

Preeti Kota:  How do you find the balance between letting go and giving up?

John Purkiss:  I don't give up. I think giving up is completely unhelpful. Answer, no balance. Letting go is not giving up. I don't recommend giving up.

Preeti Kota:  I feel like when people are trying to start to let go, they are afraid of giving up.

John Purkiss:  Yes. Well, it might be helpful if I distinguish between the two. So giving up is, you just stop trying and you lose hope. Well, you might just hope that somehow things will work out, which they might, but it's powerlessness, it's like, "I have no power, I can't do anything so I give up." And in some situations, I suppose, that could work, actually. I mean, I've never done it, but I've heard about it, if someone attacks you and you just give up, then they kind of loosen their grip, so there are situations maybe that works. But letting go isn't that at all. Letting go, at least as described in the book and in the Eastern traditions, letting go is... what you're actually doing is letting go of your ego.

So if I describe it this way, in the West most of us have been brought up to believe that we are the body-mind. So Eckhart Tolle to talks about this in “The Power of Now”, for example, he talks about the body-mind. And I studied economics. So economic, psychology, finance, arguably even engineering, medicine, there are so many disciplines which are based on the idea that you and I are body-minds. And we're trying to get what we want and avoid what we don't want, so like a brain and a body.

And so when we let go... If that's how you see yourself, it may feel like, "Oh, I'm giving up now, because I'm not trying anymore." The Eastern traditions of which the Vedic tradition is largely the origin is saying, "Your brain and body are part of something extremely intelligent, which is running everything all the time. And when you let go, you stop trying to figure everything out using your brain, and you basically tune into this universal intelligence, which is running everything."

And I think, if you've been brought up as an atheist, that's very hard, because you have this strong belief system that there's nothing beyond human intelligence. Whereas, if you've been brought up in any of the spiritual tradition... I mean, I was brought up as a Christian, at least when I was ill, I had some understanding that there was something extremely intelligent that was running everything. And then, when I let go, I very quickly began to tune into it. And then, things started to work out. I mean, one example is your body, even if you don't think about it, your body will run itself. In fact, most people interfere with their bodies and stop it from running correctly. But if you don't do anything crazy, your body will run itself without any intellectual intervention.

Preeti Kota:  Yeah. So, you're mentioning the ego, so a little bit on that. How does our ego affect us, particularly our mindset?

John Purkiss:  Okay. There are two definitions of ego. Two main ones. The one which is most common in the West is the Freudian definition, which is... I'm sure you know, you have the super ego, the ego, and the Id. And the Id wants to do kinds of crazy things, and the ego regulates the Id, and stops the Id from doing stupid things. So the ego is useful. I mean, ego is a Latin word. It simply means I. So that's the ego in the West. In the East, the ego is not helpful at all, because what the... for example, the Vedic tradition is telling us, is that you are not the body-mind. How should I put it? You are supreme consciousness. You are the consciousness which is running everything.

So the guru who I follow, he says, "I'm not here to convince you that I'm God. I'm here to convince you that you are God." So the message of the Eastern traditions is you are divine, and ego is hugely unhelpful because ego is when you start seeing yourself separate from the divine, from the cosmos. So clinical depression for me was an extreme example of that. I felt completely separate and desperate. I felt separate from everybody and everything. And I was running around trying to solve problems and I wasn't tuned in at all. And of course Freud died, I think, in 1939, that's very recent. The Eastern traditions have been talking about the ego for millennia. So two totally, completely different view points.

And I think, you used the word, mindset, is that right? Yeah. So mindset. So in the West we have this idea of the mind as a thing. The mind is like some box. And we try and fix the box using medication or using maybe some therapy or self-help books or whatever, that's the idea. Whereas, the mind in the Eastern traditions is more like a process. It's a series of patterns. And you can do this on your own, or you can have professional help. If you look very carefully, you can start to see all the patterns, the really unhelpful patterns which are causing the mess, I think. And so the definition of the mind is different. So the West, I would say, sees the mind as a thing, and the East sees the mind as a process.

Preeti Kota:  Okay.

John Purkiss:  Yeah. Or processes, as you would say in the US.

Preeti Kota:  How is the ego formed?

John Purkiss:  I don't know. I don't know what Freud's view was on the formation of the ego. So my guru is called Sri Nithyananda Paramashivam, the way he describes it, which I talk about in the Power of Letting Go is he says, "The ego is made up of incompletions." So for example, when you are a small child. Small children are generally blissful, and then, occasionally they cry when they're hungry or something. And then between the ages of two and seven, we have painful experiences. And those painful experiences form the ego. So for example, I'm sure you've had this experience, if you're in a meeting or a conversation and the other person suddenly gets annoyed with something you said or something that happened, it's because some pain pattern has been triggered. And that's the ego.

And I mean, in the West we tend to say, "So and so has a massive ego because they think they're superior to other people." For example, they might suffer from poverty when they're small, when they grow up, they have lots of money. So they have an ego relating to money, that's a common. But you can also have an ego, which makes you feel inferior to other people. So some people who feel inferior to other people, they actually have massive egos on the eastern definition because they have so much pain in their system, which they accumulated between two and seven. But it's still ego. It still makes you feel separate and it still causes suffering.

Preeti Kota:  So they project the opposite.

John Purkiss:  Unfortunately, ego, we project it all over the place. So if you have some pain pattern about racism, or unfairness, or dishonesty, or something, you project it onto other people, you start accusing other people of that. Yeah. So it causes chaos, unfortunately.

Preeti Kota:  How can you simply follow your intuition when you have a fear that you might be making the wrong decisions?

John Purkiss:  Okay, that's a good question. So my favorite definition of intuition is immediate insight without reasoning. So you have an insight. For example, you might have an insight that you should call your mother or that you should turn left, whatever it is. And that doesn't require a massive thought process. You just act on it. And real intuition comes out of love. It's guiding you to do the right thing. There is a thing called false intuition. So we just talked about the ego, these accumulated pain patterns. What can happen is that, false intuition is you have a reaction to something or someone, and it's coming from pain. And so it's not really intuition, it's just a pain pattern asserting itself.

For example, you might see someone from another ethnic group walking down the street and immediately avoid them, because you have some pain pattern. Or, you might see a dog, or a cat, or a spider, and it triggers some pain pattern. That's not intuition, that's just a pain pattern getting triggered. We'll talk about it later, but if you use the correct technique, you can remove those pain patterns and you stop getting triggered. And then, your intuition operates freely because you're not getting triggered the whole time, you're just seeing things as they are. And you have a feeling about what you should do next.

Preeti Kota:  Yeah. So how do you let go of the fear?

John Purkiss:  Well, the completion technique removes the fear. So we can talk about that now. So in chapter three of the book, I describe a technique called Completion. It's been trademarked, it's now called the Science of Completions. So I learned it eight years ago from Swamiji behind me. That's why I went to India to meet him. And it's very simple. I'll give you an example. So my first day at school when I was five, I arrive at school and I have this accent. So I don't know if you know, this is the accent which the BBC sells to foreigners. This is the export version of British English. I mean, the BBC in the UK uses all kinds of accents, but when they're talking to foreigners, they tend to use this accent, which is what I grew up with.

