Psychotherapist Nica Selvaggio on LGBTQIA Mental Health

An Interview with Psychotherapist Nica Selvaggio

Dominica (Nica) Selvaggio, LMHC is psychotherapist at Seattle Anxiety Specialists, PLLC. Nica has experience working with clients on a wide variety of issues, including anxiety disorders, eating disorders, substance abuse, sexual orientation and gender identity, acculturation and systemic oppression related to race and gender, trauma and PTSD, mood disorders, personality disorders, self-harm, relational issues, and attachment struggles.

Jennifer Smith: Hi, thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today, Dominica Selvaggio, who is one of the psychotherapists at our practice. Nica has worked as a therapist for roughly a decade in the Seattle area and works with adults and adolescents aged 13 and older. Before we get started today, can you tell our listeners a little bit about yourself?

Nica Selvaggio: Yes, and thank you so much for the introduction, Jen. I'm really excited to be here talking with you today. That's always such a broad question. I never know where to start, but I guess that is the place to start that from a very young age, I was diagnosed with ADHD, and so my inability to pick where to start is a reflection of what I deal with in my brain. I love being a neurodivergent therapist because it brings a sense of understanding and compassion for folks who struggle with this sort of tangential thinking or not knowing where to start, that I find really, really helpful and I just get a lot of joy out of it.

So all that to say, I'm your local ADHD therapist. I'm originally born and raised in Chicago, the Midwest, and I've been in the Pacific Northwest for most of my adult life. I did spend three years living in Hawaii, and that was a really life-changing experience. And ultimately, I came back to the Seattle area because this land really has my heart.

Jennifer Smith: Wow.

Nica Selvaggio: I always describe myself as someone who's incredibly creative and just a lover of nature.

Jennifer Smith: That's great. And so you moved to the Seattle area from Hawaii. So what would be your favorite parts of the Seattle area, or just Washington as a whole?

Nica Selvaggio: It's the land, it's the mountains, it's the water, the plant life, all of it. I always say because of growing up in the Midwest that I was raised in corn and concrete. So when I moved to the Pacific Northwest and saw these huge mountains for the first time, even after a decade of being here, I'm still in awe. Yeah, I just really, really love the landscape.

Jennifer Smith: That's great. What is it that got you interested in being a therapist?

Nica Selvaggio: Big question. There's this storyline of The Wounded Healer that I think a lot of us are familiar with, that archetype of someone who has gone through their own experiences of pain and suffering, have tended to them, and then turned that compassionate attention outwards towards others who are struggling with similar wounds. My story as a therapist is not so different from that. I became interested in working in mental health out of necessity of caring for my own mental health throughout my life.

I'm a former foster care survivor and an adult adoptee, and so I had exposure from a very young age to some of the suffering in the world and in my own world and experience. So walking that path has really led me to wanting to provide a hand to hold for other folks on their own paths.

Jennifer Smith: Wow, that's really fantastic. Thank you for sharing that. What areas or disorders do you specialize in, besides ADHD?

Nica Selvaggio: Well, I got my start working in the clinical world specializing in eating disorders. So the bulk of my career was spent working in high acuity treatment centers, inpatient level residential, partial hospitalization, intensive outpatient, and working with folks who struggle with things like anorexia, binge-eating disorder, bulimia, ARFID, avoidant restrictive food intake disorder, which is often accompanied with neurodivergence. And when you work with eating disorders, you work with everything.

So people often think of eating disorders as being about literally food and body, and while those are absolutely components of a person's experience with an eating disorder, it's a symptom for an underlying issue. And often what underpins eating disorders is trauma, depression, anxiety, huge contributing factor, and other ways that the brain is sensitive. So for example, someone on the autism spectrum might really struggle with their sensory experience with food, be labeled with having an eating disorder, when really, it's something that's going on in a sensory way for them. It's not accompanied by cognitions and things like that.

