Our Executive Director, Blake Thompson LMHC, was recently interviewed on the Relational Psych Podcast. You can find out more info about this interview and their interview series here: https://www.relationalpsych.group/podcast/exploring-the-evolution-and-impact-of-cbt-with-blake-thompson
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An Interview with Psychotherapist Nica Selvaggio
Dominica (Nica) Selvaggio, LMHC is psychotherapist at Seattle Anxiety Specialists, PLLC. Nica has experience working with clients on a wide variety of issues, including anxiety disorders, eating disorders, substance abuse, sexual orientation and gender identity, acculturation and systemic oppression related to race and gender, trauma and PTSD, mood disorders, personality disorders, self-harm, relational issues, and attachment struggles.
Jennifer Smith: Hi, thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today, Dominica Selvaggio, who is one of the psychotherapists at our practice. Nica has worked as a therapist for roughly a decade in the Seattle area and works with adults and adolescents aged 13 and older. Before we get started today, can you tell our listeners a little bit about yourself?
Nica Selvaggio: Yes, and thank you so much for the introduction, Jen. I'm really excited to be here talking with you today. That's always such a broad question. I never know where to start, but I guess that is the place to start that from a very young age, I was diagnosed with ADHD, and so my inability to pick where to start is a reflection of what I deal with in my brain. I love being a neurodivergent therapist because it brings a sense of understanding and compassion for folks who struggle with this sort of tangential thinking or not knowing where to start, that I find really, really helpful and I just get a lot of joy out of it.
So all that to say, I'm your local ADHD therapist. I'm originally born and raised in Chicago, the Midwest, and I've been in the Pacific Northwest for most of my adult life. I did spend three years living in Hawaii, and that was a really life-changing experience. And ultimately, I came back to the Seattle area because this land really has my heart.
Jennifer Smith: Wow.
Nica Selvaggio: I always describe myself as someone who's incredibly creative and just a lover of nature.
Jennifer Smith: That's great. And so you moved to the Seattle area from Hawaii. So what would be your favorite parts of the Seattle area, or just Washington as a whole?
Nica Selvaggio: It's the land, it's the mountains, it's the water, the plant life, all of it. I always say because of growing up in the Midwest that I was raised in corn and concrete. So when I moved to the Pacific Northwest and saw these huge mountains for the first time, even after a decade of being here, I'm still in awe. Yeah, I just really, really love the landscape.
Jennifer Smith: That's great. What is it that got you interested in being a therapist?
Nica Selvaggio: Big question. There's this storyline of The Wounded Healer that I think a lot of us are familiar with, that archetype of someone who has gone through their own experiences of pain and suffering, have tended to them, and then turned that compassionate attention outwards towards others who are struggling with similar wounds. My story as a therapist is not so different from that. I became interested in working in mental health out of necessity of caring for my own mental health throughout my life.
I'm a former foster care survivor and an adult adoptee, and so I had exposure from a very young age to some of the suffering in the world and in my own world and experience. So walking that path has really led me to wanting to provide a hand to hold for other folks on their own paths.
Jennifer Smith: Wow, that's really fantastic. Thank you for sharing that. What areas or disorders do you specialize in, besides ADHD?
Nica Selvaggio: Well, I got my start working in the clinical world specializing in eating disorders. So the bulk of my career was spent working in high acuity treatment centers, inpatient level residential, partial hospitalization, intensive outpatient, and working with folks who struggle with things like anorexia, binge-eating disorder, bulimia, ARFID, avoidant restrictive food intake disorder, which is often accompanied with neurodivergence. And when you work with eating disorders, you work with everything.
So people often think of eating disorders as being about literally food and body, and while those are absolutely components of a person's experience with an eating disorder, it's a symptom for an underlying issue. And often what underpins eating disorders is trauma, depression, anxiety, huge contributing factor, and other ways that the brain is sensitive. So for example, someone on the autism spectrum might really struggle with their sensory experience with food, be labeled with having an eating disorder, when really, it's something that's going on in a sensory way for them. It's not accompanied by cognitions and things like that.
So that's the bulk of my experience and I could talk about that forever. But because I'm an ADHD person, I have a million interests and my path has diverged many a time from that foundation of working with eating disorders. So through that work, I found my way into the somatic world in treating trauma because trauma is a huge underpin of most folks with eating disorders. And I got my foot into somatic experiencing, which is working with folks more so through the visceral felt-sense experience of trauma held in their bodies and helping them to let go of it rather than talking the story to death, which can be re-traumatizing for folks at times. Absolutely has some value in reclaiming our narrative and making meaning. However, I found working in the body to be a lot gentler.
Through that world, I found my way into psychedelic assisted therapy. I did a fellowship last summer in Jamaica, working with mushroom assisted therapy, and I've done a couple of trainings in San Francisco for ketamine assisted therapy. So that is a world I'm very interested in. And then gender and sexuality. So I'm non-binary. My pronouns are she/they, and working with trans folks, working with gender sexuality came out of working with eating disorders as well because those populations tend to struggle with eating disorders, body dysmorphia, those sorts of things at a much higher rate than the general population.
Jennifer Smith: Wow.
Nica Selvaggio: And then from there, add in interest in couples work, sex therapy. So a little bit all over the place, but a really strong foundation underneath all of it.
Jennifer Smith: Wow, that's fantastic. And basically that means you can help a lot of different people, which is really great. Your online bio notes that you've been trained in several evidence-based approaches. Can you let our audience know what those are?
Nica Selvaggio: Yeah, and I'm noticing in myself through this interview, I'm talking very fast and not breathing very much because I'm oriented to my own body. I'm going to take a moment and just take a deep breath before I answer you.
Jennifer Smith: Yeah, absolutely.
Nica Selvaggio: Thanks. And if anything-
Jennifer Smith: Oh, I was just just saying-
Nica Selvaggio: Yeah, go ahead Jen.
Jennifer Smith: That's great for our audience to see too. You need a moment, take a moment. There's nothing wrong with that, and I think we could probably all do that at times and we just don't, unfortunately. And then we feel awful.
Nica Selvaggio: Well, we're not really given permission to in our culture and our systems that we operate in.
Jennifer Smith: Yeah, which is unfortunate.
Nica Selvaggio: Yeah. Which ties into that question a little bit about what evidence-based therapies I work with. Most of them I learned when working in treatment settings. So in a lot of eating disorder treatment centers, the foundation of the treatments are evidence-based therapies such as dialectical behavior therapy, DBT, which was developed by Marsha Linehan, and that was a therapy originally developed to treat folks who struggle with extreme emotional dysregulation who are feeling suicidal or are diagnosed with borderline personality disorder. So these extreme swings of mood and inability to regulate.
Off of that came... And that approach is really good for folks who are... The temperament under controlled. So under UC versus OC, under controlled versus over controlled, so more impulsive behaviors, you're going to see things more expressive. You might be able to tell I'm more on the UC side. DBT is great for that. And then on the other side, you've got OC, over control. Those folks are going to have higher levels of generally OCD type thinking, more restricted, flat affect, much more wanting to control their outer experience because their internal world feels so chaotic that it reflects on the outside. In those folks, you're going to see things more like anorexia, restricting behaviors, much more flat affect.
RO-DBT, radically open DBT came out of DBT to help over control folks. So those are two different therapies, even though they have the same name in them, but essentially they're both skills-based therapies that are laid on the foundation of mindfulness and some of our Eastern inspired practices. So as well as another evidence-based therapy that's used a lot in treatment centers, ACT, acceptance and commitment therapy by Stephen Hayes. But these therapies are really trying to bridge the worlds of that grounded mindfulness foundation with concrete skills that people can use to actively change the behaviors that are causing them distress in their lives.
I love a lot of those therapies so much because they work, they can really shift things quickly. I often use those in conjunction with therapies that maybe don't have as much of a robust research base because they haven't had the time or the funding or whatever it is, such as somatic experiencing and more experiential therapies. I went a little bit all over the place.
Jennifer Smith: Thanks. And what about your treatment approach? What's that like?
Nica Selvaggio: Yeah, so I was trained in a clinical mental health counseling master's program and the foundation of my training and program was person-centered humanistic therapy. So for folks who don't know what that means, my foundation of who I am as a clinician, as a counselor is very much through the egalitarian lens of I am not an expert in your life. You are the expert in your life and I'm coming here to join human to human to witness and perhaps equip you with skills that you need in order to change the things that you're wanting to change.
That said, that's the foundation I weave in depending on what a person needs after collaborating with them on what sort of therapy they're interested in working with, all different kinds of approaches. So again, the somatic work is a huge part of my work, bringing in the body. I also do a lot of parts work, internal family systems, and for folks not familiar with that, that involves accessing the different parts of ourselves that are often in conflict. Everyone has different aspects of self that they might connect with at different times. The part of me that's doing this interview with today is my manager part, right? I'm going to present my best self today, but maybe my inner child part is like, "This is scary. I don't like talking in front of people that I can't see." That's an example of parts work.
Who else? Again, super interested in growing more in the psychedelic assisted therapy world. It's really profound powerful work that can really jump start a person's journey, but not to be used without caution and a lot of discernment and support. Yeah, it's just different for everyone.
Jennifer Smith: That's fantastic. I'd like to go back and talk about one of the areas that you can help clients with, and that's regarding their sexual orientation and gender identity. And I was reading on The Trevor Project’s website that they offer 24/7 free, secure access to counselors for young people who are LGBTQ. In a nationwide survey that 41% of LGBTQ people age 13 to 24, so the younger range, seriously considered committing suicide in the past year.
So clearly something's going on here that's severely impacting this population's mental health. So I just have a few questions regarding this, that maybe you can shed some light on.
One is, what types of issues does someone usually struggle with regarding their sexual orientation or gender identity?
Nica Selvaggio: Yeah, I love this question. Thank you for asking this. And first I want to name... I always experience a lot of heaviness in my body when tapping into the sense of powerlessness or hopelessness that comes in for a person to feel like the best option is to end their life, that they've exhausted all of the avenues and this is the best way to escape the pain that they're experiencing when that becomes the option in their brain. This is for so many different reasons and ties to what a lot of folks in the LGBTQIA+ community struggle with, which I want to differentiate that struggling to know what your sexual identity is or your gender identity is, is not in and of itself a pathology or an issue that someone's struggling with.
What people are struggling with is how the systems in the world, how our culture, how our families, how our religions, how all of these things reflect our worthiness of access to resources, safety, the right to use the bathroom in the public. Our daily lived experiences of oppression are the issues that we struggle with, not the fact that we are part of the rainbow community.
So that being said, because of operating or living in a system that... And I can give so many examples of it's February 1st and how many anti-trans legislation bills have been pushed forward this month in January alone? The visceral, physiological, emotional, spiritual, psychological response to being faced with that. Those issues can look like suicidality, that can look like depression, that can look like anxiety, that can look like a nervous system that's chronically stuck in fight, flight or freeze because they're in survival mode because the world is reflecting to them that they're not safe.
Things more classically associated with folks in the LGBTQIA community are things around identity formation. How do I know who I am? How do I put a word or a label to who I am? Do I even want to do that? Is there even a necessity for me to come out and name myself as such? Where do I fit in and belong in this LGBTQ community? How do I move through the world in the straight world? A lot of identity formation issues in that. And again, that's not an issue of pathology in and of itself. Culture's response to that question is the issue.
Substance use is often higher. Again, this is a way of coping with all the things that I've named and eating disorders and body dysmorphia tend to be much higher incidences in the trans and LGBTQ community.
Jennifer Smith: Wow. And eating disorders too, they're often highly correlated with suicidality, correct?
Nica Selvaggio: Yes, yes. Can be. Not all, but yeah, they tend to be.
Jennifer Smith: Wow. Another question I had is often when you're doing paperwork now for a medical provider or surveys, they ask about someone's preferred pronouns. And can you talk a little bit about that, preferred pronouns and how can that affect someone's mental health? Why do they matter? Why do pronouns matter?
Nica Selvaggio: Yeah. Yeah. And I love how you changed the sentence at the end. Why do pronouns matter? Because even the language of preferred can insinuate that it's someone's choice in terms of... Okay, how can I put this? If you knew that the sky was blue and someone came up to you and was like, "You're nuts. The sky is not blue. I see yellow, and you are bad and wrong for thinking that the sky is blue. How could you?” Take it a step further: “You're going to a bad place because you think this sky is blue."
And then I said to you, “Well, you just prefer it to be blue.” Is that a preference or is that just what you see? So a person's preferred pronouns implies that it's an actual preference, when in reality, it's just their lived experience. And so when someone is vulnerable enough to even name their pronouns, even if we don't understand, even if we think the sky is yellow, the reason it's important is because it indicates a level of belief that that person understands and knows themselves better than we could possibly know, their internal experience.
Jennifer Smith: Right.
Nica Selvaggio: It indicates respect for their beingness, and it creates a level of safety for that person who may have moved through many different systems in their life where it was not accepted or not safe for them to use the pronouns that fit for them.
Jennifer Smith: That's fantastic. Thank you. One anecdote that I wanted to share is that in our practice, we were trying to decide internally, "Should we all put our pronouns in our signature block?" And I'd say one-third were gung ho for, "Yes, we should." One-third didn't care. And there were other people who didn't want to, and one of the members of our team said, "Maybe we shouldn't do this, because if a person isn't comfortable saying what their pronouns are, we're forcing them to either disclose their pronouns or force them to put stereotypical pronouns that you would think that they should be.” And for me, that was really eye-opening.
So for that reason, I went on the bandwagon of I'm not putting pronouns. That way, if someone else didn't want to, they didn't feel like they had to as well.
So I thought that was really interesting, that pronouns can really mean so much to a person and just... Yeah. So thank you for explaining that, that it really does matter.
Nica Selvaggio: Yeah, absolutely. And I love, thank you to that person who brought that point up because that's always what I like to... Oftentimes when we're trying to show up as allies in support of a community that we're not part of, it's easy to misstep and to do things out of good heart and good intention, but ultimately can contribute further to harm. And the pronouns in the bio or in your email signatures requirement is one of those ways where it's like, "Oh, we're trying to help normalize it for everyone." But again, you don't know who you're requiring to out themselves or to live falsely.
Jennifer Smith: Right. That's fantastic. And that's why part of the reason that we do this series is to help educate people and just explain things. Thank you.
Nica Selvaggio: Yeah, thank you.
Jennifer Smith: Yeah. So what can you say to people who simply might not have any understanding or have confusion about what we've just been talking about and just don't understand the distress that some people might have about identity or orientation or pronouns? Why is it a big deal?
Nica Selvaggio: Yeah. I always come back to why do we need to understand? I don't even understand myself. Why do I need to understand another person's experience for their experience to be legitimate and valid for them? I don't. In fact, it's often impossible to try. I can do my best, but I can't ever fully step into another person's experience. And so we don't actually require understanding. We require respect and compassion, just to be believed. Right? And you can compare this across many different experiences of identity. I will never know what it's like to walk through the world, say, as an Arabic man, I don't know what that is.
Jennifer Smith: Right.
Nica Selvaggio: It's not for me to try to understand. It's for me to listen and believe and provide respect. So first throwing away that word understanding, we don't need to understand. What I would say is have you... I would invite folks who really just don't get what the big deal is about to reflect on if there's ever been something in their own life that was really important to them, that they really cared a lot about, but that was dismissed or diminished, or they were told that they were foolish or crazy even for caring about that thing.
And we can do this together too, but just to take a moment and really call to mind that feeling, that memory and see what happens inside. So I notice immediately I start to contract, I start to constrict, and I start to want to feel small and to hide myself. Other folks might have a different experience. Maybe they feel angry, they want to fight back. There's no wrong response here. Just notice how do you feel when you're invalidated, misunderstood, and told that you're wrong to care about the things that you care about? Generally not pleasant.
So when we show up in that way, we're often perpetuating more of the same for people around us. If we've experienced that, then we're going to put that out on others too. Like, "Well, I had to conform. I had to shut down this part of myself, so how dare you not do that?" Right? We face a lot of anger from folks oftentimes as a result of that. Yeah. And what would the world be like if we had more spaciousness for those pauses to actually feel into, what am I reacting to in my not understanding? Am I being reminded of a time that I didn't feel understood? How can I show up in a more compassionate way?
Jennifer Smith: That's great. Thank you. Our final question, which I'm a little bummed to say because I thought this has been great. Do you have any words of advice or anything else that you'd like to say to our listeners today?
Nica Selvaggio: Be gentle with yourself. Working as a clinician, as a counselor, as a therapist, through some of these major world and global events that we've been experiencing collectively over the past decade, something I've noticed in the broader populations is that levels of fear are very high. Anxiety is very high, which makes sense. And levels of burnout, feeling like we just cannot continue on are very high. Levels of trauma and secondary trauma are very high.
In the midst of all of that, I want to invite all of us to both stand in the center of honoring and witnessing our sacred human struggles together, and also find those spaces in which things feel a little bit lighter, or we can expand more and access things like rest and pleasure and resilience, and that both of those things need to coexist in order to show up in a more whole way. So gentle, gentle, gentle, gentle. Show up when you can. Rest when you can.
Jennifer Smith: That's fantastic. Thank you so much, Nica, for finding time to speak with us today.
Nica Selvaggio: Thank you for having me.
Jennifer Smith: And for our listeners, if anybody is interested in scheduling an in-person or telehealth appointment with Nica, you can do so and self-schedule at seattleanxiety.com. Thanks again and have a great 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.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychiatrist Peter Reiss
Peter Reiss, M.D. is psychiatrist at Seattle Anxiety Specialists, PLLC. Dr. Reiss specializes in the treatment and medication management of anxiety related disorders.
Jennifer Smith: Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
I'd like to welcome with us Dr. Peter Reiss, who is one of the psychiatric providers at our practice. Peter has extensive experience with psychiatric medication management and has worked in multiple levels of care in the Seattle area, including inpatient, outpatient, partial hospitalization, and residential treatment programs, as well as in the psychiatric emergency room.
Before we get started today, can you tell our listeners a little bit about yourself?
Peter Reiss: Yeah. Hi, Jennifer. Thanks for having me, and inviting me for this interview series. As you said, I worked in quite a few places before I started working as an outpatient psychiatrist here. I took a slightly different route than the traditional way of, "What do you do when you start working after residency?"
I initially started working as a locum tenens, which includes more short-term contracts. I was doing six months to a year at different kinds of levels of psychiatric care. It just gave me a way to see what kind of psychiatric jobs I like, and it gave me an opportunity to see what the mental health resources are in the area. And, just gave me a chance to see what I could see myself doing in the long run.
Jennifer Smith: That's great. I think, like you said, to have all that different exposure probably makes you a really well-rounded psychiatrist. I think that's fantastic. Great.
Peter Reiss: I did think that. It just gave me a little bit more opportunities to really see what different acuities look like on different levels of care.
I wouldn't change a thing, so I'm very happy I did it this way.
Jennifer Smith: Fantastic. Just to let our listeners know a little bit more about yourself as well, what are your favorite parts of the Seattle area or Washington as a whole?
Peter Reiss: So, the first time we came to Seattle, I just immediately loved the area. I do think that it has this very special kind of culture. I love how it combines the urban and the nature, and just the fact that there's so much to do. Especially in the summer, with festivals going on. And, even the winter, I mean, people do complain about, or some people say we have particularly bad winters, but, in the middle of winter, it's 55 degrees, and you can go hiking or do whatever if you're okay with a little bit of rain.
Jennifer Smith: The saying is "It's not bad weather, it's bad clothing," or something like that. Right?
Peter Reiss: Well, I think our weather is our best kept secret.
Jennifer Smith: Yes.
Peter Reiss: Not as bad as people say.
Jennifer Smith: Exactly.
Peter Reiss: Or, have the reputation.
Jennifer Smith: Right?
Peter Reiss: Yeah.
Jennifer Smith: Exactly. That's great. And, what is it that got you interested in becoming a psychiatrist?
Peter Reiss: So, I didn't start out in medical school wanting to be a psychiatrist. I did keep my options open. I was leaning more towards primary care, internal medicine, possibly emergency medicine. I always knew that psychiatry and mental health is important, and that it's kind of very ubiquitous anywhere you go in medicine.
I didn't think about psychiatry a whole lot until my third year in medical school when I had my real introduction to psychiatry, where I went to the psych ward and other psych facilities for my medical school rotation. And, I just immediately loved it. I liked how it's just slightly different than other fields of medicine. It kind of forces you to think more outside of the box. It doesn't necessarily follow the standard algorithms that we have in medicine. There's a lot more nuance and room for interpretation, and it's probably the least well-understood specialty in medicine as well. So, I did the fact that there's just so much more that potential will change in the specialty in the near future hopefully.
Jennifer Smith: That's fantastic. One question that we're often asked is, "Should I see a therapist or should I see a psychiatrist, or both?" And, can you explain the difference to our audience why should someone see either of these two professions?
Peter Reiss: Mm-hmm. Yeah. So, we do have quite a good variety of mental health specialists for anyone wanting to see treatment for any mental health problems. The two options, generally, are to see a medical doctor, so a psychiatrist, or see somebody who'll focus more on non-pharmaceutical management, which would be a therapist, which would typically be clinical social workers or psychologists by training. And, it sometimes comes down to personal choice what people prefer.
I would say, if somebody's psychiatric symptoms are fairly mild, they might need to see a psychiatrist. So, not everybody would be necessarily a candidate for psychiatric medications.
Psychiatrists themselves rarely practice psychotherapy anymore. It used to be different. We are trained in psychotherapy. We do go through all these different didactical trainings, how to provide different modalities of psychotherapy, and it used to be much more prevalent back, really, back in the seventies, eighties, up to nineties, where many psychiatrists were still offering psychotherapy. But, mostly due to our insurance landscape, it really has changed that that responsibility has fallen more to clinical social workers and psychologists who are very, very qualified to provide that training. And, they're really specialized in all these different training modalities, since there's just so many of them. So, somebody who has PTSD is getting different psychotherapy than somebody who has an anxiety disorder or depression.
And, it's really hard for a therapist to be very good at all of these therapy modalities. So, I think sort of the specialization among the different therapies works very well, and it's great to just share that professional space with all these very qualified therapists that we work with.
Jennifer Smith: Wow. Have there been times when a patient will come to you and you realize this person probably doesn't need medication - do you refer them to therapy? Does that ever happen?
Peter Reiss: Oh yeah. That is quite common.
I mean, I would say, in the majority of cases, probably at least a trial of medication might be helpful, just for the patient to engage better in psychotherapy if symptoms are just a little bit too severe at that time. But, for a lot of mild cases of the anxiety and depressive disorders, often starting with therapy alone might be a good option.
Jennifer Smith: Okay, fantastic. In what ways can someone's mental health impact their physical health?
Peter Reiss: So, that's actually a really good question. I think most people do understand the connection between chronic medical conditions causing psychiatric symptoms to worsen, but it's really also the other way around. So, I mean, for example, most psychiatric disorders, whether it's anxiety disorders, whether it's depressive disorders, trauma, excessive trauma responses, they typically cause physiological changes as well. Things like, for example, chronically increased stress hormones, like cortisol. And, that can have an impact on immune function, it can increase somebody's risk for cardiovascular issues.
And then also, indirectly, somebody who has low executive functioning, low motivation due do psychiatric issues, is less likely to take care of themselves and engage in these kind of activating behaviors that tend to improve one's mental and physical health.
If somebody, for example, is less likely to engage in things that are good for social connections, that leads to loneliness. And that, in itself, leads to worsening mental health and physical health as well just due to increasing chronic stress and things like that.
Jennifer Smith: Oh, wow. So, when they say, "Mental health IS health," it really is true.
Peter Reiss: Oh, it is absolutely true. I mean the two... It's not only that it's just in your head, right? It does cause real physiological changes, whether those are directly caused by mental health issues or indirectly.
Jennifer Smith: Right. Can you talk a little bit about your treatment approach?
Peter Reiss: So, I emphasize a lot of psychoeducation, making sure that I meet my patients where they're at, and also give them as clear information about what's going on for them to make the best informed decision.
Sometimes, maybe, they have a particular treatment modality in mind, particular medications or whatnot. Just, trying to understand what their idea is, where they're coming from. So, our treatment goals might be different; we might not always agree, and that's not necessarily wrong. But, giving them as much information as I can for them to make the most informed decisions, that's very important to me.
Then also, I tend to put a big emphasis on always reassessing... Just, speaking specifically about medication management, to reevaluate the need for a particular medication. Sometimes, patients come to me having been on one medication for 10 years. We don't know if they still need to be on that. We don't need... Maybe they need to be on something different. We need to reevaluate what, really, each component of their treatment is really doing, if it still has any effect on their mental health. Sometimes, less is more with psychopharmacology.
I do always want to do check-ins, even with patients who have been on a long-term medication, "Is that really necessary, and what can we do about it?"
Jennifer Smith: That's really great that you work with a patient. And, it sounds like you strive to just get the optimal dose and really not put things that are not... Meaning that you don't do unnecessary things.
Peter Reiss: Right, because each medication could not have side effects; it could have unwanted side effects; or, something else that the patient might not know about. So, they're still... Psychiatric medication's still among the safest medication in medications in general, but we shouldn't take it lightly to have somebody on long-term medications generally.
Usually, it's not a problem. We just have to do it the right way.
Jennifer Smith: Right. And, what type of disorders do you specialize in?
Peter Reiss: So, the disorders that I see here in the clinic are fairly standard, the average psychiatric disorders, including the depressive disorders, wide variety of anxiety disorders, including OCD and different kinds of phobia. We do see ADHD patients here in our clinic as well, patients with PTSD and more trauma-related issues, and also different levels of functioning. So, there's many of my patients who are really doing well, especially on the surface. They're able to do their day-to-day activities. And then, there's patients who are not doing well at this time, who might not be able to have a job right now. So, it's a big variety of different psychiatric issues that we're dealing with, but also, different, wide variety of patient needs.
Jennifer Smith: And, let's say that I was going to sign up for an appointment with you. You are a medical doctor, so of course, I would have to complete the intake paperwork so you have an idea of where I'm coming from, what medications I'm on, my past history. So that's, I think, pretty standard. But, after that, I have no idea what to expect. So, what can I expect in the first session with you? What would we do? What would we talk about?
Peter Reiss: Mm-hmm. Yeah.
So, after a patient signs up for an appointment, there's the initial intake. That can be done either here in my office, in person, or it could be done remotely. There's always those two options. On most days during the week, I have those two options available.
The first session is just gathering a lot of information, getting to know the patient. And, that typically takes at least 45 minutes to an hour so we are clear on establishing a diagnosis, getting enough information about the patient's medical background, mental health background, social background. And, the last part of the initial meeting... Well, there's initially the psychiatric interview, and then, we kind of talk about what we're going to do.
And, if there's any disagreements, or the patient might need a little more time to think about these different options, we might talk about... Besides different medication options, we might talk about potential referrals for therapy as well to see if there's somebody who might have that particular therapy skillset that the patient needs, whether that's in our office or outside of our office.
And then. If the patient decides to be a patient with us, there would be a follow-up appointment to check in, within usually two to four weeks or so. Depending on the acuity, really, and if there's any problems.
Jennifer Smith: Okay. And, that actually leads to my next question regarding follow-ups. So, at our practice, we have a form of concierge care. Can you explain what that is to the audience? And, how does it differ from a traditional practice, and what are the benefits that our patients may have?
Peter Reiss: Mm-hmm. So, the main difference with concierge care is really that it's a subscription-based access to our services.
In a traditional setting, patients would have their appointment and then schedule follow-ups, and then, essentially, the difference in payment would just be that they would pay for each follow-up appointment. But, a subscription-based model of concierge care, it's really that patients pay a monthly subscription for, essentially, unlimited access. So, they can have one appointment, they can have two appointments; they have access to their psychiatrist via messaging system or email. It just makes it easier for us to respond in real-time to any issues that might come up.
It also helps us to see who is continuing care at a regular interval. So, sometimes in outpatient psychiatry, it becomes a little tricky, because patients might be partially lost to follow up. They might not show up for an appointment, so we're not sure is that patient still patient with us, right? But, with a subscription model, we at least know, "Oh, that patient actually wants to continue, and that patient will continue with their follow-up appointments."
So, I think it helps with patient retention in the outpatient setting.
Jennifer Smith: Great. And, I think one thing that I've noticed from the administrative end is that, because we essentially cap the number of patients that our psychiatrists will see, and you've kind of alluded to this, that our patients really can have unlimited access, to a degree, because you're seeing X amount of patients and not thousands of patients. So, there's just more time that you can give each of your patients, which I really think makes more specialized care as well.
Peter Reiss: Mm-hmm. Yeah. So, our overall patient numbers are lower than you would see in a typical outpatient clinics, which helps with just the time that we give each patient. We're not necessarily back-to-back.
I mean, there's some days where we see more patients than other days, but it just feels a little bit more... It feels a little more less time pressure, to give that extra time as well, whether it's directly during the appointment or to communicate with the patient through our messaging system and hone in their treatment that way.
Jennifer Smith: Wonderful. So, our final question, do you have any words of advice, or anything else that you would like to say to our listeners today?
Peter Reiss: So, the main thing that I probably would say is that, to somebody who's starting out with their mental health recovery, really seeing that they want to get treatment, it initially seems very daunting, but I do want to say that it does get easier when somebody is actually establishing care and is getting the help that they need.
And, oftentimes, we often forget to check in with ourselves, especially when we're in treatment, making sure that we're really doing well, that we're not just doing okay, that we're really thriving and flourishing. And, that can mean different things to many people, obviously. But, often, what suffering from a lot of mental disorders and mental illness does to us, we're losing the sense of self-worth and almost like forgetting what our normal... We're getting used to this normal baseline of functioning and being. And, sometimes, it becomes difficult to keep track of what our purpose is in life and what we can do to thrive.
So, don't settle for any less when it comes to your mental health. That would be my main advice.
Jennifer Smith: That's great. Thank you so much for your time today.
If anyone is interested in scheduling an in-person or a telehealth appointment with Dr. Reiss to discuss psychiatric care and medication management, you can self-schedule at seattleanxiety.com
Thank you again, Dr. Reiss, we appreciate your time.
Peter Reiss: Thank you, Jennifer. Good seeing you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Monica Reis-Bergan
Monica Reis-Bergan, Ph.D. is Professor and Assistant Department Head of Psychology at James Madison University. She specializes in the personality psychology.
Kendall Hewitt: Hi everyone. Thank you for joining today for this installment of The Seattle Psychiatrist Interview Series. I'm Kendall Hewitt, an interdisciplinary research intern at the Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice, specializing in anxiety disorders.
I'd like to welcome Dr. Monica Reis-Bergan today. Dr. Monica Reis-Bergan is a professor and assistant department head of psychology at James Madison University. She's an expert in the field of personality psychology, health psychology, and addictive behaviors, and has written several articles on the topic, including The Impact of Reminiscence on Socially Active Elderly Women's Reactions to Social Comparisons, and Self-esteem, Self-Serving Cognitions, and Health Risk Behavior. Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying health and personality?
Monica Reis-Bergan: Hi. Well, first of all thank you for talking with me today. My interest in personality really comes from the opportunity to teach personality at James Madison University. In my research field in health and social psychology, personality is often a variable that's measured and sometimes just controlled for to see how different interventions might impact individuals. Over my time at JMU, I have really learned to love it as a teaching domain and also use it in my research, especially more recent research looking at health and social media.
Kendall Hewitt: Perfect. So, would you give us a little description of what personality psychology actually is and why it's interesting to researchers?
Monica Reis-Bergan: So, personality psychology is a relatively large and yet small area of psychology. So, it's large in that it impacts so many different disciplines in psychology, but it's small in that the researchers and theorists that focus on it and would focus only on it are very tiny. So, within personality, we talk about what is personality, and even looking at the definition of personality as something that different theoretical viewpoints don't always agree on as far as what it is. But in general, when we talk about personality, we're talking about some kind of enduring characteristic behavior pattern. As I like to tell my students, it's something that you know the person has and is often very difficult to change.
In terms of why is it interesting to researchers and really anyone, it's that for whatever situation you might have or even research paradigm, we recognize that people are coming with their own individual differences, and one of those individual differences is these elements of personality. So, trying to assess what that is, and then also, can you change it, and then the impact it has is what makes this such a great field.
Kendall Hewitt: Awesome, thank you so much. And I know we've talked a little bit about what personality psychology is, but in the way of categorizing personality, that's changed over time in my understanding. So, can you expand a little bit on that topic a little bit more and explain what system we use to categorize personality psychology today?
Monica Reis-Bergan: Well, I think that I would say that if you look at how do we categorize, and I think you're using that kind of making types or quality approach, it is changing and it will continue to change. As I tell my students, what they're studying today could be very different than what they're going to find in 2050. As we develop our assessment tools, we develop the ability to look at things in more and more detail and look at those differentiations. Each domain of personality also has a different way of thinking about it. So, if you look at a psychoanalytic perspective, you're often talking about types.
If we look at it from a trait perspective, the Big 5, HEXACO model, what are the models of the future in that sense? And then also, as culture changes, we start to develop different personality variables that we think are important. So, 30 years ago, we wouldn't have had a measure of FOMO or something of that nature. So, I think it's really important, especially when we look at personality, to have a contextual understanding of what do we have today, how do we think about it today, and that will be different tomorrow.
Kendall Hewitt: And then how are you able to use your knowledge of personality psychology in the real world? Do you often find yourself analyzing others around you and using your knowledge to understand them better?
Monica Reis-Bergan: That's a good one. In a sense that I think I'm always thinking about people, but I'm not sure that's because I'm a personality researcher that I would do that. I think we all naturally think about people and notice differences in people. I think that's why it's very interesting for people to try to create a type or a characterization of a particular type of person. My orientation is much more a social psychology with a personality perspective. So, I'm always looking at the social environment to see what factors I think might be related to why a person is displaying a certain behavior that they have. So, I'm not as true personality as some people might be in that sense.
Kendall Hewitt: And then what is one piece of your research that you've found the most interesting in your time when looking at personality? And is there any research questions or topics within research for personality that you want to explore more?
Monica Reis-Bergan: So last year, and we're in the process of working on this manuscript now, I worked with an honor's student that was very interested in TikTok, and to be honest, she thought TikTok was terrible for people, and that's a different conversation topic. But what it led to was really good conversations about what are some of the factors that might make... what are some people who might be impacted by TikTok more positively or negatively? And the personality variable that we chose to study was social comparison orientation, and this is the individual difference variable in terms of how much a person compares themselves with others in their environment, just more generally.
Specifically, the study that we did looked at TikTok engagement and young college women, and so how much they clicked on, they liked, those kinds of things to different kinds of TikTok material. And what we found was that individuals who engaged in TikTok, so liked, all of those things, in addition to having high social comparison orientation, meaning they were more likely to compare with others, had more of the negative body eating disorder types of symptoms associated with TikTok. So, while we couldn't say that TikTok was bad for everyone, we could say there does seem to be a relation between TikTok engagement and this personality variable on this outcome variable, so.
Kendall Hewitt: That's super interesting. Is there anything that you hope to research in the future within the personality field?
Monica Reis-Bergan: So, some current studies right now are students that are looking at super fan behavior. So, the idea that 20 years ago we would've maybe read a book about someone, but now, influencers, celebrities, we have almost daily information about them, especially if you're someone that's scouring multiple social media sites and other kinds of information. So, what types of people are more likely to develop these parasocial relationships with celebrities or influencers? And specifically, are there certain personality indicators that might make some people more likely to be super fans?
Kendall Hewitt: That's very interesting. I'd be very interested to read that research in the future.
Monica Reis-Bergan: We just finished data collection and we did find among our college students that about 50% identify as super fans or “stans”, I guess, is the word.
Kendall Hewitt: Got it.
Monica Reis-Bergan: So, we found that super interesting,
Kendall Hewitt: Very interesting. And then going into that, many children and adolescents these days are using BuzzFeed quizzes or magazine quizzes to find what their personality type is. How do you feel about that and how accurate would you say that those are?
Monica Reis-Bergan: So, as you know from my class, I really believe that if we're going to have a measure, we really need to look at the reliability and validity of that measure. And that's often a pretty painstaking process in psychology to make sure we have enough types of validity evidence to really have faith in our measures. So, a lot of the measures you're going to find on TikTok or BuzzFeed or wherever are not going to be particularly valid. However, I think that there's a lot of value in talking about personality and talking to your boss or your friends or your family, just about the enduring characteristics, the behaviors that you perceive for yourself to be stable, that is valuable self-knowledge.
We do know that our own perceptions of our own personality have what we might call causal force. Like, if I think I'm really friendly, I'm more likely to go and do things that I think friendly people do. And then if other people think I'm friendly, they're more likely to select me to be in clubs and organizations. So that self-knowledge piece, even if it's not the exact correct number, maybe you're really a 35.7 instead of a 23.2, but just the knowledge that you have about yourself I think is very valuable.
Kendall Hewitt: So, do you think it would be beneficial for people to actually take valid and reliable quizzes to know what their personality type is?
Monica Reis-Bergan: I mean, I do think that especially that's part of that metacognitive self-discovery if someone's so inclined. However, I honestly think people can live happily ever after without ever knowing their score and extraversion as well. So, I think it really comes down to a lot of psychology is when you have a problem, let's explore what the problem might be. In that case, I think personality is a great thing to look at what kind of enduring beliefs, cognitions, behaviors do people have, especially that don't seem to change based on situations, as a great way to see how can this be an issue, likewise people who are striving to be better, to also have that self-reflection. But I don't think it's necessary.
Kendall Hewitt: And then how popular and accessible do you think the study and research of personality psychology is compared to other psychology disciplines such as social psychology? I know you mentioned that earlier. How accessible do you think that personality psychology is to the general public?
Monica Reis-Bergan: I'm going to start or stage back from that question. I think personality research is almost everywhere because a lot of your clinical research, your I/O research, your health research, they're including personality measures in them, because as they try to look, they're going, and we're going to account for this individual difference. We're going to measure this difference. We think this difference might be important. So, it really transcends far beyond personality journals per se. So that's number one. But as far as the general population, I do think that the language we use in personality is so universal, and so it comes from language in part.
We talk about, where did our traits come from? They come from the differences in people that we notice and then we create a word for that difference. And then we have that word in our language. Allport used the dictionary to help determine what kind of traits people might have. And I think that happens in every culture, not just the English language. We want to notice and identify those people that we want to seek or we want to stay away from. So, I think it's there whether it's always in the language that researchers or theorists use, maybe not. But I also think FOMO is a great example. Fear of missing out came in part from culture as a variable that people notice this person has this fear of missing out. Okay, let's develop a scale to measure it.
Kendall Hewitt: Yes, that's really interesting. I feel like there's always new scales coming out. You mentioned that personality psychology is always going to consistently change. And I want to take a step back, could you explain your education and career path that brought you to where you are today? And if someone were to take a similar career path, what advice would you give them?
Monica Reis-Bergan: So, as I mentioned at the very beginning, I don't necessarily consider personality psychology as part of my professional identity. I'm really more of a health social psychologist. In the part of my college degree, obviously, I took a personality class. We obviously measured personality in almost all of our studies, but I didn't think of myself as a personality psychologist because I wasn't... At that time, I felt like because I wasn't trying to understand what personality was, instead I was using personality to ask other questions and being like, this might impact these people in a different way than it would impact people with a different personality per se. And that's really how I think about myself today as well. I appreciate personality, I love teaching it but to try to actually understand it from just the sole study of personality, I'm really more interested in how it's related to other kinds of behaviors like social media, health, substance use, those kinds of things.
As far as advice to other students, I think I tell all of my students to look and see what you're curious about and realize that those curiosities can change. And personality finds itself in a lot of different domains, whether it's cognitive, it can be I/O, it can be all of these different areas that students might be curious about, and then think, oh, what personality individual difference might be important to study? So, personality is really nice to teach because I feel like students have a lot of different opportunities of which to interact with it and may pursue it more depending on the opportunities they have.
Kendall Hewitt: And once you finished your bachelor's degree, did you go straight into a master's and then straight into a PhD, or how did that fit into your life?
Monica Reis-Bergan: So yes. So, I went directly from my undergraduate degree into a PhD program of which I got my master's degree as part of that, and all of them at the same school.
Kendall Hewitt: Oh, wow. What was that like for you? Did you enjoy doing the master's along the way programs and finishing your PhD that way?
Monica Reis-Bergan: Yeah. So, I was a little bit strange in that I was an elementary education major, who then had a double major in psychology that started as a minor, and I actually was planning to teach and I also happened to be doing research, a paid research assistant, and it just came about that I was so curious. It was in the early '90s and some of the questions about HIV/AIDS datasets that we were working with and just questions about people's health cognitions was very curious for me. And so, I just started doing the lab work and then I happen to have an extra class, so I took an advanced statistics class and then they were like, oh, have you considered graduate school? I'm a first-generation college student, I really hadn't. And then it was like, well, apply to graduate school. And so, I didn't really have the knowledge, skills, or experience to really scope out schools and think about it in that way. I was very fortunate that I had people that saw in me that this might be a good career path.
Kendall Hewitt: Very nice. And then once you graduated from your PhD program, did you go right into teaching psychology at a university and just begin research through that?
Monica Reis-Bergan: So obviously, you do a lot of research in graduate school. And in my case, I also did quite a bit of teaching. So, my first personality class, I actually taught at community college while I was working on my PhD and teaching at the university. So that was a lot to do, but I loved teaching personality. It's such a fun topic to teach and students are so excited to learn about it. So, a little different experience than my teaching statistics that they're not always so thrilled about. So definitely, I was looking for an academic home where I would have the opportunity to teach, as well as the opportunity to do research and work with students in that way. So actually, when I got here, I really hoped I would teach social psychology because I love social psychology. But I've been here for 23 years, and that class has always been filled by another faculty member, and so I just keep teaching personality very happily and health psych and research methods and statistics. I guess my position at James Madison is what cemented and really made me appreciate even more personality.
Kendall Hewitt: That's very interesting. And you've mentioned, so as a health and personality expert, are there any tips that you would give college students or research excerpts that you believe would be beneficial for everyone to know?
Monica Reis-Bergan: I don't know that I have a really great answer to that, but I think one of the things from teaching personality, and I'm just going to talk a little bit about my final project in my personality class, is that I have students who are already so interested in people, do a psychobiography project, and in that psychobiography project, they study someone in depth and then they think about how the different personality theories, which are pretty different from one another- you have a psychoanalytic theory, you have a phenomenological theory, you have trait theory, you have social cognitive theory- really fundamental different ways of thinking about what personality is and how it impacts people, to take those different lenses and look at one person. And when we look at the reflections from that assignment, what I find is that a lot of students start to realize that you have this person and this behavior, and it can really be interpreted in a multitude of different ways.
And I think that, that appreciation I think is what's important. So, when you see someone and they're behaving in a certain way, one of the questions might be why, and that why really depends on the view or the lens or the perspective that you're looking at. And the next steps really depend on the perspective you're looking at. So, I think it's important for students and people to be open-minded in that process of, there's not just one answer, they don't have a personality type, they're not an X person, for example, but let's look at it from all these different perspectives.
Kendall Hewitt: Very interesting. And then lastly, is there anything else you'd like to share with our listeners today?
Monica Reis-Bergan: Personality just is this great phenomenon. I always tell students, it's within the person. You can't go to the store and buy a new one. It's not like a backpack on the first day of school. And so, I think we will continue to be perplexed by what it is, to see how it changes. The more we learn about biopsychology, the more we learn and study how... biological functioning, the connection between mind and body, we might even learn more about personality from that. And then at the same time, our cultural world is changing, looking at how COVID could change locus of control and those kinds of things. So, I think it's just a really great and exciting place to study and to think about.
Kendall Hewitt: Well, thank you so much for joining us today and giving all your insight. I hope our listeners enjoy!
Monica Reis-Bergan: All righty. Thank you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Clinical Psychologist Rebecca Shiner
Rebecca Shiner, Ph.D. is Professor of Psychological and Brain Sciences at Colgate University. She specializes in the intersection of personality, clinical, and developmental psychology.
Sara Wilson: Hi, everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Sara Wilson, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
And today I'd like to welcome with us clinical psychologist, Rebecca Shiner. Dr. Shiner is Charles A. Dana Professor of Psychological and Brain Sciences at Colgate University. Dr. Shiner is recognized for her pioneering research at the intersection of personality, clinical, and developmental psychology. In addition to the books Handbook of Temperament and Handbook of Personality Development, she has written extensively on the assessment causes and consequences of personality disorders in youth. 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 personality development and its implications?