And when I was four, we moved about hour and a half, two hours north of London. And the accent there is different. So it's my first day at school and I'm five years old. This is my first day in the world without my Mum and I arrive at the school and I want to make friends. And they don't make friends, they just laugh at me. And someone says, "You're a bloody nutter, you're crazy." And I feel really bad. So that's how the pain pattern starts. So, Swamiji calls it, self doubt, self hatred, self denial. So the self doubt is, "I'm unacceptable." There are all these patterns. "I'm unacceptable. I'm a failure, I'm trying to make friends, but it's not working. Other people don't support me."

Then all those patterns start developing. As far as I can tell, it all happened within five minutes. And everybody has this before the age of seven. I mean, in some people, it can be something that seems far more traumatic or less traumatic, either way it happens. So when that happens, you then live the rest of your life based on those patterns because we suppressed the pain. So what happened in my case is I grew up in Lester, in the Central England, and after a while I realized that nearly all of my friends were not English or they were not White English people, they were Indian, or they were Jewish people from Central Europe, or they were Ukrainian or whatever they were, Irish.

And I was aware that I had this feeling that I was an outsider. I wasn't in the football team, soccer team, I felt like an outsider. And then many years later, I realized when I met Swamiji, I realized I had this pattern of, "I'm unacceptable." So I ended up hanging out with all the other people who felt unacceptable. And it was, in a way, it looked beneficial because a lot of us went to Oxford and Cambridge. I mean, because we didn't get any love from the other people. The only way to get on was to work hard. So we all worked hard and went to Oxford, Cambridge and did all this stuff.

But there's still this underlying pain pattern, which is, "I'm unacceptable," which is very bad news in terms of relationships, business, all kinds of things. And so the technique is incredibly simple. The technique is... I become five years old. I've got my mirror here. I've got this mirror that I use every day. So I become five years old. And I look at myself in the mirror, I'm talking to the person in the mirror, and I relive intensely those first few minutes at school.

So, I allow all those suppressed emotions to come out. So in my case it just feels bad and eventually it starts to die down. There have been cases, I mean, some people cry, some people throw up, they vomit. But basically this pain is stored in your body. And what happens is if you do the reliving intensely... and you can relive any episode in your life, what I find is, at some point it feels almost like an electrical charge has left my body. And what I'm left with is an empty memory. So it's a memory, which I can go and find a book in a library, but it's not a memory with an emotional charge, which is running my life.

Preeti Kota:  Okay.

John Purkiss:  And for me, it's such a powerful thing because, I mean, one of the really great things about it is you then become nonviolent. So much violence in the world is people being triggered, right?

Preeti Kota:  Yeah.

John Purkiss:  And then attacking each other, either mentally or verbally, so if you're not triggered, you won't fight people.

Preeti Kota:  That's true. So I guess you've already touched on this, but what are pain patterns?

John Purkiss:  Yeah, it's a good question. So pain pattern, that's a simple word. The Sanskrit word is samskara, like a scar. Swamiji uses the word incompletion. So one way to describe it is, in an ideal world, if you were completely conscious all the time, you would have a painful experience and you would live it from beginning to end. Or, a happy experience, so let's imagine you have a happy experience, you live it completely, and then it's finished. You've done it right, you've completed it. Or, you have a painful experience and you allow yourself to feel all of the pain. And then you complete the pain and then it's finished.

But what happens in reality is... By the way, British men are experts at this, is we have a painful experience and we don't like the pain, so we suppress it and we pretend everything's okay. And that suppressed pain is now stored in our bodies. I often do this. Well, I can do it with you if you want. You don't have to tell me the experience. But can you think of the most painful thing that happened to you before the age of seven?

Preeti Kota:  I don't really remember.

John Purkiss:  Okay. All right. The most painful experience you can remember at all doesn't have to be before seven.

Preeti Kota:  Okay.

John Purkiss:  Right. How old were you?

Preeti Kota:  Maybe 15.

John Purkiss:  15? Okay. So can you feel the pain of that experience now without telling me what it was?

Preeti Kota: Yeah.

John Purkiss:  Okay. And where is that pain in your body?

Preeti Kota:  I think in my mind.

John Purkiss:  In your mind. But where? Can you point to it? You can feel the pain. You're 15 years old. You can feel the pain. Where is it? Is it in your head or where?

Preeti Kota:  Yeah, I think in my head.

John Purkiss:  Okay. All right. So in 99% of cases, when I ask people that question... I say, "Okay, think of an event, feel the pain. Where is the pain?" 99% of cases, people can point to the pain in their body. They know where it is. It can be in their heart, it can be in their chest, or their stomach, wherever. But the point is it's been stored. Swamiji calls it muscle memory or bio memory. But the point is, it's not some abstract thing. I was in management consultancy for a while. I once asked this question as a former management consultant, and he said, he could feel the pain, but he didn't know where it was. Which strikes me, maybe that's very intellectual person, but most people like 99% of people, they can find it in their bodies, right?

Preeti Kota:  Yeah.

John Purkiss:  So the pain gets stored. Swamiji uses lots of analogies. My favorite one is, he says, it's like putting a carpet on a wound. So imagine you have a wound and it's all horrible, and then instead of treating it and disinfecting it, and you actually just put a carpet on it, which makes the whole thing worse. And that's what most of us do. We just suppress it because it's painful. And completion is removing all the pain. So the wound heals and then we would become whole, then you're fine.

Preeti Kota:  What is flow and what are its benefits?

John Purkiss:  I'm sure you know, there's a famous book called “Flow” by Csikszentmihalyi. Are you familiar with him? The Hungarian psychologist who invented the word flow. So it's a very thick book. I would say, for me, flow is a symptom. I mean, the state of flow has lots of benefits. So people experience flow when they are completely immersed in some activity, usually they really enjoy it. In my case, photography. If I'm immersed in photography or writing or something like that, there's a feeling of flow. You're not agonizing or analyzing, you're just enjoying the process and it happens very naturally.

But I would say, for me, that flow is more like a symptom. So maybe we'll get onto the topic of unclutching, as well. But if you are complete and you are unclutched, then flow happens naturally. One way of describing it is you become one with existence, or one with the cosmos. And so everything's happening very naturally. And you may have read about this, there are American football players, for example, who say that, when they're in a flow state, everything slows down. There's almost no thought involved and everything just happens really smoothly. But for me, there are ways of getting to that. It's a result rather than something you just do. Sorry.

Preeti Kota:  What are the benefits of it?

John Purkiss:  The benefits of flow are... of being in that state, are little or no stress, things happen very easily, relationships are easy, it's very productive. I mean, I have times when I can just sit down and write a thousand words in an hour or two. And a book is only 40,000 words. So yeah, I mean, flow is a fantastic thing. I mean, yeah, it's definitely good for your health. It's good for productivity, good for relationships, good for creativity. Yeah, definitely.

Preeti Kota:  Okay. How can people with anxiety or depression who are stuck in negative thought patterns about the past or future start to let go?