So that's the bulk of my experience and I could talk about that forever. But because I'm an ADHD person, I have a million interests and my path has diverged many a time from that foundation of working with eating disorders. So through that work, I found my way into the somatic world in treating trauma because trauma is a huge underpin of most folks with eating disorders. And I got my foot into somatic experiencing, which is working with folks more so through the visceral felt-sense experience of trauma held in their bodies and helping them to let go of it rather than talking the story to death, which can be re-traumatizing for folks at times. Absolutely has some value in reclaiming our narrative and making meaning. However, I found working in the body to be a lot gentler.

Through that world, I found my way into psychedelic assisted therapy. I did a fellowship last summer in Jamaica, working with mushroom assisted therapy, and I've done a couple of trainings in San Francisco for ketamine assisted therapy. So that is a world I'm very interested in. And then gender and sexuality. So I'm non-binary. My pronouns are she/they, and working with trans folks, working with gender sexuality came out of working with eating disorders as well because those populations tend to struggle with eating disorders, body dysmorphia, those sorts of things at a much higher rate than the general population.

Jennifer Smith: Wow.

Nica Selvaggio: And then from there, add in interest in couples work, sex therapy. So a little bit all over the place, but a really strong foundation underneath all of it.

Jennifer Smith: Wow, that's fantastic. And basically that means you can help a lot of different people, which is really great. Your online bio notes that you've been trained in several evidence-based approaches. Can you let our audience know what those are?

Nica Selvaggio: Yeah, and I'm noticing in myself through this interview, I'm talking very fast and not breathing very much because I'm oriented to my own body. I'm going to take a moment and just take a deep breath before I answer you.

Jennifer Smith: Yeah, absolutely.

Nica Selvaggio: Thanks. And if anything-

Jennifer Smith: Oh, I was just just saying-

Nica Selvaggio: Yeah, go ahead Jen.

Jennifer Smith: That's great for our audience to see too. You need a moment, take a moment. There's nothing wrong with that, and I think we could probably all do that at times and we just don't, unfortunately. And then we feel awful.

Nica Selvaggio: Well, we're not really given permission to in our culture and our systems that we operate in.

Jennifer Smith: Yeah, which is unfortunate.

Nica Selvaggio: Yeah. Which ties into that question a little bit about what evidence-based therapies I work with. Most of them I learned when working in treatment settings. So in a lot of eating disorder treatment centers, the foundation of the treatments are evidence-based therapies such as dialectical behavior therapy, DBT, which was developed by Marsha Linehan, and that was a therapy originally developed to treat folks who struggle with extreme emotional dysregulation who are feeling suicidal or are diagnosed with borderline personality disorder. So these extreme swings of mood and inability to regulate.

Off of that came... And that approach is really good for folks who are... The temperament under controlled. So under UC versus OC, under controlled versus over controlled, so more impulsive behaviors, you're going to see things more expressive. You might be able to tell I'm more on the UC side. DBT is great for that. And then on the other side, you've got OC, over control. Those folks are going to have higher levels of generally OCD type thinking, more restricted, flat affect, much more wanting to control their outer experience because their internal world feels so chaotic that it reflects on the outside. In those folks, you're going to see things more like anorexia, restricting behaviors, much more flat affect.

RO-DBT, radically open DBT came out of DBT to help over control folks. So those are two different therapies, even though they have the same name in them, but essentially they're both skills-based therapies that are laid on the foundation of mindfulness and some of our Eastern inspired practices. So as well as another evidence-based therapy that's used a lot in treatment centers, ACT, acceptance and commitment therapy by Stephen Hayes. But these therapies are really trying to bridge the worlds of that grounded mindfulness foundation with concrete skills that people can use to actively change the behaviors that are causing them distress in their lives.

I love a lot of those therapies so much because they work, they can really shift things quickly. I often use those in conjunction with therapies that maybe don't have as much of a robust research base because they haven't had the time or the funding or whatever it is, such as somatic experiencing and more experiential therapies. I went a little bit all over the place.

Jennifer Smith: Thanks. And what about your treatment approach? What's that like?