Rebecca Shiner: Okay. Yeah, thank you so much for inviting me to do this, Sara. I'm really looking forward to it. I got interested in studying personality development when I was in seventh grade. I'm not sure if you want me to go back this far, but anyhow, I will tell you briefly the story. So when I was in seventh grade, I had to write my first term paper, and it felt like a very big deal and very serious. And so I went to the library looking for sources of inspiration, and I came across a book that was a children's book about Freud. And so it covered all of Freud's theories in age-appropriate levels of description. It went and talked about the anal stage, the oral stage, the Oedipus complex, all of that. And when I read it, I thought, "Oh my gosh, this is amazing. I can't believe that no one ever told me about this."
And I was just completely captivated. There was something about taking seriously the idea that there's continuity across the course of people's lives, but also that people change over time that just grabbed me. And so I wrote my term paper on Freud, and that really has been my passion ever since. And so when I got to grad school and I realized that I could actually study people's development over time, that I could look at longitudinal studies where they follow the same group of people and I could look for traces of continuity and change, I decided that that's what I wanted to do.
Sara Wilson: That's beautiful. I love that.
So in a recent talk you gave about narrative identity in the context of personality disorders in adolescence, you've discussed three levels of personality over the course of our development. Could you introduce each of these to our audience?
Rebecca Shiner: Okay, sure. So personality is more than just people's personality traits. So I think often when people hear the term personality, the first thing they think of is personality traits. And that really is an essential part of our personality. So our traits are the ways that we tend to be at least somewhat consistent across situations and across time, and they summarize general ways that we have of interacting with the world. A good example of a personality trait that everyone knows, I think, is extroversion versus introversion. But another trait that's really relevant to clinical psychology is neuroticism, which ties into Freud. And also really what it reflects is our individual differences in how much we're prone to experiencing negative emotions like anxiety and irritability, vulnerability, and so on. So those are traits, and those emerge early in terms of our temperament. Some of the traits even emerge within infancy, although they change considerably over time.
Okay, so that's the first level, level one. Then the next level is level two. And level two, it has different names. Sometimes it's called characteristic adaptations, but level two has to do with tendencies that we have in terms of what we're trying to accomplish and the goals we're pursuing, the ways that we're motivated in our daily lives. So for example, people vary in terms of the goals that they have for themselves. So for one person, it might be deeply important for them to connect with other people, and then another person might have really strong motives for achievement, or you may have different goals depending on the context you're thinking about. So that's level two, and then that emerges elementary school age when kids start to be more able to control what they're doing and are able to really act as motivated young people.
And then finally, the last part is level three, it's narrative identity. And so that's what we're going to be focusing on today. This does not emerge until adolescence. And narrative identity has to do with individual differences in the way that we make sense of our lives, in terms of the stories that are important to us that we use to tell who we are and what we are about, how our past is connected with who we are in the present and the future. So we vary, very much in terms of the way that we narrate or tell the stories of our lives.
So a good example would actually be the story that I told you about why I decided to study personality development. That was a narrative describing how I came to be excited about this area of research, and we could analyze it in terms of different themes that pop up or how the emotional language in it is positive versus negative and so on. So we all grow in terms of the stories that we tell. As I said, it starts in late or middle to late adolescence, and then it's something that we're really working on over the whole course of our lives.
Sara Wilson: Yeah, so interesting. Yeah, that example's so good too.
Now, where does a personality disorder come into all of this, and why is narrative identity relevant? What is a personality disorder?
Rebecca Shiner: Okay, okay. So yeah, we'll start by talking a little bit about what a personality disorder is. Personality disorders are distinguished from other psychological disorders that people might have in a couple of different ways. The key features of them are that people are experiencing persistent difficulties in terms of their sense of self or sense of identity and/or, in most cases, and, they're struggling with different aspects of how they're relating to other people. So it's a fundamental disturbance in both the sense of self and in the sense of relatedness to other people. And so clearly identity is part of that because some of the disturbances in the self have to do with disturbances in the person's sense of identity, in terms of how they understand themselves, say across time, or how they see themselves in terms of their self-esteem and so on. There is a very big burst of interest right now in trying to understand how narrative identity relates to personality disorders because people haven't really been studying that directly until I would say the last five years or so.
Sara Wilson: Yeah, I think that this topic is so interesting, especially narrative identity, just because you have, in some sense, so much agency over the active construction of this self, and then at the same time, it's like a working schema that affects the self directly. So it's like this feedback loop.
Rebecca Shiner: Yeah, I agree. I think it's an exciting area to research because I think there's... And it's exciting from a clinical perspective too, because I think there's more of a sense of potential for making significant changes in narrative identity, in part because it's likely to be less heritable and is really evolving over time. So yeah, there's the potential for change there.
Sara Wilson: Yeah. One thing that I was very curious about was how does narrative identity differ from our actual real identity? And I don't even know what that means, I guess.
Rebecca Shiner: No, no, it's a great question because I think that there are different ways of conceptualizing identity. So very often when people think about identity, they think about it in terms of just how we see ourselves in terms of our role, in terms of our sense of vocation. So for example, a person's identity may involve their race or their sex or their sexual orientation. It may involve the kind of occupation that they have or their status as being a married person or a parent and so on. And those aspects of identity are fundamentally important to who we are as individuals, but they're distinct from narrative identity because narrative identity really has more to do with how we tell the stories of our lives. So you could be someone who has exactly the same sense of identity across all of these dimensions as another person, and yet your narrative identity is still going to be distinct to you because it's going to have to do with your own history and how you make sense of how your earlier experiences have impacted who you are now.
Sara Wilson: Now, as you have conveyed in a lot of your work, feeling a lack of agency over your life can really be the root of enduring mental health and personality problems. But then on the flip side, it might also come with this immense pressure to define who we are and take action because our narrative isn't going to write itself. And I was curious how, from your point of view, we should go about reconciling this kind of tension that comes with narrative identity.
Rebecca Shiner: Yeah. So let me say a little bit about what agency is and how that links up because I think that these ideas can be very abstract and hard to understand. When people share a story from their past, those stories that they tell, you can actually look at them across a bunch of different dimensions. And when people are doing research on narratives, what they do is they ask people to tell the story about something significant, for example, a turning point that helped establish their sense of who they are. So you can take those stories and you can code them along dimensions that typically characterize stories that people tell.
And so one of the really fundamental dimensions that you can look at, or you can at least look for in any narrative is a sense of agency. That is considered a motivational theme that gets at how people understand themselves in terms of how they're moving through the world, how they're motivated. Agency has to do with having a sense that you are the director of your own life. So you tell your story in a way where you're in control of the things that are happening to you, and you are active rather than just being a passive victim at the whim of your circumstances. So you're making things happen, you may be growing and changing and so on.
And agency has turned out to be one of the most important aspects of the way that people tell their stories, because across a huge number of studies, looking at a lot of different outcomes, having a stronger sense of agency, being the author and the director in your stories, it's linked up with all kinds of well-being. So a greater sense of satisfaction with life, lower levels of different psychological symptoms like depression and so on. So it seems to be really good and really positive in general.
Yeah, one other important finding that's been found by John Adler, he did a study where he was looking at the narratives that people wrote after they had therapy sessions, so while they were in the course of therapy. And people who produced stories after each therapy session that were characterized by stronger agency tended to be the ones who are getting better over the course of therapy too. So it actually seems to be not just a correlate of doing well, but seems to be an active ingredient that helps people to do better. But your question is about a sense of agency, how we go about creating that. Is that what you're asking? I want to make sure I'm answering the right question.
Sara Wilson: Yeah, and also maybe are there any caveats or trade-offs when it comes to just this pressure to define who we are. As we're shedding more light on it in a clinical context, I was wondering if there's any trade-offs to agency?
Rebecca Shiner: Yeah, that's a great question. I think that if it's agency that's being forced by someone else, it's not really agency at all, because that would be... If a person is feeling a kind of pressure to be agentic, in a way that is undermining the very essence of what it means to have a sense of agency because it's action that's initiated on your own and where you see yourself as freely choosing to act and to do things in your life. I don't know of any studies that have found a negative relationship between agency and well-being. There are definitely studies where it's not related to the outcomes that they're looking at.
Sara Wilson: This is very interesting. It's a very promising finding with the therapy sessions and the really tangible effective role of narrative identity and meaning-making and agency being very interconnected with our belief systems.
Rebecca Shiner: Right. And I think it's important to note too that it's not like people are consciously... Normally, people aren't consciously necessarily deciding that this is how they're going to tell their story. I think they could. They could. But in most of these studies, it just seems to be a process people aren't even necessarily aware of. And so the people who tell those stories with a sense of agency do turn out to be doing better.
Sara Wilson: On that note, what is the role or importance of meaning-making and why is there this focus on the client's relationship to their beliefs, narrative therapy, and in other therapeutic techniques more broadly?
Rebecca Shiner: Yeah, that's a great question. There's a whole separate line of research that's about meaning-making in life and purpose in life that in general finds that it's really an essential component of wellbeing. It's not the same as being happy, for example, but it's another really important sense of thriving in the world. So meaning, being able to make meaning out of your experiences, I think especially negative or traumatic experiences I think is fundamentally important. People can make meaning in different ways. They can make meaning by pursuing something that they feel called to do. They can create meaning by doing something in service of other people, for example. But narratives also give us a way of making meaning, because it's our way of trying to understand how the things that have happened to us have affected us, and how our own choices and ways of navigating the world also are impacting the way that we're doing right now.
I think narrative is another important contributor to a person's sense of meaning. So for example, if someone has had something very painful, very traumatic happen to them, one way of trying to make sense of that is to try to understand the impact of it and to really find a way to weave that into the story of your life rather than having it be just this standalone, horrible thing that has happened. So there's something very powerful about the process of trying to understand the impact and how perhaps you can carry that with you moving forward. That is really helpful, and I think that that is part of what can happen in the process of therapy.
Sara Wilson: I think that this is so fascinating, especially because it's not really the content necessarily of the narrative or your belief and/or your story that's changing, it's the meaning around it and the organization of it, and I guess the degree of how attentive you are to certain things, how integral they are to you, which relies a lot on your relationship to this content.
Rebecca Shiner: That's right. I think that's right, because it doesn't necessarily mean that you have to change the content of what you believe, but through the stories that you tell yourself about what you've experienced, it may affect the way that you can imagine yourself moving forward into the future.
Sara Wilson: Yeah. One study of yours that I was very curious about your paper, “The Relations between Narrative Identity and Personality Pathology among Clinical Adolescents: Findings from a Multi-Ethnic Asian Sample”, this was the first study to assess the links between themes of narrative identity and personality disorder domains in a clinical adolescent sample. Could you explain the study a little more to our audience, why you chose the participants you did, and just your findings more broadly?
Rebecca Shiner: So this is a paper... The first author of this paper is Amy See, who at the time that she did this study was a PhD student at Utrecht University in the Netherlands working with Theo Klimstra, who is a colleague of mine whose studies actually identity development in adolescence. Amy See herself was from Singapore, and so she was very interested in trying to look at whether the narratives of adolescents are linked with their emerging personalities and particularly personality difficulties that they might be having. As I mentioned, adolescents, teenagers are really in the very earliest stages of starting to develop their narrative style and are really starting to have a richer sense of what are the most important episodes from their lives.
What Amy did was she recruited a clinical sample. These were teenagers who were being seen at the largest mental health clinic for adolescents in the country. And so she asked them to write about a turning point that they had experienced. And a turning point is a specific kind of narrative where you ask the person to share something, to share an experience that they've had that really informed the way that they understand themselves, that really changed the way that they perceive themselves. So she asked them to write about that, and then she also asked them to fill out a questionnaire about difficulties they were having in terms of their personalities. So these were not young people who were diagnosed with personality disorders, they were having clinical struggles, and they were just reporting on personality difficulties they were having.
So the most striking finding from it was that there was a particular dimension of those narratives that was related to personality difficulties that the young people were having. And that dimension is one I haven't mentioned yet, which is communion. Communion is a motivational theme similar to agency that describes how much the person tends to talk about positive, loving, close relationships with other people, with friends or romantic partners. If you're looking at a sample of adults, it may also be caregiving relationships or any sort of feeling of connection with other people.
And so what we found in this paper is that the teenagers who were having more personality difficulties tended to express lower levels of this kind of positive communion with other people in the turning point stories that they told. We're not sure which came first. We don't know if it may be that they were having problems in their relationships, and so then that's reflected in their narratives. It could be that the way they tell stories was affecting their mental health, for example, by making them more depressed. I thought, if it's okay, I could share a couple really short narratives from that study because I think it will make the findings a little more concrete. Is that okay?
Sara Wilson: Yes, we would love that!
Rebecca Shiner: Okay, so here's a first turning point narrative from one of the teenagers. "I was diagnosed with depression one year ago. I was not myself and caused a lot of problems for my family. After a number of sessions with the psychologist, I started understanding myself better and why I behaved the way I did. This made me change my mindset, and I told myself to enjoy life more. I am now feeling happier and approach life in a more positive manner." So this person is talking about learning and growing through the process of therapy, but they're also suggesting that they had been having a lot of problems with their family. But they're talking about this positive connection with the psychologist and this more positive mindset that came out of it. So they're expressing a sense of communion.
In contrast, here's one from a participant who expressed a low level of communion. "So I was sexually abused by a family member a few months ago. It made me feel hurt, horrible, and disgusting. I now flinch when someone touches me, and I hate this feeling. This has made me less trusting of others, including my family." So you can see this is a turning point for this young person when asked to think about an experience they had that really changed their sense of self. They describe something that's really painful, and they talk about that painful experience of abuse leading to them not trusting people anymore. So you can see this clear distinction in terms of that theme of communion there.
Sara Wilson: Yeah. And whether the turning point itself is articulated in positive or negative terms.
Rebecca Shiner: Right. Yeah, in this case, there's a clear difference in the overall tone of those two narratives that you can see there. But I think it's interesting too, this is an Asian sample, and so in general, Asian cultures tend to be more collectivistic and to have a stronger focus on interdependence across people and stronger need to think about the group rather than just the individual. Whereas a US sample, for example, is more individualistic. So it would be really interesting to know whether the pattern would replicate in a Western sample where maybe communion is not so clearly linked with problematic personality traits.
Sara Wilson: Yeah, Because I noticed in your results that communion was perceived as more a significant dimension in that sample in particular, as opposed to agency.
Rebecca Shiner: Right, which is an unusual finding actually. Agency is more consistently associated with wellbeing in general than communion is. There are a lot of studies where communion is just not related to whatever positive outcome measures you have. And so it raises questions about whether maybe this is a cross-cultural difference that I think would be worth studying more.
Sara Wilson: Right, yeah. It also definitely raises the question of how narrative identity is highly convoluted by nurture and just your social situation and upbringing. So it's subject to change I guess.
Rebecca Shiner: Yeah, absolutely. I think narratives are a place where culture plays a big role because different cultures have different preferred ways of telling stories. US samples have a very strong preference for redemption narratives where things start out bad, but then by the end of the story, they turn out to be positive. We love a good redemption story in the United States. And that's not always necessarily a positive thing, but it's a clear cultural preference that we have.
Sara Wilson: Yeah, it's so interesting because it's not real in some sense, it's very socially and culturally dependent and context relevant, but then at the same time, it manifests itself in very real situations. It very much changes your belief systems.
Rebecca Shiner: Right. That's right, but the outcomes may vary again, depending on the culture. So I think it's important in thinking about narratives to not assume that narratives that are positive in one culture are necessarily going to have positive outcomes in another.
Sara Wilson: One more study I wanted to talk about. Can you discuss a little about your study exploring narrative identity and PTSD symptoms in veterans? I was especially curious about the finding that even if patients experienced a loss of control during traumatic military experiences, it may be possible to help them find ways of narrating their life in more agentic terms in the present through the process of therapy.
Rebecca Shiner: Yeah, let me describe that study. This was a study that was actually inspired by one of my honors students at Colgate, and this is before I really had done much narrative research. So I had a student who wanted to study veterans for his honors project, and he wanted to look at PTSD. And so we hit it on the idea of asking veterans to tell us about their most stressful experiences that they had had in the military. And we wanted to look at whether their way of narrating those really stressful experiences was predictive of whether they had PTSD symptoms or not. It's really interesting because in a lot of the literature on PTSD, there's the assumption that the memories themselves are highly relevant to developing PTSD or not, but they're not looked at in terms of narrative identity, they're more looked at in terms of whether the memories are fractured or fragmented or not.
But we thought that it seemed likely that the narrative style, the way that people tell the stories of those really stressful experiences would be highly relevant to whether people have PTSD symptoms or not. So we collected stories about the most highly stressful military experience in a sample of veterans. We found that, in fact, there was a link between narrative identity and PTSD, so specifically the veterans who told these stories in a more agentic way and also with a stronger sense of growth tended to have lower levels of PTSD symptoms. So I think this is really, really important because it suggests that, again, those memories are important because they become part of a person's narrative identity. There may be ways of working with those memories to help people to begin to narrate them in a way that is going to bring some relief to them.
It's really interesting to me that the treatment method that has the most evidence for its effectiveness for treating PTSD is something that's called prolonged exposure, which is where the person with PTSD is asked to tell, in as much detail as they can, the traumatic experience that they have had that has left them with PTSD. So they have to recount in great detail everything that they can remember about that experience. Which is obviously extremely difficult and painful to do, particularly the first time. And then they're asked to retell this story and actually to listen to recordings of them having told the story themselves. The contention is that the reason this is working is because it's exposing them to the story or the memory of something that they have been trying very hard to avoid having direct contact with.
And I believe that that's true. I believe that it's exposure that helps them put aside the avoidance that is playing a really important role in why that model works for helping people get over traumatic memories. But I also expect that there's something about the retelling of that story that helps people to actually gain a sense of mastery over it. And I think it would be really interesting to actually do a study where you looked at whether those stories change in terms of whether the person feels a greater sense of agency in the retelling of the story over time.
Sara Wilson: This is such amazing research, really, and such important implications, and it's just starting to be tapped into its full potential. Yeah, I totally definitely agree with you. I think it's very good work that you're doing.
Rebecca Shiner: Thank you. I feel very lucky to have had people who are willing to let me collaborate on this kind of work with them.
Sara Wilson: When you discuss this epistemic gap in clinical theory regarding personality disorders, I think it's interesting that you cite one of the reasons for this deficit in knowledge to be the desire to protect youth from stigmatizing diagnoses. How might a diagnosis in any domain, I guess, actually contribute further to poor narrative identity? How can we go about this maybe more carefully or be more sensitive to this in therapeutic practice?
Rebecca Shiner: Yeah, it's a great question. Historically, there's been a lot of hesitancy to use labels of personality disorders for teenagers. And in fact, the diagnostic manual, the DSM has encouraged clinicians to be cautious about using personality disorder diagnoses for people below the age of 18, even though it's recognized that these personality patterns start earlier in life, so they don't just emerge out of nothing when a person gets 18. And this has been because in the past, people saw personality disorders as being chronic and very hard to treat, like once you have a personality disorder, you are destined to have that personality disorder forever. And that seems too stigmatizing to apply that to a young person.
However, it turns out that there are a bunch of mistakes that have been made in those assumptions. It turns out personality disorders are amenable to treatment. It turns out that they do naturally change over time even without treatment. And it turns out that personality disorder problems actually may be at their worst during adolescence. And so that suggests that there may be value in at least thinking about personality disordered patterns in young people like paying attention as a clinician to whether the young person you're working with has problems with their sense of self and identity, or chronic problems and how they're relating to other people.
That being said, I have a lot of sympathy for this concern about using personality disorder diagnoses on young people. And that is because as we've talked about, teenagers are in the process of developing their sense of narrative identity. They're only just beginning to figure out what are the important stories from their lives, how do their past experiences affect who they are now? And so there is a great risk, I think, actually in giving them a label that would lead them to formulate a sense of identity that is going to be really pathological, that is going to discourage them from feeling hopeful about change.
And I'm especially concerned about this now because on social media, there has been this profusion of teenagers and/or young adults self-professing that they have personality disorders, particularly borderline personality disorder. And there's a strong tendency for people almost sometimes to almost relish having this diagnosis that makes them feel special or celebrates their sense of being a victim in a way. This has become rampant on TikTok with mental health in general, young people posting TikToks about their diagnoses and so on.
And so this is something that I have actually been gradually rethinking for myself, because in the past, I have encouraged clinicians to think about personality disorder diagnoses for young people and to very carefully present that information to young people. But I think that as those diagnoses have been promulgated in social media, I am beginning to see more and more the potential risks that are associated with that, especially because of young people's emerging sense of identity and the way that that diagnosis may play a part in how they're crafting the narratives of their lives.
Here's where I'm at on this at this moment. I may change my mind again, I still think it's vitally important to be paying attention to those core personality disorder features for people who are working with teenagers to really pay attention. Is this a person who's struggling with intimacy, is struggling with how they see other people? Do they tend to view other people in a black and white way, for example, that might characterize borderline tendencies? Is this a young person whose sense of identity is so profoundly unstable that they're having trouble beginning to navigate decisions about what they want to do after high school and so on?
So I think those are things that clinicians should be paying attention to and should develop some competence in learning how to treat, because those problems are significant for a large number of teenagers with clinical problems. On the other hand, I think that there's a really important role for being cautious about giving a personality disorder diagnosis. And I think it's important to be careful in how that is articulated to the young person. And I think explaining it in the kind of language that I've been using, it's likely to be more helpful, that these are ways of seeing the self and seeing other people interacting with them that are profoundly important, but also open to change so that the young person can start to develop narratives about who they are that are both realistic and more healthy.
Sara Wilson: Yes. Yeah, I think that expressing a critical sensitivity to narrative identity and the reality of it in therapy especially, will inevitably strengthen the therapist-patient relationship just because a lot of traditional therapeutic practices stigmatize the client's point of view as something that's disordered or subjectively inaccurate. But instead of discrediting the content of the narrative itself, the narrative therapist helps to consciously separate the story from the client and sees narrative identity as a construction over which we have agency that's separate from our core.
Rebecca Shiner: I agree. Although I think that there's a place too for reality testing in the sense that I think that the best narratives are in contact with reality, but are also healthy. A narrative identity that is entirely positive, but disconnected from a person's actual reality is going to be a problem perhaps in a different way than a narrative that's unduly negative, if that makes sense, yeah. So I think that it's important for the person's sense of identity to be both flexible and reality based, and ideally positive because there's the potential for change there.
Sara Wilson: Yeah. Thank you so much for joining us today. I really think that this is such an important concept right now, especially as so much research on the self is emerging and in our relationship to selfhood, what is the self? And there's obviously so many levels to it with so many pressing implications and very real importance for who we are and for wellbeing. So I think that this is very, very important research and a very cool concept. Is there anything else you would like to share with our audience today, Dr. Shiner?
Rebecca Shiner: I had one last thought that I wanted to mention. There's a brand new study, it actually hasn't been published yet, but it's been accepted for publication, that was looking at this construct of the hero's journey. This is a popular motif that a number of people have recognized that the most loved stories across many different cultures seem to take this form of the hero's journey, where the person begins in the dark, but then they feel this calling to leave their safer childhood home, and they venture out and they find a mentor and they have to battle the foes that may thwart them and so on. So there's a particular form that this hero's journey story takes.
Anyhow, this study has found that there's actually value in telling your own story as a hero's journey and being able to see your life in terms of that pathway from a maybe sheltered existence, but moving forward into facing your foes and your challenges and being defeated, but then continuing to move forward. This was a series of studies that showed that actually adopting that kind of sense of your own story as a hero's journey, it's good for us, and maybe it gives us courage to face the things that are inevitably going to be painful and difficult.
Sara Wilson: I wonder, do you think that we inherently value that as an intrinsically good narrative organization, or do you think it's maybe very convoluted by cultural norms, what we've been accustomed to?
Rebecca Shiner: Yeah. Right, that's a great question. I think that part of the impetus for studying this is that this is a very common narrative format across historic time and across place. There's something about this kind of story that deeply appeals to all of us and suggests that there may be something universally, humanly relevant about it.
Sara Wilson: How would you suggest that someone goes about trying to develop their narrative identity?
Rebecca Shiner: Yeah. I have a few ideas. One is I think reading good books is a good way of doing it. Actually, over Thanksgiving break, I have gone back to... I pulled out one of my childhood books that I love very much called A Little Princess. It's like a classic, classic girl's book. Anyhow, and just reading it actually makes me really... It actually follows the hero's journey pathway. And I realized how much I internalized that narrative form as a kid when I was reading it.
So anyhow, I do think there's a place for watching good movies and reading good books and so on to have a sense of the narratives of other people's lives. I also think that there's really good value in well done therapy. I definitely think some therapies are better than others for developing a sense of narrative. I think all therapies do it, but I think for people who are trying to gain more of a sense of understanding of themselves, I think some of the more traditional therapies like psychodynamic can be especially useful. I think journaling. I really think anything that has to do with self-reflection and deep thinking about yourself.
Sara Wilson: So interesting.
Rebecca Shiner: Very useful, yeah.
Sara Wilson: How many layers there are, and how many different ways there are to get in touch with yourself and make real change. Yeah, I've been very interested in the concept of self throughout my psychology and philosophy major at Colgate. And the more I study it, the more I'm just blown, mind blown. It really is such an incredible concept. It's just unbelievable how much there is to it. And the more I study it, the more I'm just dubious of what it even is, what it even means. The research is just so interesting. And I think it's so relevant nowadays, especially right now with so much more research going on with regards to what mind is and major developments in neuroscience. And I think that this very much deserves to be paid attention to, especially in neuroscience and the mechanisms behind this. It really is just unbelievable.
Rebecca Shiner: It's fantastic that you've been able to study it. Yeah, my hope is that people will be inspired to learn more about it. I highly recommend anything that has been written by the person who developed this concept, who I should have acknowledged at the very beginning of this interview, who is Dan McAdams, a psychologist at Northwestern, who really I think pioneered the... Who was drawing from a lot of existing traditions within psychology, but really helped to pioneer the empirical study of narrative identity. So I commend anyone looking up Dan McAdam's work.
Sara Wilson: Thank you so much for joining us today. It was such a pleasure to talk with you. This was Dr. Shiner.
Rebecca Shiner: Great questions, yeah.
Sara Wilson: Of course. It was so amazing.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Social Psychologist Sandra Parsons
Sandra Parsons, Ph.D. is an Associate Teaching Professor, the Director of Undergraduate Studies, and the Director of Pedagogy in the Department of Psychological Sciences at Rice University. She specializes in the various aspects and components of groups in society, such as decision-making, identity and competition.
Jack Eisinger: Hello everyone. Thank you for tuning in. My name is Jack Eisinger, and I'm a research intern for the Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'm here today with Dr. Sandra Parsons who graduated from Miami University with a PhD in social psychology, and is currently a psychology professor and RA at Rice University.
She has won three George R. Brown Awards for superior teaching, and has done research on human decision processes, executive coaching, and information sharing. Dr. Parsons, before we get started, can you tell us a little about yourself and what got you interested in social psychology?
Sandra Parsons: Sure. So I've been at Rice for about 12 or 13 years. It's fuzzy on the exact dates, because I started as a sort of a patch hire and that turned into a full-time position. And I've been teaching both in Houston, and also before that in Baltimore, and before that in Columbus, Ohio for about 30 years, which is hard to believe since I'm only about 30 in my head.
I really got interested in social psychology because people are so weird. People are so strange and unpredictable, and I was always asking, I wonder why people do that and why are people like that?
And I was also interested in trying to figure out how we could diffuse some pretty common misunderstandings among people, some things that come up over and over again that are problems in groups of people. And so when I was talking to my research advisor, an undergraduate, I told him I wanted to go to graduate school in psychology and he said, "What kind?"
And I remember being shocked that there wasn't just the one kind. I'm not sure what I thought happened to all the professors in the world who taught all the different kinds of psychology, but I think I had some conception that everyone was a clinical psychologist and then they had expertise in different research areas.
Anyway, he said, "You could be a social psychologist and study this all of the time." And I said, "Okay, well that's what I want to do." So my interest in psychology has been since forever, but specifically social psychology since about middle way through my undergraduate years. So here I am.
Jack Eisinger: That's really cool. And by the way, before coming to college, that's also what I thought, you just went to grad school in psychology.
Sandra Parsons: That's right. I had no idea.
Jack Eisinger: Somewhat common. All right. So let's get into the questions. Question one, of your published studies finds the impact of professional coaching on university students. I was hoping you could explain a little bit to our audience what leadership coaching is, and is it something that is practical and useful for the everyday college student?
Sandra Parsons: Absolutely. So we're really lucky, because this study actually took place at Rice University in partnership with The Doerr Institute. And so we have incredible resources, incredible funding with professional coaches who teach undergraduates how to develop their leadership tools, the idea being that everyone can be a leader.
Though I have to say we are very specifically talking about Rice University undergraduates. So it's not literally everyone in the world can be a great leader, but really focusing on the kinds of students that we have in this kind of institutional space.
So the professional coaching really is about looking at the literature on successful leadership tools, and helping students develop their leadership goals. So with The Doerr Institute specifically, it's very much tailored towards what kind of leadership roles students are interested in, what kind of leadership skills they want to develop, what kind of personal goals they have taking into account their culture of origin, but also the culture that they want to practice more leadership roles in. Because the way that you successfully lead is of course bound by cultural expectations and cultural norms.
And I would say that absolutely, this is something that is practical and useful for everyday college students. I think that it is fairly rare for one to be in professional spaces where there's no leadership. There is almost always some opportunity. Even if it's just the leader of your very small team at whatever level of job that you're doing, there are different tasks that come along where someone has to sort of take charge. And so I think having all of our students have some ability to harness those skills and refine those tools to better lead is wonderful. It's a tremendous asset.
Jack Eisinger: Yeah, I definitely agree, and I definitely have met some of the people that may have participated in those studies, and I definitely agree with that assessment. My next question, regarding teams and social psychology, what are some suggestions you have for those teams? Whether it's business teams or just as something as simple as college students working on a class project. What are some ways that people can foster a better experience and have more positive outcomes in these situations?
Sandra Parsons: I love this question because it really gets to the heart of one of the things that I went into my graduate schooling thinking I wanted to know more about. I talked before about how people were weird, which is clearly a driving force. But the other thing that I was really focused on is why is it that we do so much group work and yet still haven't figured out how to do it well? And so I studied a lot about how could we make that experience better.
So I think that number one, you have to define what the roles are in the group, so who's going to be in charge of what. There are some ways that tacitly develops. So that develops not necessarily on explicit understandings, though in my opinion, it's better if you spend some time being explicit about that. Because if you leave it to unspoken estimations of what other people are going to do, it takes much more time to develop those efficiently.
But also, what is the product going to be and how will people be held accountable for that product? Because one of the things that we know that happens is that when groups of people get together, it's very easy to imagine that other people will take on the bulk of the task. And we call that social loafing, the idea that if there are many of us doing it, then all of us can kind of relax a bit.
And the usual way of doing business in a group like that is to have a group product that just pops out the other side and is assessed by some external force like your professor, or the customer buying the product, or whatever it is, with little attention to who in the group was responsible for which parts of it. And when it's set up like that, then that means that people can take advantage of the shared workload and not put in their all.
So I think having some rules of holding each other accountable, either within the group where everyone agrees that these are how we're going to hold each other accountable to these, or asking the outside entity like your professor to set up some sort of a rubric or expectations about how to define whose work was what.
I also think it's important to think about, is this even a group task? Why are you doing this in a group? And I think for the group to understand why they have come together to do this product or this project together is vital.
So for example, one of the things that we assume is that a group will do a better job on a task. That if we put lots of heads on it, we'll have an even better outcome. But that's assuming that there's some either really hard lift, something that one of us couldn't do by ourselves because it's just too much work to do alone, or because we need lots of different people thinking about it differently.
And so we've already talked about the first problem. If we're doing it all together because we know that it's just a really hard lift for any singular person to do, then we better make sure that this is something we can each contribute to and be held accountable for each of our individual outputs.
If it's the other thing where we're coming together because of a diversity of skillset, then we need to make sure everyone knows in that group who is really good at what. If we don't do that, we run the risk of having everybody focus on the shared information and not talk about the stuff that they're uniquely qualified to talk about.
And so we really waste that resource, and that can potentially slow down the process and also tamp down the creativity and uniqueness of the product that you're trying to get, which is really actively working against having a group of people do it.
So trying to figure out, who's going to be responsible for what? How to maximize individual output, making sure that it's a group task, and also agreeing on how you're going to communicate about. They're all absolutely vital. And I think that those pieces of advice suit all kinds of situations. Classroom, outside of classroom, business context, really anytime you get a group of people to do something.
Jack Eisinger: Yeah. No, that's a really good answer. I've definitely been on both sides of social loafing, both in school and in jobs.
Sandra Parsons: Absolutely.
Jack Eisinger: So I completely agree with that. No one really wins usually in those situations.
Sandra Parsons: That's right. And it's such a shame, because group processes should be a really good tool for getting something done. We have so many big tasks that we have to do, and having more people work on it absolutely means more buy-in. People feel like they're involved in the process.
And so we want to continue to use groups for sure. But if we're not utilizing them to the best ability based on what we know, then like you said, nobody wins. It's just an unpleasant process and you end up with less than fabulous product. It's certainly less fabulous than it could have been if everybody had been doing their best work. So it's something we need to think about whenever we're in groups.
Jack Eisinger: To continue with groups, in teams or groups, can you talk a little bit about in group competition or in-group threats, and what would be the best way for people to handle these situations in the healthiest way possible?
Sandra Parsons: Absolutely. So I often talk about in-group versus out-group threats, usually talking about how we develop our identities in part around the people who are in our groups and by what we are not. And so we develop this strong in-group bond, and it is sort of implied whenever we're in a group that there is some out-group that is different from us, and also by definition not quite as good as us. We prefer our in-group members over our out-group members generally speaking. And there's lots of research with that in-group bias.
So then when we start looking at, well, what happens when there's actual competition from inside the group, which we know happens of course, or some sort of threat to identity that comes from inside the group.
Because it is a somewhat unexpected source of conflict, it can be very devastating. So if you think about how you know that you and your people are cohesive and connected, and you know that you're in us and that those are thems, and one of the things that makes you a good us is that you were willing to fight for resources or compete for resources with the other us against the other thems, that's kind of a comfortable space to be in, because we're used to that conception of things.
So when someone threatens your membership or when someone competes for a place within the group, it can be kind of scary because it threatens your idea of this cohesiveness, and it threatens your idea of what makes the us different from the thems.
So it can be particular threatening, and particularly insidious and difficult to deal with. And I think the best way to deal with that is to have honest conversations and to understand why it is that it's so anxiety provoking to have that threat come from someone you thought of as an us or part of your in-group.
I think it's also useful to think about your definition of your in-group. Why is that your in-group, why is that important to you? Why is that part of your identity formation process? And then perhaps use that to reconceptualize what that in-group threat means.
I say this because I know it's not always going to be easy to just say, "Well, let's just talk about it and resolve it, and then we'll all be fine again." The resolution might be that we have to redefine how we think about ourselves. Maybe we decide that we aren't really part of that group in that context, and we have to redefine where the boundaries are. And anytime we're doing that, that is going to be anxiety provoking and difficult, and we just have to give ourselves the time and space to have those conversations and decide, can we both still be in the group? Is this some irreconcilable difference? Do I need to think about my identity differently? Do I need to maybe join another group with respect to this task?
The good thing about in-group and out-group memberships is that they are often very fluid, that they're based on some expectation or some either internal or external expectation, or situational factor that's malleable. So we can decide to change the membership or we can decide to reconceive how we think about things.
Jack Eisinger: Yeah, it can be a difficult thing to balance. The larger the group, typically the more power that group has. But at the same time, the larger the group gets, the more divisions there are going to be over little idiosyncrasies or bigger things.
Sandra Parsons: Absolutely. And the more potential there is to see factions within a group. We recognize when we're in a group how heterogeneous the group is, and we tend to think that the out-group is very homogenous. But that heterogeneity while wonderful within our in-group, we also have to appreciate that's going to be the source of conflict sometimes, because we aren't all the same. We aren't all going to think about things the same way.
Jack Eisinger: Right. Just to transition to teaching a little bit, what is the biggest takeaway you want your students to have in your social psychology and positive psychology courses?
Sandra Parsons: So we'll start with the social psychology. So usually, it ends up being that I meet students early in their four years for my social psychology class. So I'm usually talking to first years and second years, with a few older students sprinkled in who are trying to get distribution credit.
And so I have the opportunity to talk to them at the beginning of their four years of college, which is a really exciting time. There's a lot of change and a lot of potentially tumult going on, where they're trying to find their way and trying to figure out who they're going to be in their new, more adult lives.
So one of the things that I want to make sure my students know is that in many cases, they have the power to change the situation. So social psychology is all about how the situation affects the way we think, feel, and behave. And that means that when we get into these spaces where there's conflict, or misunderstanding, or frustration even leading for example to violence, that those are coming out of situations that we've socially constructed, that we have somehow agreed as a group on the certain ways of doing things. We have certain normative reactions. We have certain expectations about what others are going to do.
And because they're socially constructed, that means that they can be socially reconstructed. So if something isn't working, we can decide collectively to change those situational variables to create a new situation that better serves us.
So specifically, thinking about times when we see conflict between people. It's often because there's some misunderstanding. I see the situation one way, and you're seeing the situation a totally different way. And once I understand your perspective, I can understand your behavior. So if we can come to some shared understanding of you're reacting to your construal of the situation over here, and I think it's supposed to be like this. And when you don't do it right, I get mad.
But what if we came to it with, "Okay, here's what I thought the ground rules were. This is what I thought was the environment we were interacting in. And I want to hear more about what you thought, and then we can come to a compromise."
One of the things that I worry about is that this makes it sound like it's very Pollyanna. "All we have to do is just change our expectations and the world will change." And obviously, I don't think we're going to get rid of all of the world's strife just by changing the way we construct things. I also think there are some cultural barriers where we can't just say everybody has the agency or the power to change the situation. That's just not true either.
But I do think that opening up students' minds to the idea that they don't have to go with the flow the way that the flow has been constructed before, but they can create a new flow. We get to create new places for us to be in. And especially at this age with this exciting group of students, you all will have the power. You do have the power.
So looking for ways to change those understandings and clear up misunderstandings I think is a really, really powerful tool that students can have and that humans can have to make the world a more harmonious type of place.
I often like to use the example of queuing cultures versus massing cultures. So there's some cultures where we stand in line, and then there are others where we kind of crowd around for our turn for something. And if you're from a queuing up and you think that you're supposed to stand in line for something, and you go to a place where they're crowding around, can be very frustrating, because you're wondering why aren't they doing what they're supposed to do? Why are they taking mine before? It's not their turn, right?
Likewise, if you come from a crowding place and you go and you stand in line, you're wondering, "Why are these people standing in this long line? Why don't they just crowd around and grab what they need?"
And you can see there's a lot of conflict there, because both sides are like, "What are you doing? You're not doing it right." But if you just explain to the other group, "This is what I can see the situation to be," and the other group is like, "Oh, this is how I thought it was supposed to be," then you can at least understand each other and understand where the differences are coming from, and potentially really tamp down that anger response that causes so many problems between people.
So long story short, power to change the situation. I want students to understand that they're not just being pushed along through their daily activities without any agency.
Positive psychology is actually fairly similar in terms of a lesson, but what I want people to understand first and foremost is that the goal of positive psychology is improved wellbeing. That does not mean improved happiness in the sense that everyone should be skipping through the tulips, and singing and dancing. I think about Shiny Happy People from the R.E.M. song, which is a reference probably most people don't get anymore, but I'm like, "I'm going to keep talking about it until everyone knows who Michael Stipe is."
The goal is not shiny, happy people, and that shouldn't be the goal. And I think that we are sold, especially in western societies, that is the goal. And then if we're not feeling happy in the sense of skipping through the tulips, that we're not doing the right kinds of things and something has to change.
So with positive psychology, I want people to understand that happiness is a very broad multi-tiered or multi-pillared kind of conception that has multi-facets to it, multiple facets to it. And it involves connection with other people, certainly positive feeling, meaningful work, connection, all sorts of really rich and interesting things that come with effort.
So the takeaway message for positive psychology is to reconceive happy as a much more complex construct that it has lots of pieces to it, and that it's changeable. That we do have the power to change our wellbeing, but it's going to take effort.
So it is not that we are going to magically either be happy or not happy, and if we're not happy, we have to keep trying to find this magic pill that will make us happy again. It's that we need to conceive of happiness differently, and then very consciously choose activities that support more of the good stuff. And so actively working on that, just like you would exercise every day or eat good food every day. It's not something you do once and then you checked it off your list. It's something every day, you have to pay attention to and nurture.
Jack Eisinger: Yeah. I think if I had to combine the two into one, social psychology and positive psychology, it's the need to break down the things that happen in your life. That it is not so simple that you just can follow the flow of the group, or that you're just going to do whatever you want or just feel like, and you're going to be happy. That there are things that you need to consciously think about and put effort into.
Sandra Parsons: I think that's absolutely right, Jack.
Jack Eisinger: All right. Okay, perfect. Question number five. Can you talk a little bit about stereotyping? Why do people do it? Is it an automatic process? And what are some ways that individuals... And I was particularly interested as well in governments. What can they do to try to combat this practice?
Sandra Parsons: That is a very interesting and provocative question. So let me take it apart one at a time. So let me talk about stereotyping.
So stereotyping is when we decide that there are boxes that people or things can fit into. Clearly, what you're thinking about is people stereotyping. So let's talk about that. That we decide that we know what people are like, based on certain kinds of features, we can put them in these different categories.
And it is necessary. It is automatic. It is part of the way that our brain makes order out of a lot of what would be chaotic information if we didn't do otherwise.
So we are in some sense what's called cognitive misers. We want to figure out the easiest way to tackle the largest amount of information possible, and our brains are constantly trying to organize those things into chunks of information.
If we didn't do that, the world would be full of way too much information. We would have trouble functioning even in the most simple tasks, because everything would be new to us constantly, and disordered, and uncomfortable, and not very pleasant.
And so what we do is we make these categories of people. And then once we know what we think we know about people, these stereotypes, then those help us decide how to behave. So we create these stereotypes, we create these boxes, put people in those based on some very quick judgment that we have, and some very little information often we have about those people in those groups. And then we behave and act towards them to reinforce those stereotypes.
So having stereotypes is not actually the problem, and it's a good thing it's not a problem because it is an automatic process. We're not going to be able to get rid of stereotyping. It's something that we do naturally.
The problem comes of course, when we have these assumptions that lead to discrimination and to prejudice. So it's when we have negative stereotypes, and also that we believe that they're immutable, that it's unchangeable, and that there is a fundamental difference in a group of people that is insurmountable, and that we can't be convinced otherwise.
And this actually goes back to the discussion we were having before about in-groups and out-groups. We think we know something about the out-group, because we have a stereotype about them. And so whenever we see behavior from an out-group member, we imagine that that supports the stereotype. And it's very hard for us to remember times when it refutes the stereotype, and have that stick where we start to alter the stereotype. Usually we dismiss it or we say, "Oh, well that's a unique member of that group. That's weird, because they're not like all the rest of them."
So then we get to the juicier part of your question, which is what can individuals, and then what can governments do? So I'll start with the easier one.
What individuals can do is be aware of that. So having a stereotype is not, like I said, necessarily in and of itself a bad thing. But we have to be very consciously aware and checking ourselves, how are we using that stereotyped information to guide our behaviors?
And we also have to actively seek out alternative explanations and information. It's again, a very effortful process. It is going to mean that we can't always take the comfortable, quick, easy route of just making an assumption about something, and that we have to constantly seek out others, make sure that we are not just always trying to prefer the comfort of people we think who are like us, but we have to seek out people actively who might be different from us.
And so then when we start talking about, how do we have governments be a part of that? I think it starts getting a little trickier because we have to think about what we think, what is the role of government, and how much hand does government have in our day-to-day interactions? So it's a little bit of a political question I think.
I think that we know from data, from research that when people are zoned to certain areas, if there are certain areas that have certain resources, that the areas that have more resources are going to be places where people with more resources can live. And to the extent that privileges certain groups of people in society, that is encouraging this prejudicial and discriminatory behavior. We definitely can't have that.
So I guess one of the things you could argue is that governments would have to make sure that they weren't providing resources to some groups over others or in certain locations over others.
And again, I think that goes back to a political conversation is I'm not sure... We're going to have really different ideas about how big the government could be and how far its hand should reach. But in some utopia, you would have governments enforcing only regulations and resources in ways that did not systematically privilege certain groups over others.
Because when we do that, we know that that causes strife between people. You can't just put people to together and hope that they solve their differences. When people are put together without some sort of environmental, situational variables in place, they actually reinforce those stereotypes, and things become worse between groups of people.
So providing opportunities for people to interact with people who are different from them or interact with people with whom they don't normally, or actively putting people together who have negative stereotypes about each other. With some things in place, like figuring out a common enemy that they share. It's actually a really effective way of bringing groups together.