John Purkiss:  Okay, well there are two techniques. One of which I mentioned before when we were preparing for this. So we'll deal with them in a minute. So one is completion, which I've just described. So if you keep practicing the Completion Technique, you'll remove the negative thought patterns. And what happens is, that those repetitive negative thoughts start to die down. So for example, if I have a cognition from my first day at school that I'm a failure or that I'm unacceptable, if I complete that incident and remove that pain pattern, then I won't have thousands of negative thoughts about being unacceptable or being a failure, so that's one thing. You can remove the cause, which is the pain pattern. The second thing is... and this is a wonderful technique which fits beautifully with completion. This second technique is called Unclutching, which I didn't write about in the book I'm going to write about it in the next book.And I sent you a video. So there's a six minute video and a one hour video, which you can share with everybody. But the principle is very simple, unclutching is very simple. So, are you familiar with mindfulness?

Preeti Kota:  Yeah.

John Purkiss:  Yeah. Okay. So mindfulness has become huge in the West, and it also comes from the Vedic tradition. But mindfulness, there are various ways to do it, but my experience of mindfulness was... So I'm present, I'm sitting here quietly, and then I have a thought and I get distracted by the thought and my mind follows the thought, which morphs into another thought, and another thought, and another thought. And what I need to do is bring my attention back to the present. So that can be by putting my attention on my breath or the end of my nose or whatever, or the sensation of my hands on the table. There are all kinds of things I can do to bring my attention back to the present. And that works. I mean, I did that for six years and I talked about it in The Power of Letting Go. For some people that works perfectly well. Steve Jobs did zen meditation, which is similar, for decades. Unclutching is even simpler.

So what happens is... so Imagine you're sitting there and you have this negative thought, you now have a choice, you can either engage with the thought or you can unclutch from it. So if you engage with the thought, you might for example say, "That can't be true. Or, Oh dear, here's that thought again." Or get distracted and start thinking about whether or not that thought's true. A whole thing. You'll be there for hours. You can either engage with it and allow that to happen, or you can unclutch. Swamiji invented the term. Unclutch means, "I choose not to engage with it." It's a bit like, a small child is pestering you and you ignore the child.

So this thought comes up and you have the choice not to engage with it. Right?

Preeti Kota:  Yeah.

John Purkiss:  You just unclutch, you just step back mentally. You step back from it. And my experience as a Westerner is, initially, it felt to me like incredibly lazy. Surely if I have a thought, I should engage with it, and I should analyze it, and I should deal with it, and address it, and bladi, bladi, blah. Yeah, but then you're going to be in this mess. So what I do now is if I'm doing something and I have a negative thought... which can happen. I'm winning some business or working on a book or something I have a negative thought, I can just choose not to engage with it.

Preeti Kota:  Do you just distract yourself?

John Purkiss:  Sorry?

Preeti Kota:  You just keep distracting yourself?

John Purkiss:  No, don't distract about it. It's just a choice. Okay. I mean, we can do it now. You sit there, a thought comes up, you don't have to engage with it, you don't have to think about it. You can just notice it. And then, after a while it'll go away and another thought will come. And you don't engage with that one either. You don't think about it. You don't analyze it. You don't find evidence to contradict it. You don't suppress it. It's like bubbles in a fish tank. "Okay, there's a thought." And I encourage you and anyone listening to this or watching this to do this is, if you unclutch what you will notice is... Okay, so I'm doing something and I have a negative thought and I unclutch from it. Within a few minutes you'll find there's some other thought. And they are like bubbles in a fish tank, because... the way Swamiji describes it is, we create shafts.

So one thing we do is we have a painful thought or experience and we connect it to other painful thoughts and other pain. And we create this narrative like, "I'm a loser," or, "I'm a winner," or, "I'm a good father," or "I'm whatever, I'm a victim." We create this whole narrative. Whereas in reality, these thoughts are separate and unrelated. So if you slow down a film of bubbles in a fish tank, they're all separate, they're unrelated, right?

Preeti Kota:  Yeah.

John Purkiss:  So if you start treating our thoughts like that, if we just unclutch from them, they start losing their power over us.

Preeti Kota:  That's a good metaphor, the bubbles.

John Purkiss:  It's the simplest one. Yeah. I mean, that's the way Swamiji describes it. And I find that I still have negative thoughts. Sometimes I'm doing something really ambitious and I have a thought about how it's not going to work or it isn't working, and I just unclutch. I just carry on doing what I'm doing. Right?

Preeti Kota:  Yeah. I feel like that prevents you from spiraling then.

John Purkiss:  Yeah. Otherwise, you're going to spiral. Well, you're going to waste loads of time. You're going to feel terrible. You may go and say something to somebody which causes you a problem. Instead, all you need to do is unclutch. The metaphor, I didn't understand it first. In the US, I think you call it a stick shift gearbox in a car. So I know you have mainly automatic gear boxes. But with a stick shift gear box, the clutch enables you to disengage. So, basically the gears aren't running and the motor isn't driving the car anymore. It's a bit like that. You're having all these thoughts and you just disengage and you stop engaging with these thoughts which are coming up. And then the thoughts die down. And then you can start working. And when you start working, you may need to think, but you're thinking constructively. You're not just responding to random thoughts.

Preeti Kota:  How do you build faith or trust in the idea that good things will happen when you let go or surrender? What do you do with the thought? What if it doesn't get better?

John Purkiss:  So if you've been brought up in one of the big spiritual traditions, certainly the Asian ones, so Hinduism, Buddhism, Jainism, Daoism, all of those traditions say that there's something extremely intelligent, which is running everything. They all say that in different ways. And the Vedic tradition specifically says, "This intelligence is blessing you all the time." It's beneficial. It's benign.

What we are doing is we block it. We block with our our egos. Our body is trying to run itself very efficiently and healthily, and we do crazy things. We put crazy things in our bodies which stop that from happening. So, that's those traditions. And then, we've got the Abrahamic traditions, which come from Abraham. So you've got Judaism, Christianity, Islam, which have a different view of God, but you've still got an intelligence which is running everything. So in my case, as I mentioned, I was brought up as a Christian, although I didn't understand what was going on, especially when I became ill. I did have this understanding there was something intelligent running things.

I think the difficulty is if you are an atheist. And as I understand it, there are two types of atheists. So one type of atheist is you don't believe in deities, you don't believe in a God because you haven't seen any enough evidence or whatever. Which for me is completely fine because you're being empirical. I mean, I just see how amazing nature is, and for me, that's pretty solid evidence. For some people that's not enough. But okay, so you might say, this world has been operating for 4.5 Billion years perfectly. But that's not enough evidence for me. Fine. It's okay. I think the real problem is … you can at least say by the way, when I was clinically depressed, one of the psychiatrist I talked to, he said, "Look at the animals. They're not running around being depressed, they're just getting on with things." And I do that.

But there's what I would call maybe militant atheism, which is being convinced that there is no intelligence running everything. And for me, that's completely unscientific viewpoint. I don't know. Are you familiar with Karl Popper?

Preeti Kota:  No.

John Purkiss:  Karl Popper was a very influential philosopher of science. And what he said was, "For a statement to be scientific, it has to be capable of being falsified." There has to be a means of proving it wrong. So for example, if you say the earth is flat as a hypothesis, there are ways of proving that wrong. But if you say there is no God, how do I construct an experiment to prove that's wrong? You see what I'm saying? It's an unscientific statement, but there are people who are absolutely convinced that there is no God and there's no intelligence running it and running their lives. And I would say, well, A, that's unscientific. B, I would suggest it's probably ego. And C, it makes life very difficult because if you are absolutely convinced of that, everything falls on your shoulders. It means the only way for you to be happy and successful is for you to do everything using your brain and your body.