Nica Selvaggio: Yeah, so I was trained in a clinical mental health counseling master's program and the foundation of my training and program was person-centered humanistic therapy. So for folks who don't know what that means, my foundation of who I am as a clinician, as a counselor is very much through the egalitarian lens of I am not an expert in your life. You are the expert in your life and I'm coming here to join human to human to witness and perhaps equip you with skills that you need in order to change the things that you're wanting to change.

That said, that's the foundation I weave in depending on what a person needs after collaborating with them on what sort of therapy they're interested in working with, all different kinds of approaches. So again, the somatic work is a huge part of my work, bringing in the body. I also do a lot of parts work, internal family systems, and for folks not familiar with that, that involves accessing the different parts of ourselves that are often in conflict. Everyone has different aspects of self that they might connect with at different times. The part of me that's doing this interview with today is my manager part, right? I'm going to present my best self today, but maybe my inner child part is like, "This is scary. I don't like talking in front of people that I can't see." That's an example of parts work.

Who else? Again, super interested in growing more in the psychedelic assisted therapy world. It's really profound powerful work that can really jump start a person's journey, but not to be used without caution and a lot of discernment and support. Yeah, it's just different for everyone.

Jennifer Smith: That's fantastic. I'd like to go back and talk about one of the areas that you can help clients with, and that's regarding their sexual orientation and gender identity. And I was reading on The Trevor Project’s website that they offer 24/7 free, secure access to counselors for young people who are LGBTQ. In a nationwide survey that 41% of LGBTQ people age 13 to 24, so the younger range, seriously considered committing suicide in the past year.

So clearly something's going on here that's severely impacting this population's mental health. So I just have a few questions regarding this, that maybe you can shed some light on.

One is, what types of issues does someone usually struggle with regarding their sexual orientation or gender identity?

Nica Selvaggio: Yeah, I love this question. Thank you for asking this. And first I want to name... I always experience a lot of heaviness in my body when tapping into the sense of powerlessness or hopelessness that comes in for a person to feel like the best option is to end their life, that they've exhausted all of the avenues and this is the best way to escape the pain that they're experiencing when that becomes the option in their brain. This is for so many different reasons and ties to what a lot of folks in the LGBTQIA+ community struggle with, which I want to differentiate that struggling to know what your sexual identity is or your gender identity is, is not in and of itself a pathology or an issue that someone's struggling with.

What people are struggling with is how the systems in the world, how our culture, how our families, how our religions, how all of these things reflect our worthiness of access to resources, safety, the right to use the bathroom in the public. Our daily lived experiences of oppression are the issues that we struggle with, not the fact that we are part of the rainbow community.

So that being said, because of operating or living in a system that... And I can give so many examples of it's February 1st and how many anti-trans legislation bills have been pushed forward this month in January alone? The visceral, physiological, emotional, spiritual, psychological response to being faced with that. Those issues can look like suicidality, that can look like depression, that can look like anxiety, that can look like a nervous system that's chronically stuck in fight, flight or freeze because they're in survival mode because the world is reflecting to them that they're not safe.

Things more classically associated with folks in the LGBTQIA community are things around identity formation. How do I know who I am? How do I put a word or a label to who I am? Do I even want to do that? Is there even a necessity for me to come out and name myself as such? Where do I fit in and belong in this LGBTQ community? How do I move through the world in the straight world? A lot of identity formation issues in that. And again, that's not an issue of pathology in and of itself. Culture's response to that question is the issue.

Substance use is often higher. Again, this is a way of coping with all the things that I've named and eating disorders and body dysmorphia tend to be much higher incidences in the trans and LGBTQ community.

Jennifer Smith: Wow. And eating disorders too, they're often highly correlated with suicidality, correct?

Nica Selvaggio: Yes, yes. Can be. Not all, but yeah, they tend to be.

Jennifer Smith: Wow. Another question I had is often when you're doing paperwork now for a medical provider or surveys, they ask about someone's preferred pronouns. And can you talk a little bit about that, preferred pronouns and how can that affect someone's mental health? Why do they matter? Why do pronouns matter?

