Psychologist Rebecca Shiner on Narrative Identity & Personality Disorders

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.

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

Psychologist Daniel Keating on Stress, Anxiety & Adolescent Mental Health

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.

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

Certified Mental Performance Coach Lauren Becker Rubin on the Mental Health of Athletes

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.

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