And maybe that’s why … I mean, I don't know if you know the history, but after the Soviet Union ended, lots of people, Eastern European people came to the UK. And I've met lots of people in the West, as well. But I've met a lot of people who were atheists who were brought up as atheists. It's like atheism was a religion in the Soviet Union. And in those countries like Poland and all those. Well, Poland has a lot of Catholicism. Let's say Estonia, Latvia, Lithuania, a lot of these countries they were taught atheism at school. And a lot of them are really depressed because they've been brought up to believe that the only way to do anything is using your brain and your body. And when that doesn't work, you're stuck.

So for those people, I would just say, I invite you to entertain the possibility that there's something extremely intelligent, which is running your body, which is running nature. And if you tune into it … To answer your question, when we let go, we start tuning into all of that and life gets much easier. We're not holding onto this idea that only my brain and my body can solve everything. Does that make any sense?

Preeti Kota:  Yeah.

John Purkiss:  Okay.

Preeti Kota:  So what are daily practices people can do to realize the power of letting go?

John Purkiss:  Okay. Well, what I do is, as I mentioned, I did mindfulness for six years. Then I learned transcendental meditation, which I've been doing in 20 years. I've done it twice today. And that is wonderful. I mean, it removes nearly all of my jet lag. For those who haven't experienced it, when you let go during transcendental meditation, you go into this state called Turiya, which is the fourth state of consciousness it is also from the Vedic tradition. You experience pure consciousness without any thoughts. So it's blissful and it's deeply restful.

And in terms of letting go, this was one of my early experiences of letting go was, if I have a problem or I need to have some creative idea, frequently it comes during or after transcendental meditation, because what you're doing is you're switching off your mind. You hear a mantra, you go into this state of pure consciousness, and then solutions to problems or ideas, they just come because what you've done is create a massive gap between thoughts. I mean, the gap could be up to 20 minutes. I mean, it might be just a few seconds. So, that transcendental meditation is great. Unclutching, which I've just described is also great.

So here's a really practical thing for anyone listening is, imagine you want to do something but you don't know how, and you're worried about it, you might be worried about it. So if you get really clear about what you want to create, and you can write it down, you can have pictures, whatever you want. First thing, is make sure that it's something you want to do. It's a genuine desire. It's not something you've borrowed from somebody else. It's loving. It's going to be for everybody's benefit. So it's a genuine desire. Now what you do is unclutch, so do that unclutching exercise, very simply, just disengage.

Actually, you can do this, write down on the paper. Your mind will tell you all the reasons why it can't happen. So if you pick something you want to happen and write it down, your mind will tell you all the reasons why it can't happen. Just write those down. And then, when you see all the reasons why it can't happen, that tells you where you need to complete, where you need to relive the original incident. It's like software. You've got all this software telling you bad things. So you can use the completion technique to remove all those negative patterns.

And then, when you unclutch, so what I do now is I want to do something I don't know how, is I get really clear about what I want to happen, and then I unclutch. I disengage from thinking. And then I have a flash of intuition, which tells me what to do. So having been brought up as a Christian, I would just ask myself, "Please guide me." It's in The Power of Letting Go. When I got completely stuck, I asked to be guided to the right job or business. And I was guided to the perfect job. What I do now? I mean, because Swamiji is 44, so now I just ask him to guide me. But essentially I'm letting go of the thought process asking to be guided, and I unclutch. And then I suddenly have an idea, I need to call this person, or send an email to that person, or go to that place. So you start functioning out of intuition instead of agonizing about everything.

Preeti Kota:  Yeah. Those are great useful techniques, I feel like, that are easy to implement.

John Purkiss:  Yeah, I mean they're not mine. I just found they're the easiest ones to do. And they work.

Preeti Kota:  So do you have any parting words of advice or anything else that you'd want to share with our listeners today?

John Purkiss:  If you like reading, please read The Power of Letting Go. If you don't like reading, well it's on audiobook, as well. The other thing is I would definitely take a look at Swamiji's videos on YouTube. If you type in Nithyananda, which is N-I-T-H-Y-A-N-A-N-D-A, if you type in Nithyananda... By the way, it means eternal bliss. At the end of his satsangs, his talks, he always says, "Be blissful." So step number one is be blissful. So if you type Nithyananda and unclutching into YouTube, you'll see the videos where he explains unclutching. If you type Nithyananda and completion into YouTube, there's a 20 minute video where he talks about how to use completion for health, wealth and relationships.

Preeti Kota:  Okay.

John Purkiss:  And in fact, any problem that I have, I just type Nithyananda and whatever. Like, Nithyananda and diabetes, a video will come up.

Preeti Kota:  Amazing.

John Purkiss:  So that's a great resource for people to use.

Preeti Kota:  Okay, great. Well, thank you so much for your time today and I really enjoyed hearing all the advice and strategies on letting go.

John Purkiss:  Well, thanks for inviting me. And if anyone wants to contact me, it's johnpurkiss.com. I've got a form on the internet.

Preeti Kota:  Thank you so much.

John Purkiss:  All right.

Preeti Kota:  Thank you.

John Purkiss:  Thank you very much. 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 Julie Erickson on Aging & Anxiety

An Interview with Psychologist Julie Erickson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tori Steffen:  Okay.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tori Steffen:  Thank you. Have a great one.

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

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

Psychologist Hamilton Fairfax on OCD & Mindfulness

An Interview with Psychologist Hamilton Fairfax

Hamilton Fairfax, Ph.D. is consultant counseling psychologist in the National Health Service (NHS) in the UK. He has developed Adaptation-based Process Therapy (APT), an integrative group-based approach for complex clients, especially those with a personality disorder diagnosis and another medical condition. His work also focuses on the benefits of mindfulness for those with OCD.

Preeti Kota:  Hi, everyone. Thank you for joining this installment of the Seattle Psychiatrist Interview Series. I’m Preeti Kota, a research intern Seattle Anxiety Specialists. We are Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us psychologist, Dr. Hamilton Fairfax who joins us from England today. Dr. Fairfax was a recipient of 2014 Society’s Professional Practice Board’s Award for Practitioner of the Year for his development of innovative therapeutic techniques when working with clients with complex needs. He specializes in adaptation-based process therapy, APT, an integrative group-based approach for complex clients and OCD. Before we get started today, can you let our listeners know a little bit more about you and what made you interested in becoming a psychologist as well as in mindfulness and OCD?

Hamilton Fairfax:  Yeah, of course. Thank you for inviting me.

So, I'm Hamilton. I'm a consultant counseling psychologist in the NHS, the National Health Service, which in the UK is a publicly funded health care system. And I'm working in Devon, which is in the far west end of England. And I'm in charge of psychology and psychological therapies for adults, secondary mental health care clients and that's people who've got severe enduring difficulties.