Nica Selvaggio: Yeah. Yeah. And I love how you changed the sentence at the end. Why do pronouns matter? Because even the language of preferred can insinuate that it's someone's choice in terms of... Okay, how can I put this? If you knew that the sky was blue and someone came up to you and was like, "You're nuts. The sky is not blue. I see yellow, and you are bad and wrong for thinking that the sky is blue. How could you?” Take it a step further: “You're going to a bad place because you think this sky is blue."

And then I said to you, “Well, you just prefer it to be blue.” Is that a preference or is that just what you see? So a person's preferred pronouns implies that it's an actual preference, when in reality, it's just their lived experience. And so when someone is vulnerable enough to even name their pronouns, even if we don't understand, even if we think the sky is yellow, the reason it's important is because it indicates a level of belief that that person understands and knows themselves better than we could possibly know, their internal experience.

Jennifer Smith: Right.

Nica Selvaggio: It indicates respect for their beingness, and it creates a level of safety for that person who may have moved through many different systems in their life where it was not accepted or not safe for them to use the pronouns that fit for them.

Jennifer Smith: That's fantastic. Thank you. One anecdote that I wanted to share is that in our practice, we were trying to decide internally, "Should we all put our pronouns in our signature block?" And I'd say one-third were gung ho for, "Yes, we should." One-third didn't care. And there were other people who didn't want to, and one of the members of our team said, "Maybe we shouldn't do this, because if a person isn't comfortable saying what their pronouns are, we're forcing them to either disclose their pronouns or force them to put stereotypical pronouns that you would think that they should be.” And for me, that was really eye-opening.

So for that reason, I went on the bandwagon of I'm not putting pronouns. That way, if someone else didn't want to, they didn't feel like they had to as well.

So I thought that was really interesting, that pronouns can really mean so much to a person and just... Yeah. So thank you for explaining that, that it really does matter.

Nica Selvaggio: Yeah, absolutely. And I love, thank you to that person who brought that point up because that's always what I like to... Oftentimes when we're trying to show up as allies in support of a community that we're not part of, it's easy to misstep and to do things out of good heart and good intention, but ultimately can contribute further to harm. And the pronouns in the bio or in your email signatures requirement is one of those ways where it's like, "Oh, we're trying to help normalize it for everyone." But again, you don't know who you're requiring to out themselves or to live falsely.

Jennifer Smith: Right. That's fantastic. And that's why part of the reason that we do this series is to help educate people and just explain things. Thank you.

Nica Selvaggio: Yeah, thank you.

Jennifer Smith: Yeah. So what can you say to people who simply might not have any understanding or have confusion about what we've just been talking about and just don't understand the distress that some people might have about identity or orientation or pronouns? Why is it a big deal?

Nica Selvaggio: Yeah. I always come back to why do we need to understand? I don't even understand myself. Why do I need to understand another person's experience for their experience to be legitimate and valid for them? I don't. In fact, it's often impossible to try. I can do my best, but I can't ever fully step into another person's experience. And so we don't actually require understanding. We require respect and compassion, just to be believed. Right? And you can compare this across many different experiences of identity. I will never know what it's like to walk through the world, say, as an Arabic man, I don't know what that is.

Jennifer Smith: Right.

Nica Selvaggio: It's not for me to try to understand. It's for me to listen and believe and provide respect. So first throwing away that word understanding, we don't need to understand. What I would say is have you... I would invite folks who really just don't get what the big deal is about to reflect on if there's ever been something in their own life that was really important to them, that they really cared a lot about, but that was dismissed or diminished, or they were told that they were foolish or crazy even for caring about that thing.

And we can do this together too, but just to take a moment and really call to mind that feeling, that memory and see what happens inside. So I notice immediately I start to contract, I start to constrict, and I start to want to feel small and to hide myself. Other folks might have a different experience. Maybe they feel angry, they want to fight back. There's no wrong response here. Just notice how do you feel when you're invalidated, misunderstood, and told that you're wrong to care about the things that you care about? Generally not pleasant.