But also helping people, facilitating people figuring out how they're more alike than they are different. So some sort of governmental programs that encourage sharing resources across stereotypically adverse groups or opposed groups would be one way that they could do it.
Anything that's going to encourage people to get out of their little echo chambers where they think they know everything about a different group is something that will encourage the breaking down of these prejudicial and discriminatory practices. But we're never going to get rid of stereotypes.
And frankly, they're shortcuts. They're useful. And so it's going to help me know... For example, if I have a stereotype about college students, then when I meet a college student, I don't have to think for very long what we're going to talk about, because I know they're going to be stressed right around Thanksgiving, because that's right before exams. If I know they're a third year, I know they're going to be looking for jobs. I have a stereotype about what kinds of things are going to make them anxious, and I'm going to immediately be able to talk to them about those kinds of things.
And that's good, because that makes for easier conversation. It makes for less stressful interactions. And so again, I know I'm repeating myself, but in as much as they are positive in making life smoother, they're going to be continuing to be part of our process.
Jack Eisinger: Yeah. It seems like if we don't make assumptions and we don't see the same person every single day, it could be pretty hard to talk to them. And then also for your government answer, politically, what should the government do? But what could the government do? Making people live together, and sharing resources, and making sure those are equal, like you said. Utopia, which I think was the right way to word that.
Sandra Parsons: Yeah. Yeah. I think in theory, it would be a lovely place to live where there was no competition for resources, or the only competition was where you had a perfectly self-sustainable unit where everything was equally accessed. I think we're probably describing a type of government that has been tried and failed before, but in our perfect-
Jack Eisinger: Not necessarily with fully economic resources.
Sandra Parsons: Right, exactly.
Jack Eisinger: Okay, so just to transition back to class, I remember in social psychology, one of the biggest takeaways I had... And it was something that we didn't talk about for a super long time, but it really stuck with me, was when we talked about depressive realism. And that when people who are depressed sometimes do not have the "elevated" versions of themselves that a lot of other people do.
And so I was hoping you can explain for our audience a little bit more about depressive realism, why it can develop, and what are some ways for a psychologist to determine that in a potential patient or other person.
Sandra Parsons: I love this question. So the other side of that is rose colored glasses, which has to do with the self-serving biases that we have. So the idea is that most of us, if we're mentally healthy, are walking around with a little bit elevated version of ourselves in our heads. So I referred to these self-serving biases. We bias the information that we believe about ourselves and that we think other people have about us, that's a little more positive than reality.
So for example, we think people think that we're a little smarter than we actually are, or than they actually think... We think they think we are a little smarter. We think they think we're a little more attractive, a little more clever, a little better dressed, all of these things. In fact, when we look at pictures of ourselves, one that's just us and the other one's a little enhanced, we think the enhanced one is a better picture, it's more accurate.
So the rose colored glasses are actually useful. They protect us from the harsh realities in the world, and they allow us to go out in the world and be a part of things, and continue to explore, and take risks, and be vulnerable, because we're somewhat protected. We think we're already doing pretty well. And so I'm going to extend myself in these spaces, and it should probably go pretty well because hey, I'm a pretty good-looking, smart, clever kind of person, and everyone thinks that about me.
It's when you are depressed that those glasses come off. So it's less about depressive realism developing, and it's more that you are taking away that self-serving bias, and you're being more realistic about the way the world sees you.
So it's realizing that when you're not mentally healthy, when you're a little depressed, mildly to more than that depressed, that the world really isn't spending that much time thinking about you. And that when they do think about you, they are not assessing you as positively as you hope that they are.
So I'm glad that you didn't spend a ton of time thinking about this, because when you do, it becomes in and of itself kind of depressing. It is hard to go out into the world constantly and put your best self forward without that illusion. And so it is a protective mechanism and it's one of the things that keeps us healthy. And so we shouldn't spend a ton of time tearing it apart.
Now, I think the interesting point that I think is probably behind this question is that when we're thinking about this illusion, we do have to think about the healthy version of that versus the unhealthy version of that. So we don't want to be delusional, and we don't want to be unable to accept very true and accurate criticism of self. We have to be able to learn from our mistakes, and we have to have people who can give us that negative feedback and that we will take it in.
So one of the things I would say is that when we... And again, based on research, we know that people who have an inflated sense of self that's not based on any reality, that's actually problematic. So an inflated self-esteem not based on real attributes is problematic.
So I think one of the things... And this is outside my field, but one of the things that I think clinical psychologists would want to do is to figure out, where is the illusion and the self-protective rose colored glasses turning into something more detrimental, something that's delusional? So where the line is between self-serving bias versus delusional thoughts about self or grandiosity is going to be a clinical question, I think with some sort of assessments.
And then I think for the average person who we aren't concerned has delusions, knowing that they have somebody who has their best interest in mind, who can give them realistic feedback, that they will be able to take in without having that in-group threat that we talked about is going to be really important.
So it's the difference between somebody who believes they're so spectacular, that to believe anything else is going to be crushing to them. Versus somebody who in general, thinks they're pretty great and a little better than the average bear, who has a parent or a best friend or a partner who can say to them, "You are really great, but there's this one thing that we need to talk about. You're really a terrible cook, Sandy. You really can't actually cook." Or, "You think you're being gregarious and you're actually being annoying in these spaces. You need to stop talking so much," or whatever. It is the thing that you think is really charming about you, that other people may not think is super charming.
And being able to trust that information and say, "Okay, the threat's coming from inside the house, but it's okay because I trust you." And in order to continue to have that positive feedback loop, we do have to make changes when necessary. So that's okay. Yeah, but it's hard. That's tough.
Jack Eisinger: Yeah, that's exactly what I wanted to get into, just the different spectrum from depressive realism to rose colored glasses, and the fact that not only are humans weird, like you mentioned. And I also think we can also be relatively unaware of ourselves all across that spectrum. And so like you mentioned, which is perfect, having that person that is able to tell you those things is just the crucial, most important thing to making sure that you don't stray too far.
Sandra Parsons: 100%.
Jack Eisinger: One side or the other to the point that it would cause some detrimental effects.
Sandra Parsons: Absolutely. I think you said that really well. I think you do have to have that person. And the other thing that's true about wellbeing is that one of the best predictors of wellbeing in a person is whether they have social support. And part of social support is someone who can say the good, the bad, and the ugly, who can say, "You really are all these things a little better than the average bear, but in this one area you're"-
Jack Eisinger: Social support isn't all support. Yeah, it's a little bit of pushing you in inward direction.
Sandra Parsons: Absolutely. A little bit of realism spiced in there is good.
Jack Eisinger: All right. And now to go the opposite direction of realism, I want to ask you a few, I don't know, not theoretical, but just questions that aren't so grounded in the curriculum. I was curious, what is the most misunderstood thing about social psychology in your opinion?
Sandra Parsons: I love that question. So I think that when people hear that we're going to study how other people affect the way we think, feel, and behave, they're like, "Oh, you mean you're going to study everyday knowledge, like stuff that we already know all the time?" And that's something that social psychology has a bit of a chip on its shoulder. I think psychology in general does, but specifically social psychology, because the thing that we're studying is in fact the thing that most of us are doing all day long. We're trying to figure out why are people the way that they are, how can I understand how they are, so I can control it, and I can react to it, and make things turn out the best way possible?
And there's various versions of that, but that's kind of the big thing, is how can I be in this world and understand what's going to happen so that I can predict it, so that I can react to it and get things my way? Basically in a nutshell.
And so I think what people misunderstand about social psychology is that it is not just the study of everyday behavior. That there's a scientific method to it, that the reason why you think something is true may be totally wrong. Not that it leads you to the wrong reaction to it, but the processes behind it are wrong.
And so social psychology can help us tease out those theoretical implications and theoretical predictions in ways that are surprising to somebody who doesn't study social psychology. I'm going to give you example, but I think some people might see that and say, "Well, who caress? If it leads me to the same conclusion, why do I care what the process is?" And that's somebody who just isn't interested in studying social psychology.
I think we're always going to have... My husband studies the brain and cancer cells, and I don't want anyone to have cancer. And as long as he can figure out how to prevent it, I don't really care how we got there.
So here's an example. People talk about personality all the time and they say, "I know how she I because I know her personality." And what a social psychologist would say is, "What you really know is how that person expresses their personality in the context of the situation you see them in."
And so I'm not saying that they're wrong. You probably do know, not as well as you think you do, but it doesn't matter. People think that they know how other people will behave in certain situations based on personality. And when I point out to them, "You really only see that person in a very narrow band of situations. It's the situation that's driving the behavior, not the personality." And they're like... So I think that's something that's exciting to think about, because for me, that changes the way I think about what personality is. I want people to understand that when you use that word, you mean something different than what you think you mean.
I think that's cool. Some people don't care, but then they don't have to be social psychologists if they don't want to be. Right? So that's I think-
Jack Eisinger: No, that's cool. I remember taking your class and hearing that. But even still to this day, even though I have that mental note of that distinction, when I'm talking with people, I'll still sometimes refer to them both as personality, even though I know the difference. It's a harder thing to say.
Sandra Parsons: Yeah. And even though we all know what we mean, in my head when people say that, I'm like, "Well, I don't know." That's personality or situation. And what makes it interesting to me is that means that it's more changeable than people think that it is. Because I think if I could get you in a different situation, I get you to have a different kind of response to that.
Jack Eisinger: So then is that...
Sandra Parsons: Right? And like you said, people are often really unaware what's driving their behaviors. And so to me, that's powerful, because to me I think, "Okay, well let's get you out of this situation that I think is driving you to do something that I don't think is good or healthy or equitable, or the way I want it to be selfish. Let's move you into a different location, in a different situational space. Let me change the factors, and then let's see how you behave and see if it turns out better for all of us."
Jack Eisinger: I really like that answer. And then in a similar vein, if you had to create a class about an under focused area of social psychology, or positive psychology, or really any topic that you're interested in, what would you want to teach about?
Sandra Parsons: To figure out how to best teach people how to utilize the skills and the tools that we have. I think people don't harness what we know about social psychology in ways that get the best outcomes done. And so very specifically, how do we present information to people in a way that will make them more likely to accept that information?
So this class would be something like a social movements class, or how to improve the public service announcement. Every time I see people talking about a problem that they see, and I think to myself, "I wish that they'd talked to a social psychologist about that because I could help you solve that problem." Not me personally, but social psychology. How do we persuade people to do things? How do we frame messages that can be the most useful?
So it'd be all about that. It's like how to deliver messages, how to harness expertise, how to use what we know about the way people think and feel to get them to do the more healthy thing, the fairer thing, the more just thing. That's what I would do. And I-
Jack Eisinger: So kind of like the more communicative aspect, the more practical way of getting things done.
Sandra Parsons: Yes. Even just thinking about Covid-19 rules and regulations, let's use what we know about persuasive messages, and what we know about different audiences for different types of behaviors, and tailor multiple different messages. And I feel like we just got one message. "This is what you're supposed to do." And then of course the other side is, "This is what you're not supposed to do."
We can talk to both of those groups with social psychology, we just have to tailor the message appropriately, and I don't feel like anyone did that. And so that kind of thing, like composting. How can we present composting to a diverse group of people, or cessation of smoking, or better alcohol use rules? It can apply to anything, but how do we harness that communication and what we know about message framing, and audience effects, and all of that, and make it more effective?
Jack Eisinger: I don't know how classes are made, but I would definitely take that.
Sandra Parsons: Would you take it?
Jack Eisinger: Yeah, that does sound very interesting. And then that's pretty much the end of my questions. I just wanted to ask, is there any advice or takeaways you want to share with the audience in a conclusion?
Sandra Parsons: Take a psychology class. I think everyone should have to take at least one psychology class. I think it makes us better human beings. Also try to remember that...
You know what? Here's my takeaway. Fundamental attribution error. I want the world to know that when you think someone does something, and you think that they are something, a jerk or not a nice person because you don't like what they did, try to imagine that there's some situational effect that's leading them to that behavior, and make a more gracious attribution about the person instead of immediately jumping to the assumption that they're not very nice or jerky.
Jack Eisinger: Yeah. No, that's definitely my biggest takeaway from social psychology, fundamental attribution error. It's ingrained in my mind now.
Sandra Parsons: Good. I'm so glad. We need to be nicer about our assumptions about other people, and give each other the benefit of the doubt in the same way that we give ourselves the benefit of the doubt when we do something that we wish we hadn't done.
Jack Eisinger: Put on some slightly rosier colored glasses for other people as much as we do ourselves
Sandra Parsons: There we go. That's right. I love that.
Jack Eisinger: All right. Yeah, so that's pretty much the interview. Thank you so much for taking the time to participate. For you and any of the other viewers, feel free to check out the Seattle Anxiety Specialists website, and I hope you all have a great day.
Sandra Parsons: Thank you so much. It was my pleasure. It's good to see you.
Jack Eisinger: Of course.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Stephen Oross
Stephen Oross, Ph.D. is an Associate Professor of Psychology at Kutztown University of Pennsylvania. He specializes in experimental psychology and cultural humility in healthcare.
Ryann Thomson: Thank you for joining us for this installment of The Seattle Psychiatrist interview series. I'm Ryann Thomson, a research intern at Seattle Anxiety Specialists. And I'd like to welcome with us Psychologist Stephen Oross. Dr. Oross is an Associate Professor of Psychology at Kutztown University of Pennsylvania. He is a scholar in the field of experimental psychology, and has published several articles within his career, including, “Studies of Brain Activity Correlates with Behavior in Individuals with and without Developmental Disabilities”. As well as “The Impact of Acuity on Performance of Four Clinical Measures with Contrast Sensitivity in Alzheimer's Disease”. As well, Dr. Oross has had extensive experience working with the World Health Network as well as previously having completed a visiting fellowship at Massachusetts General Hospital. Before we get started, can you please tell us a little bit more about yourself? What made you interested in experimental psychology and what led you to become a professor?
Stephen Oross: Well, thank you, Ryann. Certainly. I actually became- It's a longer story, but I'll condense it. I actually became interested in psychology and decided to be a psychologist as a sophomore in high school. And largely it was due initially to an interest in clinical, child clinical to be specific. I had read some books on autism. I had an aunt who had been diagnosed with mental retardation. And so, when I went to college, my plan was to be a child clinical psychologist. And so, I did my undergraduate work, and while doing that, did a bunch of volunteer and then some paid work interacting with individuals with different developmental disabilities, including some time as a residential house manager at a group home for children with autism. So, I honestly thought that was the direction I was going to go. But as an undergraduate, I also began doing some research with a couple professors at the University of Dayton. And some problems with the clinical end that I saw and the excitement I had with research led me to pursue the experimental degree.
I went to Vanderbilt University for my experimental psychology PhD. I stayed there, did a couple of postdocs, one in sensory perception, one on mental retardation and developmental disabilities. And stayed there actually even longer than that as a research faculty member. While doing that, I had the opportunity to do some teaching. And I supervised a student as she worked on her PhD. I was the doctoral advisor. And those experiences led me to believe that while I wanted to do some research, my interests were more aligned with teaching. So, I did stay in a research position for a number of years before coming to Kutztown and then beginning the path I'm on now that led me here.
Ryann Thomson: Really interesting. That's great. I'm glad you had such a different variety in your background before you came here. That's really nice to hear.
Stephen Oross: Yeah, actually I think it's important to do that. I think it's been beneficial in thinking about how to teach.
Ryann Thomson: So, to begin, I wonder if many people have heard the term cultural humility. And could you possibly define what that is and why it's so important when we're treating clients?
Stephen Oross: Yeah, cultural humility, you're absolutely right. Not as many people are familiar with it as I would expect. But it was introduced in the late 1990s. I believe it was 1998, by Melanie Tervalon and Jen Murray-Garcia in a journal article. And what they were trying to do was to respond to some national mandates to improve multicultural education among physicians. And what they identified was a multidimensional approach with three primary components. The first was to emphasize the importance of self-reflection and lifelong learning. And I'll come back to this point. But second was a recognition that in healthcare settings including mental healthcare settings, there's an imbalance of power. The care provider dominates the services and the care that's needed. And often the patient or client gets ignored at some level. Certainly we're paying attention to the symptoms, but not always looking at their background, and the mindset and experiences that they bring to the healthcare setting.
And lastly, they identified the importance of institutions, not just individuals, but institutions to model these principles of reflection, and lifelong learning, and acknowledgement of power imbalances. So, it's a very dynamic process. And it emphasizes the fact that when people enter into healthcare settings, there's a lot of unknowns about them. And what we need to do is to acknowledge the differences, and the similarities, and the perspectives that people bring. Why it's important, it's clear. There's lots and lots of data to indicate that healthcare providers bring a number of biases into treatment. Some of these biases are explicit and some are implicit biases. But the biases that people possess can negatively affect the care that's provided and the adherence to the treatment plan on the part of the patient. And cultural humility is an approach to try to get past these biases and to incorporate the knowledge that patients have into their treatment.
Ryann Thomson: So, in your experience, what are some barriers that the Western medical system and mental health field face when trying to implement this idea? And how should professionals go about trying to address the challenges effectively?
Stephen Oross: Sure. There are potentially a lot of barriers to implementing what seems like a fairly simple concept in many ways. One barrier, for instance, is that academic training, whether it's in medical profession, or a psychologist, or psychiatrist, really does emphasize becoming an expert on a topic or a domain. In some sense we know we don't know everything, but we still act like we know everything and have been trained to think that way. It's potentially a problem to get providers to recognize the fact that we don't know everything, and we have to provide care and conditions where there's uncertainty. Both uncertainty on our end about perhaps the type of treatment that might be called for and uncertainty about the patient's responses and their actions that would affect how well treatment works. So, that's one.
A second that's very prominent is time. Much of the training that's occurring, it's happening for professors in academic settings, physicians in a more applied settings, mental health providers really looks at a very time limited training program. I know I have to go through a series of trainings, but they're once a year and they're kept maybe an hour long, roughly. And cultural humility is not an approach that can really be taught in a single, very time limited session. It's a ongoing process. This is the lifelong learning component that is emphasized. You are trying to develop a mindset that is awareness about yourself and awareness of the individual you're working with. But that knowledge, and the awareness, and how it impacts interactions is going to be continually changing. So, you can get an orientation to cultural humility, but you really have to be practicing it on a regular and continual basis. And I think a lot of the training is capped to be short because of the other time demands that are placed on individuals. And that can be a barrier.
One other from my perspective is that it is often the case, quite often, particularly mental health care, that we're talking about an individual providing the care rather than a team. And if you have individuals rather than a team that's working collectively, it is more likely that certain biases can creep in. So, cultural humility, training and awareness becomes especially important in that context. How you can effectively train or educate people to work on cultural humility varies. I mean, I did just a quick search and there are lots of institutions that talk about training cultural humility. And I noticed that many of them have a big emphasis on self-reflection for the provider, thinking about the provider's cultural background, and ideas, and expectations.
But there's not as much that I could find talking about power imbalances, and certainly even less on how do you make an institution become aware of the cultural background and biases that are inherent in that institution. So, I think the training efforts can be done, but it's got to be a bigger, more collective effort to highlight the three primary principles of cultural humility. And we have to as providers then start recognizing that we have to live with uncertainty. Rather than always thinking we're an expert, we have to recognize that while we know a lot and certainly can bring that to bear in treatment programs, we don't know unless we search for it like cultural humility wants. We don't know how well each of the clients will respond to a treatment plan. What are their other activities from their religious beliefs, their cultural beliefs, their fact of their people possessing different genders, different sexual orientations, how all that is going to affect treatment.
And we have to, when we accept that uncertainty, recognize that we're not going to be all knowing. We're going to have things we're not aware of. But if we recognize that, and work with individuals and allow for input from the people we're working with, we can help to mitigate these power imbalances. We can gain more information on the types of approaches that clients are willing to bring to treatment, what they might adhere to, what they might not want to adhere to in a way that isn't often captured when there's a a unidirectional, here's the treatment, here's what you do independent of the client. I think that's what we really have to consider.
Ryann Thomson: Yeah, I really liked the team aspect, because I know you personally have a unique experience as you're a heart transplant recipient. So, I know you've talked about having a team approach to your personal healthcare. So, looking back on that experience as well as professional, do you see any more of these strategies being invented? And if not, what can they do for patients in the future to better that?
Stephen Oross: Yeah, if I think about my own situation, including the heart transplant and then other aspects of personal and professional lives. I've actually been fortunate. I have to acknowledge that I come from really a position of privilege in healthcare settings. Coming in as a white male with some advanced educational training, and now with at least some money in health insurance, it really affords me an opportunity to select who I want to care for me. It allows me to have a little face validity when I talk to the healthcare professionals and question why certain things are being done. And I don't tend to have a huge power imbalance between myself and the healthcare providers.
And I found particularly in the transplant setting, interesting to think about because you have to go through a bunch of screening, obviously medical, but also psychological screening prior to being approved to get a transplant. And one example that I thought of as I was preparing thinking about this interview was that while talking to the psychiatrist, a question came up about how depressed I may be or how suicidal I might feel, and whether or not I've ever had those feelings. Because frankly, the healthcare system, if they're providing you with a transplant, something like a heart, they want it to succeed. They want to have it put in somebody who's not going to intentionally damage the gift that they've been provided.
But my beliefs on suicide are not typical for many people. So, when I was asked about that, I remember explicitly thinking, well, I could give the easy story and say, "No, I've never thought about it. I've never been depressed." Quick, easy answer, and we're out. But it would be a dishonest answer because the heart issues I had started many years prior. And when they first happened, they were sudden and surprising. And I did go through a depressed period, and that did lead me at times to think about suicide. And I went to a Catholic university, University of Dayton. I was raised as a Catholic. But I never accepted the idea that suicide was necessarily a bad thing. There are many cultures that accept suicide as a reasonable approach under some conditions. And I in fact had to debate suicide, the pro side when I was an undergraduate.
So, I remember thinking, "Going to tell them this, and this may disqualify me for the transplant," but I had to be honest. And what I appreciated was they didn't have this immediate reaction of saying, "Wait a minute, you've thought about suicide at one point?" They explored the conditions under which, why did I think that? Why did I come to this belief system? And to me, that is a reflection of the cultural humility perspective. So, I really appreciated it at that time. And it highlighted in a personal way, the importance of adopting an approach where they're willing to listen to me, they're willing to explore more deeply why I am holding certain perspectives.
So, that was a very helpful component of being prepared. The downside, I've noticed a couple occasions in a couple settings where I don't feel that providers (and I'll talk about employers a little bit as well) adopted a cultural humility perspective. So, after the original damage to my heart and I had to go to varying cardiologists, there was one in particular who my wife would accompany me because I had, at the time, was using a wheelchair and had to use a wheelchair to get around. And this one doctor in particular would always direct their questions and provide information to my wife who was sitting in the exam room and barely looked at me. Despite the fact that even though he wasn't looking at me, I was the one providing the answers.
My wife has been extremely helpful as I went through this process, but she is not as knowledgeable about the health condition I had. She wasn't as knowledgeable about the damage to the heart and what I might have to do. She wasn't as knowledgeable about the medications I may have to take or other treatment plans. And yet this physician kept insisting on talking to her as if, because I had this serious heart attack, that I was incapable of responding and taking care of myself. And that was an instance where there was certainly not a cultural humility perspective. There was no real attempt to understand what I possessed, what abilities, knowledge, background I had. It was, I'm going to dispense the information to the person who looks less impaired.
It was an instance when I was like, this person's clearly not trained in a way that I think would be conducive to better healthcare. And I left their care. It was unacceptable to me. I encounter it also, not intentionally sometimes, but with individuals who want to talk about the transplant and what the consequences have been for me. Because even though I might be asked what it's like to have a heart transplant, the conversations often turn quickly to their knowledge of transplants or their knowledge of somebody else, and not really looking at what I bring and what my perspectives are and how I'm handling this. So, it's a case where I see myself being minimized, if you will, in these discussions.
I see it institutionally. Most recently at my university at Kutztown University in several ways. I won't belabor the point. But one I thought was particularly relevant when you asked the question concerns the need for medical notes when you have sick days. As a heart transplant patient, I'm immunosuppressed. I'm going to get sick. Varying types of bugs are going to affect me. The team knows this. We've gone through what I'm supposed to do, how to treat the symptoms. At what point should I contact the team? At what point do I wait it out? But Kutztown University and probably others, has a policy that if I'm sick for three days or more, I have to provide a note where I've gone to see a doctor. Well, I don't necessarily see a doctor in three days. My team knows that, that I know I'm going to be sick. It happens, it drags out for a few days. I don't necessarily have to see a doctor.
But the institution has decided that three-day policy that I have to have a doctor note. Little attempt to understand anything about the individual in this case. They're not looking at it as, why do you not have a note? Why does your team allow this? No real dialogue about the conditions and the background that I bring that might affect how and what kinds of demands they want to place on me. So, when we talk about institutional accountability with the cultural humility perspective, I think these are some of the kinds of examples that I've encountered anyway.
Now, how do you get people to be more aware of cultural humility and what ways should people train for this in the future? I'm sure we'll talk more about this. You certainly have to get people to engage in the self-reflection and the lifelong learning component. You have to get healthcare providers to recognize that they need to learn more about themselves so they know what their backgrounds and biases might be. And then they have to be interested in learning and continually learning about the individuals they're working with. And there are some training programs to do that, but I think that's a huge step, the self-reflection and lifelong learning approach. The power imbalances, we know they're there. There's certainly training to make people less willing to have those imbalances.
I am not a 100% sure what kinds of training can be available at the institutional level. The medical institutions I've interacted with most, as far as I can tell, really haven't done any kind of institutional accounting for cultural biases and adopting a cultural humility perspective. I can say that I felt that my transplant team did do that, but in other healthcare settings, both with myself and other family members that I've went to, I don't see a lot of that at the institutional level. So, looking for specific training programs for each of these three components is going to be crucial. And it's hard to mandate how that's done because it has to be a very personal reaction on the part of the providers. And every institution has a slightly different background and mission. So, the awareness that cultural humility is a perspective that should be adopted, a willingness to go look at what other types of efforts have been made at other institutions would be a first step.
Ryann Thomson: So, within this conversation, I know I personally have heard more about cultural competency. And I think you're touching on some of the ideas that differ cultural competency and cultural humility. So, how does knowing the difference and implementing both, I would say, enhance treatments of patients?
Stephen Oross: Sure. And I think that's a good point to bring up here. The perspectives that have often been taught in institutions are ones that call themselves looking at cultural competence. And there's nothing wrong with this. It's just that cultural competence approaches are training efforts to make people more aware of cultural differences, but they really think of the training as an endpoint. And what I mean is there's a set of facts that are taught in the training about people who have differing types of backgrounds. It is, in some sense, a training to teach about the belief system that is assumed to be held by individuals from different backgrounds.
There's little in cultural competence training that emphasizes looking for, well, in some sense being taught generalizations rather than stereotypes. Being taught in cultural competence, that this is a starting point for understanding individuals. But you need to interact more carefully, understand the nuances that each individual brings. Not all individuals from varying backgrounds are identical to one another. We tend to think when we say cultural competence, something really along the lines of race or ethnicity. But we have to broaden that perspective, especially if we're talking mental health to consider diagnoses. And one of the problems with diagnosis and mental health is we all know two different individuals identified with the same diagnostic label aren't necessarily acting the same way, don't necessarily show the same symptomology. So, it really is a setup where we need to learn more about the individual patients.
Ryann Thomson: So, you touched on bias earlier-
Stephen Oross: Oh. Yeah, sorry.
Ryann Thomson: Oh, sorry. If you want to keep going, go again.
Stephen Oross: Well, just briefly. There have been a few surveys in other experimental analysis of cultural competence training. And it works. People get more knowledge about different backgrounds. But it has been shown that it tends to promote stereotypes. And that's something that cultural humility will try to break down by the fact that you're going to be looking for the individual perspectives, belief systems within a framework of their cultural background. I'm sorry to cut you off there.
Ryann Thomson: No, it's okay. I didn't know if you were finishing that. So, earlier you touched on both of these points, but implicit bias within the mental health diagnosis. And education, obviously holding a really important point. But how do you ensure educational programs and training can at least mitigate or try to mitigate this bias, and make accurate diagnosis and assessments of patients? Or is that even possible?
Stephen Oross: Well, this is a big question. Let's start with a couple simple points and then build up to this. When we're talking about biases that people bring to providing services, largely talking healthcare here, we have both explicit and implicit biases. So, explicit biases are, we already have certain beliefs about people who come from different backgrounds. And we know this, we hold them, we can state what those beliefs are. Before we've even met the individual. We have certain expectations. And that type of work, I mean that type of bias has certainly been shown to provide a means for having unequal healthcare treatment based on your cultural, and ethnic, and racial, gender, sexual orientation backgrounds.
So, that part can be often taught with some formal training to have people aware of their biases, provide information to show where the biases are misleading, present alternative approaches to thinking about individuals. The implicit biases are a little more tricky because they are ones that people are not aware that they're holding. And if they're not aware that they're biased, it's very difficult to make them aware of the need for training and for changing their perspectives. But in studies that have attempted to look at this, there's been a few studies I remember that were talking about roughly two thirds of individuals who were providing services holding biases. Not that they were aware of it, but they were implicit biases that were negatively affecting groups that are typically underrepresented or marginalized. And these biases can impact what types of treatment programs and plans are recommended for patients.
So, we've seen health treatment disparities, for instance, between White and Black as one example, men and women. Different types of recommendations, different treatment options. One, as I remember prominently because I'm also diabetic, is that individuals who are Black when they experience neuropathy, the condition that a nerve damage that follows diabetes often, individuals who are Black were much more likely than White patients to have to be amputated to have a foot or leg amputated. Whereas White patients were more likely to have more extensive treatments designed to try to restore blood flow to the affected leg or limb. And that's a bias perhaps impacted by an implicit bias of who will follow treatments, what will work, the money, and the time efforts, the diligence in treatment. So, we know that populations who are underrepresented or marginalized are going to be affected by implicit biases. In mental health, this may not be something that individuals at the varying psychiatric institutes want to hear. But they're particularly vulnerable to the implicit biases. And partly I would argue that's because of the DSM itself.
There is a belief that is commonly held that the DSM has a standardized diagnostic criteria. And it does have diagnostic criteria and it can be quite standardized in some instances, little less standardized in others. But there's a tendency to not recognize the fact that the benefit of at least some of the standardization that's present in the DSM matters if providers pay attention to the DSM, and don't use their own judgment that might be more likely to be affected by biases. There are a number of providers have reported in different sources that , yeah they're aware of the DSM-5, they were aware of the changes that came out in DSM-5 compared to previous editions. They have a copy of it. But they argue that they rarely refer to it, that after a certain period of time they know how to diagnose individuals from their own backgrounds.
And the DSM is there, I remember in particular reading one report, where this provider was saying the DSM there is there really just to head off arguments from clients about diagnoses. And that really bothered me when I started reading these types of reports, because that's a perfect scenario for implicit biases about mental health challenges to creep into diagnosis. The DSM, some people and a growing number I would argue, suggest that there are concerns about how reliable the diagnostic categories are used and defined in the DSM. And if we don't have a careful system of diagnosing and identifying treatment plans, the individual biases that we all possess have a greater potential to come into play. We might think certain groups are going to be less compliant and we'll recommend one type of treatment for one group compared to a different treatment for others.
These are the conditions that have to be overcome. And the educational settings, again, I think first and foremost, we have to have awareness of the three principles of cultural humility. Of those, while all are important, I think one that is commonly missed is the self-reflection and the lifelong learning approaches. And there are some training materials out there to facilitate that. But it has to be emphasized that one time training is not going to be sufficient to do this. So, I think the field is right for the varying efforts that have been made across different institutions to facilitate understanding of cultural humility. I think the time is right for an overview, what is everybody doing? And can we pull out best practices that have worked in different institutions and share them more widely. At this point, I still see this being largely run on a center-by-center or provider-by-provider basis, rather than as widespread training as it probably should be.
Ryann Thomson: Yeah, I've definitely heard some of the changes DSM has tried to make for culture, and race, and things. It's obvious they're trying, but at the same time, how much changes can you make before... There's only a certain point, if that makes sense. Like you said, you have to recognize your bias and self-reflect on those. Definitely a major point, I think. That's important.
Stephen Oross: Well, especially when the DSM changes over time. So, if I'm a clinician and I've been providing mental health services for a number of years, am I actually paying that careful of attention to the changes that are introduced in subsequent additions of the DSM? I mean, there are many who are diligent and are well paying attention for this. But we know from self-report and a few studies that there are individuals who really are not paying that much attention to the changes. And if they're not, the efforts to become more culturally aware in the DSM are going to be ignored. And it's going to, again, make it likely that biases come into play in treatment plans.
Ryann Thomson: Well, I want to jump to this technological advancement we've had because of the COVID-19 pandemic. So, telehealth has obviously, especially mental health, telehealth has grown. And in a way has allowed us to enhance our cultural humility, and especially with treating individuals. So, can you speak to how telehealth plays an important role and how our biases can be expanded with increased uses of technology within mental health diagnosis? Or in a way, can it negatively affect?
Stephen Oross: Yeah, it's an interesting question to address because the technology is so varied that can be applied to providing healthcare services. We can talk about a simple technological advance, the telehealth, as you mentioned. I conduct a number of my sessions with clinicians through telehealth now. Some I have to go in person, but many I can do. Essentially they're a Zoom meeting at some level. And it works. There are concerns, I think about the technology because it's an unusual situation for most people to be conducting health interviews or health sessions through a camera and through a monitor. And I think there's potential there for people to act differently when they're in telehealth settings than they might when they're in person, on both the clinician and the patient end. You're sitting pretty still stable looking at a camera. Whereas in a in-person facility, you're moving around, you might be able to observe things about body movement that you're not going to pick up necessarily with a telehealth interview.
On the other hand, the integration of artificial intelligence can provide some background information about an individual's cultural and background. And that could be useful for writing reports or preparing for visits from the clinicians. I’ve heard, you know, when you start talking about technology, we've already heard of lots of wild ideas. So, I've been hearing more and more about digital twins, this idea that there would be, in essence, a virtual representation of you. And the digital twin would somehow be coded with information about me. And clinicians could interact at times with the digital twin. They could try out different treatments and see how the body in this virtual person responded.
I have a hard time thinking about how that's really going to work because it's simply going to be based on the input that creates this digital twin. And if we're not adopting a cultural humility perspective very well, we're going to miss information that should be incorporated into the twin. Virtual reality therapy we use already in mental health treatment in some cases and it has been proven effective. But how far that can go is still a little unclear to me. I think there's another issue though with technology that we're not really addressing.
The benefits are often proposed to be ones that are going to help people who are underrepresented or marginalized. And the problem is we already know there's healthcare disparities for these populations. We already know lack of money, lack of easy access to facilities, lack of freedom to select different care providers because of healthcare insurance restrictions. We already know that exists. We also know that providing technology through the internet, for instance, not everybody has equal access to the technologies, the internet access, the cameras, the monitors that might be needed to use telehealth.
And so, we saw some of that with COVID-19, where there was an effort to push both educational and health services online. And understandably so. But there were large numbers of groups who were marginalized to begin with, who became further marginalized because of lack of access to the technology that's needed to do this. So, if we're going to push technology into the telehealth kind of world or the virtual reality type of world, and hope that it helps us better understand individuals, it has to start with making sure there's full and unencumbered access to the technology for individuals. And I don't think that exists right now.
We then still have to adopt the perspective that when you've got somebody on a camera, you still have to spend the time to think about how you're interacting with them and how they're interacting with you. How the different backgrounds are going to mesh. Whether we're willing as healthcare providers to, at some level, give up a certain degree of control and recognize that people from different backgrounds won't always accept the treatment plan that we propose. And we have to do a better job of recognizing the power imbalances, living with a little less control at some level. But understanding the client or the patient better so that we can tell them in more succinct manner, more appropriate manners why we're recommending different treatments.
The COVID situation is one example. I don't think we did a very good job with public health and convincing different populations of people of the benefits of vaccination programs. And we see that by the disparities in who's willing to get vaccinated and the percentages of people who are actively fighting or ignoring vaccine protocols. Vaccines I firmly believe are beneficial for most people. But we haven't been able to recognize that not everybody believes that upfront. And how do we either inform them better so they change their mindset? Or how do we adapt to the belief that vaccines in some people's minds are not beneficial? And we're still struggling with that.
Ryann Thomson: I feel like this whole conversation, it involves every single part of our lives. So, you can take any example from any part and just like, well, here you see it in vaccinations, or in how we approach illnesses, or if we even go to the doctor. It's literally anything you can think of. I think you can see an example of it.
Stephen Oross: I think you're absolutely right. And my understanding, my familiarity with cultural humility came a little later than when it was first introduced. But I had the belief system already in place from working with people who had developmental disabilities. And the awareness that whatever their clinical label may be, there are variations in the symptomology, and the beliefs, and the behaviors of those clients. I had that perspective. So, when I encountered cultural humility more formally, later, it was easy for me to accept it and to understand it.
And I think that afforded me an opportunity to, as you said, recognize it applies in multiple contexts, not just healthcare settings, not just mental healthcare settings, but in every aspect of our lives we're encountering different people. And we have to understand that we're going to have certain beliefs, we're going to have certain generalizations about people when we first meet them. But we have to get to know those individuals. We have to think, why did I hold my beliefs and are they valid beliefs? Should I change those beliefs? I believe as people become more aware of cultural humility and as we develop more effective training programs for this, it will affect all aspects of our life.
Ryann Thomson: Yeah, I definitely agree. Now, I know you have a class to teach in 10 minutes. So, is there anything else as a health psychology professor, you want to say to our audience? Any advice or ways to move forward from this conversation?
Stephen Oross: I think we've touched on quite a bit of this. I think really, from my perspective, one of the most important keys, I guess I would say in a multi-lock system, is that we have to give up when we're providers of services. We have to give up the idea that we are an all-knowing expert. Certainly expertise is important. Certainly academics and physicians are training to understand their domains better and better, and more sophisticated manners. Certainly there's a great deal of knowledge that's possessed by the individuals. But we have to give up the idea that we're all knowing and recognize that there is a dynamic with whomever we're working with. And they are not just a receiver of whatever treatment or information we want to provide, but there's some level, almost a negotiation with the individual that has to take place. And I think that's probably the biggest point that I think of. I'm sure others can have different perspectives. But for me that's the biggest point. Can we recognize this dynamic interaction between patient or the client and the provider?
Ryann Thomson: I like that you never really stop learning. You always have to keep learning about other people and an open mind about things. That's really nice.
Well, that is all the time we have. And I want to thank you again for talking with this about me. I learned so much and actually a lot of interesting ideas I'm going to look up after this. And I hope we can see you in the future. And I hope you have a nice day.
Stephen Oross: Thank you. It was my pleasure to do this interview. It was really interesting to think about this and how to present it in this kind of context. So, as I'm talking, we had the time limit, but I'm thinking, "Oh, I could say so much more here." I could say-
Ryann Thomson: Yeah, I know.
Stephen Oross: But I enjoyed it, so thank you for the opportunity.
Ryann Thomson: Yeah, of course. 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.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Ami Shah
Ami Shah, Psy.D. is a licensed clinical psychologist in private practice in New York and New Jersey. She specializes in working with adults and geriatric patients and helps support caregivers suffering from burnout (in particular caregivers of those with dementia, cognitive decline, and medical illness).
Adithi Jayaraman: Great. Thank you all for joining us today for The Seattle Psychiatrist Interview Series. I'm Adithi Jayaraman, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.
Today, I'd like to welcome Dr. Ami Shah. Dr. Shah is a clinical psychologist in New York who specializes in working with adults and geriatric patients. She also specializes in the areas of bicultural, multicultural identity, relationships, marriage concerns, family, individual stress, and grief and loss. Dr. Shah received her master's and doctoral degrees in clinical psychology from the University of Indianapolis. Today, we'll be speaking to her about her work with caregivers and caregiver burnout. So, before we get started, Dr. Shah, can you please share a little more about yourself and what made you interested in working with caregivers?
Ami Shah: Yes. Thank you for the lovely intro, Adithi. So, my journey to becoming interested in working with caregivers was a bit roundabout. I initially started off thinking I wanted to work with kids, and as I began to work with individuals clinically in training, I recognized there was a large gap at that time in terms of older adult care, and then when I did my fellowship... I'm sorry, I had done research prior to that at the VA in caregiver interventions for older adults that have dementia. That was the first time I was exposed to and recognizing there was a big gap in terms of, we were working on a research project at that time, it was a phone intervention, long before we had Zoom, and we were working on a phone intervention to provide emotional support for caregivers of veterans that had dementia at that time. And from that, during fellowship, we continued to do caregiver work in the same capacity, primarily as well caregiver interventions for veterans, again, that have dementia.
So, that was the capacity I started, and now most recently, I work at a skilled nursing facility and I'm seeing folks who are caregiving a number of older adults. So whether it's primarily, it's secondary to, say, a fall. Perhaps it's chronic falls, it's chronic pain. Sometimes it is cognitive decline. So, there's a number of caregiving capacities. That's sort of the capacity, so the capacity and context I'll be talking about is primarily in working with adults and older adults.
Adithi Jayaraman: Perfect. Thank you. Yeah, and then on that note, can you provide us a working definition of what caregiver burnout is and how common it is in the States?
Ami Shah: Yeah, I think that's a great question. Caregiver burnout I think is, it may go through waves, and sometimes it doesn't. So, it really depends on a number of factors. It's quite complicated, actually. When we think about caregiving someone at a certain point in time, say for example, I'll speak to individuals I see currently, if you're caregiving someone that perhaps fell once, it depends on the nature of the injury. The context is always critical in any of these situations. If it's a one-time fall, depending on their age, their premorbid functioning, the caregiving capacity could be more acute and short term, and so perhaps it really may not necessarily disrupt or impact someone's functioning as much.
What becomes a bit more complicated is, depending on the nature of the injury, but also understanding the caregiver's individual life and responsibilities, including their own health, caretaking other folks. So, burnout, really the word burnout, I think it's important to understand at a single point in time, what is the experience of the person they're caretaking and what is the experience of the person that is doing the caretaking? Of course, as we all know, burnout is essentially saying, at a certain point of time, someone is perhaps giving more than they're able to at a certain point in time, which can of course contribute to feeling distressed.
I know with, for example, caregivers of dementia, at large, again, this is generalized... I'm trying to think back. I think 60% at some point report experiencing some sort of, quote, unquote, "burnout", and sometimes as much as 40% may experience clinical depression. And so sometimes it can be a depressive episode, which can be normalized to, well, what is going on at that point in time? So yeah, I would say even more than the commonality, it's important to understand the context at a certain point in time.
Adithi Jayaraman: Thank you, thank you. And then in terms of, you kind of alluded to this, but what are some of the main concerns or themes that you've seen in your work with caregivers and the general caregiver population?
Ami Shah: I think one of the biggest factors is thinking about more of the structural. So, depending on, again, the context here of caregiving, in the sense that if someone is prepared mentally to care-give X, Y, Z person, there's time to plan. So, for example, I see a number of folks here, it's a skilled nursing facility, folks are here for physical rehab, oftentimes due to a fall, multiple falls. So, they've been here more than once. So, if the caregiver has time to think about, for example, if they're planning on being discharged home as opposed to a skilled nursing facility, perhaps that lessens the, quote, unquote, "burden" of responsibility, where they can call insurance, make sure the house is safe for return. So, in more the physical or structural capacity.
Oftentimes, what happens is folks are not always prepared. Sometimes insurance, I would say more than 80% of the time, determines how long someone is staying at a facility, which then can directly, indirectly affect caregiving if they are also, again, aging themselves, working, have other responsibilities, personal responsibilities. It creates this increased stress for everyone that's involved. I think another thing too in terms of caregiving, again, in the capacity of primarily older adults that I see, is finance. Things that we don't necessarily talk so much about. How are we going to finance certain things if insurance doesn't cover it? If there's multiple kids, family members, money is one of the biggest topics that come up. And time. Who's going to care-take so-and-so, and to what capacity, if it's not in a skilled nursing facility?
Another thing is, which comes up quite often in working with older adults, is what they call decision-making capacity. If there's sort of two major, and I'm speaking about it broadly, if so-and-so, Mr. Smith is unable to make decisions for himself, first of all, how are we determining that, and what decisions? So, say Mr. Smith, he recovers from rehab, he's like, "I'm ready to go home," and there's questions about his cognitive capacity. Who's making those decisions about where he goes next? How are those decisions being made? It's not always that clear cut, I'll tell you that. It looks pretty on paper and in textbooks, but in reality, things are moving fast.