What's the next bit? Oh, it's why did I want to become a psychologist? Yeah. Good question. I started off doing theology and philosophy and classics and I suppose probably because I'm very bad at philosophy, I got a bit frustrated that it was all really interesting, but I wanted some practical ways of helping people and I think that was my interest all the way along was trying to find ways of trying to be helpful to people and I haven't got many other skills to do so and I ended up being a psychologist and that's still debatable in terms of the skills thing as well.

In terms of mindfulness, I was probably first introduced to it as a concept about 20-odd years ago through DBT and I pursued it from there. And the main focus on OCD is in the work that we were doing. We see anybody here with a complex, any diagnosis of complex care. And in that particular team I was working at the moment, at that time there was a really, really long waiting list and a lot of people with OCD. So, it was a case of how can we see people with the resources we have? And that led to, I'd be thinking as well about limited thoughts and mindfulness and just seemed like let's give it a go for an OCD group, mindfulness based.

Preeti Kota:  Great. So, just to begin generally, what is OCD?

Hamilton Fairfax:  Really difficult question there, isn't it? I guess traditionally, that would be seen as part of an anxiety disorder. I think it's a bit more than that. So, I suppose OCD is the idea of sort of a compulsive need to perform some behavioral or thinking rituals to help neutralize, prevent, or manage really distressing, intrusive thoughts in somebody's mind. And I guess it's on a continuum as well that I feel is about most mental health difficulties, that it's on the continuum, it's dimensional, we've all got a bit of something that it gets more and more extreme. And what OCD really is is awful. It's really, really life bothering and distressing for people. And I think the World Health Organization's still have it high on their worst conditions to have. So, OCD and it's worse because can be completely debilitating for people.

Preeti Kota:  Mm-hmm. Yeah, definitely. Why do you think many clients failed to engage or complete treatment for OCD when using the techniques of cognitive behavioral therapy or exposure and response prevention? Also, if you want to go into what those are generally.

Hamilton Fairfax:  Yeah, sure. So, it's a really good point, isn't it? Because I think they have some studies certainly in the UK saying that sometimes people weren't diagnosed with OCD for up to 15 years from their first presentation because there is something quite shameful that people can feel about OCD. Logically, they know this isn't the case, but they just feel compelled to do it. So, there's something often very shameful about that.

Also, when you start to tell people about exposure and response prevention. So, that is developing a series of graded ways of confronting your fear, that could be really scary. So, if you really think that something really bad could happen if I don't wash my hands 50 times and someone comes along, "Right, the treatment we're going to give you is we're going to make you stop washing hands 50 times and we're going to do it week after week after week in slow steps," it could be really, really off-putting for people to do that. So, there's a lot of fear and I think some people perhaps have read about things and they think, "Oh, no. I've got worries about contamination. I'll have to stick my hand down the toilet." They see these kind of videos out there. So, I think there's something about education in that as well.

And it's a really, really hard condition to treat. So, people won't tell people in huge details about what their thoughts are. Sometimes these thoughts and behaviors are really embarrassing for them. Sometimes they're really shameful and sometimes they're really scary. So, if you've got intrusive thoughts, for example, about being a pedophile, telling people that can have some really difficult consequences and people will respond differently to you. So, that's very, very difficult.

And I guess what we know from people with OCD is often, say, they'll present maybe the top of an iceberg of their difficulties and it would be for the therapist to really, really drill down into what's really going underneath that. And that takes time that you need to build a relationship, not just necessarily steam in with the behavioral side of things. So, it takes time to build that trust. And if you don't address the core, the roots, you might change certain behaviors but they could substitute different behaviors, which happens a lot from the evidence. Sometimes it can be 50, 60% of people relapsing or having a different kind of OCD. I think those are some of the reasons why it can be difficult.

Preeti Kota:  Hmm. Is one in particular CBT or ERP more effective or ...

Hamilton Fairfax:  If so, in the UK we have something called NICE, which is the National Institute for Clinical Health and Excellence. So, that's basically an organization that looks at the RCT forms of research and recommends treatment on that for the more common mental health conditions. So, they would argue that cognitive behavioral therapy with exposure and response prevention would be the best way of treating that. But, of course, the more complex people become, the more you need a bit more sophistication.

Preeti Kota:  Hmm. Yeah, definitely. What about mindfulness do you think makes it an effective solution for OCD?

Hamilton Fairfax:  Yeah. I think there's several things that helpful. One, I mean, it's incredibly portable. I think there's a book on mindfulness, isn't it? I think they're called “Wherever You Go, There You Are” in the sense that if you're being mindful, your body and who you are is always around. So, there's something you can practice and try out wherever you are in the world. I think, as well, I got particularly interested in cognitive mechanism suggested behind OCD called thought-action-fusion. And that's the idea that to have the thought is exactly the same as if you've done the behavior. And there were two types of thought-action-fusion. One's called moral thought-action-fusion, which is, if I have a thought that I'm a pedophile, what kind of person does that make me? I must be that evil person. And then it sets off.

So, the thought is just as bad as being that thing and there's a likelihood thought-action-fusion. If I keep thinking about the plane could crash, it could crash. So, I need to do something about it. It's almost like I'm making it crash. So, this way of the thought-action-fusion is really awful because it really starts that behavioral response automatically. So, I think something good about mindfulness is it begins to start to have a break between that thought-action-fusion. It begins to say, "Hang on, hang on. Okay. Yeah. That happens, but let's just stop and try and get that meta mindful position and try and break that link between thought-action-fusion."

Preeti Kota:  Do you think it's also ... Sorry.

Hamilton Fairfax:  It's also ... Sorry. Go ahead.

Preeti Kota:  Do you think thought-action-fusion is something that we have as an automatic bias or something we develop?

Hamilton Fairfax:  Good question. I'm guessing it's both. I think it has a function as well but that, over time, you feel more... I suppose it depends on the nature of the thoughts, as well, behind it if something is so horrific, either morally- or likelihood-wise, it might become more an ingrained pattern. Good question, though. It's difficult one to answer, but I think it's probably down to individuals-

Preeti Kota:  Yeah.

Hamilton Fairfax:  ... and what happened.

Preeti Kota:  And I'm sorry.

Hamilton Fairfax:  Yeah, yeah. No worries. I think also what's useful about mindfulness and the treatment of OCD is that it really helps engage in a behavior. So, for example, if you think checking the door loads of times is going to help prevent something happen. If you do it mindfully, if you mindfully check the door, you have to say, "Okay, I'm going to mindfully do this. I'm going to observe myself moving the handle and feeling what the metal feels. Oh, I'm surprised. Oh no, no, bring it back to that task." It really makes that person engage in that behavior. So, you're going to be obsessed with mindfully in a sort of paradoxical way. That helps because what we know about OCD, the way that it affects certain brain areas, but also anxiety and distress in general, is it hits our executive functions and our memories. So, it's very hard to do that.

So, when you begin to doubt yourself. "Oh, did I do it 15 times? Actually, no. I do remember really moving the handle." So, you get this whole sensory as well as to format memories as it lays down the links, which makes it more, "Okay. Maybe I didn't ... No, I don't need to go back and check, because I do remember doing it." So, it has that utility as well.

Preeti Kota:  Yeah. Are there specific types of mindfulness that are more beneficial than others, such as meditation over yoga?