So when we show up in that way, we're often perpetuating more of the same for people around us. If we've experienced that, then we're going to put that out on others too. Like, "Well, I had to conform. I had to shut down this part of myself, so how dare you not do that?" Right? We face a lot of anger from folks oftentimes as a result of that. Yeah. And what would the world be like if we had more spaciousness for those pauses to actually feel into, what am I reacting to in my not understanding? Am I being reminded of a time that I didn't feel understood? How can I show up in a more compassionate way?

Jennifer Smith: That's great. Thank you. Our final question, which I'm a little bummed to say because I thought this has been great. Do you have any words of advice or anything else that you'd like to say to our listeners today?

Nica Selvaggio: Be gentle with yourself. Working as a clinician, as a counselor, as a therapist, through some of these major world and global events that we've been experiencing collectively over the past decade, something I've noticed in the broader populations is that levels of fear are very high. Anxiety is very high, which makes sense. And levels of burnout, feeling like we just cannot continue on are very high. Levels of trauma and secondary trauma are very high.

In the midst of all of that, I want to invite all of us to both stand in the center of honoring and witnessing our sacred human struggles together, and also find those spaces in which things feel a little bit lighter, or we can expand more and access things like rest and pleasure and resilience, and that both of those things need to coexist in order to show up in a more whole way. So gentle, gentle, gentle, gentle. Show up when you can. Rest when you can.

Jennifer Smith: That's fantastic. Thank you so much, Nica, for finding time to speak with us today.

Nica Selvaggio: Thank you for having me.

Jennifer Smith: And for our listeners, if anybody is interested in scheduling an in-person or telehealth appointment with Nica, you can do so and self-schedule at seattleanxiety.com. Thanks again and have a great day.

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

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

Psychiatrist Peter Reiss on Psychiatric Medication Management

An Interview with Psychiatrist Peter Reiss

Peter Reiss, M.D. is psychiatrist at Seattle Anxiety Specialists, PLLC. Dr. Reiss specializes in the treatment and medication management of anxiety related disorders.

Jennifer Smith: Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us Dr. Peter Reiss, who is one of the psychiatric providers at our practice. Peter has extensive experience with psychiatric medication management and has worked in multiple levels of care in the Seattle area, including inpatient, outpatient, partial hospitalization, and residential treatment programs, as well as in the psychiatric emergency room.

Before we get started today, can you tell our listeners a little bit about yourself?

Peter Reiss: Yeah. Hi, Jennifer. Thanks for having me, and inviting me for this interview series. As you said, I worked in quite a few places before I started working as an outpatient psychiatrist here. I took a slightly different route than the traditional way of, "What do you do when you start working after residency?"

I initially started working as a locum tenens, which includes more short-term contracts. I was doing six months to a year at different kinds of levels of psychiatric care. It just gave me a way to see what kind of psychiatric jobs I like, and it gave me an opportunity to see what the mental health resources are in the area. And, just gave me a chance to see what I could see myself doing in the long run.

Jennifer Smith: That's great. I think, like you said, to have all that different exposure probably makes you a really well-rounded psychiatrist. I think that's fantastic. Great.

Peter Reiss: I did think that. It just gave me a little bit more opportunities to really see what different acuities look like on different levels of care.

I wouldn't change a thing, so I'm very happy I did it this way.

Jennifer Smith: Fantastic. Just to let our listeners know a little bit more about yourself as well, what are your favorite parts of the Seattle area or Washington as a whole?

Peter Reiss: So, the first time we came to Seattle, I just immediately loved the area. I do think that it has this very special kind of culture. I love how it combines the urban and the nature, and just the fact that there's so much to do. Especially in the summer, with festivals going on. And, even the winter, I mean, people do complain about, or some people say we have particularly bad winters, but, in the middle of winter, it's 55 degrees, and you can go hiking or do whatever if you're okay with a little bit of rain.

Jennifer Smith: The saying is "It's not bad weather, it's bad clothing," or something like that. Right?

Peter Reiss: Well, I think our weather is our best kept secret.