So, considering also that individual, Mr. Smith's sense of autonomy in this process. If so-and-so has decision-making capacity, is able to, to some extent share an awareness of why they're in a facility, what they're being treated for, that then directly, indirectly affects caregiving capacity. Are we allowing Mr. Smith the opportunity to say, "Hey," and this comes up a lot, "I would rather just go home"? And they're saying, "I'm not sure we have the time or ability to care-take." Then what? If someone has the ability to speak for themselves and the caregiver is saying, "I'm so overwhelmed," what do you do?
These are family conversations that oftentimes I think bring about a lot of tension for the caregiver, anyone involved with caregiving Mr. Smith. So, I think that comes up quite a bit. And the autonomy part, is caregiving means helping someone to get through X in some capacity, and I think with that, sometimes Mr. Smith may lose his voice at times, assuming he has that capacity. And even if he has, say, mild cognitive decline, he still has feelings. So, it's thinking about how... Caregiving, it goes two ways. Caregiving also means recognizing, preserving someone's autonomy, and it's little sometimes, right? It's allowing someone to eat on their own or maybe they make a little bit of a mess, and it's not the end of the world. So, I think those are big themes.
Adithi Jayaraman: Yeah, it shows caregivers go more beyond just caregiving physically, but also emotionally, spiritually, mentally, and that's definitely a large feat to hold.
Ami Shah: Oh yeah.
Adithi Jayaraman: Perfect. Thank you. And then in terms of caregiver burnout, can it be prevented, or what are some steps that a person can take to reduce it or to prevent it coming on?
Ami Shah: That's a good question. I think it's quite complicated, again. To your first point, can it be prevented? I guess that's like saying anything else that could be prevented, is who knows? If we were to think about it, if it's something that's more abrupt and sudden, someone caretaking, say someone falls and then they're working and they're not expecting their mom, for example, to fall, and suddenly they're in this capacity, there's a shock factor, one. Emotionally coping with, "Mom fell, oh my gosh. Maybe I'm aging as well." Again, context on both ends.
In that moment, I think number one is seeing if you can have at least someone to talk to in that moment in time. If it's a friend, family, a therapist, it doesn't matter. In some capacity, having a place that isn't mom, because you're both going through this thing together and perhaps you both need an outside person or professional, that would be my opinion, others may say otherwise, to kind of walk through that. And number two, the structural, which is calling insurance and making sure, because a lot of the distress comes from, "Is this covered? Is this not? What do we need to pay for?" A lot of stress comes out of the finance, like I was saying before. So, the stress can be by educating yourself on the insurance policy. These are very real stressors that come up.
So, I would say prevented, who knows? It depends on what you're going through at that time. I have some caregivers who, before they even fell into the role of caregiving or perhaps chose to be a caregiver, they already had a therapist. They already had a solid group of friends and a spouse, partner, whatever, and they tend to perhaps at least emotionally feel a bit more sound. So, I think the prevention part, it's a tricky question, because I think at large, we need to do a better job with understanding what contributes altogether with folks' distress, even before they're in the caregiving capacity.
Oftentimes, a caregiver capacity can exacerbate existing stressors. If someone has a history of depression, for example, and then they come into this caregiving capacity, whether it's suddenly or even over time, depends on the severity of it, how stable mentally are they feeling before taking on this pretty large responsibility? It's almost like caretaking a child. I'm not sure if that answers the question, but...
Adithi Jayaraman: Yeah. No, makes sense.
Ami Shah: Yeah.
Adithi Jayaraman: Yeah. No, thank you.
Ami Shah: Yeah.
Adithi Jayaraman: I think that's very interesting. I think that even the finances you brought up, that's something I think that not many people talk about, and I can only imagine how much, if you're abruptly placed in that role and you have to figure out the whole healthcare system in a few days.
Ami Shah: Right. It's a nightmare.
Adithi Jayaraman: Yeah.
Ami Shah: It really is, because even if the caregiver is in the healthcare field, I mean, it took me at least two years with time to really understand health insurance and how it works. These are things that even if you're in school as a mental health provider, we're not taught how to. And insurance, it's all about billing, and that then directly, indirectly affects caregiving. If insurance isn't going to cover certain services, such as physical therapy, which comes up a lot, physical therapy, is Mr. Smith better going to a facility that offers that? Is that covered? That then affects the caregiving quality of life, and for Mr. Smith. So, that's a difficult job.
Adithi Jayaraman: Yeah, definitely.
Ami Shah: You know?
Adithi Jayaraman: Yeah. There's a lot of infrastructural forces that are-
Ami Shah: Oh, sure.
Adithi Jayaraman: Yeah.
Ami Shah: Yeah.
Adithi Jayaraman: And then in terms of once a person is no longer a caregiver, do you tend to see that they normally just bounce back, or there's some rebounding or burnout continues? What have you seen post that caregiver position?
Ami Shah: That's a good question. I'm not sure I'm equipped to even answer that, because I'm not necessarily seeing folks post-caregiving. I primarily see them when they're in the moment.
Adithi Jayaraman: In the moment. Mm-hmm.
Ami Shah: If I were to imagine some folks that have taken on caregiving as their sole responsibility, I imagine if Mr. Smith ends up and it's sort of this informed decision where they've discussed it and he has that capacity to make a decision and agreeable to it, I imagine things might be a lot lighter, in this sort of picture-perfect scenario. Which is great. Doesn't always work that way. So, maybe I said this a million times, but the context is important at that time. So, again, burnout is a certain point in time. It doesn't necessarily mean they feel that way at all hours of the day.
Adithi Jayaraman: Yeah. No, that makes sense. And you mentioned how a lot of preexisting mental health concerns get exasperated by this caregiving position. So, when you treat caregivers, do you oftentimes, it goes beyond just talking about caregiving, goes into some of their root fears or concerns that are brought up by the responsibilities they have as a caregiver?
Ami Shah: That's a good question too. I'm trying to think back to when I first started doing the phone interventions. Well, it was part of a research study, I should add. The research study is about focusing on caregiver distress, so we did talk about, it was primarily about caregiving as opposed to even, are you saying even going beyond the caregiving and talking about their own needs?
Adithi Jayaraman: Yeah.
Ami Shah: Yeah, that's a good question. In the capacity that I've seen folks for caregiver distress, not so much. More recently, I did speak to an individual who was caregiving her husband who had aphasia, but this individual already had a therapist, and so it wasn't my place to sort of-
Adithi Jayaraman: Oh, yeah. Yeah.
Ami Shah: So, we just focused on the spouse. But I think the times that, I'm trying to think too, there have been times where I've suggested they speak to someone. It depends on the capacity and the setting you're seeing someone in. So, for example, when I was at the VA, it was a research intervention. It was protocoled. It was a bit more like session one, session two. That's not reality all the time. At the nursing facility I work at now, obviously the patient many times is the primary focus, and if they're unable to, in this case, this gentleman with his aphasia was having trouble with speech, is when I sort of went to the caregiver and to kind of see the best way to support him. So, again, our focus was on him.
Adithi Jayaraman: Yeah.
Ami Shah: And she also had shared she had someone. But it's certainly, to your point, it's a great idea, I think to explore. And this is more short-term acute care.
Adithi Jayaraman: Yeah, yeah.
Ami Shah: I seem them one to five times. This isn't long-term therapy.
Adithi Jayaraman: Exactly, yeah.
Ami Shah: And a lot of times in these settings where you're meeting caregivers, it may be in a hospital setting. Not always. Perhaps I'm just speaking to my own experience. If you're in a setting where you're allowed to and you're able to, and again, see someone beyond just the patient, you can explore if it wouldn't be conflicting to see the caregiver as well, or perhaps even provide them resources if you're unable to for whatever reason. So, yeah.
Adithi Jayaraman: Wow. Thank you. And just one last question. How has your work changed post-pandemic? Have you seen some significant changes in the caregiver field and just generally mental health-wise in regards to caregivers?
Ami Shah: I think that question is a great question, and it's complicated, because I think post-pandemic, it's hard because there could be a number of factors. I'm not sure I can just pinpoint the pandemic as the only factor, but I think as human beings, which then of course translates to caregiving to some extent, and with increased use of technology and social media, think of climate change, I mean, there's obviously all the things happening in our world, there's sort of this increased, I should say decreased distress tolerance capacity as human beings.
And so for example, in the setting that I'm in, sometimes when someone wants something, whether it's the patient or the caregiver, they want it now. And yes, of course, there's certainly, if it's an emergency, it's a crisis, that's understood. That's a given. But it's sort of a top-down effect. It's that all of us are experiencing this sort of vortex of, "You need to get this done right now or else," in some ways, because of inflation. But things are more costly now for folks. So, if things are more costly, then I'm going to have less time to spend caretaking Mr. Smith, and then Mr. Smith gets less from me as his daughter, then that sort of creates that trickle effect. So, the economy, the environment, I think perhaps we're just sort of aiming for good enough. Perfection is sort of an illusion here. So, as long as we can say, "Hey, am I doing enough today? Am I able to at least accomplish what was necessary to get done today?" and just leave it there.
Adithi Jayaraman: Yeah, definitely. And I think that mindset just applies to all of us and-
Ami Shah: Yeah.
Adithi Jayaraman: ... the capacities we're functioning in. Yeah.
Ami Shah: Absolutely.
Adithi Jayaraman: Definitely. Well, thank you again so much for your time. I really appreciate you being part of our interview series. Yeah, and I'll leave it there. Thank you again, and best of luck with your future endeavors.
Ami Shah: All right. Thank you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychotherapist Rachel Kuras
Rachel Kuras, Psy.D., LMHCA is psychotherapist at Seattle Anxiety Specialists. She provides therapy for individuals and families, and helps clients of all ages - including children. Her clinical work focuses on: trauma, attachment, gender & sexual diversity, family conflict, grief, anxiety, depression, and ADHD.
Kate Campbell: Hello, everyone, and thank you for joining us for this installment of The Seattle Psychiatrist Interview Series. I'm Kate Campbell, a research intern for Seattle Anxiety Specialists, PLLC. We are Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us Dr. Rachel Kuras, a licensed mental health counselor associate who recently began working with the Seattle Anxiety Specialists as a psychotherapist.
Since graduating with a doctoral degree in psychology from Pacific University, Rachel has trained in trauma-focused cognitive behavioral therapy, acceptance and commitment therapy, and attachment therapy and commitment regulation. Prior to joining SAS, Rachel completed an internship through Idaho Psychology Internship Consortium, where she provided in-person, individual psychotherapy for children and adolescents, comprehensive neuropsychological assessments, and comprehensive diagnostic assessments. Welcome to the interview series, Rachel, and thank you so much for joining us.
Rachel Kuras: Thanks for introducing me, Kate.
Kate Campbell: Of course. So before we get started, can you tell our listeners a little bit about yourself?
Rachel Kuras: Yeah, so my name is Dr. Rachel Kuras, formerly Rachel Rower. I changed my name this year. I grew up in Tacoma, Washington, and I was a graduate from University of Washington Tacoma campus, where I majored in psychology and obtained a minor in global engagement. Directly out of undergrad, I pursued my doctoral degree from Pacific University in Hillsboro, Oregon. And the fifth year of that program was an internship in Idaho, where I worked at Pearl Health Clinic, as you already described. So a lot of what I'm saying is repeating what you already said.
But yeah, aside from pursuing my degree and being a student for most of the time that I've existed, I really love my pets. I have a cat who is a calico polydactyl cat, meaning that she has extra toe beans, so she has thumbs, which is really fun. Her name is Pickle. And then I have a dog who just turned six last week, and her name is Daisy. And I spend a lot of time with them. I'm a huge animal lover. And I really enjoy backpacking and hiking, which unfortunately I haven't done very much in the past five years. Graduate school takes up a lot of time and energy, but I'm getting back to it.
When I graduated high school, I worked in Yellowstone National Park as a room attendant for a summer. And I really enjoy going back to Yellowstone, spending time in the Tetons. But at heart, I'm a Pacific Northwest person. So yeah, I like national parks. I enjoy playing music recreationally. I sing recreationally. I also like gaming, but I'm kind of a cozy gamer. My favorite games are Animal Crossing, Mario Party and Stardew Valley.
Kate Campbell: Yeah, no “Call of Duty” or anything along those lines.
Rachel Kuras: No, I like games where I can catch fish and garden.
Kate Campbell: That's awesome. And I love that where you went to school for undergrad is where you are now a psychotherapist. So that's really cool that you continue to get to work in the same area. And on that note, I think it's just a cool thing to be able to see different parts of the Pacific Northwest, but I was wondering, what's your favorite part of being in the Seattle area now?
Rachel Kuras: I have been so grateful to be in Seattle. Growing up in Tacoma, Seattle was a north neighbor. So I spent a lot of time here growing up, and I missed Washington very dearly when I was away. Right now, my favorite part of Seattle is my neighborhood. My childhood best friend lives just like a five-minute walk away from me. So I've been moving around and away from home for a while, and now I have a best friend close by. So I've been enjoying going on walks with our dogs and just spending time in a neighborhood near people who I grew up with, which is really nice.
I also love Olympic National Park. The Olympic Peninsula is just magical, and the Puget Sound. I remember growing up, I heard stories from my dad about whales coming through the Puget Sound in the past, and I was like, "Oh, that would be so cool. I want to see a whale so bad," but not like whale watching. I want to just see a whale by chance. That sounds funner. And now they're back. They're coming through the Puget Sound, so I'm hoping to get to see them. But yeah, I love the ocean and I love the mountains, and the Pacific Northwest has it all.
Kate Campbell: Oh yeah, that's awesome. That's what I miss about the Pacific Northwest since moving back to the East Coast, so I totally know what you mean. So I was wondering what else got you interested in being a therapist? So you talked a little bit about loving where you grew up and being happy to be back in the area, but what else in terms of your experience growing up made you interested in therapy?
Rachel Kuras: Yeah, that's a big question that I could probably talk about for hours. I think to narrow it down a little bit, I had a lot of experiences growing up that really highlighted the importance of mental health literacy and access to mental health services. My experiences of being human and my experiences of suffering have fostered an interest in what it means to be human. And I really value every person that I work with sharing their individual experiences with me.
So ultimately, I have struggled with mental health myself, and mental health struggles significantly impacted my family growing up. And I saw multiple therapists as a teenager, and there was one in particular who really inspired me, and I was like, "Oh, that's who I want to be when I grow up." And I did it. So I think having access to quality mental health services is something that I'm really grateful for and I was very inspired by. And mental health is something that impacts literally every human. I think that, that did inform my interest in child and family work and in trauma work, with my own experiences growing up.
Kate Campbell: Awesome. Thank you so much for sharing. I was wondering, so what areas or disorders do you specialize in?
Rachel Kuras: So, I have the most experience working with people who have experienced childhood trauma, so post-traumatic stress disorder (PTSD), and other specified trauma-related disorders, and also anxiety disorders, like generalized anxiety, social anxiety. I've worked with lots of kids experiencing separation anxiety, and I've worked with a few people experiencing selective mutism, so kind of the whole anxiety disorders chapter of the DSM. And right now, I'm currently working on increasing my competence in obsessive compulsive disorder (OCD). So trauma and anxiety have been my main focus, and I am expanding my competence working with people who have been diagnosed with OCD.
Kate Campbell: And it's interesting, because I feel like a lot of the times therapy is hardest for people that have anxiety and your OCDs, because opening up about those kinds of disorders make people feel extremely vulnerable. And then getting to know a new person, especially a new therapist, there sometimes can be a wall up. So I was wondering, what's your treatment approach when you're going into those kinds of situations when you first meet a new patient?
Rachel Kuras: I use a person-centered, integrated approach to treatment. I have training in multiple treatment modalities. I was really lucky to work with a lot of people with a lot of different perspectives and experiences. It's a long sentence that I've strung together to try to summarize my approach. I am an attachment-oriented, trauma-informed, cognitive behavioral, acceptance and commitment, and existential therapist. So that's a lot of different treatment modalities. My approach is to meet someone and go from there. Everybody has commonalities between our experiences, but we also have things that are unique to our own lives.
So I like to start with a conversation. The therapeutic alliance is at the core of my approach, because we know through research that the therapeutic relationship is one of the most important determinants in terms of the outcomes of therapy. So if we want positive treatment outcomes, the relationship is what's most important. And as you were saying, Kate, relationships are vulnerable, especially living with chronic anxiety. So my approach is to start by building comfort, to start by getting to know each other. I'm a feedback-informed therapist, meaning I solicit feedback often, and I try to integrate client feedback actively into my approach. So my approach is pretty flexible. I like to tailor it to client needs, but I also really enjoy acceptance and commitment therapy and existential therapy.
So that was a long-winded way of explaining what it means to be an integrated therapist. But yeah, I draw from a lot of different treatment modalities. I view suffering as a central part of being human. Everyone suffers. And it's a challenge to figure out how to build a relationship with suffering and with being human that feels authentic and genuine. So I like to provide support to people in increasing the amount of internal empowerment that they have over their lived experiences. So I like to help people build a relationship with life, build a relationship with their experiences of anxiety, and find ways to connect with the present moment and exist in a way that feels less laborsome. So I like to acknowledge the role that suffering plays in our lives, and inevitably suffering is there. It's just a matter of how do we think about suffering, how do we interact with our suffering?
Kate Campbell: Wow. That's really awesome. It just sounds so individualized. There's cultural competence, it's empowering. There's just so much wrapped up in that. So I think it's awesome, just all the different facets that you incorporate into your style and your approach, so thank you for sharing it really is amazing to hear.
Rachel Kuras: Thank you. Yeah, I think it can be a little overwhelming to summarize at times. I'm also very interested in liberation psychology. Liberation psychology is an area that I've been trying also to increase my competence. And within liberation psychology, there's this idea that what each individual needs to heal is already within them. So the role of the therapist is to help someone find that within themselves. It's not my job to give advice or to provide answers. It's my job to, if your life is a trail and you're walking on it, to walk with you for a moment and to observe with you and explore that with you. Yeah, so I do really value that individual experience. And I think that there's different value in different treatment modalities, but there's also a thread that connects a lot of them. So I like to see that thread, see where they meet, and try to integrate it in a way that works for my clients.
Kate Campbell: That's super cool. I'm excited to look up liberation therapy after this just to learn more about it. That's really interesting. So on that note, how is your approach with working with children, and what's your favorite thing about getting to work with that age group?
Rachel Kuras: My approach is sitting on the floor. I'm on the floor a lot. I'm coloring a lot, playing lots of games, doing lots of art, and exploring through play. I think that kids are so fun and funny. I'm laughing a lot. It brings out a youthfulness and a playfulness in me that I really enjoy cultivating in the therapeutic space. It's hard for me to really articulate how it's different from working with adults, because I think that all adults were kids once. So there's aspects of working with kids that mirror working with adults, but kids have never been adults. So there's a lot of emphasis on cognitive development and behavioral skills.
And I focus a lot on attachment relationships, working with kids. Another thing I enjoy about working with kids is that there's a lot of wiggle room in terms of their cognitive development. There's more neuroplasticity in childhood, meaning that there's more give. As we grow into adulthood, we often become more rigid in our behaviors and our beliefs and in our worldview. And we're digging deep into the roots of what's going on, whereas with kids, it's not as deeply rooted because there hasn't been as much time for-
Kate Campbell: Within their formative years, yeah.
Rachel Kuras: Yes, exactly. So I think that there's a lot of hope and playfulness. And I'm just honored when I work with kids and families to be a part of that development. And I think these things are true working with adults as well. It's just kind of less at the center of therapy. Yeah.
Kate Campbell: Yeah, I could definitely see that. And then also the family aspect, I assume that when you're working with kids, the parents are going to have a heavier involvement than, say, a spouse would be necessarily, if it's an individual.
Rachel Kuras: Yeah, that's a good point. Working with kids is working with systems, is working with family systems, is working with school systems, is working with the foster care system. So I think that I've also really valued the experiences I've had providing services to kids, in that they give me a big picture of what's happening in the world. I didn't mention this previously, but I take a systemic approach to therapy. So I like to view our internal daily struggles within the context of larger systems. And with kids, you can't avoid that at all. With adults, sometimes one-on-one work, systems is just as important. And since you're not doing as much collaboration necessarily, you're not thrown into that systemic involvement in an individual outpatient setting with adults as much as with kids.
Kate Campbell: Yeah, that makes a lot of sense. And I know that over time there may be different changes in the way that you would approach both your therapy with children and adults. So I was wondering, what was your favorite part about your initial training, and then how has your perspective changed over time with that, both with different age groups, or how you have to approach your end goal when you're working with each patient?
Rachel Kuras: Yeah, so my favorite part about my training is people. I'm trying to think of the best way to word this. I feel very honored throughout my training to have been trusted by the kids and families that I've worked with, and to see some really pivotal moments of growth, amongst some really pivotal moments of suffering and pain and setbacks and stuckness. I've really enjoyed seeing kids learn about their brains and their bodies and how it works and what's happening when they have an emotion.
And I think a lot of the time when talking to kids, we don't always realize how much they're retaining, but one of my favorite parts of ... I worked with a kiddo for a long time. And I wasn't quite sure if what I was saying was landing. And then at one of our last sessions, it was like they basically described to me what happens in your central nervous system when you're feeling afraid and how they know in their body when their central nervous system is starting to get activated. So I really enjoyed those moments of like, “Yeah, you get it.”
Kate Campbell: The light bulb. Yeah.
Rachel Kuras: “You get it and you're benefiting from it and you're applying it.” And I think sometimes we underestimate kids' ability to do that. So yeah, I really valued seeing those moments of growth. And there was another part to your question, right?
Kate Campbell: Yeah. It was just what was your favorite part about your initial training, and then how has it changed a little bit?
Rachel Kuras: It changed over time. I think that I was a graduate student at a very unique time. The COVID-19 pandemic hit during my first year of practicum. So I had been working with people for about six months and then everything went online. So I think the events that have occurred during my training have really emphasized the importance and the need for mental health services, for quality mental health care providers. And it's been exciting to see more people talking openly about mental health, where in a time where when I was a child, even with my own experiences, it wasn't something that was very openly talked about. We didn't have a lot of information in my family and my neighborhood and my community about what was going on.
So it gives me a lot of hope and excitement to see the stigma around mental health decreasing. I don't think that it will disappear, but it's changing. So I think the things that have happened while I've been in grad school have really emphasized the importance of mental health care, and I feel very honored to be a part of that process. Did that answer your question?
Kate Campbell: It definitely did. It actually carries really well into my next question, because you talked about how much the conversation around mental health has changed and just some of the generational differences. It's really nice to see that kids feel more open talking about some of their struggles. But I was just wondering, so what are some of the ways that you think that the psychology community can continue to grow? You did already answer some of the ways that you've seen it transform over time, but if you have details on that too, I'd love to hear too.
Rachel Kuras: Yeah. I think that there's been an effort to expand access to resources, even just with telehealth, being able to go to therapy from home. Yeah, so access to resources, I think there's been a push for that to increase. I think that will continue to happen. And the COVID-19 pandemic and other large-scale events that have happened over the past 10 years and really over the course of human history, but just viewing this snapshot, it's something we all experience together. So I think that it's been beneficial to have a sense of humanness, to connect in our humanness as a society, whether that's between therapists and client or on a larger scale. I've seen a lot of efforts towards connection and towards valuing ourselves and valuing each other. And I hope to see that continue. And I think it will.
Kate Campbell: Yeah, it's kind of ironic that COVID-19 brought us closer together, but in a weird way, it did too.
Rachel Kuras: Yeah. And I think for a lot of people, it really emphasized the importance of social connection, because working with kids, I mean, the effects of the pandemic have been incredibly destructive on people's routines. And for kids, not going to school is a huge thing. These really essential interactions that were once there weren't there anymore. So I think it, for me, has made me value our connections. And not that I didn't before the pandemic, but it just gives a different perspective and urgency around maintaining connective relationships that cultivate growth and love and acceptance of each other.
Kate Campbell: Yeah, absolutely. And as a final question, do you have any words or advice that you would like to say to our listeners?
Rachel Kuras: Yeah. I think that if you are seeking therapy services for yourself or for a family member, I encourage you to try it, right? Even if there's fear about how it might go, dive in, be vulnerable. There's so much value that each individual person has, and I think it's easy to lose sight of that and feel disconnected from that, and it's easy to be hard on ourselves in this society. So, if you are feeling like you would benefit, even just from having a space to come and be witnessed and be heard, I encourage you to seek out therapy services, try it. And yeah, be vulnerable. Talk about mental health. Don't shy away from subjects just because they've been taboo. Yeah. I think that's it. Be open, dive in, be vulnerable.
Kate Campbell: Yeah, absolutely. Thank you for those words of encouragement, Rachel, and for joining us in our interview series. Hopefully, everyone can take something from this, and thank you all again for joining us.
Rachel Kuras: Awesome. Thank you, Kate, for having me. I'm really grateful for this opportunity.
Kate Campbell: Of course.
* For those interested in working with Rachel, click on our appointment page to see her current availability.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with CEO Ruth Stronge
Ruth Stronge, MA is the CEO of Snowdonia Donkey Sanctuary. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. She specializes in helping children, teens and adults build resilience and mitigate various anxiety disorders at her farm sanctuary.
Jennifer Smith: Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
I'd like to welcome with us Ruth Stronge, CEO of Snowdonia Donkey Sanctuary, located in Bangor, Wales. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. Ruth was a primary school teacher by training, and with the founding and development of Snowdonia Donkeys, she has been able to combine her passions. Before we get started today, Ruth, can you tell our listeners a little bit more about yourself, and how the rescue organization got started?
Ruth Stronge: Hi. Well, thank you for inviting me. Yeah, I would say I have a passion for donkeys, and I have always loved donkeys. Maybe about 12 years ago now, there came an opportunity for me to get two donkeys, and I got two little donkeys. I kept them with my daughter who had a pony, and my children were older, my daughter had a pony, and our son was at the village, so we never rode our donkeys. We always took them for walks. And for me, spending time with those donkeys before work and after work were just the best time of the day. I would do it before I'd go to school where I was teaching, so then I was ready for school. And then on the way home, that would be my downtime of reflection. It went on from there and people, our friends that we knew said, "Please, can we come and walk the donkeys with you?"
And then we would bump into people with our donkeys, and they would say, "Oh, it's been ages since we've seen a donkey." And then, people just wanting to come and spend time with our little donkeys. It grew from there in as much as I wanted a donkey to ride, so I got another donkey. And then a group of friends, when we were out walking the donkeys, we were talking and decided if we could help any local donkeys, we would do that. We set up a small charity, and that was just 10 years ago now, a small charity to help local donkeys, and that's how we began, really.
Jennifer Smith: Wow. That's great. Your website has a large banner that states, "Rescuing donkeys and changing people's lives," and I think that's a pretty moving statement, and I'd like to talk about some of the work that you do there. One of the first courses that you developed was for vulnerable adult learners, so that they could help build confidence by working with the donkeys. Can you tell us a little bit about that? How can caring for donkeys help someone?
Ruth Stronge: It was a chance meeting with another organization, and telling them about the looking after the donkeys we do, and how volunteers were coming to help us, and how we were working with just giving people opportunities and time to spend time with the donkeys. And it was an organization in the center of Bangor who worked with adults, providing them with opportunities for support if they had mental health difficulties. And I invited their manager to come out and see the site that we worked on, and go through some of the activities that we did of how we managed our donkeys, which was following a simple routine in a quiet place, and basically just really being quiet around the donkeys, and being around each other, explaining to people how some of our donkeys are not used to people, and how we have to approach them, and how we read their body language so that we can support them in the best way.
And it was that opportunity and those conversations that allowed us to run a small program of one afternoon a week for people to come spend time outside with the donkeys. Initially, our volunteers and staff had done all what we would class as the "donkey work", so they'd done all the cleaning out, and the working out, and the feeding. But then just giving people time to brush a donkey and learning which brushes to use, how you would approach a donkey, basically reading body language, as well, of an animal, and giving them the story of the animal, and finding their character was the start of all that then, really. And for some of the people engaged with us, they became more and more interested, wanting to come more often, be more involved with what the animals needed for their welfare needs. And one of the really important things that we took from it was that it was a conversation piece for people. They had something to talk about with other people, what they had done.
Jennifer Smith: Wow. Oh, that's great. And just for our audience to know, I actually met Ruth when I went for a tour of Snowdonia Donkeys, and it was really fabulous just getting to spend time with the donkeys, and I have to say there is something very soothing about it. Just brushing them, like you said, just petting them, just having that quiet moment, it really is nice. And going for a walk, and seeing beautiful scenery with them is a wonderful thing. I think you've stumbled upon, and definitely have built, a beautiful organization.
Ruth Stronge: Oh, well, thank you for that. But I would say it's how I want to spend time with my donkeys. I know it works for me. And sometimes when I'm talking to people, if we're explaining the kind of work we do, and with our young people as well, and I would have to say it isn't for everyone, and that's okay. If you are more interested in fast moving things, and you are boisterous, and you are running around, then we are actually not the right place for you to be, because you would frighten the donkeys. And it's a case of, okay, let's take a step back. And our donkeys and our organization is very good at supporting quiet, anxious people, because that's the way we look after our donkeys in a quiet way, building confidence, following routines. And partly that has just evolved, but also my training as a teacher, I was an early years teacher, so the routines and the structures that we put in place to take away too many decisions initially for people were simple things like which donkey you're going to work with.
Well, if you've got a pink brush in your hand, then you are going to be brushing the donkey that's wearing a pink head color. The one in the picture behind me is wearing a pink head color. So you would know, she would have pink brushes, a pink bucket for her feed, and if you were going for a walk with her, she would have a pink lead rope. It sounds simple things, but it takes away anxiety from people if they don't have to ask questions. Some things are just pointed out for them, and next time they come, that routine is built upon.
Jennifer Smith: Wow, that's wonderful. Through a partnership with Adult Learning Wales, you run an accredited course on animal care, which focuses on supporting young adults. Can you speak about what that entails, and how can young adults psychologically, emotionally, and socially benefit from that course?
Ruth Stronge: Again, you realize as you do these other, things happen by meeting and talking to people. Behind the scenes, the young people that we work with, or the adults, for them, they don't always know where the funding comes from as enablers to deliver sessions for them. So behind the scenes, it's a bit like a jigsaw puzzle so that they can have the best opportunities. And if they are interested, they can stay as long as they can if we can afford them to stay, and to progress their development. So Adult Learning Wales are a national organization here in Wales that fund accredited and non-accredited courses for people over 16, and we had been delivering some courses that it called engagement courses, which were non-accredited. But working with some of our other young people who had come through us from another grant program which allowed them to do one-to-one sessions with an adult and a donkey, basically just being in a nice quiet environment, having someone to talk to if they wanted to, or just spending time with a donkey.
We were looking for a next step for some of these young people when we identified that for a vast majority of them, they hadn't engaged with the education system at all. They had, whether it be anxiety built on after COVID, or for whatever reason that they had, not been in the education system, so there were no exams, and there was nothing on paper for them to take their next steps. With the program that we had delivering one-to-one sessions, we then built on that, offering them some small group sessions, which for us would be no more than four or five at the most for a few weeks. And then Adult Learning Wales, because myself as a trained teacher, I can be a tutor for them, I approached them and said, "I have this group of young people, who some would like to go to formal college in the future, but I want to be able to acknowledge the progress they've made. And also once the summer holidays comes for some of our other young people, what do they do for six weeks?"
And I wanted them to be able to come and work with us, but we didn't have any funding to enable that to happen. So Adult Learning Wales helped me find a couple of, we would call them entry level modules, so not too high, but requiring some academic input on animal care. We would do things like how to muck out, and how to brush an equine. And the young people that we had focused on having come for one time, one session a week as an individual, and then as a small group, were then asked to apply, we knowing that they would always get on the course, but to give them a formal leading to it, to apply us for a fortnight, coming every day to take part in practical activities and record those activities using photographs and written work so that they could then submit it for an accreditation from one of our organizations, Agored Cymru which accredits their work and then they can build on that.
That was a journey. We've been plotting a journey for some of those young people, and they themselves wouldn't know who had funded their journey, but behind the scenes, we were able to do that. And for our funders, that's interesting as well, because they like to see that it has an impact, which it certainly does.
Jennifer Smith: Oh, that's really fantastic that you help people to transition in that way.
Ruth Stronge: And one of the things you asked was about their anxiety and their social skills, so that because they had had those small steps before they got to something that we called education, but we often didn't use that term, then we were trying to look at adding one new thing every time they came. If they were all familiar with the setting, then one-to-one was their first step, be familiar with the setting. The next change would be to work with a small group of people, and then to come every day for a longer period, so trying to increase that confidence, and reduce the anxiety as they took on new things, then.
Jennifer Smith: Oh, wow. Yeah, that's similar to exposure therapy, correct? And like you said, to lessen their anxiety, the social anxiety and such, that's wonderful.
Ruth Stronge: By the time they got to the accredited side, brushing a donkey was what they would do automatically, so it wasn't the new thing. The new thing may have been recording or talking about what you'd done. So yeah, it's those small steps, and just building on that was really important.
Jennifer Smith: Ah, fantastic. You also offer one-on-one sessions for those with additional learning needs. What types of conditions is this specifically geared for, and who can benefit the most from these sessions? Would it be people with social anxiety like you mentioned, or general anxiety, or anything else?
Ruth Stronge: A lot of people with either social anxiety or general anxiety, and we do quite a bit with people with autism as well, who have communication difficulties. Communication difficulties on the side of struggling to verbalize their needs, or anxiety, or shyness, or selective mutism. And again, through following those routines and building that confidence, we've worked with quite a number of young people in that way to increase their confidence. And again, hopefully moving from one-to-one sessions onto small groups. For some of the people that we work with, it isn't always appropriate to do that, but if we can, we can do that, or we would then change or build on the activities that they're doing, so they are being more engaged in different activities. Some of our work, we also work with young people who may have learning disabilities, and may have reduced cognitive abilities, and again, we would match the donkey to their needs.
Some of the autistic people we have worked with are very sensory, some of them like to throw things around, so sawdust moving around the place obviously isn't appropriate for all our donkeys. And so, we've got some donkeys who are very chilled, and don't mind those things happening. But I would say where I find most pleasure is working with people with anxieties, and shyness, and quietness, because to see them make that progress, and to be able to talk, even to their families, about the donkey that they've worked with is just amazing, really.
Jennifer Smith: Wow, that's wonderful. In terms of the people who have the mutism, as you said, or if they're on the spectrum and not very, or nonverbal, have you noticed where they do become more verbal, or this therapy isn't really applicable for that? Have you noticed a change?
Ruth Stronge: We do notice a change, yes. And for us, it's trying to not put them into situations where they become more anxious, or it's not putting them in those situations where it makes it more difficult for them to speak. Just by following those routines every time they come, and building a rapport with one of our support workers, and especially with the donkey, then we found almost that the donkey acts as that diversion, that there's someone else, so there's something else to talk about, to be involved with. And then our staff are very much aware of the sensitivities of some of the people we work with, and wouldn't then ask them direct questions. They are very good at supporting the people to shine, and to build on the skills they've got, so almost praising them in a positive manner, using the language of support, and making suggestions together to do things is the way that we tend to build on people's development.
Jennifer Smith: That's fantastic. And this sounds so perfectly suited for you and your background. It's really wonderful that you've been able to develop this.
Ruth Stronge: It has just been amazing. Yeah, I feel very privileged to be able to do that, and also then to look around at the other people that I work with and say, "Yeah, I couldn't do it all myself," because there's not enough hours in the day, but we have some lovely members of staff who themselves have maybe been through some of our systems as well, and are able to talk about how working with the donkeys, and following the routines, and just being out in the fields with them doing field work, and then having something to talk about to people. Because we have visitors coming to see the donkeys, and they've got something that they can talk about that they've achieved, they know about this donkey, in a supportive environment. There would always potentially be a member of staff or a key volunteer who would be around, if we saw them faltering or being more anxious, could then step in and support, so that they didn't have extra worries themselves then.
Jennifer Smith: That's fantastic. Can you tell us about the program that you run with the BBC Children in Need? What is it, and who does it serve?
Ruth Stronge: Okay. BBC Children in Need is a national charity, a national grant-giving charity here in the UK, and we've had funding for quite a few years from them. And our program for them has always been targeted at young people, so for them, that's under 18, who have social and communication difficulties. And that can be, from our point of view, I guess it started with shy people and quiet people with anxiousness, and that's how we've kept on going with that. We offer them one-to-one sessions for an eight-week period of an hour with an adult and a donkey, in a quiet period of our week. And then, if they are keen to carry on, then we offer them small group sessions for a longer period. So that, again, a bit linking what you were saying back to the exposure therapy, they are quite familiar with the donkeys and the donkey routine when they've done the one-to-one sessions for six to eight weeks, and wanted to come for longer.
The only thing that is different then is there may be more people around. The staff tend to be the same, so they've got familiar people to support them. They know the donkeys. It's just extra new people, then, and that seems to work quite well. And those groups then go on as they get older, and we've had some people with us for quite some time now, so we've moved to being volunteers, or we call them supportive volunteers. Again, they are supported by key staff, funded by Children in Need, familiar adults who know or are aware of their own personal needs. But the older young people then, one of the targets is to take our donkeys to a local agricultural show, and show the donkeys to be part of something bigger, and that works really well. We do that as a day out, so they take the donkeys out for the day.
The show is a four-mile walk to get to, so they have to come the day before and get the donkey ready for the show. Then they have to come early on the day it's happening, walk the donkey to the show, be in the show ring. They will have spent quite a few months actually preparing for all this, but that is on those following through, and that's what we aim for them to be part of, so that then, again, following the journey with Children in Need, then they can be active volunteers then, in some respects giving something back to us, as well as their own lives then.
Jennifer Smith: Wow, that's a fantastic cycle. Like you said, people get help, and then they help others, and it's just a wonderful thing.
Ruth Stronge: It's really important for me behind the scenes, to provide that route for people. And I guess that's not just my teacher background, but also the psychology side of it is where do you go? Where is your journey on it? And I would say that I actually do that for all the donkeys as well. They all have a learning journey, too, and targets that I need them to achieve, and things that they can be good at, and stuff like that. But if the young people or the adults coming to us on the one-to-ones are making progress and want to stay with us, then we discuss with them those journeys we would like them to be able to take, if that's what they want, and how we can best support them on that.
Jennifer Smith: Wow, that's wonderful to have those specific goals to try to reach for, if they're able and want to. One thing I saw on your website was that there was a video showcasing the experience of Zoe, who is 16 years old. Can you tell our listeners a little bit about what she experienced in life, and why time at the sanctuary has been essential to her mental health? And this is just one story, but I think it really signifies what your sanctuary can do to help people.
Ruth Stronge: Yeah. Zoe has been with us for quite a few years now, and when she first joined us, as with all our children funded through BBC Children in Need, we asked them to be referred to us by a professional working with them. That could be a school nurse, it could be a teacher. We have something we call CAMHS over here, which is Children and Adolescent Mental Health Services so that we had some kind of filtering system, and we'd sent information to our school nurses and CAMHS, and also I often will give talks to the local authority, and give them some examples so that we work with the right people, so that we can have those best outcomes for ourselves, and for the people we work with. And Zoe was referred to us by CAMHS. She had moved to Wales just before COVID time, it was. She'd moved to Wales with her mother.
It was a one-parent family, and moved to quite an isolated place in Wales, as well. Quite in the countryside, quite remote, but didn't go to school, so was homeschooled as well as moving to a new place with one parent. And so Zoe came to us doing one-to-one sessions for her eight weeks. We had to let Zoe know before she came which donkey she would be working with, which adult would be there, reassure her that the adult would be waiting for her when she got there, again, to remove all those anxieties. And we actually sent her, before she came to us, a picture of the donkey she would be working with, so that she had some knowledge of what she was going to be doing. We knew that Zoe liked animals, and this was a good opportunity for her.
After her one-to-one sessions, she wanted to carry on coming, which was wonderful. And so, she joined a group that stayed for more, so she came from morning session again, five or six children at the most, with adults that she had met. But again, those preparation time and the information, so she knew what was coming, who she would be working with. Zoe had quite a lot of anxiety, as it sounds like, obviously when I'm presenting that to you, quite a lot of anxiety. And her anxiety would not only manifest before she came, but also during sessions, as well. If there was going to be something new happening, we would tell her beforehand.
There would be a lot of demonstrations. If it was maybe learning how to tie the donkey up, then a lot of demonstrations, let her do it without being watched, because she found that very anxious to be watched, or if she felt she wasn't achieving it, or couldn't get it right. A lot of support for Zoe in that way, repeating, and again, positive reinforcement, the things that she had done right, and then taking those small steps.
Zoe came when we were talking before about the two-week course. Last summer, Zoe came on that course for two solid weeks and she had never been... She was 16 then. She had never been in education since 11. That was the first time she'd ever done anything like that. In order for her to get support at college, which she then managed to go to college on the basis of having spent a fortnight with us and could demonstrate to college that she could commit to something, and was able to do that.
She had to have a psychology report, an educational psychologist's report. And what I personally found quite touching, and also quite a big responsibility, is that we were actually the only outside organization involved with that child, because she was homeschooled, didn't attend anything. There was nobody else to talk to the psychologist about her needs, and how best she learned. I spent a lot of time with the team that would've been supporting Zoe when she moved on to college, with the local authority, explaining how we supported Zoe. And again, I would say had I not been in the profession I was, I wouldn't have liked to have taken it on. And fortunately for me, the psychologist who was assessing Zoe, I knew her from school. She used to be my Ed Psych in school, so it was like, oh, that's great. We knew the language we could talk, which was really useful.
Having set that up for Zoe, and then her doing the two-week course, she was keen, and as she said in the little video clip, she was keen to start college, and excited to start college. And she has now just completed her first year at college, and has had really good attendance, a few ups and downs along the way, as most teenagers would do, but was very pleased to have finished her first year, and be accepted into the second year. We are just so pleased for her.
And the time with the donkeys, when you listen to her talking about it, she has a favorite donkey, and that's the donkey she's drawn to every time she comes, and the conversations that she would have with that donkey to help her work through some of her anxieties, and also helping him to work through some of his, because sometimes, we ask our donkeys to do things they don't necessarily understand. And it is those conversations that are helping the children or the young people that we're working with understand why we're doing this with the donkeys, and how do we teach them to do that, enables them themselves then to think about themselves, and how they can move forward as well.
Jennifer Smith: Oh, wow. I recall also in the video, and correct me if I'm wrong, that Zoe was initially homeschooled due to bullying, and she developed some severe depression. And it sounds like because of the social support that you offered her as an adolescent, which is really critical to maintaining good mental health, that she was able to really develop great resilience. And, like you said, now she's in college, whereas before, it sounded like her life was almost at a debilitating level, where she was unable to really just get out there and function with others.
Ruth Stronge: Yeah, it is amazing when you listen to what she says that we were the only place she would come, and then small number of people around her was all she could cope with. She wouldn't talk to anybody else. And some of the young people that we work with in BBC Children in Need who did that video always ask us can we give them a case study? They'd asked before, and Zoe wasn't ready to talk, because, and this is something we've had on a couple of occasions from our young people, when I come to the donkeys, this is special and I don't want anybody to spoil this, so I don't want to tell people at school, because that isn't a nice place where I want to be. This is my safe space.
For Zoe, on a number of fronts, it was very brave of her to talk about, not just what she had been through, but then almost that this is what she does, and she loves what she does, and she's a wonderful advocate for it. But it was an incredibly brave thing for her to do. And the amount, like you say, her resilience, and how far she has come is all credit to her. She's worked really hard.
Jennifer Smith: Oh, fantastic. And the donkey that she likes is Norman, am I correct?
Ruth Stronge: No, that's Walter. It's Walter.
Jennifer Smith: Oh, Walter!
Ruth Stronge: She likes Walter, and she says they have the same birthday. They're exactly the same age. Yeah, he's her favorite, and she does have a special relationship with him. He can be, as most animals can sometimes, he can be quite cheeky, and she won't stand any nonsense from him. One of the wonderful things that they did with this group of donkeys, and she was in charge of Walter, is one of the walks, I know you went on one of our walks, and one of the walks that we do, there's a little bridge going over a small stream, and if we could cross the bridge, we can go on longer walks.
But Walter couldn't cross the bridge. He just couldn't cross over this bridge, because of the running water underneath it. He was quite frightened. And for long, I'm saying years here, we would stand and look at this bridge. And one day I was on site, but I wasn't leading the group that Zoe was with. I think there was four young people with one of our other members of staff. And apparently, they'd gone out for a walk, and I knew they were due back at a certain time and they were late coming back.