Hamilton Fairfax:  I guess they are different practices. So, yoga obviously would be more physical-based. And I suppose the, it's the intention behind what you're doing it. I mean, there's different kinds of traditions in mindfulness and there's loving kindness meditation as well. But I guess they're doing different things in some way. So, I would always say, "Whatever kind of mindfulness you are doing, what's the intention behind doing it?" I mean, to be mindful is not to be relaxed. Far from it, often. You're really sort of immersed in the experience of feeling, "Oh, my god. What's all this about?"

So, it's not a relaxation technique at all. And the same with yoga. It embodies you, which is really important. That's what mindfulness can do as well. Embody you, but I guess with yoga there's an explicit meaning behind the practice.

Preeti Kota:  Can you elaborate on what you mean behind the intention of doing the practices?

Hamilton Fairfax:  Yeah. So, I'm thinking, well, and a poor example, some people will think, "Okay, so mindfulness is about being relaxed," and it isn't, but if your intention is, "I'll do this and I'll feel more capable of managing my distress or getting out there in the world," that's a bit difficult because mindfulness, I guess, personally for me, I don't feel is a set of skills. I think it's a way of being and that's a very different way to approach it. So, I think that's what I mean by the intention.

So, if we set the intention in treating OCD with mindfulness in the sense that, "Okay, what I'd like you to do is just really be aware of when you touch the desk 10 times. I really want you to feel it. I want you to notice." So, you're really actually priming the person about why you're doing what you're doing. You're being really explicit. "Okay." And then you'll say, "What will happen is we'll do this. Your mind will wander. You'll feel racy. You will have those in compulsive thoughts. That's alright. All I want you to do is practice bringing your head back and forth to that sensation." So, it's something again there about why you're doing what you're doing. I think that's what I mean by intention.

Preeti Kota:  Okay. In treating OCD, is mindfulness best suited as in addition to traditional therapy, in addition to medication or involving both?

Hamilton Fairfax:  I would say it depends completely on the person. How I've used it is all of the above. Most people I see will be on medication and they'll need more than just mindfulness practice. It needs to be contained within a wider psychological formulation. So, I'd say complete depends on the individual. I think I'd go back to intention again, but if you're wanting to talk to people about mindfulness in a therapeutic way, it needs to be part of a formulation that's explicit and co-constructive and like, "We're doing this because, and this is what I'd like you to ..." So, I think it depends on the person. I wouldn't separate it.

Preeti Kota:  So, when you're deciding based on the individual, is that related to the severity of the OCD or ...

Hamilton Fairfax:  In terms of medication, yes. So, sometimes medication can be helpful, sometimes it can't. I think I don't I'd ever just do be mindfulness, use mindfulness with somebody, but it would need to be part of the ... I wouldn't say as adjunct. I just say it's part of the therapeutic process.

Preeti Kota:  Okay. How long do the techniques of mindfulness last after completing a mindfulness program? Is it something you have to continue practicing often?

Hamilton Fairfax:  Well, you see, this is where we're bad practitioners in the NHS, because often we don't do follow-ups. But, actually, some of our groups, we did manage to do that. I can't remember if there's a paper written on it, but I think it was 12 months we did, certainly six months. And mindfulness people continue to feel better. When we asked them what was the thing they found most helpful in the group, which was cognitive behavioral as well as ERP and mindfulness, it was mindfulness. So, they carried on practicing the mindfulness.

In terms of what do you have to do? Yes, you do have to keep doing it because it gives you that authenticity. If you're asking someone to sit with their thoughts and manage that meta and the struggle of not getting it right, whatever that means. You need to have your own experience of doing that. It doesn't have to be... Sorry.

Preeti Kota:  Oh, no. You continue.

Hamilton Fairfax:  No. No. I was going to say it doesn't have to be wedded to any particular religious belief or whatever, but you do need to have that authenticity. So, you know what it's like to struggle.

Preeti Kota:  Is it the thing that … casually or something like dedicate time to each day?

Hamilton Fairfax:  I'm sorry. I lost you there over the Atlantic. I couldn't quite hear that.

Preeti Kota:  It's okay. Is mindfulness something that becomes more of an automatic habit or a scale or is it something that you have to dedicate time explicitly to practice each day?

Hamilton Fairfax:  Right. See this is why, depends on who you are as a person and what you need to do to remind yourself to do it. So, I'm very bad, because I suspect as a practitioner I need to be reminded to do these things. I need to have a commitment to do it, not me. I have to do it for an hour or anything like that. But there's also something, back with our client, it's very portable. You can do mindfulness. You find a form of mindfulness practice that suits you. For example, I quite like mindful walking, just really sort of noticing what it means to walk, which can make you feel really unbalanced.

But, so, I think it does take a commitment to actually doing it on an ongoing way. Does it become automatic? I think we're human beings, we resist these things and sometimes they become more familiar and sometimes they don't. Just depends where we are, but it does take a commitment.

Preeti Kota:  Okay. Do mindfulness and OCD affect similar brain areas neurologically?

Hamilton Fairfax:  Tricky and this is where I'll probably get in trouble with all my neuroscience colleagues. I'm not a neuroscientist, but what I'm aware of is that I think what mindfulness does in some of the studies I've seen, it certainly helps, I think it's thick in some of the prefrontal cortex. And I think it's been linked with a lot of the regulation of the limbic system and small amygdalas, I think. So, that would.

And with what we know of OCD, we know, again, the prefrontal cortex, the caudate nucleus, and the singlets are all sort of implicated, particularly that sort of relationship between the frontal cortex and the basal ganglia and the caudate nucleus. That sort of idea that here's the front bit that says here's our choice decision-making and here's the sort of more movement-y bit and that sort of error checking bit that gets skewed in OCD. That's a terrible, terrible neurological description. But anyway, so what I think that mindfulness does is that I think it calms down the reactivity of the system. So, I don't think it necessarily targets brain areas as such. Perhaps it just helps reduce the energy in those certain areas.

Preeti Kota:  Okay. So, I mean this might be too neurological of a question, but it doesn't really rewire the brain. It kind of just-

Hamilton Fairfax:  Well, I think that's interesting because if you go with... I mean, yeah, neuroplasticity I don't but I think, absolutely, because if you do something enough times you are going to rewire that kind of connection. So, absolutely. But I think that's true of any of our experiences. So, yes, I'm sure, I think therapy does help to do that kind of neuroplasticity change.

Preeti Kota:  And that's probably most likely in the prefrontal cortex that does that?

Hamilton Fairfax:  Again, I think you need someone who's much better qualified than me to do that. But, I guess, I think about brain functioning in terms of systems and yeah, across regions, but also systems. I don't know if it's just in the prefrontal because I guess you got the temporal lobes with the memory and all sorts of things. So, I think it might be more diffuse than that. I think that's what mindfulness might do as well. I think it's probably diffuse neural. But again, talking to someone who knows what they're on about.

Preeti Kota:  Okay. Is there a genetic basis for OCD, and also, is there a genetic basis for the ease of practicing mindfulness? Does it come automatically to someone more than another person?

Hamilton Fairfax:  Yeah. The best I've ever come across. I mean, you haven't looked at it for ages, was that 50/50 in terms of genetic bias of OCD. It might be slightly more than that.