Jennifer Smith: Yes.

Peter Reiss: Not as bad as people say.

Jennifer Smith: Exactly.

Peter Reiss: Or, have the reputation.

Jennifer Smith: Right?

Peter Reiss: Yeah.

Jennifer Smith: Exactly. That's great. And, what is it that got you interested in becoming a psychiatrist?

Peter Reiss: So, I didn't start out in medical school wanting to be a psychiatrist. I did keep my options open. I was leaning more towards primary care, internal medicine, possibly emergency medicine. I always knew that psychiatry and mental health is important, and that it's kind of very ubiquitous anywhere you go in medicine.

I didn't think about psychiatry a whole lot until my third year in medical school when I had my real introduction to psychiatry, where I went to the psych ward and other psych facilities for my medical school rotation. And, I just immediately loved it. I liked how it's just slightly different than other fields of medicine. It kind of forces you to think more outside of the box. It doesn't necessarily follow the standard algorithms that we have in medicine. There's a lot more nuance and room for interpretation, and it's probably the least well-understood specialty in medicine as well. So, I did the fact that there's just so much more that potential will change in the specialty in the near future hopefully.

Jennifer Smith: That's fantastic. One question that we're often asked is, "Should I see a therapist or should I see a psychiatrist, or both?" And, can you explain the difference to our audience why should someone see either of these two professions?

Peter Reiss: Mm-hmm. Yeah. So, we do have quite a good variety of mental health specialists for anyone wanting to see treatment for any mental health problems. The two options, generally, are to see a medical doctor, so a psychiatrist, or see somebody who'll focus more on non-pharmaceutical management, which would be a therapist, which would typically be clinical social workers or psychologists by training. And, it sometimes comes down to personal choice what people prefer.

I would say, if somebody's psychiatric symptoms are fairly mild, they might need to see a psychiatrist. So, not everybody would be necessarily a candidate for psychiatric medications.

Psychiatrists themselves rarely practice psychotherapy anymore. It used to be different. We are trained in psychotherapy. We do go through all these different didactical trainings, how to provide different modalities of psychotherapy, and it used to be much more prevalent back, really, back in the seventies, eighties, up to nineties, where many psychiatrists were still offering psychotherapy. But, mostly due to our insurance landscape, it really has changed that that responsibility has fallen more to clinical social workers and psychologists who are very, very qualified to provide that training. And, they're really specialized in all these different training modalities, since there's just so many of them. So, somebody who has PTSD is getting different psychotherapy than somebody who has an anxiety disorder or depression.

And, it's really hard for a therapist to be very good at all of these therapy modalities. So, I think sort of the specialization among the different therapies works very well, and it's great to just share that professional space with all these very qualified therapists that we work with.

Jennifer Smith: Wow. Have there been times when a patient will come to you and you realize this person probably doesn't need medication - do you refer them to therapy? Does that ever happen?

Peter Reiss: Oh yeah. That is quite common.

I mean, I would say, in the majority of cases, probably at least a trial of medication might be helpful, just for the patient to engage better in psychotherapy if symptoms are just a little bit too severe at that time. But, for a lot of mild cases of the anxiety and depressive disorders, often starting with therapy alone might be a good option.

Jennifer Smith: Okay, fantastic. In what ways can someone's mental health impact their physical health?

Peter Reiss: So, that's actually a really good question. I think most people do understand the connection between chronic medical conditions causing psychiatric symptoms to worsen, but it's really also the other way around. So, I mean, for example, most psychiatric disorders, whether it's anxiety disorders, whether it's depressive disorders, trauma, excessive trauma responses, they typically cause physiological changes as well. Things like, for example, chronically increased stress hormones, like cortisol. And, that can have an impact on immune function, it can increase somebody's risk for cardiovascular issues.

And then also, indirectly, somebody who has low executive functioning, low motivation due do psychiatric issues, is less likely to take care of themselves and engage in these kind of activating behaviors that tend to improve one's mental and physical health.