As you do, I was worrying, where had they all gone? The parents were arriving, and they all came back laughing, but very late. And I said, "So, where have you been?" And Zoe said, "Well, I just said to Walter, 'today is the day we're going to cross that bridge. Sometimes, we have to do things like that. It's hard, but we can do it.'" And she got him to cross the bridge, and they all went over the bridge and could go for a walk. But he couldn't come back over the bridge, so they had to walk the long way round. They were all laughing. These young people were just howling with laughter that they've managed to do this with Walter, and Zoe had been wonderful and got him over there, but he said once was enough.
Jennifer Smith: Oh, that's wonderful. And what a fulfilling experience for her to be able to get across, at least that one time.
Ruth Stronge: He will go now. Next time, he was fine. He was just once was enough on that day. Because we do say to him now, "Zoe, are you going over the bridge?" and she says, "Yes, and we're coming back over the bridge, too."
Jennifer Smith: So Walter had his own exposure therapy, it sounds like.
Ruth Stronge: His own exposure, but for her, when she was saying to him like, "Walter, we look at this so often, we are going to do this bridge now." And that was just like, yeah, you are an amazing young woman to be able to say, yeah, I'm going to do this, and do it for herself, and for him. So, yeah, it's lovely.
Jennifer Smith: It's very empowering. That's wonderful. Thank you. During the pandemic, you started a Long Ears Listening Project. I know donkeys have long ears, but what is this project?
Ruth Stronge: Long Ears Listening is really all my passions all in one place, which was quite a privilege to do. As an early years teacher, when I left school, I knew I still wanted contact with young children. We do a lot of work with young people and with adults, but young children is an interest I've taught all my life in the early years, we would call it here in the UK, and outdoors and environmental education is my other interest.
When I left school and worked with the donkeys full time, when the pandemic came, we have a lovely patch of woodland that we manage, and it was used a lot during the pandemic by people visiting. I would leave activities and resources in for people to use, and then when we could meet together, we started a formal parent and toddler group for parents, and it's outdoors in the woods, and the donkey comes every session and carries some of the resources. With a focus on language and literacy through storytelling, then, we have a group of parents who meet every Monday morning and share time together. And whilst it is an emphasis on language and literacy for them, it's also a time for them to get together and just be outdoors enjoying themselves, and giving their babies and young children exposure to nature, access to animals, in a friendly, supportive environment.
Jennifer Smith: And the benefits of nature therapy, or ecotherapy, like you said, just spending time in nature, and then you're with an animal, and then there's the reading... It's just beneficial on so many levels.
Ruth Stronge: It's been a fascinating journey, that one, as itself has developed, too. And we have a small number of songs that we now use every time we meet in Welsh, so that we are then doing that bilingually for them. And they are about donkeys, obviously, so we do a few counting rhymes that we have. If you've ever met early years teachers, they'll sing to anything, a song, a counting song or anything like that, to a familiar tune, so we've made up a couple of songs that we sing about donkeys to start it off, and just a relaxing place for them to be out there. And they all have a little activity bag, which would have some sensory activities in, and a book. And again, that bit started with COVID when we couldn't share resources the same, so everyone had to have their own resources, and we actually just kept that up. If the child is not old enough to walk around, they've still got activities that they can do and interact with their babies with, then.
Jennifer Smith: Oh, that's great. This has been extremely informative, and I think this time has unfortunately flown, for me, anyway. As we wrap up, is there anything else that you'd like to share with our audience about the sanctuary, or anything else mental health related at all?
Ruth Stronge: Yeah, I think one of the things that it makes me realize is that I started it probably by accident, and because I know the benefit I got from being with the donkeys, and stroking them, and mucking them out before and after school, and then part of my work, making time to be out of doors in nature was so important to me, personally. And to be able to offer those opportunities to other people that, as you said, I went back to Uni to do my clinical health psychology degree, because I'm thinking, I don't want to just be the person that says, "I know it's good, and it really is nice." I wanted to embed it in the research, really. And we still work with Bangor University to try and get the psychology students to use as case studies. And for us, it's often another pair of interested hands as well.
But we're really keen that the work we do is the best it can be, not only for the people we work with, but to give the work that we do with donkeys, who often get quite a bad press, or are often looked down upon, and they're very hardworking animals, to give them a value as well. Because it just doesn't happen by accident. If it looks from the outside that it's easy, then sometimes, I think, well, actually that means we're working really hard, and it is working well. But behind the scenes, all that theory, and the small steps, and the thinking about how people need to move forward, and how we can help them do that is important. And I guess I would also throw in as well that for our staff and volunteers, we try to make time for them always to have what we would call "donkey time," so that they have their own mental health moments where they can just be with the donkeys, and enjoy doing those things and being in the moment with them.
Jennifer Smith: Oh, that's wonderful. For our audience listening, for those of you who are local, or plan on traveling to Wales or the Bangor area, we're definitely going to link up in the interview so people can check out your website. Also, learn about different ways to support your group, sponsorship opportunities. I know you have some wonderful little knitted donkeys. I forgot to bring mine. (*photo at bottom of page)
Ruth Stronge: I forgot to leave one out as well. Yeah, should have done that.
Jennifer Smith: Yeah, different ways to support you guys and this wonderful mission that you're doing, that's helping both donkeys and people in a really wonderful cycle. So, again, thank you Ruth Stronge, for speaking with us today. And tell Jenny the donkey that I said hello. That was my friend that day. And we wish you all the best.
Ruth Stronge: Thank you very much for the opportunity to talk to you, and we would love to see people over here. It'd be amazing.
Jennifer Smith: Thank you.
Jennifer Smith with Jenny the donkey. (left)
A souvenier “knitted donkey” from Snowdonia Donkeys posing for a picture near the sanctuary in Bangor, Wales. (right)
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Albert Garcia-Romeu
Albert Garcia-Romeu, Ph.D. is an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. He's a founding member of the Johns Hopkins Center for Psychedelic and Consciousness Research and the International Society for Research on Psychedelics. His work specializes in the clinical applications of psychedelics, particularly as it applies to addiction treatment.
Sara Wilson: Hi everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. My name is Sara Wilson, and I'm a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
Today, I'd like to welcome with us psychologist Albert Garcia-Romeu, PhD. Dr. Garcia-Romeu is an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine. His research examines the effects of psychedelics in humans, with a focus on psilocybin as an aide in the treatment of addiction. His current research interests include clinical applications of psychedelics, real world drug use patterns, diversity in science, and the role of spirituality in mental health.
He's a founding member of the Johns Hopkins Center for Psychedelic and Consciousness Research and the International Society for Research on Psychedelics. He serves on the board of directors for the College on Problems of Drug Dependence (CPDD), and is an associate editor for the journal Psychedelic Medicine.
So before we get started today, could you please let us know a little bit more about yourself and what made you interested in pursuing psychedelic research as it relates to the study of consciousness, selfhood, and therapeutic development?
Albert Garcia-Romeu: Yeah, absolutely. So thanks for the intro. My name is Albert Garcia-Romeu. I'm a researcher here at the Johns Hopkins School of Medicine. And let's see. I mean, it's a long story in terms of how I got involved here. I've been doing this work here at Hopkins for over 11 years. And so before that even, I became interested in this area.
But initially, my work in graduate school was not even focused specifically on psychedelics. It was really much more driven by curiosity about the intersection of spirituality and mental health, and also how certain types of spiritual experiences could interact with mental health in both positive and negative ways.
And so I think a really good example of that is that people can have spiritual, or transcendent, or other types of peak experiences that can be tremendously helpful for them in a developmental state, in terms of how they developmentally are able to move throughout the lifespan and help them build resilience against difficult life events that they may face.
But other people have really powerful, intense experiences that sometimes have more negative repercussions. Things like developing psychotic and delusional states and sometimes dealing with persisting mental health challenges.
And so that was the starting point for me. My undergraduate work, I had been exposed to both eastern religion and spirituality, and philosophies like Buddhism, Taoism, and Hinduism. And that also came along with practices like meditation that I found very compelling. And I had some very powerful experiences in the meditation club that I joined during my undergraduate when I was studying philosophy and psychology at Tulane University.
But that really translated later into a curiosity about where the overlap and where the divergence was between all these spiritual and philosophical schools and what they thought about in terms of mind and selfhood, and all of the Western psychology that we learned. Including things like neuroscience and behavioral and other paradigms of psychology.
So that kind of led me into studying other schools of psychology, including humanistic and existential psychology, which Maslow was a big proponent of. And one of his areas of studying self-actualization specifically also brought in this concept of peak experiences and the idea that people could have peak experiences that help them become more self-actualized.
And so that was really a jumping off point for me in graduate school to start studying these types of experiences that some people might consider altered states of consciousness, and that they have some relationship to things like psychedelics or meditation practices.
Sara Wilson: Yeah, thank you. I think that it's really interesting, this intersection that you've achieved in your research among existential philosophy, and therapeutics, and spirituality. I think that it's very, very good work that you do.
So now, arguably there is no single thing that is more real and immediately known than our own consciousness. However, the specific constituents of this sense of self and sense of conscious experience remains highly elusive, even among the seemingly intuitive conviction that we all have. So I was wondering before we get into the nitty-gritty, what is meant by the term consciousness, and how is this distinguished from the brain?
Albert Garcia-Romeu: Yeah, that's a great question. I would say I don't have a good answer for you. And that was something that I was very interested in early on in my research and studies when I was in undergraduate and even in graduate school. I was really curious about consciousness and what does that mean, and where does it come from?
I've gotten a little bit more frustrated with the field over the last 10 years or so, feeling like in many ways you're kind of stuck because... And we've talked about this I think in our prior email conversations, but the idea of this hard problem of consciousness is one that we're kind of at an impasse perhaps in terms of what we're able to observe, measure, and study in an empirical manner.
But consciousness is hard to define, and it's a very slippery term. But I tend to think of it as a sort of sum of all of the things that we're aware of, both internally and externally. And so we're aware of what's going on around us in the environment, and we're also often aware of what's going on in our bodies if we're feeling certain sensations or we have emotional states that we're going through. And so this is a sort of immediate first person experience that we're living in. So that's typically what many of us think of as consciousness. And of course, that's changing from moment to moment, and that can also be altered by using certain practices like meditation or psychoactive drugs.
But there's probably not one definition of consciousness that everybody would agree on. And that also makes it really hard for us to find meaningful ways to study that phenomenon. Because when we're talking about consciousness of certain stimuli, for instance, we can start to look at what are the component processes that the brain is going through to be aware of, say something like a sound, or something that we're seeing visually.
But when it comes to the whole gestalt or the whole first person experience that we're going through in a subjective experience at any point, there's really not a good explanation for the mechanics of that, how that comes to be, where it comes from, and why it even is that we have the type of experience that we have. And so that then makes it very difficult for us to be scientific about studying it, although there are lots of folks who are working on in that area, many of whom are very interested in brain related mechanisms and processes. But eventually, I sort of veered away from that and much more towards clinical work.
Sara Wilson: Right. Yeah. I remember you saying in an interview with the American Psychological Association, that many of these trials with psychedelics, for example, are focused on how the brain is responding to these drugs. And you say that it's more of a question of how the mind is responding to these drugs, which I think is definitely conversant with the hard problem of consciousness, because that's where you start to see changes in self-identity in a way that allows someone to fully live their life. And maybe that can manifest itself in measurable behavioral changes or brain functioning, but it is hard to clinically measure. So I guess that's an enduring problem in both psychology and philosophy, I guess, and many other disciplines.
Albert Garcia-Romeu: Yeah, yeah, I agree with you. We kind of run up against a limitation of what we're able to observe, because consciousness is in many ways, a first person phenomenon. So even the idea of whether or not other people around us are conscious, or whether the kind of consciousness that they experience is similar or not to what we experience is hard to say. I mean, we can't really tell that for certain. And so that makes it a sticky problem for something like empirical hard sciences to wrap our collective minds around.
Sara Wilson: Yeah. So you already touched on the hard problem and the problem of other minds, so I think it's fair to move on. I was just curious, why do you enjoy studying consciousness through catalysts such as meditation and psychedelics? Why is this research important in a therapeutic context?
Albert Garcia-Romeu: Yeah. To me, that was a really important jumping off point just because the idea that there's a sort of baseline state of consciousness as people like Charlie Tart have posited, and that we're kind in this baseline state of consciousness much of the time without knowing that, that we flip channels between being awake, being asleep, sometimes dreaming, and then that there's these other channels or modes of consciousness that we can enter, really became clear to me when I started practicing meditation initially when I was in undergraduate, and having specifically a really powerful experience practicing a meta loving kindness meditation, and having this feeling of... I don't really even know how to explain it, but there was this strong feeling of love radiating out of me all throughout the entire universe. And also just sitting there, and then all of a sudden opening my eyes when the bell rang, and just having tears streaming down my face, and a lot of really intense emotions coming along with that.
And realizing, "Wow, the way that I'm walking around most of the time doesn't mean that that's the way that I always have to be feeling and experiencing the world," and that there are these very powerful tools that we have at our disposal, these techniques or these practices, to change that way that we're experiencing things.
And that was an important realization for me that led to an ongoing fascination with what is consciousness and what are altered states. And eventually, really zeroing in on how we can use these in a way that's pragmatic and helpful.
Particularly for things like mental health conditions like major depression, anxiety, substance use disorders, where you might even think of the actual condition as almost a state of stuckness of consciousness to certain patterns. Getting trapped in these loops over and over again, thinking about oneself, thinking about negative things that could happen or that have happened, or being constantly focused on certain compulsive behaviors, or obsessive thinking about whatever it might be. Substances, for instance, is a great example. And how do we shake one out of those dysfunctional loops, so that they can get back on with their lives?
And so that was eventually where I landed. It took quite some time from initially being interested in what are these altered states and how do we elicit them, to finally getting to a point of saying, "Well, now I know more about what they are, but now we need to understand, how do we use them?" And that's kind of where I've landed most recently.
Sara Wilson: Right. Yeah. I think that you touched on a lot of very interesting points in that response, particularly ramifications of being conscious with your sense of self and a sense of agency over self. I feel like humans have a tendency to think of the world and think of self as fixed entities that we don't have much agency over.
So I guess bringing the conversation more towards selfhood, in your article “Self-Transcendent Experience: A Grounded Theory Study”, you discuss self-transcendence. What is self-transcendence, and how do participants describe a self-transcendent experience?
Albert Garcia-Romeu: That is difficult to pin down, because just like consciousness, the idea of what the self is isn't really any... There's no conclusive sort of definition that everyone's going to agree on throughout different disciplines and psychology and philosophy. But there is, again, a very intuitive sense that many of us have that I am this self, I am this person, and that's a collection of memories, and experiences, and also behaviors and habits that we kind of grow into and develop over time. And of course, that also encompasses our bodily sense of self, us being this being in the world that's moving around in space and time.
So the idea of that self then becoming enmeshed with or entangled with something greater than itself. So connecting with something bigger. And that's often a theme that you find in things like spiritual experiences, for instance, or these types of peak or mystical type experiences. Where the feeling of selfhood is temporarily almost offline, such that the boundaries between what I thought of as in here myself and out there, everything else, are very blurry.
And then all of a sudden, there's this sense of interconnectedness between what's inside and outside, or even this sense of non-duality that there is no inside or outside, that there really is just one entire organism or process, if you will, that's happening, and that you're just one part of that process.
And losing that sense of selfhood can both be frightening and overwhelming. And that can often happen to people when they're having experiences both in meditation and using psychedelics. But that can also be a very ecstatic type of experience, and it can lead to a lot of positive emotions, and potentially, I think psychological healing.
And that's really become one of the main areas that we've been focusing on specifically with therapeutic use of psychedelics, because these self-transcendent experiences outside of psychedelics and psychedelic research, they tend to be difficult to elicit. We can't make them happen when we want them to happen. They tend to occur spontaneously a lot of the time. When I was doing that small study that was part of my graduate dissertation work, I had interviewed a number of people about experiences that they considered transcendent, where they felt like they were in touch with something larger than their normal sense of self.
And what struck me is that there were a number of different triggers or catalysts that seemed to help people get there. And some of those included taking psychoactive substances like psychedelics. But also, others included engaging in spiritual practices, meditation, going on retreats, having different types of fasting or prayer practices that they were engaging in.
For other people though, this seemed to happen much more spontaneously. I mean, it would just come out of the blue. There wasn't necessarily any intentional practice to get there. And that was also something that maybe was elicited by something like being in nature or being around something that could be awe-inspiring like a waterfall or the Grand Canyon.
So the idea that we can't necessarily have these transcendent types of experiences happening when we want them make them very hard to study, we kind of have to do it retrospectively and try to put the pieces together.
But the exciting thing about the research with psychedelics over the last few decades has been specifically that in many people, it seems like we can, by using both careful preparation and then high dose psychedelic administration, help people get there in a much more reliable fashion. And then that allows us to study these types of experiences in a way that's much more convenient and easy to do, even in a laboratory setting.
So that's I think one of the major ramifications of the work we're doing, is that it allows us to really put these experiences under a microscope. Whether we're putting people in brain scanners, or we're just having them on the couch and then asking them about what it is that they're going through.
Sara Wilson: What are the perceived therapeutic outcomes of having a self-transcendent experience?
Albert Garcia-Romeu: That can be really hard to say, because it varies so widely between people. And for some people, this can be a short-lived just moment of “Aha”, this feeling of insight or realization, and going back to the way they continue to operate for some time.
For other people, it can actually sometimes be not so therapeutic, and it can be distressing, and it can lead to some destabilization, I would say. And even for some folks, in extreme cases, they can end up having delusional thinking or psychotic types of symptoms, which can be short-lived or sometimes persisting. So obviously, that's something to keep an eye on and to be concerned about.
But for other folks, there's definitely what you would consider benefits, therapeutic types of effects. So I'm just coming out of a room from a session where we're doing here for one of our studies, and the person really describing to me that the experiences that they've had here with psilocybin, which really were a powerful altered space, were really helpful in a lot of ways for them outside of the session room and in real life.
For instance, one thing that I was just told was - it was feeling that oftentimes, when people are treating her in a way that's not healthy or positive, that her gut reaction was just to let it slide, not to say anything, and just to kind of move on and suck it up. And that since she's had the experiences here in the study that she's been in, she's been much more forthright about the fact that it's not okay with her to be treated that way, that she's not comfortable with certain things, just being upfront and honest about it.
And so changing that pattern of communicating and socially interacting with people in a different way, which she also felt has been much better for her in terms of her mental health and feeling like it was really nice to get that off my chest. And that when I responded in that way, people also responded in kind and said, "I'm sorry. I shouldn't have been acting that way. That was a misstep, and I apologize."
So there's often shifts that can come along with these types of transcendent experiences that people can have, where it kind of shakes them out of some of their old patterns. And some of those old patterns might be behaving in ways that are not healthy. And if you can help instill in a person this movement in the right direction, then these experiences can be very therapeutically helpful to overcome some of those negative past patterns, and to put in place things that we hope are healthier and more adaptive.
Sara Wilson: Yeah, I think that you definitely bring awareness to the fact that we need to be aware that not everybody is ready for these catalysts of self transcendent experience. So to be aware of important markers of when somebody might be ready to transcend the boundary of self.
And I think it definitely also speaks to the importance of acknowledging a person as a being that goes through stages of development. So I know that in major depression or the dissociative disorders, maybe schizophrenia, it's characterized by a lack of a foundational sense of minimal selfhood. So maybe in order to transcend self, it's important to still have an effective sense of self before you can get to that next stage.
Albert Garcia-Romeu: Absolutely. And so we think about that. In different terms, you can talk about, for instance, having sufficient ego integrity. But yeah, having that sense of self that's stable enough that it can be shaken up a little bit, or that some of those boundaries can get blurred without necessarily leading to adverse reaction, or a feeling of total destabilization, or getting immersed in chaos.
I think it was... Gosh, I forget who said it, but I think it was Joseph Campbell who said, "The person who's going through psychosis is drowning in the same waters that the mystic is swimming in."
And so it's this idea that for some people at certain times in their lives, they can go into these transcendent or peak experiences and lose their sense of self, and it can be therapeutic or it can be beneficial for them in the longer term. And for others, they may not be in a place where having that kind of experience is a positive one, and it can actually lead to more disorientation, distress. And so that's something you have to be mindful of, certainly with psychedelic therapies. But even with things like meditation, where you've seen that certain folks can have difficult experiences that can sometimes lead to ongoing problems.
Sara Wilson: Right. Yeah. One question that came to mind from an evolutionary perspective was, how could it ever be adaptive to lose ourselves? How could it ever be adaptive for any organism to overcome self-interest?
Albert Garcia-Romeu: Well, you can think of the evolutionary purview in many ways for us to survive, procreate, keep the organism alive, basically. And so that means find food, find safe shelter, safe haven, avoid things that are trying to harm you, and find potentially a mate and procreate, and then keep the biology going. And on very simple terms, that's what we're programmed to do.
But you can also think of all of the culture, and language, and stuff that we built up in the history of humankind. And obviously looking at things like social media, or how many followers do you have, we can get very entrenched in this tunnel vision. And I think that's something that we've seen ever since post industrialization for sure, but maybe even earlier on, is that people get sucked into certain things that they're very perhaps over-concerned with. And that may be things like status, it may be things like social standing, how other people perceive us. And that can potentially lead to this ongoing over concern or rigid pattern of really reifying these things, these constructs, whatever they may be.
And so when we get stuck in these patterns and we potentially end up in pathological or unhealthy ways of being and thinking and feeling, so exactly that is when the idea that you could get outside of those loops or those patterns, I think is when we'd be able to potentially have a therapeutic intent to go in there and then shift those patterns, get somebody out of these maladaptive ways of thinking about themselves or the world.
So you can think in a very basic sense, if somebody's got just a very negative view of themselves in the world, and that's the way that they see things, and that's the way they sort of have landed in terms of their worldview and their way of thinking about things, then that would be a really nice thing to be able to transcend out of, to then potentially see other ways of seeing the world in themselves and say, "Oh yeah, I've gotten really stuck, entrenched in thinking about things this way. But there are other ways of thinking and seeing things, and maybe I can practice some of that, and maybe I can become part of my repertoire that could then lead to a healthier mental mindset."
Sara Wilson: Yeah. I think it's very hard to extricate ourselves from a lot of our daily practices once we become so entrenched in them, and not even fully comprehending what it's doing to us, to what it's doing to our ability to interact with others, and perceive our world, and how we perceive ourselves. And I think the importance of having an existential experience related to a core selfhood is maybe one of the only ways to really get out of those patterns, of those maladaptive patterns.
Albert Garcia-Romeu: Yeah. And sometimes, something that's adaptive at a time, at a certain stage or phase of our life or of our existence, may not be later on down the line. And so in order to get from point A to point B, we may need to transcend ourselves multiple times over time, the lifespan.
And just thinking about something as simple as object permanence or conservation from Piaget in development, when children go through these stages of not knowing that when you're playing peekaboo, that you're not disappearing, that you're still there. And then all of a sudden, having this kind of transcendent realization that, "Yes, even when I can't see them, they're still there." And then moving on up through that.
Those are in ways, key developmental milestones where all of a sudden, we've shifted the way that we understand the world around us. And so I think it's kind of inbuilt in us in many ways to continue to transcend.
However, it's also extremely common nowadays, I would say, for adults to sort of get to where they're at in perhaps their twenties, thirties, and so on, and stop developing in some ways, and becoming stagnant.
So it can lead to what my mentor and professor at graduate school, Jim Fadiman used to call this psychosclerosis, this hardening of the attitudes where we just kind of like, "Well, I know everything I need to know. I'm a fully formed person, so what else is there to do or to learn?" But if you keep having this idea in the back of your mind that there is more growth and there is more development, then that allows us to keep visiting that transcendent territory, and hopefully becoming a better version of ourselves.
Sara Wilson: Yeah, for sure. Yeah, I love that. So we've already touched on this quite a bit actually, but could you explain to our audience what psychedelics are, and what specific altered states of consciousness can occur with psychedelic interaction?
Albert Garcia-Romeu: Yeah. Psychedelics are a fascinating class of substances. And I even hesitate to use the term drug. I mean, you can say drug because some of them are molecules that were made by humans, but many of them are just these naturally occurring, found in nature molecules. And psilocybin is a great example.
It's something that is an alkaloid that's produced by over 200 different species of mushrooms. Why exactly do mushrooms make this specific chemical? We don't know. But for whatever reason, it interacts with our brain's serotonin receptors. And specifically what we call the classic psychedelics, including substances like LSD, psilocybin, DMT, mescaline. Many of these are occurring in nature, and then they're something that people have had a longstanding relationship with, have used for a long time. These mushrooms, for instance, that are containing psilocybin, because of their psychoactive effects. And so in terms of how they work, we believe that the serotonin 2A receptor is a big part of the puzzle in terms of the neurotransmitter, the pharmacology of the drug.
There's more to it than that. And we're slowly unlocking these mechanisms as we do more science to really drill down on what's happening in the brain when people and animals are exposed to these substances. But they have these really profound psychoactive effects, which I think is one of the reasons why people have taken them for so long.
And so for instance, we know that for thousands of years now, people have made artifacts around these types of mushrooms, showing that they have a sacred status in ancient and indigenous cultures. And the Aztec people, for instance, called the mushrooms teonanacatl which roughly translates to the divine flesh.
So for a long time, people have known about these substances, they've used them. And in terms of what they're doing, they can produce changes in our perceptions, and changes in our cognitions, the way that our mind is working and that we're thinking, and intense changes in our emotional state. And when that's happening, people are under the influence of psychedelics. It can last, depending on the substance, six hours, eight hours, or even longer.
And during the drug effects, people feel these altered states of consciousness. So their brain and their mind is working quite a different way from their normal sense of self.
But what's also very interesting and what we found in more contemporary research over the last 20 years or so, is that those temporary altered states of consciousness also seem to have an association with or can be linked to altered traits or altered ways of being in the world, and altered ways of experiencing ourselves and the world.
And that from a psychotherapist standpoint is very exciting, because one of the key things that people come to therapy for is because they want to find some way to change something that's not working for them, or somewhere where they feel stuck.
And so there's something about the altered consciousness that psychedelics can bring about that seems to lend itself to helping people make these longer term trait changes, which is fascinating because there's not a lot out there that we know of that can really do that in a reliable way.
Now, in terms of what kinds of altered states that people experience, it really runs the gamut because people can have... And it depends on the dose, which is very true in pharmacology in general. If you have a little sip of wine, it's going to be a very different experience than having a whole glass or a whole bottle of wine. And so the dose definitely affects the way that the drug is experienced.
But on lower doses, people often are having visual perceptual changes. It also depends on the drug, because they all have a slightly different pharmacological profile the way that they work and bind to different receptors.
But generally, these serotonin 2A agonist classic psychedelics are causing both these visual and perceptual changes, which are reminiscent of the types of tie-dye and paisley art and imagery that we see from the 1960s when psychedelics were a big part of the counterculture.
But then there can be certain characteristic types of experiences that people have when they're under the influence. And some of these can include autobiographical content that can come up.
I've talked to people, for instance, who have said they've taken ayahuasca, which is a DMT containing psychedelic mixture that's used in Amazonian cultures in Central South America. And what they've said about their experiences, it was almost like their brain was playing a highlight reel for them of all the terrible things they ever did in their lives, all of the things that they regretted, they felt bad about. And that in through going through, that they were also in a way able to go back and come to terms with and forgive themselves for having gone through that, and realizing maybe I knew better, and I needed to learn from that experience. Or maybe I didn't know any better, and that was just an honest mistake that I made.
But by going through that process, it can be very helpful, or at least people have told me that can be very helpful for letting go of some of these feelings of guilt and shame about things that have happened in the past.
Besides autobiographical content, though, people can have all sorts of really unusual content. Whether they feel like they're seeing imagery. And some of that imagery may be very basic geometric shapes and colors. But other times, people can find themselves in whole alternate dimensions where they see themselves in outer space, underwater, seeing themselves interacting with other creatures or beings. Some that might be experienced as having sentience or consciousness of their own.
Sometimes, people feel as though they're having encounters with higher power of some sort, and that may be a deity like Jesus Christ or some sort of incarnation of a Buddha, for instance, or saints, or visions of other types of spiritual figures.
Sometimes, people talk about having experiences where they're in contact with lost relatives and loved ones that they're no longer with us, but that they're able to re-contact during their experience.
Sometimes people can also have very challenging and frightening experiences where they feel paranoid, they feel strong anxiety, they feel a lot of disorientation. So that's something that we have to work with acutely when people are here in the dosing sessions. And it's also something that we see obviously, when people are using these substances recreationally. And sometimes they need to be cared for either by medical or psychological people, or by friends and loved ones who happen to be there.
And another big experience that we see and that we've spent a lot of time studying is this what we call mystical type experience. But I think that can really be interchangeably called a number of different things, whether we're talking about a unit of experience, or a spiritual or transcendent experience.
And really, there the key is just this sense of oneness with everything around us or with the universe. And I think that sense of unity is one of the key features that people will often describe when they go through these high dose experiences.
Sara Wilson: Yeah. In your article “Clinical Applications of Hallucinogens”, you find a meaningful interaction between mystical experience and the big five personality traits, particularly increased levels of openness to experience. And I was wondering if you could explain these findings a little bit for our audience.
Albert Garcia-Romeu: Sure. And so that's from some early work that was published out of this lab here at Hopkins. And what I think is more interesting now is that we've seen a shift in the data. So they're not all consistent, and that's not uncommon in science.
But what I would say is that really, the initial cohort that went through some of the early studies with psilocybin here at Johns Hopkins, this was work that was conducted by Roland Griffiths and Bill Richards, and others who were here at the time, Mary Cosimano.
And what they found though, was they took a bunch of healthy people. So they weren't people with any particular mental health condition like depression, but they actually had a clean bill of mental health. And they volunteered to join the study where we would give them a high dose of a psychedelic drug. Many of them had never taken any type of drug like that before.
And what they found in these early studies were that those people were coming in with a high level of baseline openness, higher than your average, at least average college student, which is what a lot of these data come from with psychological tests and inventories.
However, what they also found was that the greater mystical type experience they had under the influence of psilocybin, then those individuals were having increases in their personality openness, which is one of the five domains that's been proposed within this model of five factor model personality. There's openness, conscientiousness, extroversion, agreeableness and neuroticism.
And so what we found with healthy people is that when you get people who have mystical type experiences with psychedelics, that increases their personality openness. And that's actually quite interesting, because personality openness has got a number of little subdomains or factors. But that includes things like aesthetic appreciation for art and music, and also open-minded tolerance of others' viewpoints. And so by being more open to others' views, that's something that could really be helpful in a lot of ways, if you think about what we find ourselves in contemporary culture.
Now, that data though, now that we've kind of zoomed out... And I recently came back from the Psychedelic Science conference in Denver where I went with a group of my colleagues here from Hopkins, and one of them, Nate Sepeda, was presenting on some data that we'll publish soon.
But he looked at data from hundreds of people that have gotten psilocybin in these different studies. And what he was finding was that there wasn't one clear path in terms of how high dose psilocybin was affecting your personality. But that for instance, different groups of people were showing different patterns.
So one of the things that's been found is that, for instance, people with depression, they tend to come in with higher baseline levels of neuroticism. And that tends to be something that comes down after treatment with psilocybin. And for some people, there's also increases in things like extroversion. Or basically, the ability and the desire to be social with other people.
So I guess the story here in terms of impact of psychedelics on personality is still taking shape, and it's still a little unclear. But depending on where you start, we can say that there's potentially some type of response that you may have in terms of your personality possibly being changed after these experiences. And for some people, the mystical type experience, certainly for healthy people, can lead to increases in openness. And for other people, we can see different changes like reductions in neuroticism or changes in some of these other factors like extroversion.
And so there's still a lot more to study there. But I think one of the takeaways there is that it sort of depends on what your personality is like when you go into that, which is a big maximum of psychedelic research, this idea of set and settings. So the person that's going into it is going to be impacted differentially because of who they are when they show up to that experience.
Sara Wilson: Yeah. Okay, yeah. This leads us really nicely actually into my next question, which is, are the changes in personality elicited by psychedelics encouraging or bringing out traits that were already in the person?
Albert Garcia-Romeu: So that's a difficult question to answer. We can't really say yay or nay on that, because it's kind of unclear where a person's, what their inherent tendencies are. You can say psychedelics are really uncovering who a person was all along, but it's hard to say yes, that's who the person was all along, in any sort of authoritative way.
But there's an idea in psychedelic therapy, this idea that psychedelics can kind of help people get in touch with parts of themselves that perhaps have been obscured or maybe covered over by life experience. And by getting back in touch with those parts of ourselves, they can help us get to where we're supposed to be going or develop more towards our true self, whatever that is, leading us towards more authenticity. So I think that that's certainly a working hypothesis that many people have brought to this psychedelic therapy and research space.
Sara Wilson: Yeah. I guess regardless of whether it's helping us get in touch with our true self or helping us get to where we ought to be going, I think it definitely does illustrate the positive, powerful potential in the human brain as something that we can unlock certain things, whether that's who we are or where we should be going.
Albert Garcia-Romeu: And really, what I think is more pertinent is that if you think about people, a lot of who we are is predicated on what we experience and what we're taught. And so for instance, a person who's raised in a certain family, and culture, and environment may take on lots of ideas and beliefs that they may not have chosen. They're just what were thrust upon them as they were children and then growing up.
And so what's really nice about psychedelics is that it seems like it can help people to take a step back, and reexamine those beliefs and those ways of thinking about the world and themselves and say, "Now how much of this is actually true? How much of these are beliefs that I want to hang onto and that I feel are authentically a part of who I am?" And how much of this can I say, "You know what? That was stuff that other people basically spoon fed me, and I don't think I need to be this way, feel this way, think this way anymore." So you can think of lots of examples.
But being raised in a xenophobic, or racist, or homophobic type of situation I think is a great way to think about when we're spoon-fed some perhaps not particularly healthy ways of thinking about the world, and we're able to step back and say, "Is this really who I am or who I want to be?" And then making a more conscious, informed decision as an adult.
Sara Wilson: Why do you think it's difficult for people to address deeply rooted issues naturally, and how might psychedelics help facilitate getting in touch with our subconscious?
Albert Garcia-Romeu: That's a great question. I think it really depends. But oftentimes, just like what we're just talking about, when we have big experiences, traumatic experiences even, they can be so overwhelming that, again, the ego integrity, our ability to really process those experiences just isn't there yet.
And so it may be something that we just don't know what to do with. It's almost like you're handed this big experience that is really powerful, and intense, and disruptive in a way to one's worldview and one's sense of self and saying, "I don't know what to do with this. I have to put it somewhere where it's out of sight and out of mind," so it can stay there for many years for lots of people.
And I should say I'm talking more now from clinical and lived experience and less from empirical data here. But it seems to me that when we go through these types of really difficult experiences... And it can happen at any time of our life. It might be childhood, but it could be in adulthood, it doesn't matter. It can be so frightening, powerful, or overwhelming.
And you can think of, for instance, a veteran who's in a combat zone and is in an experience where their life is in danger. They may see other people that they're with being harmed or killed. And again, their number one priority at that point is survival, make sure I get through this. So they may not have time to even then as adults, process that experience then and there. And it may be so unpleasant and so intense that again, it kind of gets swept under the rug.
So we have a tendency to often have these big experiences and try to get past them, move beyond them, but perhaps not really deal with them to the level that they need to be processed for us to make sense of them and to come to terms with them.
And I think psychedelics have a really powerful way of sweeping out whatever's under the rug for us to see and say, "Hey, this was important." Whether you were able to deal with it or not, now is a time for us to go back to this and look at it, and try to put this together with the rest of the life experience in a way that is cogent and makes sense, and that we can also come to some sense of acceptance or at least acknowledgement that yes, this is something that occurred. This is a part of my life story, whether I would've chosen it or not. It is there. It is what it is. And from there, I think you can get to a place where from a therapeutic standpoint, people can engage in some healing around that.
Sara Wilson: Yeah. What would the introduction of psychedelics look like in therapy, and why is it important to couple talk therapy with the psychedelic sessions?
Albert Garcia-Romeu: So because of the powerful alter state of consciousness, I think it's really important to have some level of psychological support around that. And it may not necessarily be a formal psychotherapy, like cognitive behavioral therapy, or ACT, or motivational interviewing, but it could be. And that's something that we've used. We've used these types of therapeutic modalities successfully in different studies here, and other labs across the country, and even overseas. And what we're doing there is a couple of things. And they're very basic, but at the same time complicated in many ways.
So the basics are that first, before there's even a real therapeutic process, we're often screening people just to assess their level of physical and mental safety to undergo this type of experience. I think this is a really important part of the process that doesn't get talked about enough, because people often want to jump right to the drug experience or to even the therapy.
But before we start the therapy, it's kind of like when people are coming in for any sort of medical procedure, we want to make sure this person is going to be able to go through this safely. And that could both mean looking at their liver and kidney function, looking at their cardiovascular function, but also looking at their past history of mental health and their family mental health history.
Because sometimes, there's clues there that perhaps this person may have an adverse reaction. And obviously, you typically are trying to avoid that, specifically in cases where you think you might trigger something like a latent psychosis or a potential bipolar mood condition. So those are the types of things we're doing before we even get started in the process.
But when we get into the actual psychedelic therapy, we're often starting with several weeks of just rapport building. Meaning if I'm sitting in the sessions with somebody, before we give them the drug, we're going to spend six to eight hours with them over the course of several weeks, getting to know more about them, making sure that they feel comfortable with us, getting a good sense of their life story. Particularly formative events.
And that can mean anything from their childhood and family history, growing up, going to school, important relationships, friendships, mentors, romantic relationships.
And then going from there, to just develop a sense that you're safe here with us. You're in a place where you can be yourself and be honest and open with us. And then developing that I think is really one of the first steps to doing psychedelic therapy safely so that even if people encounter these really scary or difficult parts of an experience, that they can work together with the facilitators to make it through that in a way that's not harmful.
The other big piece of this preparatory process is twofold. The one is explaining to people what it is that they're going to be potentially experiencing, because it is a very strong altered state of consciousness that includes intense emotions, changes in perception and thinking. That can be disorienting and frightening.
And so giving people a lowdown and saying, "This is what sometimes happens. And we don't know what's always going to happen, but we want to give you a sense for where we're at and what could occur." And finally, setting some form of therapeutic intention. Specifically when we're doing this as part of a therapy package, that typically is going to come along with some sort of therapeutic target or indication. Major depression, tobacco use disorder, existential distress related to illness.
And so part of understanding the person's life and their life story is where they're at now, and what's brought them here to us, and what is it that they're dealing with, and what does that look like in daily life when you're depressed or when you're struggling with an addiction.
And then that then sets the stage for saying, "Well, this is where I'm at." And then kind of determining, so where do you want to be? Or what would you like to get out of this process? How can we help support that? And what would life on the other side of a successful treatment look like to you?
And so really helping the person envision that, and also come up with strategies. Because it's not just a matter of, bam, take the pill and all my problems are gone. But it's really about on the ground, how do you make this something that's a sustainable change that's for the better for this person?
So that's really I think what the whole supportive therapeutic process is about, is getting somebody ready to go through the experience, providing the safe container for them to have the experience during the drug session or sessions. Sometimes, we'll go up to three sessions or more. But then also afterwards, providing a supportive process for integration where if there were insights, if there were difficult memories or difficult parts of the experience, or really anything that came up during the sessions, that you're able to work together to make sense of it, and take away anything valuable or useful from that. And put it into practice, so that it's more of a long-term change and not just, "Wow, I had this realization. But now I'm going to go right back to the way I was beforehand."
Sara Wilson: Yeah. Okay. So in your article “Clinical Applications of Hallucinogens”, you claim that it is a moral responsibility of biomedical researchers to explore every possible treatment, which I think is very interesting. Could you talk about this a little more for our audience?
Albert Garcia-Romeu: Yeah. Well, my main thrust there is that there was good research in the 1950s and '60s and '70s to show that when used responsibly and carefully, that psychedelics would be really potentially useful for a number of different types of mental health conditions, including things like alcohol use disorder.
Now, the data weren't always consistent. Part of the problem there being the early research, they didn't necessarily have a good grasp on what the proper model was to use these types of tools. They were very new at the time. LSD was not even really discovered until 1943, psilocybin not until 1958. And so when using these new tools, there were different results in early research, but there was still an underlying thread there that this could be helpful.
And unfortunately, this really got wrapped up in a lot of politics, the counterculture. And I wrote a little blog for Psychology Today about this as well called “Psychedelics Reconsidered”, where I really talk about more of the historical arc of this culturally.
Because at the time, psychedelics and cannabis got really associated with the counterculture, and the counterculture was seen by the powers that be at the time, and certainly the Nixon administration, but just conservative politicians in general as a real threat to the status quo.
And so as a result, there was a huge amount of energy put into stigmatizing this idea that these were dangerous, that they're going to destroy your children's lives, and that they're something that need to be banned, put under lock and key. And as a result, it became very taboo to think about doing the type of research that we're doing now from 1970 on.
And so it took several decades until you finally start to see that thaw, where scientists like Rick Strassman, Roland Griffiths, Franz Vollenweider and others begin to set the modern era of research underway, Dave Nichols. And they're really starting to bring it back to, "Okay, let's see, can these things be useful? Or are they just these dangerous drugs of abuse, like many people have been saying for years?"
And come to find now that absolutely, there are ways that we can use these therapeutically, and they seem to hold a great deal of potential. And there's a lot there that we don't know yet, but there's been studies from various labs around the world showing robust, rapid acting antidepressant effects.
And when you're dealing with a large number of people who are struggling with major depression, and a not inconsequential number of people who are refractory to treatment, meaning that we give them the best medications and talk therapy that we have, and that they're not getting much better, then I think it is our moral responsibility to explore all the avenues available. And psychedelics represent one area of that, but there's lots more going on.
So it's a pretty exciting time, I think, for mental health research. And we're seeing a lot more outside the box thinking, which is I think a good thing.
Sara Wilson: Yeah, certainly. So I don't think that there's an obvious answer to this question, but feel free to postulate. Your studies really illustrate not only what consciousness is and the current metaphysics of mind, but also what consciousness can be, and what it can mean to be human. Based on the research you've pursued, do you think that there's a higher level of consciousness that can be achieved, and maybe what might this look like?
Albert Garcia-Romeu: Yeah, that's a really interesting question to sit back, and ponder, and hypothesize about. Lots of different people are going to have different answers to this question.
I think one of the most compelling accounts that I've seen of this type of thinking of higher levels of consciousness is really from philosophers like Ken Wilber, and others whose work he based his work on, like Jean Gebser. Beck and Cowan who did Spiral Dynamics.
So these thinkers have sort of postulated that just like a regular single human being is going to go through different phases of development in the lifespan, and just like we're talking about with cognitive development and Piaget, and this idea of developing object permanence or getting to a level of understanding conservation.
As we move through these stages, one might say that it's a higher level of consciousness, or one might say simply it's a different level of consciousness, where we've reached a different level of understanding, again, of ourselves in the world. Now what's higher or lower, what's better or worse? Some of that can be relative. And certainly, there's also cultural differences that come to play here.
But I do think if you want to step back and look at us as a species of creatures that live on a planet with finite resources and other creatures on the same planet, that there are certain things that work better than others. And if we're going around, for instance, killing off all the other species, or even harming each other, whether it be across racial boundaries, or across territorial or religious boundaries, those are not necessarily outcomes that are desirable.
And so many thinkers like Wilber and others have seen that as humans develop over time and go through different phases and stages of development, that perhaps cultures also do the same thing. And that in that regard, perhaps higher states of consciousness and cultural development as well are those that are leading us to live in more peace and harmony with ourselves and with other cohabitants of the planet where we are.
And so that's probably my best answer, my best guess as to an answer is really anything that leads us towards having a more peaceful and harmonious existence with one another and within ourselves. And so coming back to the individual level is, how do we get to this state of optimal well-being? And how do we then put that into practice by hopefully having positive and peaceful interactions with the people and creatures around us?
Sara Wilson: Yeah. So as this very stimulating conversation is now coming to a close, I wanted to ask you, is there anything else you would like to share with our audience about avenues of research you are finding most exciting right now, or just more broadly?
Albert Garcia-Romeu: Yeah. I mean, there's a lot going on with the field of psychedelic research, which I'm heavily involved in. But I find it really exciting to see both this area of clinical and therapeutic research is really taking off, both doing bigger and more well controlled studies and conditions like depression and substance use disorders.
But also starting to explore new conditions. Alzheimer's disease, chronic Lyme disease, different areas that we're starting to dip our toes in the water to see, can we use psychedelics for these populations? Can we help people with end of life existential distress? Can we help people with chronic illnesses?
So that's a really exciting area. And we're seeing more and more research too on the mechanisms of, how in the world do these drugs exert these long-lasting changes and benefits that people are reporting? So brain research, neuroimaging, animal research, cellular molecular research is elucidating the mechanisms of how these drugs work, which is, I think, really exciting.