It also means, yeah, on that continuum of OCD, we've got tick disorders, we've got neurological things, we've got other things. So, I think it's in maybe about 50/50. In terms of genetic for practicing mindfulness. I guess it's more about personality and temperament than genetics for being why to do it, I guess. I mean, that's a hard one. That's back to the nature/nurture. So, I don't know about that. But what we do know about mindfulness it’s been practiced for thousands of years in cultures across societies and across cultures. So, everyone can do it. Yeah. So, I don't really know about a genetic thing. I wouldn't have thought so but we're animals as well.

Preeti Kota:  Mm-hmm. Are there certain personalities that you were referring to personality-wise, that it depends? Are there certain path personalities you think are better at mindfulness?

Hamilton Fairfax:  Just on my experience and sort of just in gut feeling, I guess again, it's those people who are openness to experience who are sort of perhaps slightly more extroverted. You don't need to do that. But openness to experience that are willing to give things a go that are psychologically minded, that can make connections between things, that like to do new things. I suspect they'll probably be more willing to engage. But that certainly doesn't mean that people who are more reserved or more introverted can't do it.

Preeti Kota:  Yeah, I would actually expect people who are more introvert to be better because they're already kind of in tune or with themselves I guess.

Hamilton Fairfax:  Or a perception of themselves. And I guess that's the thing that we do with the mindfulness is are you introverted or someone called you... I mean, it could be. You could be absolutely right. There's something about that almost as diagnosis of introverted or extroverted but you probably could unpack through mindfulness.

Preeti Kota:  Mm-hmm. Yeah, definitely. Does mindfulness involve dissociation in that it practices separating the self from sensory experiences?

Hamilton Fairfax:  No, I don't think so at all. I think it's quite the reverse. I think it is about engaging with sensory experiences, either very explicitly, such as smell this coffee literally, or smell these. We did an exercise in one of these groups which was smelling Quavers, which in this country, is an incredibly fragrant, almost sick-making crisp that smells very strongly of cheese. So, we thought, "Fantastic. We're doing Quavers, not raisins," because they're far too traditional. But to do that, we were asking people to really engage with this Quaver. So, it felt funny and it really strongly smelled. So, they had to engage with that crisp and having all these thoughts going on and actually nobody really wanted to eat it, because the more you engage with it, the smell took over.

So, that's just an example I think of... It's not. It's about immersing yourself in the experience but having that step back that observes. It's not dissociative. It's an observing mind, it's an observing way of being. So, you need to know all these kind of things and it asks you to be in your body, because if you're sitting there thinking, "Oh, god, I didn't know my stomach felt like that when I'm having this thought." Okay, just observe it. Just hold on to it. Carry on with what you're doing. So, I think it really invites you to be far more embodied. And you can use mindfulness with psychosis as well. I know some can be quite worried about that, but there's some really good evidence of mindfulness in psychosis.

Preeti Kota:  Hmm. Can you just elaborate on the differences between mindfulness and disassociation, because I feel like mindfulness also involves kind of taking perspective, but I don't know much about dissociation.

Hamilton Fairfax:  Dissociation are often a highly understandable and effective way to deal with trauma. But what you're doing in dissociation is literally cutting off from an experience. You're putting your head somewhere else out of that environment. Whilst you're being mindful, you are engaging yourself in that environment. Yes, you're trying to have a meta-perspective to observe it, but you are fully immersed.

Preeti Kota:  Okay.

Hamilton Fairfax:  You're fully present, well dissociation to cut off.

Preeti Kota:  Okay. And then, do certain emotions or situations increase one's tendency to urge surf or act impulsively? And if you want to generally go over what urge surfing is as a concept.

Hamilton Fairfax:  Yeah. Well, I think it takes me back to my DBT days. So, this idea that you'll be flooded with, it's about emotional regulation often. So, you'll be flooded with feelings that just takes you to certain kinds of ways. And how mindfulness and DBT with certain other ways as well is to sort of stop and say, "Yeah, here's that flood of emotions. You can surf the wave, you don't have to be swamped under it."

So, mindfulness is a way of sitting back, setting the board on the wave as opposed to drowning under it. And in terms of acting impulsive, I guess that's what we're trying. That's the antidote that you're surfing it, you're riding it, you're not ignoring it, you're being aware that you feel pissed off or angry or whatever it is, but you're not letting it take you over.

Preeti Kota:  Okay.

Hamilton Fairfax:  And in certain situations do that, I think anything that's traumatic will do that. In terms of the emotion dysregulation. So, if you ask somebody who might have been diagnosed with personality disorder, which I prefer to say, "Complex trauma," there's lots of hardwiring for your environment where you are going to be highly sensitive to certain environments that you might feel abandoned, rejected, or under assault. And that could trigger you instantly into that sort of emotional overload, that storm of affect.

Preeti Kota:  Okay. How long does the emotions of trauma affect the tendency to urge surf?

Hamilton Fairfax:  How does it ... Go on. Say that again?

Preeti Kota:  How long do the emotions of traumatic situations affect one's tendency to urge surf?

Hamilton Fairfax:  How long? I guess it really depends on the situation and what's happening. If, for example, someone is self-harming and that's been what they've done before and we know that the positive thing of self-harming is that the cutting helps express a feeling, helps regulate an emotion, what we're wanting to do is try and change that behavior differently. So, it will depend, again, on the individual. It'll depend again on the context. In terms of a timescale, it's difficult. If that's how you've had to manage your life to survive for decades, it's going to be an instant thing.

Preeti Kota:  Okay. And then, for cases not directly relating to trauma, are there daily emotions or more common emotions that trigger urge surfing or impulsivity?

Hamilton Fairfax:  So, yeah. I mean I think anything that's ... There's small-t trauma, not necessarily sexual abuse and all the rest of, but small-t traumas, things that sort of interfere with our quality of life will lead to arousal of affect. And again, it is going be dependent on the person, what triggers you in that way. And again, the triggering is not necessarily always extreme. So, we're talking about I suppose the fight/flight's freeze way of understanding situations and how that relates to your emotions.

Preeti Kota:  So, it doesn't necessarily have to be negative emotions in terms of arousal, it can also be positive?

Hamilton Fairfax:  Sorry. I missed the first part.

Preeti Kota:  So, it doesn't necessarily have to be negative emotions just in terms of arousal. It could also be positive emotions that ...

Hamilton Fairfax:  Absolutely. Absolutely. If you're a big sport fan or a music fan, you know can really be easily taken over impulsively in the moment and sometimes do things you wish you hadn't or whatever or just be in a different place. Absolutely. So, it's just all mindfulness and I suppose other techniques is other ways of therapy is just trying to rebalance.

Preeti Kota:  Okay. Just also getting on a little bit of a tangent. For positive emotions, since it feels very good to be very happy, how would one be motivated to practice mindfulness to kind of tame those kinds of emotions? Because I feel like more … some people with maybe bipolar, with before you have something might not want to do that.

Hamilton Fairfax:  Yeah. I heard most of that I think, but tell me if I haven't answer your question properly. So, something here about how do you convince people with really high positive emotions that they want to stop doing that and try and be it more balanced?