If somebody, for example, is less likely to engage in things that are good for social connections, that leads to loneliness. And that, in itself, leads to worsening mental health and physical health as well just due to increasing chronic stress and things like that.

Jennifer Smith: Oh, wow. So, when they say, "Mental health IS health," it really is true.

Peter Reiss: Oh, it is absolutely true. I mean the two... It's not only that it's just in your head, right? It does cause real physiological changes, whether those are directly caused by mental health issues or indirectly.

Jennifer Smith: Right. Can you talk a little bit about your treatment approach?

Peter Reiss: So, I emphasize a lot of psychoeducation, making sure that I meet my patients where they're at, and also give them as clear information about what's going on for them to make the best informed decision.

Sometimes, maybe, they have a particular treatment modality in mind, particular medications or whatnot. Just, trying to understand what their idea is, where they're coming from. So, our treatment goals might be different; we might not always agree, and that's not necessarily wrong. But, giving them as much information as I can for them to make the most informed decisions, that's very important to me.

Then also, I tend to put a big emphasis on always reassessing... Just, speaking specifically about medication management, to reevaluate the need for a particular medication. Sometimes, patients come to me having been on one medication for 10 years. We don't know if they still need to be on that. We don't need... Maybe they need to be on something different. We need to reevaluate what, really, each component of their treatment is really doing, if it still has any effect on their mental health. Sometimes, less is more with psychopharmacology.

I do always want to do check-ins, even with patients who have been on a long-term medication, "Is that really necessary, and what can we do about it?"

Jennifer Smith: That's really great that you work with a patient. And, it sounds like you strive to just get the optimal dose and really not put things that are not... Meaning that you don't do unnecessary things.

Peter Reiss: Right, because each medication could not have side effects; it could have unwanted side effects; or, something else that the patient might not know about. So, they're still... Psychiatric medication's still among the safest medication in medications in general, but we shouldn't take it lightly to have somebody on long-term medications generally.

Usually, it's not a problem. We just have to do it the right way.

Jennifer Smith: Right. And, what type of disorders do you specialize in?

Peter Reiss: So, the disorders that I see here in the clinic are fairly standard, the average psychiatric disorders, including the depressive disorders, wide variety of anxiety disorders, including OCD and different kinds of phobia. We do see ADHD patients here in our clinic as well, patients with PTSD and more trauma-related issues, and also different levels of functioning. So, there's many of my patients who are really doing well, especially on the surface. They're able to do their day-to-day activities. And then, there's patients who are not doing well at this time, who might not be able to have a job right now. So, it's a big variety of different psychiatric issues that we're dealing with, but also, different, wide variety of patient needs.

Jennifer Smith: And, let's say that I was going to sign up for an appointment with you. You are a medical doctor, so of course, I would have to complete the intake paperwork so you have an idea of where I'm coming from, what medications I'm on, my past history. So that's, I think, pretty standard. But, after that, I have no idea what to expect. So, what can I expect in the first session with you? What would we do? What would we talk about?

Peter Reiss: Mm-hmm. Yeah.

So, after a patient signs up for an appointment, there's the initial intake. That can be done either here in my office, in person, or it could be done remotely. There's always those two options. On most days during the week, I have those two options available.

The first session is just gathering a lot of information, getting to know the patient. And, that typically takes at least 45 minutes to an hour so we are clear on establishing a diagnosis, getting enough information about the patient's medical background, mental health background, social background. And, the last part of the initial meeting... Well, there's initially the psychiatric interview, and then, we kind of talk about what we're going to do.

And, if there's any disagreements, or the patient might need a little more time to think about these different options, we might talk about... Besides different medication options, we might talk about potential referrals for therapy as well to see if there's somebody who might have that particular therapy skillset that the patient needs, whether that's in our office or outside of our office.

And then. If the patient decides to be a patient with us, there would be a follow-up appointment to check in, within usually two to four weeks or so. Depending on the acuity, really, and if there's any problems.