And then the other stuff that I think is also really important and is a little bit outside of the medical arena is the idea that we can also use psychedelics in other areas. Not just for people with mental health conditions or with physical illnesses, but also with people who are healthy and who are wanting to have spiritual or different types of altered states that may be helpful for their development.
And so as Bob Jesse puts it, for the betterment of all people, using psychedelics for people who are healthy in ways that have nothing to do with illness. But are really about promoting health, wellbeing, and even creativity.
And this was something I was just talking about a little while ago with a reporter from Scientific American. But this idea is not a new one, which is that in the 1960s, they were studying psychedelics as agents to enhance creative problem solving. And lots of people like Steve Jobs, Kary Mullis, and others, who have talked positively about the impact of psychedelic experiences on their own innovative ways of thinking, and the products that then led to down the line for them.
And so it's, I think, really exciting to think about using psychedelics outside of the medical model. But for people who are wanting to connect more with their spirituality or people who are wanting to change the way that they're thinking, or view themselves, or different problems that they're working on from a different perspective, which could potentially then lead to some new ways of approaching some of the big problems that we're facing now. Whether we're talking about climate change, ecological crises, etc., there's a lot of problems that need to be solved. So anything that we can use as a tool to help us solve those more quickly or more efficiently, I think is welcome.
Sara Wilson: Yeah, thank you. Well, thank you so much for joining us today. This was such a cool discussion. And I really think that every human being, no matter your discipline, can learn something incredibly valuable from your practice. I think that this has major promising implications not only for personal well-being, but as you were speaking about, societal harmony, and how we treat each other, and our environment more broadly. So thank you for having this conversation with me.
Albert Garcia-Romeu: My pleasure. Thanks for having me on.
Sara Wilson: Of course.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Spencer McWilliams
Spencer McWilliams, Ph.D. is a a Professor Emeritus of Psychology at California State University San Marcos. He specializes in Constructivist approaches to personality and self, Personal Construct Psychology and Buddhist psychology.
Sara Wilson: Hi, everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. My name is Sara Wilson and I'm a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
Today I'd like to welcome with us psychologist Spencer A. McWilliams. Dr. McWilliams is a Professor Emeritus of Psychology at California State University San Marcos and served as the former President of the North American Constructivist Psychology Network. He earned his PhD in Clinical Psychology at the University of Rochester in 1971 and his interests include constructivist approaches to personality and self, personal construct psychology, and Buddhist psychology. So before we get started today, could you please let us know a little bit more about yourself and, ironically, what made you interested in studying the self as it relates to psychological dysfunction?
Spencer A. McWilliams: Well, thank you. I've thought a lot about this since you invited me for the interview. I guess one of my early life experiences was kind of feeling like I didn't quite understand social interactions and stuff, why people said the things they did and why people said things they didn't mean and things they didn't say and stuff like that. So I always felt there was an interest in me to try to figure out what to make of this life that I have on this plane.
So when I went off to college, I decided just to be a liberal arts major my first couple of years. I couldn't decide what I wanted to major in, actually I was thinking about being an engineer and then suddenly I discovered that I didn't really care that much for math and science, and so I took a lot of different courses and when it came time for my junior year, I had to pick a major. So I chose psychology – I was interested in literature, in art, in psychology. I figured if I majored in literature or art, I probably wouldn't be able to get a job, but if I majored in psychology, maybe I could. And I had some experiences that kind of got me interested in clinical psychology.
I had the opportunity to work as an assistant to a psychologist in the Juvenile Hall during my junior year, and that kind of got me pointed towards clinical psychology. And so I went off and got into graduate school and, as you said, got my PhD in clinical psychology with an emphasis in community psychology at that time. So I was fortunate to get a good job at the University of Arizona right after graduate school. And I started out there trying to continue the work in community psychology that I had done with my mentor in graduate school. But I found over time that it wasn't very satisfying to me because I wanted to have a clearer sense of what a person is, what a human being is, and community psychologists were doing all these wonderful things out there in the community, helping people, but it didn't quite fit for me.
And then I got a chance to teach psychology of personality as my undergraduate course, and I had taken that class at Cal State Long Beach where I got my Bachelor's, and I really liked the way the instructor had done it. He'd chosen individual books for each individual theory, and so I decided I was going to do that. And I was at an APA Convention looking at various books, and I saw that there was this book by George Kelly called “A Theory of Personality”, which I learned is the first three chapters of this major work. And I had remembered that one of my profs in graduate school had told us a story about Kelly, about how he had applied his own theory to some problems that he was having to deal with himself. And I thought, well, that really appealed to me, the idea that if we're going to have a theory personality, it ought to be able to explain what we do rather than just say that it's for other people.
So I decided to have his book, along with a book on psychoanalysis and a book on behaviorism and a book on Carl Rogers. And so I hadn't read anything about the guy. So I actually was about two weeks ahead of my class reading that book, and it was like an epiphany. It was like suddenly I said, "Oh, this is my tribe. I've finally come home to people who look at the world the way I do." So I got to reading everything I could find about Kelly and his work and found out that at that time, most of the work in the field was going on in England and I had a sabbatical coming up, and various colleagues I got in touch with, some people in England, seeing if I could come and study with them in my sabbatical. And I heard from everybody, but one of them, a woman named Fay Fransella, who was really one of the key players in personal construct psychology in the UK at that time. And she invited me to come and spend a year with her at the Royal Free Hospital School of Medicine where she was a faculty member.
And I got to hang out with all kinds of different people who were interested in Kelly's work. And then when I came back to Arizona and said, "Okay, what am I going to do next?" So I continued working on Kelly's work, and I'll describe his work more fully when we talk about constructivism, and then I got interested in, this is on my personal path, interested in Buddhism and started working with a teacher at the Zen Center of Los Angeles, a woman named Charlotte Joko Beck, who had just started teaching, well she was in her 60s at that time, and I became one of her students and studied with her for about 30 years until her death about 10 years ago.
And I continued to practice what she taught and continued to read her work. And so that's a major part of my journey in life. So the question about self, it comes up in different ways in each of these various places. The constructivists are going to say that the self is an inventive construct that we made up. And the Buddhists, of course, are going to say that there really is no such thing as a self, it's just an illusion that we have. So that kind of gives you an overview of the kind of things that I've studied over the course of my career and even since my retirement.
Sara Wilson: Great. This is really, really cool. So getting right into it, in your paper, “Inherent Self, Invented Self, Empty Self: Constructivism, Buddhism, and Psychotherapy”, you outlined many of the valuable aspects of constructivist psychotherapy over foundationalist psychotherapy, drawing on, as you said, Buddhist outlooks on the human condition. So first and foremost, you mentioned this term constructivism and constructivist practice. Could you explain to our audience what constructivism is?
Spencer A. McWilliams: Well, sure. I'm happy to do so, but I want to have the caveat that this is just my construction, my understanding of it. This is not the truth or the final word on it. So, one of the things that struck me about George Kelly's work when I started reading it is he said that, his basic philosophical assumption underlined here is that all of our present interpretations and understandings of the world are subject to revision and replacement. So I'm getting goosebumps just saying that, what it's really saying is that we humans are creating or constructing our understanding of our experience in the world. And we try to make sense of it, but there's no external source of what we should do.
Basically, the constructivists would say that, well, some of them would say that constructivism is about how we find meaning to life and others of us would say that constructivism is all there is in making sense of life. That we humans are basically dealing with the world, seeing things that are familiar and unfamiliar, things that we recognize and don't recognize. And out of that, we begin to develop these bipolar dimensions and things like hot versus cold and up versus down, and very, very hot these days versus much cooler. And that while we learn from our community, obviously we learn languages and words and how to apply words to these dimensions that we come up with, that the dimensions are just bipolar dimensions that we use to make sense out of what it is that we see.
Now, we give words to those dimensions and we give words to the things that fit along those dimensions, and this is getting more into the Buddhist perspective, but the words that we develop lead us, and the fact that we separate things that we recognize and don't recognize leads us into the idea that individual things exist, individual things that we give names to. But what we begin to see from the constructor's perspective is that those are our personal dimensions. Those are our personal ways of making meaning out of life. And one of the constructs in person construct psychology is the notion of poor constructs, that we develop some sense of who it is that we are in relation to our experience that we have in the world, and most of the constructors would say it has to do with our experience of the world, not with the environment, because there really is no fixed environment. It's our experience and how we make sense of it.
Sara Wilson: Just, if I'm understanding you correctly, there are at least two branches of constructivism. So one of which boils down to how we make sense of our world and that is all we are in touch with, regardless of whether there is an external world or any truth to the external world. And then there's maybe the Buddhist outlook on constructivism, which asserts that that is all there is; just our meanings which aren't conversant about any external world or ultimate truth.
Spencer A. McWilliams: Yes, I wouldn't refer to Buddhism as a branch of constructivism. I think the fact that I have... I learned about constructivism then I learned about Buddhism, and initially it was a problem because I thought, well, these are really incompatible, but as I learned more, I found, well, no, they are compatible, but they're different. I think the difference is that, I'm talking about from a therapeutic or counseling perspective, that the constructivist perspective basically helps people to make sense out of the way they look at the world and helps them to see how the ways they're looking at the world may not be effective in having them be able to meet their needs and what they want in life.
The Buddhist perspective is focused on the same kind of issue of dissatisfaction in life, why life is so dissatisfying, but rather than trying to figure out how to make your sense of the world work better, the Buddhist perspective is then to say, "Well, what's important is forgetting your perspective on the world and what you're trying to make sense of it. Just be with what's going on in the moment, because all those words and all those concepts and ideas take me away from this experiencing life as it is."
Sara Wilson: Yeah, for sure. And now just kind of bringing this into a therapeutic context, how does constructivism differ from this term or this practice, foundationalism? And what are the potential dangers of a foundationalist view of self in the context of mental health?
Spencer A. McWilliams: Okay. Well, let me talk a little bit about foundationalism. It's actually pretty much the way that most people look at the world. It has evolved out of the Christian frame of mind and science, but the foundationalism, other names for it are realist for example, is the view that there is, in addition to our being in the world and our way of looking at the world, there is something external to us that we think of as the way that the world is. Okay? So if we're trying to learn about how to make sense out of life and what's going on and the foundationalist view would be to say, there is a specific way and that any knowledge, in order to be true or valuable, has to correspond to the way the world actually is independently.
Okay? Well there's a big problem with that because we would have no way of knowing. There's no way that we could figure out. One of my favorite early Greek sophist philosophers, Gorgias, talked about this. And basically he said that the problem is that, in order for us to determine whether our view of the world is the correct view of the world, we would have to have a separate referee, separate from we humans who could look at our theory, our idea about things, look at the way the world really is, as if there was a way that it is, and be able to tell us whether that was correct.
Okay? Well that's a nice idea, but it doesn't exist. It's impossible. So there's no way we can really know how the way world is or the world or the universe and whatever we want to call it is on its own independently of us, because the only way we can come to know it is through our trying to make sense using our constructs that we invent to make meaning out of the experiences that we have and trying to continue to improve our knowledge and understanding so it seems to make more sense for us, but even though sciences, we talk about discoveries as if Einstein was walking along the path one day and kicked a rock, rolled over and up jumped this thing that said, "Hi, I'm the theory of relativity," and he discovered it. Well, he didn't discover it, he invented it. He used his own intelligence to make sense out of physics and that's what he came up with.
So, there's a big debate that goes on and there's a kind of little war between the foundationalists and the constructivists in some of the literature because the constructivists want to believe that there is a truth and a reality that we're dealing with and that there is an exact way that things are. And when the constructivists say, "Well no, there are a variety of alternative ways of making sense of the world and none of them are the absolute truth," foundationalists get kind of anxious about that. That makes them a little bit worried because they want to know the truth. And this is a perspective that most people have, that there's something that is the truth out there, whether it's a scientific truth or whether it's a religious truth or whatever else, that there is a truth and that we want to know what that is.
So the difference between the foundationalist view and the constructivist view is that the foundationalist view is saying that there is something real, that there is something called the self that is something real we possess. I don't know who it is that possesses it in there, but that's the idea that we have, we have a personality that psychological problems can be categorized into the diagnostic and statistic manual, we can attach these diagnoses and things to people when they're having troubles with their lives. The constructivists would say, "No, we're looking at people as individuals. We want to know how they look at the world, what's going on in their life, and how we can help them to make better sense of it." So those are some differences then.
Sara Wilson: Yeah, I think you put that really well. And it does really come down to reconstructing this narrative around agency, because on the foundationalist account, psychological wellbeing consists of, as you said, adjustment and adaptation to this so-called fixed reality of self and environment, as well as the absence of disorder. So in turn, not really leaving room for agency of self and ignoring this very real ability to create meaning for an organizing and understanding experience, as you mentioned.
Spencer A. McWilliams: Yeah. Makes a lot of sense that what most of us are looking for in terms of helping other people is that idea of helping people to be an agent in their lives and helping them to continue evolving, I think, is the way that I... But the foundationalist approach tends to want to stop at a certain point in evolution and say, "Well, this is it. Evolution's over and we're done and everything's fine now," but somehow life doesn't seem to want to go the way I want it to.
Sara Wilson: Right. So we already touched on this a little bit, but what is the value of constructivism in a therapeutic context? And could you maybe give an example of what this might look like in therapy?
Spencer A. McWilliams: Sure. The idea with constructivism is the same, that there's no truth out there, there's no external source of truth or absolute about how it is that we are supposed to behave or what we need to do, how we're supposed to be. A lot of the problems that people have is that they're trying to behave the way they think they're supposed to behave rather than the way that they would naturally behave. So the constructivists would, rather than trying to pin a label on a person and consider it a disorder and look for a specific cure of that disorder, would be helping the person come to understand themselves and how they make sense of things.
I'll give an example, when I was in England on my sabbatical, one of the things that my mentor, Fay Fransella, had done, she had done a lot of work on applying personal construct psychology therapy in stuttering, and stuttering is a big problem in the UK. In England, there's a lot of emphasis on being proper and saying things the right way. So a lot of people who have difficulty with that end up being stutterers, and so she assigned me a client who was a stutterer. And so getting to know him, he worked as an interior designer. He had trouble saying that. He worked for one of the brewing companies, so he designed pubs. So he always said he was a pub designer – he could say that easier.
And so one of the things that we did was to use a tool that George Kelly had developed and other people since then have really elaborated on a lot, where we ask the person to come up with names of people who have played different roles in their life, and you have maybe a list of maybe a dozen or 15 people, and so then bringing them together in groups of three. So say maybe this was your high school teacher and this was your father and this is your first girlfriend, and ask, what is a way in which two of these people are alike that make them different from the third? Okay? So they're having to come up with, on their own, there's not some truth about it. I mean you can't use, "Well, these two are female and this one's male," yeah, but what about their personality, what they're like? And out of that, you begin to develop a network and a hierarchically organized network of what this person sees as the way other people in their life are like and how they see themselves, because the self is also one of the elements that they would use.
And one of the things I found in working with this fellow is that he had come from the north of England, now he was in London, which is sort of like coming from Arkansas and now being in New York. And of course he didn't speak the way the Londoners spoke. It was an accent that he had and that was part of the problem with his stuttering. But one of the important concepts for him about who he was is that it was important to him to be perfectly natural was the term he'd use, as opposed to the contrast to that being putting on airs. Okay? So he was really stuck because he wanted to be able to get along in London and be effectively good in his job, but he wanted to be perfectly natural. He didn't like to feel like he was putting on airs, but if he talked like they did, then for him that would be putting on airs. So we were to kind of separate those things out, seeing that it wouldn't necessarily have to be putting on airs for you to practice a different way, just a different role you can try on for the moment.
And so we worked out a description of a role that he could play where he would be perfectly natural but also fluent verbally, and it was like, okay, you're going to pretend to be this character we just made up for two weeks and then the character's going to go away and you're going to come back. So it isn't like you have to be this way, there's something wrong with the way you are, it's just wouldn't it be interesting to try to behave in a different way to see how it works out? And so that's another of Kelly's original methods. And of course, we've been elaborating on a whole lot more in the 50 years since Kelly did the work that he did. That's one example.
Sara Wilson: Yeah. I think that that is a very inspiring story for people who feel trapped in a certain kind of self and feel inclined towards attachment and fixation to a certain being. And I think that your practice very much emphasizes acceptance in a way and acknowledgement, but also really highlights this ability to make real change that starts with your thoughts. So you already touched on this a little bit also, but I think it's important to go back to this kind of foundation; what parallels can be drawn between constructivist approaches to psychological dysfunction and Buddhist outlooks on the human condition?
Spencer A. McWilliams: That's a really good question. Well, to go back to the classical constructivist view, kind of like Kelly, his definition of the psychological disorder is the continued use of a way of anticipating events in spite of their repeated invalidation. It sounds a lot like what Einstein said was the definition of craziness; continue to do the same thing over and over again and it didn't work.
So the constructivist would want to help the person to take a look at the way they're making sense of the world, find a way for them to be consistent with their most deeply held values, but maybe try out different experiments with their life. But I think even most of the constructivists, and this was a problem I got into when I got into Buddhism, dealing with my own issues there, is that issues we would sort of say that the self, in constructivism, is the constructs you use, the dimensions that you use to make sense of the world and make sense of yourself in relation to other people would be the kind of person that you are, what are your core values? So you don't want to try to encourage the person to behave in a way that's inconsistent with their core values, but you can see if you can find alternate ways that they can behave that are consistent with their core values, if they can give them a chance to try out something different.
Okay. Well the Buddhist perspective, basically their fundamental issue is that the Buddha was concerned with why is it that life seems so unsatisfactory for people? And how can people get out of feeling that life is unsatisfactory? The term that he used to refer to a dissatisfactory life is a term that is something like Dukkha, which literally means a bad fit between a wheel and an axle. Okay? So as you can sort of imagine though, if the wheel is wobbly on the axle, the cart's not going to go very well. If it's sticking and can't turn well, it's not going to go well. So the basic issue in Buddhism is, how can people get away from feeling that their life is not working well, that their life is a bad fit between their wheels and their axles?
So what he found as he worked on his own journey was that the problem we had is that when we go through life, there are certain things that happen that we like, and there are certain things that happen that we don't like. Now these things just happen. There's no purpose to any of it, it just goes on out there. So our liking or disliking it is our own issue, but we have this tendency to want to be attached to the things that we like. We get greedy for the things we like, we want them to stay with us and never go away. And we want to get away from the things that we don't like. And that, by doing this, we're living an illusion and thinking that the world is composed of good things and bad things. Okay?
Sara Wilson: Right.
Spencer A. McWilliams: And so what happens is that, again life never goes the way we want it to go. Again, the universe is on its own. The universe doesn't care about what we say about or the words we use. And so the whole approach then in Buddhism is for us to begin to come to understand these bipolar dimensions that the constructivists talk about, how it is that they end up running our life. And so we need to find a way of learning about those dimensions in a way that's going to sustain itself over a lifetime.
So the Buddhist practices, you start out with meditation where what you're doing is, well, first of all, what you're doing is trying to see if you can sit still for a while and not get caught up in all the stuff you think you have to do in order for everything to be okay. And that usually takes the first few years of a practitioner's life and just where you don't think every thought comes into your mind as something you got to do something about. And over time you begin to see what the patterns are in your thoughts, the thoughts that come in, and over time, if you sit with them long enough, you get bored with them and you begin to be more open to the immediate situation. And the openness to the immediate situation means being able to experience what's going on fully, just experience what it feels like and what you're seeing, rather than immediately making this judgment that this is good and I got to do more, this is bad and I got to get away from it, or something like that.
So in doing that, you kind of see through the illusion that there's a self, but one thing, who is it who's having all of these thoughts? And that's one of the things that people want to get. They say, "I want to find out what the self in there is like." Well, the problem is that every time you go looking for yourself, that's just more thoughts. So if you're looking for the thinker, you can never find the thinker, all you're finding is thoughts. And eventually you become aware that the notion that we're separate beings doesn't really make sense and it actually fits in nicely with what's going on currently on the cutting edge of sciences like physics and chemistry.
I've been recently looking at the great courses, which is a thing you get online to listen to lectures from people in these fields. And what we end up seeing is that, well first of all, everything is made out of the same stuff. And that same stuff really isn't anything, it's mostly just these vibrations that go around the nuclei of atoms. And I guess they see now they're getting down where they can see that the nuclei are made up of quirks and strangeness and stuff like that. But it's really no thing. And in this force in chemistry you see that all of the elements are made up of exactly the same kind of atoms and electrons, it's just some of them have more than the other ones. Okay?
So everything in the universe is really just all the same stuff. But when we get into labeling things, you see words, labeling things and saying, "Well, this is a tree and this is a rock," then we begin to develop the idea that our world is composed of individual things that have their own individual identity, their own selfhood. Okay? So we think that a rock is a rock and there's some characteristic that it has, it is inherently the rock-ness of it. I don't mean this particular example of a rock, and Aristotle was big on that, if you look up the word, there must be something that it refers to. Well, no, it's just our words. So what we're looking to do is to come to see that there is no separation, there is no separate self, there's no innate, inherent self in the human being any more than there's some innate, inherent thing that is tree-ness, the trees have in common, the rock-ness that rocks have in common. And so that's an unfolding way of looking at the world.
Sara Wilson: I think that this leads us really nicely into my next question because this line of thinking is absolutely applicable to knowledge as well. So in your discussion of epistemological understandings of self, you note how knowledge is evolving interdependently within social and personal contexts and it's passed in conventional rather than absolute language. And so we cannot assume that our knowledge about the self proves the existence of an objective self metaphysically. And so I was wondering if you could explain this distinction between epistemology and metaphysics to our audience and how this might inform therapeutic practice.
Spencer A. McWilliams: Well, okay, sure. One of the things that George Kelly said when I first started reading him way back was he said that when a person makes a statement about their experience of the world and proposes how they might understand it, there are two ways that we can look at that. One is we could say that, well, what they're saying is the way it really is out there in the world, independently of a person, or the other way is that this is just one person's hopeful way of trying to make some sense out of being out of their mind. So there are two really different ways, and they're reflecting the foundationalist view on the one hand that there's a truth out there and the constructive view that says, "We humans are responsible for making sense out of what we do." So a lot of the groundwork in constructivism is related to the philosophy of pragmatism. And the philosophy of pragmatism says that since we don't know how we would ever know whether our thoughts and ideas and theories and concepts are the truth, then the issue should be which one of these ideas is likely to work better for us in solving human problems? And we can think of that on a societal level saying, what is it that's going on in our lives that is a problem and how do we solve this particular problem? Now, if we come up with a solution to this particular problem, it doesn't mean that we've found the truth. It means that, well, this worked this time and it may not work the next time, and that we keep our minds open and recognize that it's all we human beings. There's nothing external to us that's going to help us out there.
So if we think epistemologically, what we're doing is we're each, as individuals and then as a society, because we grew up in a society and we learn a language and we learn how to, I mean a lot of learning language as children is learning the names we're supposed to give to things, that's a tree and that's a bird and this sort of thing. And then there's this solution that because we got the name for it, we understand something about it, which we don't necessarily, but that we're making sense out of things in that particular specific way. Whereas in the constructivist view, again, we're saying we don't know anything beyond what we experienced, but over the course of our lifetime, we come into contact with different people, our parents and the society we live in where, again, we learn various words for things, we learn various things that are good and various things that are bad, what are considered good morals and that sort of thing. And we come to have the sense that that's the way the world is, particularly most people grew up pretty close to where they were born, and they interact with the same people pretty much their whole lives. And so they begin to develop this idea as they develop their sense of kinship, or maybe even a tribal sense of belongingness with this group, that this group's way of looking at the world is the way that it is. And then when they come in contact with people who are different from them, there's a tendency, so our group is better, we're better than the other people, they're inferior to us. So that sense we have, a kind of belongingness through our tribal membership, it inevitably leads to ethnocentricity where we think that our group is doing things the right way. And so anyone who's not in our group is inferior, so we don't need to treat them in the same way we would treat our kinship.
And that creates a lot of the difficulties and problems, and I'm probably wandering away from the exact question you were asking, but you were asking about epistemology and metaphysics, how do we view the world that we live in? If we view the world that we live in as made up of different things, some of which are good, some of which are bad, of different people, some of whom are good and some of whom are bad, then we're constantly in struggle with the world around us. And all the things you read on the news are good examples of that.
Whereas, if we think of the world as a process rather than a thing, that it's a process where things continually change, things continually evolve, then we can see that things are more like events that occur in particular times and places and its way of dependent interaction with other events that are occurring. So things have their qualities and characteristics, but they're changing and they only have those characteristics because they're emerging out of other patterns and other flows of various events. So when you think of an event or even a person as an interaction of constantly evolving and changing processes that don't have any permanent nature to them, well, we'll see the world in a different way. We're not something separate. We're just part of those flowing processes ourselves.
Sara Wilson: Right. Yeah. All of this really reminded me of John Locke's theory of ideas. In my philosophy major, I engaged with him a little bit, and he's concerned with what we can know from this theory of ideas, and according to Locke, and I think the constructivists would agree, knowledge is the perception of the agreement or disagreement of our ideas.
Spencer A. McWilliams: Yeah.
Sara Wilson: And in this alone it consists. So, a system of epistemology and a system of understanding self, for example, relies on ideas alone, since it's all our mind really has access to. And so it's evident that our knowledge is only conversant about ideas. And I think this would scare a lot of people, and especially the foundationalists, but I think when you lean into constructivism and really take the time to understand it, it becomes evident that agency really becomes possible.
Spencer A. McWilliams: Yeah. Yeah. It's only in a place where there's no fixed truths is there room for us to grow and develop and evolve and solve our problems.
Sara Wilson: Yeah, yeah, yeah, for sure. Now, in your paper, “The Sacred Way of Liberal Arts”, you employ this religious metaphor, idolatry, which arises from our failure to appreciate our knowledge as a human invention that can only represent reality but cannot be reality. What is the importance of epistemic humility and perhaps embracing obscurity and paradox when it comes to informing conceptions of self and contributing to happiness and wellbeing?
Spencer A. McWilliams: Well, as we've been saying, it's probably most useful to regard self as a social construct, a convention that society finds useful, reading something about it recently that was talking about how society creates this notion that you are something in there and then it holds that thing responsible for what it does. So it's kind of a little paradox. So, remind me what the question was here.
Sara Wilson: It was an elaboration on this term idolatry as it relates to a therapeutic context.
Spencer A. McWilliams: Okay. Yeah, yeah. So you're asking about what the benefit is to us of having this open-minded view about the world, that it gives us an opportunity to grow and develop and then gives us an opportunity to make changes. And it also gives us an opportunity to move beyond being stuck in the past, stuck in the past of our own experience growing up in life and the past of human beings. And there's, sorry, I had a quote I was going to mention, but it slipped my mind. That's what happens when you get to be my age, you have that to look forward to.
Sara Wilson: Yeah. Well, I mean we talked about this a good amount, but all of this certainly contributes to a rich philosophical discourse surrounding truth, so your papers “Truth as Trophy” and “Who Do You Think You Are?” inquire about the origins and validity of the term truth? Could you share your conclusions with our audience? And also how might reconceptualizing what truth means inform our approach to psychological dysfunction and our personal relationship to negative thoughts?
Spencer A. McWilliams: Well, first of all, I would make it clear that the word truth is a judgment. Truth or falsity is a judgment that human beings make of a statement that another human being made. Okay? So truth only has to do with sentences that we speak or sentences that we write. That is whether someone agrees with it or not, because again, there's no way to find that separate way of asking, this idea of true. So I think if you look at science, you see that science is an evolving process of people coming up with sentences and theories that they find useful in making sense out of their study of the field. And what happens is that if enough people begin to find that theory or that perspective useful, then pretty soon the society of scientists in that field are going to come along to adopt that theory as being the dominant theory.
So they will say that it's the truth. That's what the term in my paper, “Truth as Trophy”, that it's the award that we give to a theory or concept that someone has come up with that we can't find a way to refute, for now. Okay? But if you look at the history of science or history of human knowledge, eventually every theory has holes in it, and then you have a scientific revolution where somebody comes up with a new theory and people are going to live in that for a while. And that's the way that we humans can operate, just to keep evolving our ideas and our way of making sense out of things, but to not get stuck on the idea that because we've come up with something that everybody agrees upon, that now we've hit on a universal truth just about the world itself.
Sara Wilson: Now, how might a person integrate this line of thought within their personal relationship to their mind or to their self or who they think their self is or negative thoughts?
Spencer A. McWilliams: Well, I think first of all, it's useful to be open to the awareness that the self is something that evolves over time, over the course of a lifetime. The best book I like, my favorite book on that, is by a guy who was at Harvard College of Education, see if I can pull up his name. Robert Kegan, his book is called “The Evolving Self”, and he talks about how we can evolve our understanding of ourself in the world and we can get it to a point where it seems to be working for us, we know our way around town, we know our role in relation to other people, we know how to solve problems and things like that. So we're happy, we're content, and we're happy to stay in this perspective. And about half the population is basically in that perspective, it's, again, that sort of ethnocentric belongingness to their group kind of point of view. But we can evolve beyond that, if we can step back from the way that our experience has been in the world and begin to see that there are other ways that people live in the world, there are other possibilities. I know for me, one of the big experiences in my life was I grew up in a relatively small city in Northern Colorado. The high school sponsored a spring break educational tour, and I managed to talk my folks into letting me go on it and saving up enough money to do it. And we went to Chicago, we went to New York City, we went to Washington DC, we went to, what's it down in Virginia? It's amazing how many of these common words slip out of my memory, Williamsburg.
And when I went back to my hometown, it just didn't look the same. I mean I had met people who never even heard of my hometown. Who can imagine that? So I think when we have experiences where we get outside of our comfort zones and outside of where we have been all of our lives and interact with other people, we begin to see that there are more options and more possibilities, and we can use that to evolve our sense of self. And as somebody who has certain strengths and certain capabilities to be effective in the world. And then beyond that, eventually at some point really seeing the total relativity of all of the ways of being, ways of life that people have, and begin to see that there's not one that's better than the other, they're just different. And we can treat everybody in the world the same way we would treat our own family because we see that we are connected with them. Now, that's a hard place to get, and Kegan thinks that probably only a few people get to that, maybe 10% of the population gets to the point where they can see things in that way. And probably only past the age of 40 or so when we evolve that far, where we can continually evolve throughout our lives, the idea that there's not one way of doing things and the way that we grew up is the correct one.
Sara Wilson: Yeah. This is great. Now, throughout this interview, we've been leaning a lot into this notion of the dependency and the emptiness of self, but I did want to touch on the flip side of that. In your paper, “Inherent Self, Invented Self, Empty Self”, you do acknowledge that many psychotherapeutic approaches describe human development in terms of an identity at one stage, which evolves into an identity at the next stage. And so in such Buddhist approaches, which emphasize seeing through the illusion of an inherent self, require a prior development of an effective sense of self structure as some foundation. So keep this in mind, how should we view the self in a therapeutic context?
Spencer A. McWilliams: Well, I think, and I've come to this late in my career, I think that the developmental psychologists, they like people who do lifespan development, are on the same thing. Now, people are sort of familiar with Piaget and he has the concrete operations and formal operations and those kinds of things. Well, Piaget was a constructivist and Piaget's ideas, some people who have studied him in the original French have said that he was a constructivist by saying that what the child is doing is organizing their experience. In the US, we have a tendency to say it's organizing the environment, that it's the environment that they're making sense of, rather than that it's their experience. But there are these consistent phases or steps in development that Maslow, Loevinger, other developmental psychologists, Ken Wilbur has integrated and synthesized all of them. He's an independent scholar that knows everything about everything and makes sense of it.
But I think it's useful for us to be aware that we need to understand the stage of evolution that is perceived in. So for example, if a person is in that really almost childhood stage where they're primarily focused on power and safety and security and getting things for themselves and tit for tat responses to people that get in their way and things like that, there are a few adults around who behave like that. Some of them are in the news a lot, and that's almost like dealing with someone with a sociopathic personality. They haven't gotten to a point where they've evolved into seeing themselves as connected with others, which is where we get into, I think high school as the place in our lives, that adolescent time, we want to make sure that we fit in, we get along, we belong, we identify with our school or our church or whatever it is.
Okay. Someone who's in that stage of development, they're going to have a very strong sense of relationship, who they are as a relationship. They'll probably think of themselves as a parent or sibling or what their job is or something like that. So, working with someone in that perspective, you need to be aware of that and be conscious of them. If a person is in, or probably many people who would go into therapy would be in that next stage where they're finding out that there's an individuality to themselves, finding out that they can still be members of their family, but they can be off doing something that's different. They're, again, developing their own skills and that's what comes from getting a good education and evolving that stage of evolution we are in. And then they can evolve beyond that to the constructivist or postmodern view where they can look back on all of those skills they developed and all of those characteristics as being ways that they could make sense of the world and make it meaningful.
But they're within a context of and the idea that we don't know what the final answer is, before it even makes sense to even ask questions about the final answer. So those stages of evolution, I'm coming to see, is more and more important in working with people therapeutically, knowing where a person is coming from, because that's how we create the sense of identity as being different in each of these stages. Where our identity is with our group, our identity is with my own ideas and beliefs in life. My identity is as part of the group, part of the larger group, part of the worldwide group.
Sara Wilson: So, as we're coming to a close with our conversation, I was just wondering if there is anything else you'd like to share with our audience?
Spencer A. McWilliams: Well, I think about this in terms of the writing that I've done over the last 20 years, and you referred to, that in my writing, what I'm trying to do, I'm very much a scholar. I have lots and lots of citations and a big, long, long set of references. But for me, those references that I refer to in the body of the paper are ways of pointing a direction for someone who might be reading, and saying, "If you want to know more about this, here's where you should find it." Sort of like finding the path to different reasonings. So don't just take what I've said, but if it's piqued your interest, here's where you can really find out more about it. And I would say that what I would emphasize in life is to continue finding out more about things, and ourselves too, come to know ourself and to see the rigidities and all the problems in the way that we come to develop this hardened notion of who we are, begin to let go of some of these ways of being. And it's a lifelong process, and I know that when I was in my late 30s and I started doing meditation, working with Joko, she was saying that after about 20 years of sitting, you'll begin to get some benefit from it. I thought, “Oh my God, I don't have time for that.” Well, that's 40 years ago now and I'm still just beginning to get what the benefit is of it. So it's something that we continue throughout our entire lives if we're open to it and it gives us a lot more freedom.
Sara Wilson: Well, thank you so much for joining us today. This was such a cool conversation and I really think that every person, no matter their discipline, can learn something really valuable from your practice. So thank you.
Spencer A. McWilliams: Well, thank you very much for inviting me here.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Social Psychologist Sharon Goto
Sharon Goto, Ph.D. is a Professor of Psychological Science and Asian American Studies at Pomona College. She specializes in Asian American psychology, cross-cultural psychology and issues of intergroup relations.
Kaylin Ong: Thank you today for joining us for this installment of the Seattle Psychiatrist Interview series. I'm Kaylin Ong, an undergraduate student at Pomona College, and 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 Dr. Sharon Goto, Professor of Psychological Science and Asian-American Studies at Pomona College. Dr. Goto has a PhD in social psychology with minors in industrial and organizational psychology and quantitative psychology, and has also published several papers within the field of Asian American and cross-cultural psychology.
So before we get started, can you please let us know a little bit more about yourself and what made you interested in studying Asian-American psychology?
Sharon Goto: Thanks, Kaylin. So happy to be here. I’ve taught at Pomona College in Asian American psychology and Asian American studies and psychological science department for over 25 years. Currently, I am chairing the Department of Asian American Studies, and I have been teaching a class called Asian American Psychology. That is one of my favorite classes to teach along with some other classes. It's been really fun to see how the field has changed across the years. I also do research and my research is generally trying to understand how bicultural individuals navigate different cultural worlds, different racial worlds, and trying to understand the psychological processes related to that. And in addition to that, I guess, let's see, my pronouns are she/her, and I have a lovely family, my husband and two daughters who are currently home right now back from college and my two adorable stray cats. So happy to be here.
Kaylin Ong: Yeah, thank you so much. So your research explores the prominent role that culture plays in self-construal. Can you explain what this means and talk about some ways you studied this in the lab setting?
Sharon Goto: Yeah, so self-construal is a way that people kind of define or think about themselves. So it's a series of different theories about that and there's been a lot of empirical work on it. And it's slightly different from the way that Freud, for example, would learn about them, the self and just sort of through introspective techniques, it's more empirically driven. So there are some theories that talk about the difference between the ought self, the ideal self, the actual self. There are some distinctions between the public self, the private self. What I'm really interested in is the differences in the distinction between the interdependent self and the independent self. In some ways that I studied or has been studied and I study as well is we look at, for example, just simple self-report, for example.
So, you could ask a person to measure the level of interdependent self-construal. How important is it to include other people when you're trying to make a decision for independent self-construal? It's really important for me to make decisions on my own, agree, disagree, how much agree to that. So that would be different ways to tap those using self-report measures.
And the reason why it's such a big deal to look at interdependent independent self-construal when you're looking at cross-cultural research is because it actually predicts a lot of variance in behavior and attitude. So it really turns out to be super important when you're looking internationally, globally as well as within a particular culture. And there are also more experimental ways to understand self-construal, like using electrophysiological measures and trying to understand the way the brain is processing information differently based on their cultural orientation of interdependent versus independent self-construal. So it's not alone. There are many people who have come before me. It's really, I think, a super interesting construct that has really stood the test of time.
Kaylin Ong: Yeah, that sounds really interesting. I think cross-cultural psychology is such an interesting field and has so much depth. So yeah, thank you so much for sharing. So on that, cross-cultural research often uses the phrase collectivist versus individualist to talk about, for example, cultural differences. Can you explain what these two terms mean and also give some examples of how this might manifest itself in human behaviors and attitudes?
Sharon Goto: Yeah, so if you're not familiar with the terms independent and independent self-construal, you might be familiar with the terms collectivism and individualism. So that's probably a more well known, maybe more interdisciplinary approach. It was probably one of the entrees into psychology about how culture was first studied. And it does look at the amount of importance the group carries over the individual. So collectivism is more cultural level and individualism is more cultural level or aggregates of people level constructs. So groups of people can be more collectivist in nature, more group oriented or more individualistic in nature or more self-oriented or individually driven. And it turns out some important things are, for example, the way that rewards are distributed. It's very interesting. It varies very much by collectivists versus individual orientation, for example, in terms of how people think reward distribution is fair or not.
So, for example, collectivists might be very happy if rewards are distributed equally within your group. So, everyone gets $5 and that feels good. Versus individualists might tend to be more what's called equity based. So, they want to earn their money, so they're really okay if some people that do more work get $10 and other people that don't do the work get $0. So, it's a different way of distributing and a different way of really defining what is fair. And it's really interesting that the very notion of what is fair is actually culturally driven and understood by collectivism versus individualism, for example.
Kaylin Ong: Thank you. I had a quick question. So collectivist versus individualist. I think a lot of the times I've associated, for example, collectivism with East Asian cultures or just eastern cultures in general, and then Western cultures are a little bit more individualist oriented. Would that be correct or accurate to say?
Sharon Goto: Yeah, so there have been a lot of studies that have done, starting with Hofstede’s original studies, looking at the amount of collectivism versus the amount of individualism in different nations. And you're exactly right. So East Asian cultures tend to be more collectivists and less individualistic. And Western European, North American cultures tend to be more individualistic and actually more individualistic than basically the entire world. So very much outliers. And I do want to say that although it's important to understand the idea of individualism and collectivism at the aggregate level, there's analogous to interdependent and independent self-construal at the individual level. So collectivism tends to be comprised of people that have high interdependent self-construal individualism tends to be comprised of people that have high independent self-construal. But it's also really important that you have that distinction because just because you're in North America doesn't mean that you're necessarily individualistic. You could have very strong interdependent self-construal tendencies as well. Does that make sense? So it really allows for that's not just so essentialized that you really do have a broad representation.
Kaylin Ong: Oh, thanks for the clarification. Okay, next question. So, one of your most recent publications focuses on cultural priming effects on the N400. Can you explain for our listeners what the N400 is and why it's been an essential component of your research?
Sharon Goto: Yeah, so the N400 is like a time locked event related potential. So basically what you do is you attach these fancy electrophysiological equipment to the scalp, which people have probably seen. And based on surface level activity, you have some insight in terms of the brain processing, the neural processing that's going on. So basically, what we do is show you stimuli and about 400 milliseconds afterwards, you are getting some gauge of semantic processing, which is the amount of sense making a person is doing.
So, for example, if I were to tell you ‘The boy gave his dog a bone.’ Okay, that makes good sense. Versus, ‘the boy gave his dog a bugle.’ That's a little bit more confusing, and there's probably a little bit more processing that's going on to make sense of that. So it turns out that the semantic processing of information can vary by culture, and it's a more dynamic way to understand cultural differences, particularly for example of bicultural people who might move in and out of different cultural frames. It's also very sensitive, and that's why we have tended to use it in our lab.
Kaylin Ong: Right. That's very, very interesting. So in your lab, do you collaborate with the neuroscience department or neuroscience students, for example?
Sharon Goto: Yes, absolutely. So our lab is called the Cultural Race and Brain Lab, and I'm one of the professors and also Professor Richard Lewis who has an appointment in neuroscience. And our students are a combination of people that are in Asian American studies and psychological science and in neuroscience, all interested in culture and the brain.
Kaylin Ong: Oh, great, thank you. So, you've briefly studied the role of discrimination on the mental health of students of color, and as a professor with a background in organizational psychology, how do you see your findings as being relevant today?
Sharon Goto: Yeah, that was an interesting sort of study that I had done with a student actually as a senior thesis at Pomona College. Pomona College students are amazing. So it's been known that discrimination is a stressor and it leads to negative mental health outcomes. And what we wanted to do is we wanted to look at the mechanism for that. So we were wondering if one of the mechanisms of being in a stressful organizational setting, so either educational or workplace setting, if that would lead to more psychological distress. And if the mechanism or the reason why that might be the case would be what's called depletion of self-control.
So, the idea is self-control. There is a limited amount of self-control we have. It takes energy to maintain our self psychologically and physiologically. And whenever there's a stressor, it kind of depletes it a little bit, and one of those stressors could be consistently being in a hostile environment or an environment where you have to be wary. And what we showed empirically is that, yes, for students of color being in a psychologically stressful environment, for example, a classroom setting in a predominantly White institution can lead to psychological distress. And the mechanism for that is depletion of self-control.
So, self-control is really interesting because you could also learn to build it up a muscle, you could exercise it, but at a particular time you're using a lot of energy, if that makes sense and that's why you have the depletion.
Kaylin Ong: That makes a lot of sense.
Sharon Goto: So yeah, I think that's particularly relevant now with the racial tensions and it's definitely whether you're in education in the classroom or in the workplace or whoever it might be, if you're in a setting where you're thinking about these issues, you're worried about issues related to discrimination, then it's probably taking a little bit of a mental toll and cumulatively it could have a negative effect on your psychological distress.
Kaylin Ong: And the next question I think is a little bit related to that. So why is cultural diversity important in the workplace setting? And have you done any sort of research on this topic as well?
Sharon Goto: Yeah, so that's one of the reasons that I really got into this area, just looking at the demographics, I understand that workforce diversity, just diversity in our society in general is only going to increase. And to pretend it's not is just probably not the most productive way to go. So, counter to what some of the recent Supreme Court decisions have been that have made decisions against the role of affirmative action, there's a really long-standing tradition of empirical tradition: understanding that diverse work groups do better in many ways. They come up with more creative solutions. If you have enough time to work together, people are very satisfied with their interaction within a diverse setting. There's really fantastic outcomes that come to play. So it's really, really super important.
And although I haven't done research looking at, for example, diversity and group performance for example, I do indirectly look at it because I'm looking at how bicultural individuals might interact or be in a workplace with culturally different or racially different others. And I'm trying to work from a model where it's not necessarily an assimilationist model. So, where you have to become completely like those people in the workplace that you're seeing, shed your language, shed your cultural values and shed your cultural behaviors. But rather what are ways that those cultural differences benefit the workplace and what are ways that being different from others can be enhancing and not self depleting? So that's what I do.
Kaylin Ong: I think especially as a student, and obviously Pomona College is a very liberal institution and it's very, very diverse and I feel very grateful to be surrounded by just such a diverse crowd and so many diverse students of color. But yeah, I think just because of the affirmative action and just the recent events, I mean, I guess surrounding that and the dialogue, I feel like it's particularly relevant today for students.
Sharon Goto: Yeah, it's really interesting. I mean, there really is a trickle-down effect in terms of the way people think about each other and what their goals are. And so I'm really hoping that this time is a time where people just really keep the conversations and communications going.