Preeti Kota:  Yes.

Hamilton Fairfax:  Really ridiculous. Particularly people with bipolar disorder, cyclothymia and often when you meet the people that actually miss those high states, because there's something really addictive about not caring and just being happy in the moment. But I suppose what you need to do, again, is to look at the consequences of behaviors and they can often be really, really bad and they can often influence the bipolar shift the other way sometimes.

So, I think what it is, again, it's all about balance. It's not about destroying those high states. It's building relationships therapeutically with that person and saying, "Look, we want you to be in control of your feelings. That doesn't mean you have to be a robot. So, it doesn't mean you have to do these kind of things." But, like with OCD, we all have it a bit, but when it interferes with the quality of our lives, then it becomes a problem. And that's all we'll be saying to our bipolar people as well, I guess. These things, these emotional states interfere with the quality of your life and the quality of other people's lives. So, that's why we just need to bring this down a bit.

Preeti Kota:  What about-

Hamilton Fairfax:  Sorry, go ahead.

Preeti Kota:  It's okay. What about for people with OCD who just experienced such a high level of satisfaction from performing certain behaviors that they're just not motivated to practice mindfulness, to kind of change those behaviors even though it's affecting their life?

Hamilton Fairfax:  If someone doesn't want to change their behaviors, nothing we can do about that. But I'm guessing the fact that they've come in to talk about it would be some chink of saying, "Something's not okay here." I don't know if I fully answered that question. What was the first part of that?

Preeti Kota:  I think it was how people with OCD could be motivated to resist the satisfaction they get from performing the compulsive behaviors.

Hamilton Fairfax:  Yeah, okay. Yeah. That's an interesting one. I guess the people I tend to see aren't satisfied. It's all they're far from it. So, although there's a sort of, "I've done this. Things are okay." They're not happy because it's controlled their lives for 20 odd years or longer. So, there's a sense of satisfaction, but it becomes something really, really very toxic and they're there because this isn't okay. Or they can live with it, but no one around them can. So, that's a chink in as well. Or they don't want their children to pick up their behavior. There's some knowledge, there's some awareness that they don't want anyone else to have what they're doing.

Preeti Kota:  Okay. And then you're talking about the spectrum of OCD before, how some cases are very extreme and some are mild. So, on that spectrum, I guess what range can mindfulness help with, even mild is there?

Hamilton Fairfax:  Oh, yeah. You see how massively optimistic. I think you can help in all presentations because, again, it's about, the formulation, it's about the intention behind it. It's a very helpful way to get into exposure and response prevention in a certain way. Because the first thing you're doing is I'm gluing thoughts and saying, "Look, all I'm going to ask you to do is spend 30 seconds just sitting with that." So, it's a way of inducting people. So, I think you can work at any level of extremists and we've certainly had people, the OCD groups who were really intensive OCD units in the UK, real lifelong people, 40, 50 years plus of OCD. Had some lady who was so concerned about contamination that she would unscrew her floorboards throughout the house and clean the screws every single day. So, it's really quite extreme things and people benefitted from that.

Preeti Kota:  Mm-hmm. That's great to hear. So, what advice do you have for beginners trying to get into mindfulness?

Hamilton Fairfax:  Don't be put off and don't think you have to be a guru or anything like that at all. You don't have to be Buddhist. You can be. Don't have to be. It's just the way of being and the idea about being a beginner is what we all are. Because it's not about failing or succeeding, it's just noticing and being kind to yourself. So, please, please, please be kind to yourself. We're all beginners. There's a path of mindfulness practice, which is seeing as if for the first time, and that's a really good reminder because we become automatic with our perceptions. And so, if you all begin it, great. You're doing it. It's not about pass or fail. It's just about practice and just noticing what's happening.

Preeti Kota:  And do you also have advice for when someone with OCD relapses or even just someone without OCD trying to practice mindfulness but struggling and they're just harsh on themselves and they get kind of demotivated or unmotivated?

Hamilton Fairfax:  Really kind of compassionate. And also this is a good thing about having your own practice. It's just say, "Me, too. It's a bugger, isn't it? It's really difficult." And so, then you sit with them and think, "Okay, so what were you trying to do?" Well maybe they got into thinking, "I must be mindful, I must be mindful this time and this time. Well, I'm not doing my mindfulness." And just trying to work out what's getting in the way. And sometimes it just might be they've got really busy lives. So, just sort of stop and be compassionate and find out what's happening.

I guess one thing with OCD, I did notice with mindfulness is we saw one gentleman who had really, really severe mindfulness, was in several inpatient units, specifically for OCD. And what we noticed with him, I think he was able to say eventually, is that, when he was given instructions like CBT or whatever, he would internalize them as a ritual.

So, with the mindfulness, when we were talking about wise mind and the rest of it, it became an obsessive ritual. So, he would say things like, "Right, I'm doing my mind," while he wasn't being mindful. So, there's something to watch in that as well, just to make sure that people are doing, and that's why it has to be experiential and talking about the practice.

Preeti Kota:  Yeah, definitely.

Oh. Lastly, is there anything else you would like to share with our listeners or any final words of advice?

Hamilton Fairfax:  Yeah, this is for people with OCD and people treating OCD. Yeah, I just have enormous amount of hope. As I said, in these groups and I haven't run them all. Other people run them as well. People with 60 year histories of OCD, people who have had their life controlled by it - it can change. And you can tell your therapist anything. They're really unlikely to be flustered. Even if it's something you're really, really fearful of, we're here to help you. But it's the massive amount of hope that there can be change in OCD or any mental health difficulty.

Preeti Kota:  Great. I love that. We ended on a very optimistic note. Well, thank you so much for being here.

Hamilton Fairfax:  No problem.

Preeti Kota:  I definitely learned a lot and it was great to have you.

Hamilton Fairfax:  Thank you very much for inviting me.

Preeti Kota:  Of course. Bye.

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

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

Therapist Claire Jack on Autism Spectrum Disorder

An Interview with Therapist Claire Jack

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Ghahari:  Oh wow; years.

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

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

Claire Jack:  Absolutely, yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Claire Jack:  Thank you.

Jennifer Ghahari:  Have a good day.

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

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

Atmospheric Researcher Kyle Hilburn on Wildfire Anxiety

An Interview with Atmospheric Researcher, Kyle Hilburn

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Social Worker Erin Maloney on the Innocent Lives Foundation

An Interview with Social Worker Erin Maloney

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

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

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

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

Erin Maloney:  Thank you for having me.

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

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

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

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

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

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

Erin Maloney:  Yes, yes.

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  Yes.

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

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

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

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

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

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

Erin Maloney:  Yes, yes, exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  It truly is. Yep.

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

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

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

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

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

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

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

Erin Maloney:  Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

Erin Maloney:  Yes, yes.

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

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

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

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

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

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

Erin Maloney:  Yes.

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

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

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

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

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

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

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

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

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

Erin Maloney:  Exactly, exactly.

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

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

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

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

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

Erin Maloney:  Exactly, exactly.

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

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

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

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

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

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

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

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

Erin Maloney:  Wonderful. That sounds great.

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

Erin Maloney:  Of course. Thanks for having me.

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

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