Kaylin Ong: So it's clear that the COVID-19 pandemic has had profound impacts on mental health across the globe and research states that Asian Americans in particular have been affected by the pandemic more than other racial groups. And so I wanted to ask you, in what ways have they been affected more and how would you potentially explain this finding?
Sharon Goto: Yeah, so I am a little bit less interested in the comparative experiences of the COVID pandemic across different groups, but I have seen a lot of research that was looking at the effects of the pandemic on Asian Americans in particular. And you really do see faring worse during and after the pandemic. So it's really due to health related stressors, economic related stressors, social stressors, like racial discrimination and the pandemic, that physiological, everything is a stressor that has affected, in particular, some people within the Asian American community more than others. So I think those are just things that need to be looked at more carefully.
Kaylin Ong: I think the social determinants of health in particular are very, very interesting and sometimes they get overlooked. And so I also wanted to ask a follow-up question. Do you consider, for example, historical trauma at all and in your research, or I guess what is your take on that in implementing a broader scope of history and the historical traumas or generational traumas that Asian Americans have faced?
Sharon Goto: Yeah, I think that's something that is really so important. It's actually one of the reasons why I got into this area in the first place. I was really taken by my Asian American psych class as an undergrad that Stanley Sue taught and really wondering within my own personal family, what would be the negative impacts of internment, which my parents had both faced in terms of long-term consequences.
I haven't looked at it directly as a research question, but some people have Donna Nagata and University of Michigan, and I think empirically you're seeing it more and more in research. I would love to adopt some frameworks and some theories about it. What's really interesting is we just finished a study looking at older adults and help seeking within the Asian American community. So it's a community based sample. We're wondering about how the COVID related incidents, both due to the virus and also due to increased racial discrimination and violence really has affected older adults, and in turn, whether or not and how they help seek or not.
What was really interesting is yes, so there was some reluctance, some stigma as you might imagine, but also people would come up to us after and they would say things like, "Our community," or, "I've been through so much before that this..." They wouldn't say is nothing, but, "I know I can make it through this." So it was really personal testimony and resiliency that I wish that... Maybe it will be our next study. I thought it was so very interesting. It wasn't outside the kind of questions we're asking, but you could really see it as the strength of the community.
Kaylin Ong: No, I think that's a very, very interesting topic because I'm also Asian American and my grandparents, they lived through the Great Depression, they're very old now. But they were saying very similar things where it's like they've been through a lot and they're very, very resilient and it's just unlike anything our generation has experienced. And so that difference in generational knowledge and generational experience and also help seeking behavior and health seeking behavior is very, very interesting to me just because I feel like there is a fine line between older individuals who are reluctant to seek help even when they may need it. And so it's just that line between they're very resilient, but at the same time, I feel like more outreach maybe needs to be done, especially because the pandemic has affected older populations, especially my grandparents and my great aunts and uncles who are still around. So yeah, it's very personal, but very interesting.
Sharon Goto: Yeah, yeah, very personal, very interesting and really super important. So there's more people that do this kind of work. We always need more people to do this kind of work.
Kaylin Ong: Yeah, it's very, very interesting to me. So my next follow up question, it's pretty general. What can be done to potentially address the declining mental health of Asian Americans throughout the pandemic?
Sharon Goto: I mean, think it's about making sure that people have the resources that they need. One thing that we did find is that the older Asian Americans were likely to seek help from friends and family, surprisingly equally likely from law enforcement, just in case there were race-based situations, but much less so statistically, significantly less so for mental health resources. So trying to get the mental health resource piece together, it's been long standing in the community based on stigmatization and access and that sort of thing, but particularly stronger now. And what's interesting in our data, it suggests that when people are thinking about seeking help, the collectivism piece comes back. So thinking about how I am seeking help now from friends and family will help share my experiences so they will know what happens.
So the old adults in my sample, they were really thinking about younger people too, setting a good example. They're wondering if other people are going to be available and willing to listen. They're wondering about whether the police are going to be available, if they ask, reach out. They're also asking questions about the social norm around help seeking. That was also really big. So really looking differently than other samples that are less probably interdependent self-construal would probably look at our sample, which you would guess was very normatively driven, very collectively driven. So I think what can be done would be to do things like attack the problem of stigmatization, show role models of people who have sought help from mental health and have done better.
I remember in graduate school, for me, mental health help seeking was not something, not a tradition in my family that we really talked about. I remember there was a graduate student that was a little bit older than me that I really looked up to, was profoundly smart, had their act together so much, and then she would talk about how she would see her therapist, and I thought, "Ah, maybe that's the ticket."
So role modeling, more communication, more availability, more help to access the resources if they want to seek mental health. That would be a big step: resources. That would be a big step I think of in terms of, right, you could do now, right?
Kaylin Ong: Yeah, I think the Asian American community especially, there is a mental health stigma and asking for help and reaching out for help. It's definitely a barrier. And it comes from a lot of personal experience, and I'm sure you've had very similar experiences as well. And yeah, I think it's cool that it's this collective experience that we have and it's something that we can overcome together through collective help and just an increase in resources, like you said.
Sharon Goto: Yeah, absolutely. You could probably link it to one of the, again, once again, that some of the collectivist values of not wanting to be a burden on other people. If you think about a really tight group, then you know, want to try to hold your own, other people don't have to worry about you. And so, it is a little bit driven by that.
Kaylin Ong: And then moving on to our next question. So before the pandemic, what were the biggest mental health challenges typically faced by Asian Americans?
Sharon Goto: Before the pandemic, I think you would hear about differences or difficulties in acculturation or adjustment, immigration adjustment or acculturation adjustment, discrimination, racial discrimination, and also stereotyping. So having to live with one way or the other, the model minority stereotype is a big stressor on the community. So, I think those were things that would appear in the literature before the pandemic.
Kaylin Ong: Yeah. Could you elaborate a little bit more on the model minority myth for listeners who haven't really heard of that term?
Sharon Goto: Yeah. So, the model minority myth stereotype is the idea that Asian Americans, and it was originally with East Asian Americans, but also now extended to South Asian, Southeast Asian. It just is a really strong stereotype, very persistent. They are the model. They don't need anything. There's something about their culture that's special. They work hard, they don't complain. They do their work, they don't need any extra resources, they don't need any help. They figure it out themselves and they do a good job.
So on the surface, the model minority myth sounds really fantastic. "Oh, yes, I am a part of a model group." But there’s really a little bit more difficult of a read in it. So if you dig down a little bit deeper and you see when the stereotypes started to occur, I think it's not an accident. And many others think it's not an accident that it started to be more popular during the civil rights movement. So when other groups were really asking for more justice for them, so African Americans and Chicanx populations were really asking for more justice for their own situation, then, then popular media, politicians, et cetera, were saying things like, "Well, we don't need to change our structure. Our institutions look at the Asian Americans. They're doing really well." And that's really the beginning.
So, it really did then, and it does now, it really creates a wedge with using Asian Americans as a wedge group to divide people of color. Does that make sense? So, to deny that racism exists in our institutions.
Kaylin Ong: Right. And I think that goes a little bit back to what we were talking about with affirmative action. I think there's a very interesting stratification between different minority groups now, especially Asian Americans sort of being grouped with White Americans as opposed to all other minority groups in higher education. And I think that has so many implications right now. And so it's interesting to see how things come back and things are very interconnected right now.
Sharon Goto: Yeah, I think that's a really good point. So yeah, with affirmative action stuff now in educational settings, you have to, and it's really been a rough place for Asian Americans to continue to build their coalition among Asian Americans, because yeah, the umbrella of Asian Americans are very diverse, different ethnicities, different languages, different experiences within educational settings. And so I think particularly if you think about in workplace settings, extending that to workplace settings, and all of a sudden it's all gone in terms of the model minority and everybody and needs a little affirmative action. I know that I benefited very much from some mentorship that was based on race. Yeah.
Kaylin Ong: Very interesting issues.
Sharon Goto: Yes, yes.
Kaylin Ong: All right, so just wrapping up, do you have any other advice or anything else you'd like to share with our listeners today?
Sharon Goto: Well, Kaylin, I wanted to thank you for really doing your research, asking really super good questions and bringing this important topic out to people that might be listening or thinking about these issues or maybe wanting to know a little bit more, benefiting from a little bit more. So thank you for that. My message would be that our communities are really rich. There's a lot of strength in our communities and in our families. And so I think the best thing during hard times would be to really lean into the strengths.
So if you need help from people that have always been there for you, that would be the time also to ask for some assistance. And the flip side of the coin is if you're in a position where you're seeing someone else and they may not be asking you explicitly, but you think that maybe you could share some stuff, some time just listening, maybe some advice, some resources, or just really just being there for someone. I think that would be my best advice. Very simple, every day things, just the humanity that we have for each other, I think would be, and really relying on our cultural strengths, would be the best advice.
Kaylin Ong: Yeah. Thank you so much. Yeah. And on that, thank you so much just for being willing to answer my questions and sharing your knowledge. And I think it's so important to be generous with our time and share stories and listen and whatnot. So yeah, thank you for joining me today, and I wish you the best in the future.
Sharon Goto: And right back at you. Thank you so much. Appreciate it.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Daniel Keating
Daniel Keating, Ph.D. is a Professor of Psychology, Psychiatry, and Pediatrics at the University of Michigan, Ann Arbor. He specializes in adolescent development and adolescent psychology.
Mai Tran: Awesome. Okay. Hi, everybody. Thank you for joining us today for another interview in our Seattle Psychiatrist Interview series. My name is Mai and I'm a research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. Today, I'd like to welcome Dr. Daniel Keating.
Dr. Daniel Keating is a professor of psychology, psychiatry, and pediatrics at University of Michigan, Ann Arbor. And Dr. Keating is an expert in developmental psychology and he specifically focuses on the integration of knowledge on developmental processes, social factors, and population patterns in developmental health and how they affect individual and population health.
He's made significant contributions to research in the field and some recent academic articles that include "Cognition in adolescence and the transition to adulthood", "The Kids Are Not All Right: Adolescent Sadness, Hopelessness, and Suicidality are Skyrocketing. What to do?" And his book "Born Anxious: The Lifelong Impact of Early Life Adversity - and How to Break the Cycle."
All right. So before we get started today, can you please tell us a little bit about yourself and why you initially became interested in studying developmental psychology?
Daniel Keating: Sure. So it's a long story, but I'll condense it. I did my graduate work, my PhD, at Johns Hopkins. And the work that I was doing at that time was really focused more on individual differences rather than developmental differences. But the focus was on early precocity, that is to say individuals who were advanced in during their early adolescence in terms of their math and scientific expertise and measured in a variety of ways. And so there was a developmental component to that obviously in terms of how people came to those things. There was also one of the giants in the field of developmental psychology was also was a professor at Hopkins when I was there, Mary Ainsworth, who is responsible for a lot of the work that's been done on attachment and the sequelae of attachment from early childhood. So I managed to come by some of that knowledge through her being on the faculty.
My first tenured position was at the Institute of Child Development at the University of Minnesota and increasingly began to focus on a variety of things having to do with how the differences develop as opposed to just that they exist and how we might deal with them.
And then I subsequently moved to the University of Toronto and was invited then somewhat out of the blue to take on the task of setting up one of their networks in a think tank called the Canadian Institute for Advanced Research. And it was on human development and it went across the board from sort of molecular and single-cell neuroscience all the way through anthropology, sociology, and so forth.
And then that really sort of provoked my interest in how both, individually, how the things develop, but also in terms of the population impact of a variety of things, focusing as I think the evidence led us to look at what are the circumstances that lead some individuals to thrive and other individuals to struggle. What are the kinds of things that are going on? And, of course, in that context, early life adversity plays a major role. So that's the very thumbnail version.
Mai Tran: Yeah. And I also recall reading some of that in your book "Born Anxious."
Daniel Keating: Right.
Mai Tran: And I'm really interested in one of the concepts that you kind of laid out in the book, social epigenetics, and the links to stress dysregulation. So can you explain what these are to our audience in layman terms?
Daniel Keating: Sure. So let me break it apart a little bit. So epigenetics is a relatively new field of study, certainly as it bears on behavior. And basically, the idea there is that of course we all know that the DNA you get at the moment of conception is the DNA blueprint that you'll carry throughout your lifespan, that doesn't change. But what does change is when we take a closer look at how genes function, and among the things that how genes work, basically, is that they're, if you think of them as little manufacturing centers and they're producing certain things that they're designed to produce. All of them have a region, it's called a number of things, the promoter region or the regulatory region of the gene. And what that does is in a sense, whatever it is that that gene does, the promoter region tells us when to do it, how much to do it, when to turn off, when to turn on, et cetera.
That portion of the gene is malleable. It can be affected by a variety of different things. It can be changed by physical exposures like toxic exposures. One of the best documented is in terms of the impact of cigarette smoking makes a lot of epigenetic changes that are thought to play a significant role in the development of cancer, for example. But the breakthrough from our point of view is the other term, social. And basically what was emerging and discovered and since has exploded is in really around 1999, 2000, was that first with animal studies and later with human studies, it turns out that social experiences, especially stressful experiences also cause epigenetic changes.
And some of the most important of those, we don't know all of them for sure by now, but some of the most important of them, earliest documented and most frequently documented are changes to the stress regulation system, which is basically what causes our stress system to respond, how much does it respond, how long does it take to go back to baseline and so forth. And so obviously, I think we all know that a stress system is essential for survival. We need to have it, but when it gets overly engaged, often because of stress exposure either in infancy or even in the womb, that then can make an epigenetic change that can carry forward in terms of how that stress system works.
Mai Tran: Right. That's really interesting. And I am sure that a lot of people would be curious to know as what specifically are some of the most common environmental factors that can cause changes to your epigenetics?
Daniel Keating: Right. Well, as I say, the stress response and the stress influence on this is the one that's, at this point, the best understood, although it's still not by far completely understood. But basically what we're looking at there is exposure to stress in a variety of ways. And it depends, of course, on the age of the organism.
So in the womb it's relatively straightforward in the sense is that if for whatever reasons the mother to be is experiencing high levels of stress or adversity, all the way from worries about sort of getting the material necessities of life or shelter, food, that kind of thing, or more seriously if they're in an abusive relationship and have stress because of that. So kind of those as the extremes, those, if they are sufficient, or if the mother's response to them is sufficient, that it produces a level of cortisol, which is one of the main products in the stress response system, if that cortisol is at a sufficiently high level, it can break through the uterine barrier and enter into the womb. And if those circulating chemicals then include cortisol at a sufficiently high level, they can trigger the epigenetic changes in the fetus even before they're born. So that would be one pathway that happens.
After being born, the first year to two are the most sensitive periods. And stress can come in a variety of ways. It's largely around the absence or a dysfunctional nurturing of the infants. So if they're not being taken care of, whether it's in terms of meeting physical needs or meeting comforting, nurturing needs like being held and that sort of thing, that then can elevate the stress level as well.
And then as individuals get older, those are the most sensitive periods, but it can happen later as well. But basically what that does is set up the stress response system, that high stress during those critical periods, sets up a system whereby the organism learns, in a sense, biologically, that it's probably a not very safe world out there. It's a dangerous world out there. And so if you're going to survive in a dangerous world, what you want to do is to have a stress response system that's more like a hair trigger. Even things that most folks might see as neutral, they would regard as dangerous and do that and respond excessively. And then excessive cortisol has a lot of negative consequences behaviorally, health-wise, and so forth.
The other thing I just want to point out is that we often speak of it, and I try to avoid it, but it's not easy, is to think of this as a problem or a deficit or whatever. I think it's better to think of it as an adaptation to what the organism perceives as a dangerous environment. So if in fact you are in a highly dangerous environment, having that kind of quick trigger stress response and immediately engage in fight or flight is perhaps survival, helpful.
And it doesn't do a whole lot of good for your body, but it does in fact maybe keep you alive. So think of the predator in the bush or a tiger in the bush. If you're in an area that's relatively safe and all of a sudden it's invaded by new predators, organisms that respond quickly to that are more likely to survive than individuals who don't. And so we have to understand, although in our environment, that's typically not the kind of environment we're living in, but the system doesn't know that, and so it doesn't know where the stress is coming from. And so it's typically more problematic for individuals with that stress response dysregulation, even though it really is evolutionarily an adaptation to dangerous environments.
Mai Tran: Right. Yes, that's really interesting to hear. And speaking of that kind of stress adaptation, how would you describe what it feels like to experience that kind of constantly elevated stress response or as you called it in the book, a stress response system that is constantly locked on?
Daniel Keating: Right. So basically the experience of it is just an elevated version of what all of us experience at one time for another. So if we're all we're anxious about a big test coming up or we're fearful about something that's happened, we respond with... And one of the adaptive purposes of cortisol is to activate your system. So it's actually in many ways beneficial. It focuses attention, it increases heart rate, lung capacity and all those other sorts of things that make it possible to react and to do stuff. In a system that is more or less locked on, not totally locked on, but sort of on a continuum, it's certainly more so. You have that experience a lot all the time. And so you're kind of on edge, nervous, agitated, concerned about things that may not really exist as dangerous to you or as problems or challenges for you, but you perceive them to be so.
And so it's important to recognize that, of course, once you've activated that, and it can be an internal activation, it doesn't have to be an external threat. And that is a lot of the anxiety disorder, you're activating a system that's actually not in response to some challenge in the real world. So if you're doing that a lot, you're constantly kind of on edge or restless or concerned, and the body doesn't know whether that stress response has been triggered by an internal thought or an external threat. It activates and then it causes these changes. So essentially you're looking for a flight, fight, or you're looking to run away, even though nothing particularly problematic is actually out there in the external environment to provoke it.
Mai Tran: Yeah. And I know that sometimes it can get pretty serious. So what do you think would be the short and long-term consequence of that?
Daniel Keating: Well, they're very similar in some ways in the sense that they're across the board. So it can have behavioral consequences. So you are quick to anger, you go into reactive cycle more readily than other individuals, which then certainly doesn't endear oneself to people around you because they can't predict your behavior, what's going to set you off. So there's a behavioral consequence, which is then because of the accumulation of various kinds of things, can cascade into various kinds of psychopathology, externalizing being kind of the excessive fight response or internalizing being the excessive flight response going inside or at another level of freeze response where you just don't react at all to anything because it seems too dangerous. So there's all those behavioral consequences, there's mental health consequences. And I think what has now started to enter the common understanding is that it has massive health consequences.
So individuals, some of the earliest studies, this is prior to epigenetics, but some of the earliest studies showed that the sort of fetal environment is predictive of cardiovascular risk in your fifties and sixties. So it is a lifespan kind of thing. We now understand that most of that is occurring not only, but largely through the stress response system. So one of the superb scientists in this area, Bruce McEwen, who passed away relatively recently, is responsible for a lot of that work and showing why it is at a stress response system that is dysregulated, remembering it's adaptive in some sense, but this kind of dysregulation provokes this kind of sustained cortisol level. And his term for that was "allostatic load". You're carrying too much around all the time. And as it turns out, cortisol can be toxic to almost all organs of the body.
So essentially it can show up in health as cardiovascular problems, as a whole host of other kinds of metabolic problems, and so forth. The link to cancer is not that clear. There's probably a link, but it's not as clearly strong because a lot of those come from exposures to carcinogens in one version or another, physical exposures. But a lot of these things that we, sort of at a population level, of course, we wouldn't know these things if we didn't look at populations. For a given individual who shows up with a medical problem at some point in their life, what the decades long history that brought them there, we don't know all of that. But if we look at populations, it gives us an idea of what kind of consequence or sets of consequences it has.
Mai Tran: Right. Yeah. And what do you think when the stress response becomes maladaptive to us, what do you think is a good way for us to receive help or help ourself in those situations?
Daniel Keating: Right. Well, for that, I think the place that we would be looking is into the literature on resilience in one way or another. And so the literature on resilience has mushroomed in recent years in parallel with our better understanding of trauma and stress and so forth.
And again, this is far from settled issues, but I think that if we look at the big picture, one of the big, and probably the most well-documented way to redirect that maladaptive pathway is through social connections. That is through positive social connections. And so that can come in many, many different forms. So it can come in childhood by sort of having a responsive extended family network who can help to deal with issues that are not working well, parent, child. And so that's one example where it can happen. We have good evidence that particularly in late adolescence and early adulthood, close friendships, intimate friendships, romantic relationships can have a similar effect, if the romantic or friendship partner is supportive and has the capability to help one learn how better to regulate these sorts of things.
And there's very good evidence of this in many ways, what is come to be known as a Romanian orphanage study. Looked at infants who, for a variety of political and economic issues at that time, there were many, many orphans who were not being cared for. There was large numbers of them, a government policy of promoting birth but not supporting families. And basically those individuals, those infants were in situations where basically the most minimal things to keep them alive were done. So they were provided with physical nourishment, food, water, milk, that kind of thing, but not much else. They were pretty much left unsupported or non-nurtured.
What we know is that those individuals, certainly up to about age one, maybe a little after that, if they were adopted from those circumstances, and there are some, it's a very tragic story, but individuals who were adopted into highly nurturing families by around age six or five or seven, looked pretty much normal. They didn't seem to have that stress dysregulation going on, or at least it wasn't affecting their behavior in major ways.
After that time, they pretty much do have lifelong consequences. So there's something about it becoming biologically embedded during sensitive periods that make it difficult to deal with. But the way that it does, those circumstances where it does work almost always involves some level of a change in the social network of closer affiliations and so forth. And so I think that stands out as the most well-documented one. Certainly in terms of particularly in childhood, things like parent-child therapy can help, right? To establish if there's enough capability for change to change what is a dysfunctional relationship in a direction that is encouraging of relational health, for example, can have a similar kind of effect, but that's of course a person to person thing as well. It's just guided person to person kinds of interactions.
The other one that stands out, and it goes by so many names, it's hard to give a comprehensive one, but it has aspects of the mindfulness approach, aspects of acquiring a set of purposes and goals and values and wanting to do some particular kind of thing. Having a focus can also be helpful and restorative in terms of giving some shape and substance to what it is that one might want to do.
Mai Tran: Right. Thank you. That was a very extensive answer. And now I'd like to move on to your recent Psychology Today article, which is really useful. It takes on the really crucial topic of dealing with adolescent sadness, hopelessness, and suicidality in a society that keeps on triggering these responses. You mentioned a misdirection to avoid is to ignore the existential stressors in favor of the seemingly more manageable phenomenon of screen time and social media when you were discussing the effects of issues like gun violence. So how do you think we can offer help as loved ones for adolescents and prevent this epidemic of adolescent sadness, hopelessness, suicidality as these situations keep on occurring and we don't really have control over it?
Daniel Keating: Right. So I think one of the things is that I largely think the high focus on social media as the cause of all of these mental health problems in teens is misdirected. Which is not to say that it might not be harmful for some individuals, but careful studies with large samples followed longitudinally essentially say that if there is an effect at all of screen time and social media, it's really kind of small. It's not that big a deal for most individuals. If you break it down a little bit further, it does look as though individuals who may have preexisting difficulties or challenges may accentuate it. On the other hand, there are individuals for whom it is beneficial, who might have difficulty maintaining positive relationships, and social media may well be a boon to them. And of course, we saw examples of that every day during the pandemic where teen peers are just enormously important and salient. We can see it in the brains to teens.
If you say, "No, that's it. You can't have any connection," it is likely to be very dangerous. So individuals who were in social groups and maintained them through a variety of uses of social media was beneficial. So I think we have to weigh that. And it's probably just for the vast majority of kids in the middle, it doesn't matter one way or the other, right? Particularly so, or at least we don't have any evidence that it does. So there may be effects, but the effects are relatively small. My problem with that view that it's the source of so many of the problems is that it blinds us to the fact that the other problems are much more important. So I've started to call this a stress pandemic. And it's not just in the US, it's not just teens. It really is a kind of universal phenomenon. And it's hard to ignore the fact that that's because so many things are going wrong, taking the US as our prime example, right?
Concerns about climate change... Now that will probably affect youth more because they understand they're going to bear the brunt of it than the folks who are making decisions, who are the CEOs of oil and gas companies or whatever. So they're going to suffer. So they're aware of that. Growing up, figuring out how to avoid active shooters is bizarre, right? That's just an enormous stressor. It is a huge stressor. And you can go on and on with other kinds of things. And so what I think we need to think about are at two distinct levels of this. And one of which we should focus on and we focus on a lot, but we don't focus on the second one.
The first one, Desmond Tutu, or at least a quote attributed Desmond Tutu, is that in addition to trying to scoop folks out and help them who are coming down the river with all sorts of problems and try to support them, we need to go upstream and find out why it's happening. And so the downstream stuff, I think, is what we are attempting to do when we do sort of psychological interventions, when we try to create therapeutic circumstances for individuals to figure out how to do it, and more broadly, sort of communicating effective techniques for coping with stress.
And of course, we know that some individuals are resilient without intervention, they wind up doing fine. The problem with relying only on that is that then we can tend to blame the individuals who don't succeed, who have had long histories of problems and stressors, and most of them without some kind of major support will not succeed. And so we don't want to blame them for that. We created the burden. We don't want to blame them for carrying the burden and not being able to overcome it on their own. And I think the techniques there, a lot of them are out of the resilience literature that we just talked about, which can be therapeutically supported by intervention, clinical, if it's serious enough by prevention programs or just general education. So you can have universal programs, targeted programs, clinical intervention programs, all of which are helpful, but it's not helpful enough to save everybody or the vast majority of people.
And the more folks who are coming downstream, succumbing to the stress, the less effective we are in terms of how many people we can help. The upstream problems are what we tend to ignore. Why have we created a world in which the stress level is so high? And I think if we fail to attend to that, it's a problem. That, by the way, in terms of the resilience literature about the second issue around purpose and goals and so forth, I do think that for youth, for teens and young adults and so forth, I do think that a lot of them have figured out that focusing on trying to change the big picture is actually beneficial individually. They feel efficacious, they connect with other people with similar views and so forth. And we often talk about adolescent risk-taking, which is another area that I'm working on now as a negative thing. And we're concerned about it when it is a health risk like reckless driving or substance abuse and that kind of thing.
But there's this tendency to be exploratory, to try new things, to push ahead, this also has positive sides. And that's what I think we need to encourage. So coping with the stress that you can't avoid, yes, but also breaking out of yourself and figuring out how do you create networks and alliances to address the upstream problems is something that I think is also a very valuable. We don't have as much evidence of that as we might like to have, but I think the evidence is trending in that direction.
Mai Tran: Yeah, I really appreciate your perspective on trying to address the issue at the roots instead of shifting blame on other miscellaneous issues that may or may not contribute to the problems.
Daniel Keating: Right.
Let me just mention, I do think on the social media side, let me just be clear. I think we do need to change how we're approaching social media. It's a proprietary, obviously, setup, so we don't have, from outside, much influence on it. But to the extent that the algorithms aggravate problems, I think we should be addressing that. I think we just shouldn't be laying it all off on that and ignoring the other big existential problems out there.
Mai Tran: Yeah, definitely. And I also know that you advocated in your article that psychologists should not, quote, unquote, "stay in their lane" by helping kids with the consequences and ignoring the roots of those existential stressors like you just mentioned. So how would you recommend for professionals in the field to take steps towards addressing the roots of these issues?
Daniel Keating: So I think there are a couple of ways. One is, in the individual therapeutic relationship, I think creating the space rather than focusing down on what the sort of immediate stimulus was for the problem the individual's experiencing is creating enough space for kids to open up about what it is that's truly worrying them. And that is happening. There are some relatively new therapeutic interventions that focus on climate fears, for example, or other kinds of things. And I think we need to create a space for individuals to be able to do that. And so I think that being more broader in the therapeutic content that we would entertain, I think is potentially a very helpful kind of thing. I think the other thing about not staying in the lane is essentially to say, "Well, my goal," and I'm working very hard at it as a therapist, "is to get as many kids out of that downstream before they go over the falls as I can." And that occupies me. That's what I'm doing.
And I think in many ways, that's great, but I think to not recognize what might be going on upstream and how do we try to deal with that because we are encroaching on other disciplines, we're encroaching on sociology or politics or economics or whatever, we should not be intimidated by that. We are, or claim to be, the experts in behavior and things that cause problems for individuals in their life. Well, let's look at that, right? Let's not be put to the sidelines when the sociologists get ahold of it. And I have lots of very good sociologist colleagues and whatnot. So it's not a matter of individuals, it's a matter of who owns what part of the problem. And our Canadian Institute for Advanced Research was designed specifically to overcome that so that we would have force and interdisciplinary dialogue across these many different dimensions and bring all of that expertise to bear in an integrated fashion.
So I think it's basically, it has an impact on the therapeutic relationship, but it also says we shouldn't just stay in our silos that even if we're doing great work in what we're doing, I think being aware of the fact that the problem is bigger than that and trying to speak to it when we can in whatever way we are capable of or comfortable with, I think is, er, not comfortable with, we should be uncomfortable, but that we should embrace that discomfort and deal with those and try to deal with those kinds of issues.
Another is I don't think we're ever going to be addressing successfully the issue of how racism affects youth in this country without being discomforted, right? It's not just an easygoing, "Oh, okay. Everything's rosy now." No, it's not. We need to figure out what's the impact of the legacy and how do we deal with it? And all of those problems that we're talking about have long legacies. I think we need to understand why and try to figure out how to address those as well and in concert with others who do different perspectives on the problem.
Mai Tran: Yeah, I definitely hope that we'll reach that point in the future soon. And you also just mentioned briefly that you've done research on adolescent risk-taking and risk-taking behaviors. And I also read in your recent review article, "Cognition in Adolescents and Transition into Adulthood", you also discussed the paradox of development versus the high mortality rates in adolescents. Can you explain why this may be the case and what efforts have been done to alleviate this problem?
Daniel Keating: Sure. Well, there are a number of different angles, different angles to it. I think that one of the things that we need to understand is that when it comes to health risk behavior, the big reason we're interested in it, of course, is not just the scientific part of it, but it is in the impact on everyday lives. And so we know that the rate of morbidity, significant illness, injury, and mortality is way higher than it should be based on how physiologically sound that period of life is. So in many ways, it's a pinnacle of physiological health. So that population particularly, so let's say in the second decade of life, is one where individuals have managed to get through exposures to all sorts of childhood illnesses and exposures and whatnot and have arrived at adolescence.
And we also know that in a variety of ways, different things begin to accumulate. So by the third decade and fourth decade and beyond of life, those things start to manifest. So it should be the healthiest period of time, but we know that the levels of morbidity and mortality are much higher than, in a sense, should be just based on the physiological aspects of that age group. The reason for that is what we've come to call behavioral misadventure, in one way or the other, that individuals are engaging behaviors that have a high risk for mortality or morbidity, and that we need to think about how we might... We want to understand the basis of it more. And we want to figure out how that helps inform our approach to trying to mitigate this problem.
Now, we do have some very good examples. There are ways of modifying population behavior in this age group. One of the best documented is in terms of graduated driver licensing programs, where most states now have a period of time where you gradually get to the point of being able to operate a motor vehicle under any circumstances and includes things like not having unrelated gears in the car or minors in the car, maybe some restrictions on nighttime driving or highway driving or other kinds of things.
There's been very, very good essentially econometric studies of that showing that over the last several decades that the rate of mortality attributable to teen driving has dropped in the 40% to 50% range. So it's not impossible. We can do that. Similar things, not just specifically aimed at teens, but in the population or the society as a whole are issues around smoking essentially by changing the attitude about smoking, right?
Now, I know a lot of youth are into vaping and so forth, but certainly the smoking rate has gone down dramatically. So the point here is that we can identify, or at least in some areas, we have been successful in identifying ways to mitigate that risk for adolescents. The big areas that remain in terms really of morbidity rather than mortality are things like substance use that can turn into substance of abuse or substance use disorders of one kind or another.
The unprotected sexual activity is another one that's a significant contributor to morbidity to various sexually transmitted diseases and infections. And part of that is we seem to be going in the wrong direction, or at least in some places. So there are state by state changes or differences in how sex education is handled in schools. So if we just look at that, there have been studies where we've looked at many different influences in terms of sex education and so forth. And if you put it on a continuum from, "The only thing we're going to talk about is abstinence, that's it. Just don't do it and therefore it will reduce it." So if everyone followed that, yes, that would reduce it, but it's not realistic. That is not how the world works, how human bodies work. So there's that end. And then the other end is a very comprehensive sex education with lots of information and even with community support to get easy and non-embarrassing access to condoms and so forth and so on.
So if we look at the state differences and what's taught in schools, which is not a massive influence, but it's a significant influence, the rates are dramatically different in the sense that the abstinence-only sex education leads to higher levels of unwanted teen pregnancies, higher levels of sexually transmitted diseases and infections, and a whole host of the attendant problems that go along with that. So there's an example of one where we kind of know the evidence is real clear what we should be doing. There's then political and sort of, for some individuals, moral opposition to that. But we definitely know that we have a massively positive impact on that health risk if we just said, "Comprehensive education is what we're going to always do and community support for safe sex."
Mai Tran: Yeah, I can recognize that that's definitely important, especially education-changing policies and community support. And so finally, would you like to share any additional messages or advice to our audience today?
Daniel Keating: Well, I think we've covered a lot of the territory. I think I would sum up by saying I would encourage folks on either side of the therapeutic relationship become more aware that it's not just an issue in your mind. If you're having problems, it's not just a problem in your mind, that it is rooted also in the body. We use the term biological embeddings going back a few decades now. And it really does, it gets embedded in your body. And so you need to think about how at both ends of that relationship, to what extent are those contributing factors? How are they operating? And what kinds of things do you want to do? So for example, I think that a shift towards more trauma-informed practices, a shift towards focusing on the key role of relational health as an adjunct to a specific mental health kind of thing is where we need to be going.
I think that we need to have a broader view and a more interdisciplinary view that brings together the biological, the psychological, and the social. And those directions I think will necessarily point us toward looking at the bigger picture that we need to think about changing if we want to create a more less stress inducing world, less of a stress epidemic. And by we, I mean encouraging youth to become involved in that. They're already more involved in many ways than middle-aged and older adults. But I think that encouraging that youthful effort to change things, I think, is really important.
It can be overwhelming and so just ignoring it, in a sense, in some ways is coping, but it's not the best kind of coping, it's a kind of an avoidance coping. And that it also then can have a very positive impact on the individual's sense of efficacy and self and meaningfulness. And we are already seeing that. I think the, that generation, Gen-Z generation in particular is much more involved in these kinds of issues and thinking about these issues. And we need to find ways to support that. I think in many ways the answers will come from that generation if we can support it or at least get out of the way of the kinds of things they might want to be trying to accomplish.
Mai Tran: Yeah, definitely. Thank you so much. That was really great advice. And if anything, I think we've managed to take away today that to be more aware of environmental risk factors, as you've mentioned extensively about that. So yeah, thank you so much. It was really lovely to finally meet you, and thank you for all the great nuggets of wisdom that you've offered us today. And I will definitely recommend everyone checking out Dr. Keating's research articles and his book "Born Anxious". And finally, thank you everyone for tuning in, and we'll see you all next time.
Daniel Keating: Thank you.
Mai Tran: Yeah, thank you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Certified Mental Performance Coach Lauren Becker Rubin
Lauren Becker Rubin is a Hall of Fame field hockey & lacrosse athlete at Brown University. She is an advisor to Haverford College’s varsity teams to ensure their mental health well-being as competitive athletes.
Jordan Denaver: Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Jordan Denaver, research intern at Seattle Anxiety Specialist. I'd like to welcome Lauren Becker Rubin. Ms. Becker Rubin is a certified mental performance coach who works closely with Haverford College's varsity teams. She also works with collegiate and high school teams as well as individual athletes. Before we get started, can you please tell me a little bit more about yourself, any sports that you may have played that made you interested in studying mental performance?
Lauren Becker Rubin: Absolutely. Good morning and thanks so much for having me. I've been involved in the mental performance space for about 30 plus years, and I think why I'm so passionate about it and why I love it so much is because I was absolutely the athlete that needed it. I was a collegiate athlete at Brown University. I played field hockey and lacrosse. Honestly, if you look at my athletic resume on paper, you would say, "Wow, you had a lot of success, a lot of awards, a lot of accomplishments." But my day-to-day didn't feel that way. I was often frustrated. I had a very hard time dealing with pressure and stress. I didn't feel like I was consistent, I wasn't meeting the big moments and I think mostly I had a really terrible relationship with losing.
I know most athletes don't like to lose, but I really took it personally. I would lock myself in my room after a bad game for hours in the dark and it would take me days to get over things, and it was just a super unhealthy relationship with how much pressure I put on myself, how I never thought I was good enough or never played well enough and just was really unhealthy, so this was 30, 35 years ago when I was in college. One day our lacrosse coach took us to the counseling center and we met with a psychologist who was dabbling in sports psych, which is pretty rare for the 35 years ago - it wasn't as common. A light bulb went on for me and it flipped a switch. I was like, "Wow, this could really help me and it could make me feel a lot better." And it did help me a little bit.
As an athlete, I found it late. That was my junior year, but it really changed my life. I just really got involved in mental health around athletes and mental skills coaching, mental performance as it pertains to athletes in sports just became my life's work.
Jordan Denaver: Nice. All right, so then into our first question. In your experience, what are the mental health challenges that athletes may face during their participation in sports?
Lauren Becker Rubin: Great, so athletes face a lot of the same mental health challenges that everybody does. It just gets ramped up a little bit because we're performing. Athletes are on a public stage, so everything they're doing is out in the open and then there's the pressure of winning or losing or playing. The mental health issues are similar. Stress, anxiety, pressure, worry, a lot of fear - fear of losing, fear of winning, fear of embarrassment, fear of getting injured, fear of losing social status, fear of losing your position - so there's a lot of fear of worry, stress, anxiety about performing.
I would say embarrassment is a big one that affects mental health. There's also injury really plays into mental health issues, not playing, being left out, being isolated plays in. I'd say a big one that really affects mental health is loss of identity. If you get injured or maybe you're not playing or maybe you're not the star anymore, athletes identify as being athletes and for their whole lives that's their number one thing and then all of a sudden it's either over or it's taken away, so struggling with identity really affects what's my next identity? What else do I identify with? Affects mental health as well.
Jordan Denaver: Definitely, I've experienced that too as an athlete. It's definitely tough.
Lauren Becker Rubin: Yes. I think one of the hardest things for athletes, especially the higher you get at collegiate level, pro, Olympian is when you don't play, whether that's somebody else is playing in front of you or you're injured and it's taken away from you, it's very difficult to process those feelings and it definitely weighs on your mental and emotional wellbeing.
Jordan Denaver: Speaking to that, what are some positive mental health benefits that athletes can experience?
Lauren Becker Rubin: There are a lot of them, and one of the biggest is social connection. I remember reading maybe 10 or 15 years ago an article from the “Happiness Lab” at Harvard that said the number one indicator of wellbeing is social connection. Being part of a team, being with people really bumps up wellbeing and mental health. The other pieces of participating in and benefits of athletics is you're part of something bigger than yourself, you're finding meaning and purpose, you're all working towards a common goal, so there's some shared humanity in that. That shared humanity when you win feels good, but also shared humanity when you lose and you have other people to work through it, and those are all really good health benefits.
The other things that athletics has shown to do is build resilience. It shows us we can do hard things. It makes us more adaptable, and because you never know if you're going to win or lose, you have to start learning how to manage emotions around that, and that's very correlated to life. There's ups and downs, there's good things, there's bad things. You have to learn to be able to manage your emotions around that and athletics really helps you do that.
Jordan Denaver: I think one of my favorite things about working with Haverford College on the lacrosse field is being a part of that team. I love the sport, but on the other hand I love being a part of the team and being with the girls.
Lauren Becker Rubin: That makes a lot of sense. Connection, community is just so huge for wellbeing and mental health.
Jordan Denaver: I think we touched on it a little bit, but then on the other hand, what are some potential negative mental health impacts that athletes may encounter?
Lauren Becker Rubin: They're there for sure. Athletes tend to be very hard driving, type A, on a mission, goal oriented, so with that comes some issues around perfectionism and not feeling good enough, not meeting moments which could lead to some issues with low self-esteem. There is the managing the emotions around stress and pressure and anxiety of games. We did touch on a little bit sometimes when you're injured or maybe you're not playing, you could feel a little bit isolated. That I think some of the other negative things that happened with athletics is maybe some shame around not performing. Then one of the biggest things that could be negative is if it's a toxic culture or toxic coach or toxic teammates and you're in that environment all the time, that really could be negatively impacting your mental health.
Jordan Denaver: Definitely. All right, so what do you think are the mental health differences in competing in sports on a competitive level versus recreationally?
Lauren Becker Rubin: It's a great question, and I'm not an expert on recreational sports, but I have read a ton of research and there's a lot of literature out there that about just the benefits of exercise and movement. If you're doing something recreationally, whether it's walking or yoga or Zumba or playing tennis for fun or running a 5K just to collect the T-shirts and it's something that you're doing for fun, it increases mood, it builds the positive feel good hormones. Again, there's social connection in that, and there's a lot of benefits around fun, having fun and a lot of research these days on just doing play. We play as kids and that's one of the most enjoyable parts of the day, but then as we get older, we start losing that playfulness. Doing things recreationally is play, and play enhances a lot of wellbeing, and on a physical, emotional, mental level, we just feel better.
I do want to say there are a lot of health benefits for competitive sports too, and we touched on a little bit about meeting and purpose and being part of a community, but sometimes people throw around the term like pressure is a privilege, and what's behind that is if you're feeling pressure, it means what you're doing is important to you. If you're involved in something that's important to you, there's going to be some benefits there by seeing it through, so there are health benefits of that pressure and of that competition that add to the movement, the exercise, the fun, the social connection that you get recreationally. There are benefits for both, but I think recreational athletes are enhancing mood, they're connecting, they're feeling good, they're having fun, they're playing. There's a ton of benefits there as well.
Jordan Denaver: Yeah, I agree. I think the pressure of the competitive play definitely works into some of the mental health effects for college athletes.
Lauren Becker Rubin: And I feel we'll talk about it, but it's how you interpret pressure, which really correlates directly to your mental wellbeing and your mental health. If you feel pressure is something that helps you, helps you get ready, helps you get your body activated, helps you focus because this is something that's really important, then it's a positive benefit. If pressure really makes you shrink and it really makes you worry and it really raises your cortisol and all the not so good hormones, then it's a negative. A lot of it comes to how you interpret what's going on.
Jordan Denaver: Then on that note, are there any unique challenges or stressors that elite athletes face in terms of their mental health?
Lauren Becker Rubin: Here's really interesting and what I've found in my practice working with youth, high school, college, and even professional athletes, the challenges are similar. Even the youth athletes and working with the 12 year-olds right now, they feel frustration, they feel stressed, they feel pressure, they have anxiety over performance, they worry about things, so many of the challenges are the same. I think for elite athletes, what makes them unique, and this is college, pros, Olympic athletes, is that they need to be “all in”. They need to be solely focused and it's not a balanced life.
One of my favorite people in the mental performance space right now is David Goggins. And in his last book he called it “Savage Mode”. Elite athletes have to be in savage mode all the time, and that means you have to be selfish, you have to prioritize yourself, you have to prioritize your mission or your goal. I think sometimes that puts you at odds with people in your life. Relationships suffer. I think people judge you. I think it's a little bit isolating. People don't understand you, they want to bring you down.
So I think that is a real challenge for somebody who's trying to be elite, where they just have to be all in, solely focused, very selfish. I think the consequences of that is that people don't get them, and people want to judge you and they want to bring you down or tell you what you're doing is not balanced, but I think it's very hard to be balanced and be elite. I think when you're on that path to being elite, you have to have your blinders on and be all in to get what, to accomplish what you want to accomplish.
Jordan Denaver: I think just to tie into the pressure, I think especially on an elite level, maybe higher up college like D1 or pros, the pressure of a fan base too really plays into the pressure that athletes feel.
Lauren Becker Rubin: I think you're absolutely right. I think social media and fans and money and contracts. Imagine an Olympic sprinter who trains for four years and then has 10 seconds to do their craft. I just think that everything we talked about, pressure, stress, anxiety, worry, isolation, just really ramps up the higher you get.
Jordan Denaver: That ties into our next question a bit. How do you think societal expectations, performance pressure, and competition affect an athlete's mental wellbeing?
Lauren Becker Rubin: This is a great question because this is the work, and I'm going to give you a roundabout answer to that and not direct answer only because the answer to that is it depends, it depends on the work behind how you allow that to affect you. How it affects you depends on what your skill set is, what your tools are, what your strategies are, and then this is absolutely the mental skills work or the mental performance work or the sports psychology work. It's about having skills and tools and techniques and strategies to manage societal expectations, the performance pressure, the emotions, the competitions, because at the end of the day or the beginning of the day, all those things are always going to be there. The pressure, the emotions, the adversity, the challenges, the social media, the judgment, all of that is going to be there, but if you have skills and you work on the skills and you practice and you train that part of your life or the game, then you have some techniques and strategies to work through those.
One of the things I really like to say is mental toughness and mental performance, managing the mental part of sports is directly linked to mental wellbeing. The skills translate, the more you train and develop the skills that help you perform, the more skills tool strategy you have for mental wellbeing and mental health. The work is training it and the work is doing and the work is having it be part of your daily protocol, building a platform so that when societal expectations ramp up or when you're preparing, feeling performance pressure and it's always going to be there, the adversity, the challenges, the setbacks, it's always going to be there. You have skills to help you navigate it so that it directly correlates to how it's going to affect you. The more skills you have, the more you work on it, the more it becomes part of your daily protocol, the more you can catch it and work with it. Does that make sense to you?
Jordan Denaver: Yeah, that definitely makes sense. I think especially as you gain more experience, you just know how to deal with the mental pressures of playing at elite levels and just the performance pressure in general and societal expectations.
Lauren Becker Rubin: And I think the more you replenish yourself, you bolster yourself up with things like breath mechanics and mindset or visualization and imagery, focus, working on resiliency, working on your belief system or limiting beliefs. All of this skill, all of these skill sets becomes part of your toolkit, so then when you're feeling that performance pressure or you're not feeling your best physically, you don't go down a rabbit hole, you go back to... I know with the team sometimes we use physical things like pound your chest, get your energy up, or maybe some EFT to bring down your stress and your anxiety. There's lots of skills and tools that you know can just proactively set yourself up to be in a better place, show up as your best version of yourself, but be able to reset quickly. All of those things weigh into how does it affect you? It affects you different ways when you have skills to counter it or to proactively set yourself up to be in a better place even before that happens.
Jordan Denaver: Our team does love the heart tap.
Lauren Becker Rubin: Tap your chest or get big, expand yourself, take up space to feel power. There's just lots of anchors and tools that we can use to help ourselves navigate that, those pressures, because they're always going to be there. It doesn't go away. We just get better, more adaptable and more flexible with working with it and that directly ties into our wellbeing. That's the coolest part of the mental health and mental performances are tied together. We work on skills for helping us play better, but those same skills help us feel better, our overall mental health.
Jordan Denaver: That's very true. All right, so what role does the team environment and social support play in promoting positive mental health among athletes?
Lauren Becker Rubin: If the team culture is good, then we're talking about community. Again, connection, fun, shared experience, being in a group, striving for something bigger than ourselves. There's so many positive environmental and social support benefits of being part of a team. There's also teamwork and leadership opportunities, trust building, all these things are great for mental health. Then the vice versa is also true. If the culture's not good, if there are toxic teammates, then the environment weighs in a negative way, but being part of groups is really a great social support network if it's a positive culture. Do you feel that way on your team? On the field stuff helps off the field stuff. We're striving to win games and win championships, but then your group becomes your social support network off the field as well, I would imagine.
Jordan Denaver: Exactly. My best friends are the girls on my team, and I think we work really hard on building up our team culture, so that takes a lot of time to build that team culture outside of sports and outside of practice and that's why doing a lot of team activities, just like getting to know one another and building that culture and that trust outside of the field, it helps so much. Then you'll see that trust and that support play out onto the field when we're playing games and during practice. I think that's so important.
Lauren Becker Rubin: Yep. It's bidirectional. It really is on the field, off the field. I love that you used the word trust, because trust and confidence go together. In fact, I think the root of the word confidence is an inner or intense trust, so the culture builds trust, trust builds confidence. The more you trust each other, the more confident you are, the better you play. The more you love each other, the better you play. It is really bidirectional, so culture, environmental, social support really is very entwined.
Jordan Denaver: I remember it was a semifinal game of this past year and our coach, Coach Zichelli, she said that you need to play for your teammates. I think that speaks a lot to what we're talking about. She's like, "Play for your teammates, play for your seniors who are leaving." So I think it's a lot for just playing for each other and in that way you tend to play well because you're playing for each other. You want to boost people up, you want to show off your teammates, and I think it just all ties together very well in the field.
Lauren Becker Rubin: I love that concept. Playing for something bigger than yourself, playing for each other really helps us step up into the moment because we don't want to let people down, we care about them, we love and it really brings out the best in us, so I love that concept.
Jordan Denaver: All right. Next, how do you think athletes can take care of their mental health while participating in sports?
Lauren Becker Rubin: I think this is an important question and I'm glad that you're bringing it up to the forefront because it's not always upfront. Sometimes it's in the back in crisis, what do we do? So I feel like having it upfront, making athletes know that they have resources. I think how athletes can take care of themselves is to use their available resources, teammates, coaches, counseling centers, mental performance coach like myself, know that those resources are there and don't be afraid to use them and ask for help. Don't hide it. That's another way that you can take care of yourself. We need to change the stigma around mental health, that it's a weakness and by bringing it up, it's really a strength. That means you're working on something just like we would do a physical skill. In lacrosse, if your non-dominant hand isn't strong enough, you work on it. If your mental health, if you're struggling with mental health, you work on it, you don't hide it, you don't lock it away.
And I would say one of the biggest things, ways an athlete can take care of their mental health is to be proactive. Meaning make this part of your daily protocol. Do things every day that build your foundation and get that foundation as big as possible. What I mean by that is sleep, nutrition, working on recovery, maybe meditation, watching funny movies, doing social things that are fun, having friends, going out in the sun or nature, getting a massage every now and then. Every day as an athlete you're doing a lot of things that are depleting yourself, physical exertion, mental exertion, stress, pressure around your sport. You have everything that's depleting you. Not to mention in a college setting all the academic pressure. You have to balance that out with things that replete you, replenish you, and you have to do that daily, know what those things are.
And if it becomes part of your daily protocol, then every day you're having mini wins, mini win, mini win, mini win, mini win. What that does, it adds up to big wins and it builds this great foundation of strength so that when you do have a setback or you might be feeling a little bit off or something really knocks you over the head that you weren't expecting, you're coming at it from a more replenished space. The biggest way I think to help with dealing with mental health is to build up wellbeing and make it part of your daily protocol so that when you do get whammied, you've got some resource already built in.
Jordan Denaver: Yeah, I agree. I think having that framework is so important, so that you can fall back onto what you know and what skills you've built. Are there any strategies or interventions that coaches, trainers or sports organizations can implement to support the mental health of athletes?
Lauren Becker Rubin: I think the biggest strategy is to normalize the conversation around mental health. Just normalize it. Just like we normalize that sports are hard and that it's going to take some effort and we're going to get knocked down and get back up. We normalize that life is hard. I think we have to normalize that there are mental health issues with athletes, and when we normalize it then we aren't afraid to talk about it. I also think that coaches and trainers can bring in resources, they can bring in a mental skills coach like myself. They can bring in counseling, they can bring in speakers, they can bring in resources like books or articles or webinars that normalize that, "Hey, this is mental health issues are part of life of being an athlete and things are going to come up and we can talk about it."
I think the other biggest strategy that coaches, trainers, or organizations can layer in is bringing fun to whatever they're doing. Just because you're training hard and you're trying to be the best version of yourself as an athlete, win games, win championships doesn't mean it can't be fun. I did read a research article about this. The best teams, the most accomplished teams over time combine two things and that is grit. Angela Duckworth from Penn has written a lot about hard work over time, perseverance over time, that's grit. You have to do the gritty work, you have to get in there and you have to do the hard stuff, but when you add it to fun, grit, and fun, that's when teams are most successful. That's when athletes are most successful, so I think in a proactive intervention besides the resources and besides normalizing, just make it fun. Make it fun, make it enjoyable, and that really helps support athletes' mental health.
Jordan Denaver: We talked a lot on our team is bringing the fun back into the sport because I think when you're younger, that's everything that you have really is the fun and the love that you have of the sport you're playing, but as you enter the more competitive level like college, pros, you lose that fun and now you're suddenly just in this space where you're just working to win or you're working in this competitive, this nature and you lose the fun that you used to have as a child and the love that used to have for the sport sometimes. We focus a lot on trying to have fun and bringing back the love that we have for the sport because that's why we play it.
Lauren Becker Rubin: I love that you're talking about it and that it's an emphasis, because I think it gets lost a lot in college sports where it becomes a job and you lose the fun. I think it really not only affects performance and success on the field, but it definitely affects mental health and wellbeing. I love the fact that you talk about it and that it's part of your culture.
Jordan Denaver: All right. Next, are there any specific warning signs or indicators that athletes, coaches or peers should be aware of to identify mental health issues in athletes?
Lauren Becker Rubin: This is a great question and it's a great thing to have some awareness around because sometimes there are no signs. Sometimes, especially for athletes, they want to suffer in silence and they're afraid of the stigma or the shame around mental health issues and the stigma or the idea that athletes have to be tough and strong and show no weakness. Sometimes there are no signs, and that's really tricky when some major mental health crisis happens, everyone says, "How come I didn't see it?" But a lot of times there aren't any signs.
Here are sometimes signs that come up that you could look for: different behavior. Is somebody who's normally social not going out and isolating themselves? Maybe somebody's drinking more or someone who used to drink is not drinking alcohol and drugs. A change in behavior, like someone who is normally loud and social, is being really quiet. Other signs might be someone skipping team functions, maybe sleeping a lot, or maybe you have a teammate that's going home every weekend, that could be a sign that something's going on. Then some of the more obvious signs is someone's just unhappy or they're appearing depressed or somebody is losing a lot of weight or gaining a lot of weight.
The signs are look for differences, somebody's acting, looking, behaving differently. It could be a sign that something is going on behind the scenes that they're not expressing outwardly, but they're trying to deal with inwardly. I would say another thing to look for is if you have a teammate, is it who's injured? I think being injured really plays into mental health and mental wellbeing for athletes because again, you're pulled out of what you identify with and what you love and it's very isolating. If you have a teammate that's injured, I would definitely check in with them and make sure they're okay and make sure they're still feeling included.
Jordan Denaver: I can speak firsthand to that because I've been injured and I've spent time on the sidelines because of an injury, and watching your teammates play and on the field, it's really hard sometimes knowing that you can't be out there to help them or support them and that your role on the team has changed in a way, especially when the injuries are potentially season ending. It's very difficult.
Lauren Becker Rubin: For sure. How did it affect your mental health and how did you work through some of those things?
Jordan Denaver: It was hard. I was out for I think five, six months. I think I recognized that my role on the team was different, that I was on the sidelines and that I had to be more of a cheerleader and less of a contributor on the field, but then I think there was also a lot of hope that I will come back soon, which is also scary too, because coming back from an injury and you haven't played in six months, that's really tough too, but I think the team's very good about it. I think also making sure that you're not isolating yourself. Still maybe attending practices and just watching, still attending those games, still attending other team activities to keep yourself integrated even while injured is super important.
Lauren Becker Rubin: Well, I want to applaud you. You used a lot of great skills and when you're in a difficult time, sometimes it's really hard to find the things that pull you out of it. One of the biggest pieces of working on mental skills, mental health, mental performance is not being stuck, not being either stuck in one place or spiraling backwards. Do we want to keep moving? And part of keeping moving is shifting out of it. I love that you said I needed to find a new role. If we can use our mindset, "Okay, I'm not on the field, but what role can I take? How else can I look at this where I can be the best teammate? Or maybe I could be a good scout or maybe I could watch film." So you're shifting your mindset to find a different role is a great skill.
And you also use the word hope. Having hope, having faith, believing in things that you don't necessarily have all the proof of yet keeps you moving forward and it keeps you on a path of, "Hey, this could work out, this could be good." So those are all great strategies to keep you from staying stuck where you were or spiraling backwards. Great job of keeping yourself working on... Using tools to get you moving in the right direction.
Jordan Denaver: Thank you. Let's see what's next. What steps can be taken to reduce the stigma surrounding mental health in sports? I think we touched on this a little bit.
Lauren Becker Rubin: Some of the things we mentioned about normalizing it and bringing resources I think helps reduce the stigma. I think on a broader level, I know that the NCAA is doing a lot of research and work and education on this topic where they are providing resources to colleges just to make them aware that this is an issue. In fact, I read one of the NCAA research studies they did where they found that for collegiate athletes, 24% of male athletes experienced some mental health issues and 36% of female athletes surveyed expressed mental health issues. I do know that also self-reporting is lower, so it's probably even a little higher than that.
I think education and providing resources by the NCAA would help on the collegiate level, but I really think what helps reduce the stigma is when people step up and talk about what's going on with them. Like Michael Phelps talking about anxiety and other pro athletes like Simone Biles in the Olympics, her anxiety got to her. Kevin Love in the NBA was talking about pressure and stress and some of his issues, and Naomi Osaka from the tennis world. When professional athletes step up and say, "I am working on this, I'm dealing with this. It's not preventing me necessarily from performing, I just have to manage it, influence it, control it, work on it, but it's part, it's there for me." I think it really helps normalize it and it just shows that everybody's human and it's okay not to be okay.
I want to take it into the weeds just a little bit further and say, I think the culture around this could start changing in youth sports. The message just tough it out, run through walls, get up, when someone might be having a mental health crisis is not the right message. We have to do hard things at athletes and we have to push ourselves, and getting out of our comfort zone is one of the most important things that we have to learn how to do, but I think if coaches have an awareness and players have an awareness that there could be something else going on, then there's more language around it, there's more education around it, there's more compassion around it, and it becomes more normalized as part of, this is part of sports, this is part of life, this is part of who we are and let's have some resources to work on it.
Jordan Denaver: I agree. I think it does start younger because those messages start a little bit less, so when you're younger and they really build as you get older. I think too, having more public figures, spread awareness on it too helps people like college athletes, high school athletes recognize that they're not alone in their anxiety. That these people performing at super high levels also feel it too. I think that's really helpful. I think just spreading awareness of it will help reduce the stigma for sure.
Lauren Becker Rubin: Right. I agree with you. Kristin Neff, who's a psychologist that specializes in self-compassion is out there with her method, which is breathing and mindfulness, but a piece of that is shared humanity. “Other people are going through this, I'm not alone.” I think as athletes, one of the most difficult things that we struggle with is being compassionate to ourselves because we're so used to being tough and strong and do hard things, but the research that doesn't support that is that when we're more compassionate to ourselves, when we don't play well, when we make a mistake, when we lose, when we're having a mental health crisis, the quicker we actually rebound and reset. That compassion piece is really important. I think the more we normalize it and the more education is out there and the more the culture changes around it, the more compassionate we are to ourselves, actually, the better we can cope with the setbacks and the struggles, because like I said, they're going to be there. That's part of life, that's part of sports. The more we normalize it and then the more we can manage it.
Jordan Denaver: I agree. All right. Are there any notable research findings or studies that have explored the mental health impacts of participating in sports? I know you mentioned a couple.
Lauren Becker Rubin: Yep. I mentioned the NCAA one. In fact, I went to that lecture and heard the psychologist that works with the NCAA delivered just how prevalent their mental health issues are with collegiate athletes because of the pressure and there's money and scholarship and losing your college education tied into it, so that's really high. I did read a research article from the American College of Sports Medicine recently that said 35% of elite athletes struggle with mental health issues including eating disorders, burnout, depression, anxiety, social anxiety. At the elite level there is also a lot of mental health issues. There are pros too. I've read plenty of research on what participating in sports, the positive parts, it improves psychological well being, it can improve self-esteem, it can lower depression, anxiety and stress. I read articles where participating in athletics decreases suicidal behavior and substance abuse and reckless behavior, and that piece is maybe being accountable to teammates and to the team.
There's definitely a lot of research on increasing resilience, confidence, empowerment, empathy, just because you're going through shared things. A big thing about participating is increasing healthy habits. When you are active and you're participating in sports, it bubbles over into other parts of your life. You're eating better, you're not doing substance things that you just get on a path. There is a lot of research both ways and I think the research is still developing here, and also the research around how to deal with the pros and the cons is developing as well. It's a rapidly changing space around research and interventions, both positive and negative.
Jordan Denaver: I think having you speak to our team, I think it's almost biweekly at this point, is so helpful. I know it helps the girls and me too so much, and I think that's a big thing too. Bringing in people to speak to the team and to speak to these issues that are a little bit more stigmatized helps normalize it, because it brings you into a space where you can talk about it, where you have resources to air mental health issues.
Lauren Becker Rubin: I agree. I think the more you talk about it, the more resources, the more... What's really cool about this space and why I think I'm so passionate about it, as you can tell I love it, is it's ancient wisdom and modern science. The people I've been talking about, a lot of these things, the ancient stoics and Buddha and a lot for years, and now modern science is catching up and the research is backing. Breathing, compassion, visualization, self-talk. All of the tools that we're using are now research-backed, so the ancient wisdom is being supported by the modern science, and I love marrying the two. Giving a concept about manifestation, put it out there the way you want it to happen, and then having research back it up. It's a lot of fun to have the two worlds combined together.
Jordan Denaver: Actually I've used a lot of the breathing techniques just completely outside of sports. Just any anxiety or stress I'm feeling like, "Okay, I'm going to do a box breath right now." And it's so helpful. It really is.
Lauren Becker Rubin: I love hearing that. Obviously I want you to be the best lacrosse player that you can be and be the best version of yourself as an athlete, but I really want you to be the best version of yourself as a human being. That's why mental performance and mental health directly intersect. What's so amazing about what I do and why I'm so in love with the mental performance world is because these skills translate to life. The fact that you're using it for anxiety off the field or stress or pressure or in relationships is just really satisfying. What I hope I'm doing is creating opportunities for the athletes and the teams that I work with to reach their full potential, to be their best versions of themselves on the field and off the field.
Jordan Denaver: And as you said before, a lot of the negative mental health issues that athletes face or a lot of just normal issues that non-athletes face and it just ties more into playing sports. Those are still stressors that people feel outside and breathing techniques and even the heart tap, that helps a lot. It's completely outside of lacrosse and sports.
Lauren Becker Rubin: Yes, for sure.
Jordan Denaver: All right, then I think it's our last question. Do you have any final words of advice or anything else you'd like to share with our listeners today?
Lauren Becker Rubin: The biggest piece of advice, and ironically when I'm first working with an individual athlete or a team, I often lead with this because I feel it's so important. The advice is that mental toughness, mental strength, mental mastery, mental health is not about making it all go away. It's not about making the stress, the anxiety, the pressure, the challenges, depression, fear, worry. It's not about making it go away. It's really about hanging in there long enough so that you can shift, that you can shift out of it, that you can create enough space and awareness that, "Hey, this is going on." And then start using your tools and your strategies.
If you can recognize that these things are normal, start with the premise that life is hard, sports is hard, these things are going to happen. Hang out in it long enough that you can start using your tools, your strategies, your techniques to shift out of it, to move a little bit to get on a different path. I think that's my biggest advice is hang in there long enough that you can shift. Part of that shift though is building the resources on your own with other people, using support so that you have tools and strategies to help you shift out of it, but just to summarize, the advice is don't think that it's good feel... Feelings and emotions are not good or bad, they're just information. Use all the information, hang out long enough, shift out of it. Use your tools, your resources so that you can keep moving down another path.
I think most of us want to close the gap to where we are now and where we want to be, and the work that around the skills, around mental performance, around mental health helps us keep moving towards where we want to be, but where we're now is part of it and it's normal and sometimes it's difficult. When we go in with that mindset, then we're more adaptable, we're more anti-fragile, more flexible, and having that mindset that, "Hey, we could get knocked down, but we're going to get back up. We're going to learn, we're going to grow." Like a growth mindset that we talk about a lot with the team. It keeps us moving, so my advice is build up your resources, have tools, have strategies, know that it's going to be hard, that there's going to be setbacks. Hang out long enough that you can shift out of it and just try to keep moving.
And then my last piece of advice is don't suffer in silence. Get help, reach out, use your support, use your networks. Don't think you have to do it alone. My last piece of advice, sorry, I'll wrap it up, but growth happens when we get outside of our comfort zone and that's called adaptability. Sometimes people call it anti-fragility, but when we stress ourselves, we grow, but our body and our mind, our emotions, our thoughts, all of that stuff, we don't like to be outside of our comfort zone. When we get out of our comfort zone, what happens is we adapt and that adaption keeps us on the path of wellbeing and positive mental health. Getting stretched and getting out of our comfort zone, getting knocked back, initially it's not going to feel good, but with resources and with skills, we'll adapt to it and we'll grow. Adaption and growth is mental health and mental wellbeing, so stay in the fight long enough to grow and to adapt, and that's how we can build our mental health and our overall mental wellbeing.
Jordan Denaver: I completely agree. I think that's some great advice. Thank you so much for doing this and for joining the Seattle Interview Series.
Lauren Becker Rubin: You bet. Thanks for having me. It was a lot of fun.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
* Note: Video is unavailable for this interview.
An Interview with Psychotherapist Jerome Veith
Jerome Veith, Ph.D. is a Senior Adjunct Professor of Philosophy and Psychology at Seattle University. He specializes in the process and healing from traumatic experiences and helping those struggling with issues of purpose, meaning, and personal identity.
Jennifer Smith: Thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series! I'm Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today, psychotherapist Jerome Veith. In addition to his work as a therapist at our practice, Jerome also teaches at Seattle University. He designs interdisciplinary courses for students in Psychology, exploring the significance of trauma and what it means for us to process and heal from traumatic experiences. Jerome has also published numerous articles, a number of literary and philosophical translations, and a recent book focused on understanding our relationship to our past. Prior to his graduate studies in Psychology, Jerome earned a Ph.D. in Philosophy, making him an exceptionally good fit for clients struggling with issues of purpose, meaning, and personal identity.
To get started, can you tell us a little more about yourself?
Jerome Veith: I divide my work fairly evenly between teaching philosophy and psychology at Seattle University (where I’ve been working since 2012), and practicing therapy at Seattle Anxiety Specialists (where I’ve been since SAS’s inception in 2018). I really enjoy both of these lines of work - they complement each other superbly! Beyond work I read, cook, spend time with friends, listen to music, and occasionally try my hand at playing it. Since moving here over 20 years ago and falling in love with the Northwest, I’ve made a point to get to know the area more and more.
Jennifer Smith: What are your favorite parts of the Seattle area, or Washington as a whole?
Jerome Veith: In Seattle it depends on the weather, and if I’m wanting bustle or seclusion (or a mix of both). I gravitate toward places with character, atmosphere, trees, or a view: parks, pubs, lookouts, and bookstores. Further afield, the Peninsula exerts a particular pull on me (I look for the mountains every morning), and I try to make it to a little island in the San Juans at least once a year.
Jennifer Smith: What is it that got you interested in becoming a therapist?
Jerome Veith: A half-joking answer would be: drugs! Perhaps like many a teenager who dabbled in psychedelics, I fancied myself an oh-so-wise shaman-apprentice, ready to guide others through their ego-death. Luckily that hubris wore off fast. Psychedelics did spark an abiding interest in the depth and breadth of the mind, though, and that’s been a thread of my studies ever since.
A more serious response is that, while majoring in philosophy and psychology at Seattle University, I learned not only that entire therapeutic movements had been influenced by existentialism, phenomenology, and hermeneutics - which by then I considered my intellectual homes - but also that SU has a graduate program dedicated entirely to training those kinds of therapists. The folks in and around that program seemed to have a distinct way of listening to experience: a way of being inquisitive together, of allowing more to be questionable and meaningful than we commonly permit ourselves, and of noticing the interpretive moves we’re always making. That attitude (or mode, practice - whatever you wish to call it) resonated powerfully with me, and pointed toward my eventual therapeutic path. First, I went off to get a PhD in philosophy, though.
When that (seven-year!) process atrophied something in me and I desperately needed therapy myself, I experienced firsthand how illuminating and revitalizing it is to be heard in therapeutic relation. That’s when I knew this was work I wanted to do, and I enrolled in SU’s therapy program.
Jennifer Smith: You were born in the US but raised in Germany, and you lived there until you came to the US for undergrad. Your schooling before the US was entirely German, while your home life was American. Has this informed your thinking or your practice at all?
Jerome Veith: It has influenced so much! My upbringing shaped my identity profoundly - along with my eventual interest in identity itself, and certainly my way of holding identity in therapy.
Growing up in Germany at the end of the Cold War, adjacent to a US military supercomplex and near the French border, surrounded by facets of history both buried and bare, greatly shaped my attunement to all sorts of cultural edges. I became aware very early on how much is at stake in having and expressing an identity, yet for all sorts of reasons I couldn’t easily inhabit just one - but laying claim to many was also challenging. That suspension between cultures eventually became a quite generative space: one where identity is resonant but never fixed, and one that invites free exploration.
That isn’t to say that finding this space was easy or comfortable. It takes an ongoing effort to maintain. For this reason, I resonate in my work with folks who experience cultural othering or inhabit several cultural positions. They might struggle with all sorts of outsider-ness, as this can be a blessing and a curse. One sees differently from the margins, but this isn’t always a welcome or comfortable perspective. One might not be seen at all or as one intends. There is also an immense pain in exclusion that can open onto deep uncertainty about one’s permission to be, and about one’s and aspirations and possibilities of experiencing home, community, or belonging.
Jennifer Smith: What areas or disorders do you specialize in?
Jerome Veith: This is difficult to label on a diagnostic level, because the DSM’s taxonomy is so problematic and fails to capture so many of the nuances of human experience. I tend to be a good fit for clients whose anxiety, trauma, stuckness, or lostness resonates with questions of identity, self-worth, or wider meaning. Another way to put this is that I work with clients who struggle to integrate with some aspect of themselves, of the world, or even with the world as such.
Jennifer Smith: Can you talk a little about your treatment approach?
Jerome Veith: I mentioned before that I tend to work well with clients who experience deep questions underneath their presenting symptoms. However, it’s not always clear from the outset whether or how these questions are present. Discovering that, and allowing one’s questions to find articulation, is part of the work of therapy. Without talking through what’s happening, it might seem like one simply can’t manage the stresses of daily life; one might simply feel lost, stuck, or out of balance. Sometimes it only becomes clear belatedly that one needs new language or a different framing of the issue. Sometimes that reframing is the entire work of therapy; sometimes that’s just where the exciting work begins.
That said, much of my approach is a shared noticing of what’s going on - on affective, embodied, cognitive, and relational levels - both from within the client’s experience, but also from the stance of someone alongside that. Being accompanied in this noticing can be immensely helpful. It’s not that I necessarily have a better perspective, but I do sometimes have a different one; and often that’s sufficient space for new interpretation.
Jennifer Smith: As a professor of philosophy, do you find that being a therapist helps you in the classroom - and conversely, does being a professor help you in any way as a therapist?
Jerome Veith: Yes and yes! I have a sense that years of university teaching - and doing so in a spontaneously responsive sort of way - prepared me both for the unpredictable conversations one has in therapy, and for the mode of listening that these require. Sitting with confusing texts and ideas, often for immense spans of time, turned out to be great preparation for the attentive mode in which I accompany my clients.
My therapy work has, in turn, deeply informed my teaching. In working through real and deep issues with people, I’ve come to recognize layers of human experience that are rarely captured in academic writing. I try to point my pedagogy toward these lived textures, either by way of more experiential media (film, literature, poetry, music) or by bringing in direct case material.
Jennifer Smith: Do you have any words of advice or anything else that you would like to share?
Jerome Veith: Nothing has been more impactful for my sanity than receiving, internalizing, and continuing to give myself “permission” - whatever this might mean in a given context. For me, it’s often permission to pause, play, or ponder without needing an outcome. In a culture that seems to demand perfection from us at all turns, this can be a liberating practice.
* For those interested in working with Jerome, click on our appointment page to see his current availability.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.
An Interview with Psychologist Ann Haynos
Ann Haynos, Ph.D. is a an assistant professor in clinical psychology at Virginia Commonwealth University. Her research specializes in destructive excess goal pursuit and restrictive eating disorders.
Ananya Udyaver: Hi! Thanks for joining us today for this installment of The Seattle Psychiatrist Interview series. I'm Ananya Udyaver, a research intern at Seattle Anxiety Specialists. I'd like to welcome Dr. Ann Haynos, an assistant professor in clinical psychology at Virginia Commonwealth University. She's an expert on the field of neuroscience and clinical science with an interest on the phenomenon of excess goal pursuit that leads to destructive health outcomes. Her research is primarily focused on restricted eating disorders and how they can become consuming and life-threatening. She's written several articles on the topic, including “Beyond Description and Deficits: How Computational Psychiatry Can Enhance an Understanding of Decision Making in Anorexia Nervosa” and “Moving Towards Specificity: A Systematic Review of Cue Features Associated with Reward and Punishment in Anorexia Nervosa.”
So before we get started, can you please tell us a little bit more about yourself and what made you interested in specifically studying restrictive eating disorders?
Ann Haynos: Sure, absolutely. So just briefly about myself, I guess. So I am new faculty member here at VCU. I just started last August, and before that, was on faculty at the University of Minnesota for several years. And so a lot of the research I'll be talking about was actually performed in Minnesota. I had gone there as part of my training and stayed on with my lovely colleagues to go into a faculty position there. So more generally about my background, I've been working in the field of eating disorders for a long time, since I was, I suppose an undergrad.
And along the way, have also become interested in some sort of intersecting fields like those pertaining to emotion regulation, reward, neuroscience, and have taken so those bits of training and integrated it into the work I'm doing. So as you mentioned, I do a lot related to the clinical neuroscience of eating disorders, but I also have a treatment arm of the research I do. And the hope is that our lab integrates both. So as far as how I got interested, I think the thing that really drew me to the eating disorders field was some early experiences. I grew up in sort of the DC metro area and went to a small all female school there. And when I was there, my graduating class was something like a class of a hundred, and we had a disproportionate amount of people affected by eating disorders in my class. I would say... Maybe the average estimates of how many people are affected by anorexia nervosa or something like 1%. And I would say, just based on my knowledge, something like 10% of my graduating class probably met criteria for anorexia nervosa.
Ananya Udyaver: Yeah. Wow. That's a lot...
Ann Haynos: And some of these people, I was quite close to and could see really upfront the devastating effects of these illnesses and would often get disheartened about how people would think about eating disorders in the lay public as sort of a disorder that might be something about wanting to look a certain way. And I could just tell people, based on firsthand experience, that it was so much more devastating to the people and the families affected by it. And then also as part of that experience, I saw some of the people I knew who were struggling with eating disorders got treatment and got better and seemed to recover without as much effort. And then some people really struggled to find the treatment that worked for them and continued struggle with their eating disorder for many years. It just really struck me that we needed more options for people, especially those who don't respond to initial treatments. So that's sort of what sparked my initial interest.
Ananya Udyaver: Yeah. That makes a lot of sense. Okay. Well, I read a little bit in your most recent article about excess goal pursuit and how that can affect psychiatric illnesses like anorexia nervosa. Can you please explain what this means and how it pertains to your study and understanding of anorexia nervosa?
Ann Haynos: Yeah. So sort of the background on thinking about anorexia as a disorder of excess goal pursuit is... A lot of studies in psychiatry and in psychology tend to look at places where people with psychological disorders or mental health problems have deficits in some sort of ability, right? For instance, the assumption would be all of us should have self-control and people might have problems with self-control, and that could lead to different sorts of problematic behaviors, like say drug use or something like that. Or maybe everybody should have the ability to manage their emotions effectively and people with psychological problems might have problems with doing that.
And one of the things I started to find when I was doing research on folks with anorexia nervosa, and I'm sure this is true of other clinical populations too, this is the area I worked in the most, is that I would find certainly some areas where there were deficits or problems and certain abilities, but I also found places where I was seeing actually distinct strengths in abilities that we usually think of as good, like the ability to inhibit impulses and work towards long-term goals. Society usually thinks that's a good thing. And so I would see the strengths. And the problem is a lot of times, those strengths get missed because people are so busy looking for the weaknesses that might lead to mental health problems.
And one of the things that concerned me about this bias towards looking at these sort of deficits or relative weaknesses that might lead to mental health problems is that there is a possibility that certain things that we really encourage as a society, like self-control, like the ability to focus on a goal very narrowly and intently, if taken too far, could actually cause some problems. But we encourage those things as a society. And so one of the ways I've begun to conceptualize anorexia nervosa is this may be a disorder where people with this disorder are doing what society has told them to do. They are pursuing a goal. And specifically, they're pursuing what is often a socially sanctioned goal, which is weight loss. They just keep going and going past when most people would stop. But I think it can be very confusing if you're told, "This is the right thing to do and this is a thing that will be rewarded," and then at some point people say, "Oh, no, no, no, stop doing that thing." Right? And so that's how I started pursuing that area of research.
Ananya Udyaver: Okay. Makes a lot of sense. And it's really interesting, the idea of goal pursuit and how you also have to consider patients' strengths and not just their weaknesses when you're looking at disorders like this. So when you talk about computational psychiatry in your research, what does that entail, and how does it relate to treating anorexia?
Ann Haynos: Yeah, I'm smiling because it's such a complicated... It's an umbrella term, and it's very complicated. I think a lot of people who even work closely on areas related to computational psychiatry get a little confused about exactly what it means. So basically, the field of computational psychiatry developed mostly out of partnerships with neuroscience. So over time, mental health fields have been more and more drawing off of some of the tools and theories that neuroscientists have been using to look at things at a much more fine-grained level, like how brain circuits work. And one of the things that neuroscientists have learned is that there are different ways that our brain makes mental calculations to solve different problems. So you could have a problem in front of you, like there are different types of reward in front of me. Which should I pursue? And there are many different mental calculations that should go into how you make that choice.
So you could mentally calculate, what is the cost of pursuing option A over option B? You could calculate the relative reward of these different options. You can calculate, how much do I know about option A, option B? And all of us do this throughout the day in living our everyday lives. If you think about where you choose to get a sandwich for lunch or whatever, you're usually doing some sort of probably quick, but mental calculations, weighing out familiarity, effort to get someplace, how much things cost, et cetera. Now, the idea of computational psychiatry is that sometimes those mental calculations can be either over applied in certain situations, or applied insensitively, or otherwise just go awry, and that can lead to mental health problems. So again, taking the example of the mental calculations that go into getting your lunch sandwich, let's say you are always selecting the deli downstairs, except that costs a ton of money and you don't have a lot of money.
Well, suddenly that's a problematic way of making that mental decision because it's leading over time to bad outcomes. You just don't have enough money in the same ways we can make mental calculations that can over time lead to mental health problems. So some of the... One example from my work in anorexia is we're starting to see some evidence that people with anorexia nervosa make decisions... They form preferences very quickly and stick very rigidly to their preferences about things. So that can translate to, if you have decided that the thing you really care about pursuing is weight loss, maybe you may be quick to jump to that as a solution to certain problems, and it might be harder for you to stop and say, "No, I need to do a different thing at this moment."
Ananya Udyaver: That makes a lot of sense, and that was a really great analogy with the sandwich.
Ann Haynos: Maybe it's just cause of lunchtime and I'm hungry.
Ananya Udyaver: Yeah. Okay. So I guess you kind of answered this question in this sense of what is the difference between under responding and over responding and how an individual can recognize that type of response within themselves.
Ann Haynos: And so when you refer to under responding and over responding, are you talking about to rewards?
Ananya Udyaver: Yes, or to...
Ann Haynos: Okay.
Ananya Udyaver: Yeah.
Ann Haynos: Yeah. Okay. So as far as rewards go, all of us want to seek out things that are going to be pleasant or enjoyable or give us some payoff in life, right? And there are some problems that can arise with mental health where people over respond to rewards, generally speaking. So let's say, for instance, this is something that could lead to impulsivity. If you were just saying like, "Ooh, food, ooh, drugs, ooh, sex," whatever, all the rewards, that's going to lead to not making sensitive decisions about also the cost of those behaviors.
On the other hand, you could have a problem related to overall under-responsivity. So that might look like what you might see, for instance, in people with depression, where nothing really interests me, nothing's that rewarding. Not just like, oh, I don't care about the food, sex and drugs, but I also don't care about talking on the phone with friends or watching a movie. And that would be a really clear example of overall under responding. Your brain is just not gravitating towards any rewards, which is problematic because you need your brain to want to do some things in order to function in the world.
The other thing we tend to see in eating disorders specifically, and I'll talk about anorexia nervosa here, is that some disorders are associated with over responsivity to some rewards and under responsivity to others. So one of the things we found in anorexia nervosa is that... And not just us, a lot of research. This is summarizing a lot of researchers findings, but people with anorexia nervosa tend to show a lot of under responsivity to rewards that the average person would find enjoyable, like winning money, seeing pleasant videos, or having social interactions, but tend to respond to rewards related to their eating disorder, so things like exercise cues or weight loss cues, or engaging in eating disorder behaviors. And that imbalance is also a problem. Because if you only have these sort of problematic weight loss things that make you feel good and nothing else really makes you feel that positively, then you're just going to keep going for the same rewards over time, even when they're problematic.
Ananya Udyaver: Right. Yeah. That makes sense. Okay. My next question was actually about rewards and punishments, but I feel like that question was kind of answered by your last response. Yeah. So do you think it's important for individuals suffering from eating disorders to understand the psychiatric basis behind their thoughts and actions? And if so, why?
Ann Haynos: I find a lot of folks with eating disorders are very interested in understanding sort of the neurobiology and some of the psychological and psychiatric mechanisms that underlie their disorder. At this point, I've run a lot of people with eating disorders through research studies, and they're often very eager research participants, because A, they know how much they've suffered from their disorder and they want to help other people. But B, I think a lot of times people are confused about what's driving their behaviors. They know they're really stuck in their eating disorder behaviors, and they know that they try really hard at times to get out of those behaviors, and it's very difficult. And so I found that by describing some of the neurobiology and other research that has helped to understand how eating disorders function, a lot of times, that can be helpful for people to just understand themselves, and also, I think hopefully can relieve a layer of self-criticism and self-blame.
Ananya Udyaver: Right.
Ann Haynos: This is another reason why I've gravitated in my work to towards looking at things that could be strengths that also could be problematic. I think that allows me to say to people I work clinically with, "Look, this set of skills that you're using is great, and if applied in to the right things and in a judicious way. I don't want to get rid of your hardworking nature, your willing to use control and effort. All of those things are not bad in themselves. We just got to attach them to good outcomes, and also make sure you balance it out with the ability to be flexible and give yourself a break sometimes." So I tend to, when I work clinically with people, try to bring in as much of the research as possible.
Ananya Udyaver: Yeah, I think that's a really great way to motivate your patients to want to do better and get better. So that's really interesting. Okay. And then I read about in your research, the positive effect treatment and as a cognitive behavioral intervention. And I was wondering if you could please more explain this intervention.
Ann Haynos: Yeah. Absolutely.
Ananya Udyaver: Yeah.
Ann Haynos: Oh, sorry. Sorry, I had a little bit of a delay talking over you.
Ananya Udyaver: It's okay. Go ahead.
Ann Haynos: Do you mind just saying the second part of your question again?
Ananya Udyaver: Yeah. Just explaining the intervention and its potential benefits for patients.
Ann Haynos: Wonderful. So positive affect treatment, I'm really excited to talk about this right now because we're sort of in this pivotal stage with this research that I'll talk more about. But positive affect treatment, which is abbreviated. We call it PAT, but the person who developed it calls it PAT often. But it was originally developed by Michelle Craske at UCLA. She developed it as a alternative treatment for depression and anxiety. And the idea that motivated her developing this treatment is a lot of treatment for people with depression and anxiety is focused on reducing negative emotions.
And we know those work, but we also know that in addition to having high negative emotions, people with anxiety and depression often have low positive emotions, and decreasing the negative emotions does not always lead to increasing the positive emotions. So a good example of this is antidepressant medications often help people feel less anxious, less depressed, but also often have the side effect of making people feel kind of numb, less interested in things around them. So that's an example of decreasing negative, but also just not helping positive emotion at all. So she had really good initial findings from delivering this treatment in depression and anxiety, basically finding that this treatment could reduce depression and anxiety symptoms, as well as suicidality. So we learned about it, and we're really interested in translating it to anorexia nervosa. This is me and my colleagues at University of Minnesota. Dr. Carol Peterson is the main person I've worked on this work with.
And what appealed to us is this treatment is really designed to target the neuroscience of reduced positive affect. So what goes on in the brain, and how can we correct that behaviorally for people who are just under responding to the rewards in their environment like we described before? So what we wanted to do is take everything that works so well for that set of problems, and then we added on some additional components of the treatment that target the over responsivity to weight loss rewards that we might see in anorexia. So the way we talk about this treatment is we tell clients our goal is to grow your life and shrink your eating disorder so that your life is so good that you don't need to rely on your eating disorder to do whatever it was doing for you in the past. So we just finished writing up our initial manuscript of our pilot study for this treatment. And the treatment involves some sort of cognitive behavioral interventions, as well as some mindfulness and self-compassion interventions, all targeting increasing positive emotions outside of the eating disorder.
Ananya Udyaver: Right.
Ann Haynos: And what we found is that this treatment was associated with people who went through the treatment, decreased their eating disorder symptoms and increased their body weight, which is what we want for people with anorexia nervosa. And also, unlike other treatments for eating disorders, we saw that anxiety and depression also really decreased...
Ananya Udyaver: Wow.
Ann Haynos: ... during this treatment. Yeah, which we were really excited about because a lot of times people will say, "My eating disorder is better, but I'm still miserable." Right? So we're about to publish... Well, we're about to submit that for publication. But the other really exciting thing is we're going to start a new study piloting this treatment for people stepping down from higher level of care after they've had an acute episode of care for anorexia nervosa in residential or partial hospitalization or intensive outpatient treatment. And we're going to be doing PAT and comparing it to more standard eating disorder treatments during that sort of pivotal step down period. And the treatment's virtual, so anybody across the country could participate in it. So if anybody's hearing this and this sounds like an interesting option for them or their clients, hopefully while this is up, we'll be running the study.
Ananya Udyaver: Yeah, definitely a lot of people that are interested in getting help will be reading and watching these interviews, and this is a really great study that you're doing because I'm sure people will definitely want to join. And that was actually one of my questions, which was, do you have any potential treatment options or a study going on that could help people watching these interviews and seeking help? So that's a really great thing that you're doing.
Ann Haynos: Absolutely. And I'll just put in one extra pitch, which is, one thing, you could do this treatment study while also doing other treatments. So it can be the only treatment people are doing, but it could not be as well. The other thing is it's completely free. And in fact, people get paid to participate in the research side of things. So this is a good option for folks who might not be able to financially access other eating disorder treatment during their step down period. So if anybody out there is listening and interested, please reach out to our group. We'd be happy to see if you'd be eligible. (email: haynosa@vcu.edu)
Ananya Udyaver: Definitely. And we'll make sure to put all your information on the website so that they can contact you.
Ann Haynos: Wonderful.
Ananya Udyaver: And then just to wrap things up, since we are coming to the end of our interview, as a professor in the field of clinical psychology and a researcher, do you have any other advice or recommendations for our listeners who may be seeking treatment or suffering from a psychiatric illness?
Ann Haynos: I think first, for anybody who's acutely struggling with an eating disorder or any other psychiatric illness, I guess I would say as a first thing, that I recognize how difficult that is, and it can feel at times near impossible to get the right type of treatment or the right type of resources to help alleviate your symptoms. So I guess the first thing is, I know it's hard. And I guess I also want to instill some hope. We do know that there are... Taking disorders as an example, even among people who have been struggling with their eating disorder for very many years, the evidence overwhelmingly suggests that most people do recover, even if it takes a while to do so. I think we are trying to get better as a field about understanding how to help people with the right treatments at the right time. But I would just always say to keep that glimmer of hope.
I've worked with so many clients who, at the moment when I've been working with them, have been just severely struggling, very uncertain about the directions to go in, not certain if they can overcome their psychological problems, whether that be eating disorder, anxiety, depression. And then I'm lucky enough to have people keep in touch with me sometimes and tell me where they are several years later. And a lot of times, they've built these beautiful lives. I think the other thing I'd recommend is just, to the extent you can, do the research about what are the evidence-based treatments for you. There's a lot of non-evidence based treatments for eating disorders and other disorders out there. And I think a lot of people get stuck in a place of getting treatment that actually is not going to benefit them for too long. And so that would be the other piece of advice. And get a support system to the extent you can, because it's hard to go through dealing with mental illness on your own. And having more supports, even if that's just your therapist, anything can be really helpful.
Ananya Udyaver: I think that's amazing advice and definitely very motivational to anyone who is seeking help.
Ann Haynos: I hope so.
Ananya Udyaver: Yeah, thank you so much for that. But anyway, thank you so much for your time and for your willingness to participate in our interview series. It's been a pleasure speaking with you, and we wish you the best on your future research and hope that you find more interesting things that can help people out there.
Ann Haynos: Wonderful. Well, thank you so much for having me.
Ananya Udyaver: Of course. Thank you.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.