Jennifer Smith: Okay. And, that actually leads to my next question regarding follow-ups. So, at our practice, we have a form of concierge care. Can you explain what that is to the audience? And, how does it differ from a traditional practice, and what are the benefits that our patients may have?

Peter Reiss: Mm-hmm. So, the main difference with concierge care is really that it's a subscription-based access to our services.

In a traditional setting, patients would have their appointment and then schedule follow-ups, and then, essentially, the difference in payment would just be that they would pay for each follow-up appointment. But, a subscription-based model of concierge care, it's really that patients pay a monthly subscription for, essentially, unlimited access. So, they can have one appointment, they can have two appointments; they have access to their psychiatrist via messaging system or email. It just makes it easier for us to respond in real-time to any issues that might come up.

It also helps us to see who is continuing care at a regular interval. So, sometimes in outpatient psychiatry, it becomes a little tricky, because patients might be partially lost to follow up. They might not show up for an appointment, so we're not sure is that patient still patient with us, right? But, with a subscription model, we at least know, "Oh, that patient actually wants to continue, and that patient will continue with their follow-up appointments."

So, I think it helps with patient retention in the outpatient setting.

Jennifer Smith: Great. And, I think one thing that I've noticed from the administrative end is that, because we essentially cap the number of patients that our psychiatrists will see, and you've kind of alluded to this, that our patients really can have unlimited access, to a degree, because you're seeing X amount of patients and not thousands of patients. So, there's just more time that you can give each of your patients, which I really think makes more specialized care as well.

Peter Reiss: Mm-hmm. Yeah. So, our overall patient numbers are lower than you would see in a typical outpatient clinics, which helps with just the time that we give each patient. We're not necessarily back-to-back.

I mean, there's some days where we see more patients than other days, but it just feels a little bit more... It feels a little more less time pressure, to give that extra time as well, whether it's directly during the appointment or to communicate with the patient through our messaging system and hone in their treatment that way.

Jennifer Smith: Wonderful. So, our final question, do you have any words of advice, or anything else that you would like to say to our listeners today?

Peter Reiss: So, the main thing that I probably would say is that, to somebody who's starting out with their mental health recovery, really seeing that they want to get treatment, it initially seems very daunting, but I do want to say that it does get easier when somebody is actually establishing care and is getting the help that they need.

And, oftentimes, we often forget to check in with ourselves, especially when we're in treatment, making sure that we're really doing well, that we're not just doing okay, that we're really thriving and flourishing. And, that can mean different things to many people, obviously. But, often, what suffering from a lot of mental disorders and mental illness does to us, we're losing the sense of self-worth and almost like forgetting what our normal... We're getting used to this normal baseline of functioning and being. And, sometimes, it becomes difficult to keep track of what our purpose is in life and what we can do to thrive.

So, don't settle for any less when it comes to your mental health. That would be my main advice.

Jennifer Smith: That's great. Thank you so much for your time today.

If anyone is interested in scheduling an in-person or a telehealth appointment with Dr. Reiss to discuss psychiatric care and medication management, you can self-schedule at seattleanxiety.com

Thank you again, Dr. Reiss, we appreciate your time.

Peter Reiss: Thank you, Jennifer. Good seeing you.

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

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

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 Ami Shah on Caregiver Burnout

An Interview with Psychologist Ami Shah

Ami Shah, Psy.D. is a licensed clinical psychologist in private practice in New York and New Jersey. She specializes in working with adults and geriatric patients and helps support caregivers suffering from burnout (in particular caregivers of those with dementia, cognitive decline, and medical illness).

Adithi Jayaraman:  Great. Thank you all for joining us today for The Seattle Psychiatrist Interview Series. I'm Adithi Jayaraman, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

Today, I'd like to welcome Dr. Ami Shah. Dr. Shah is a clinical psychologist in New York who specializes in working with adults and geriatric patients. She also specializes in the areas of bicultural, multicultural identity, relationships, marriage concerns, family, individual stress, and grief and loss. Dr. Shah received her master's and doctoral degrees in clinical psychology from the University of Indianapolis. Today, we'll be speaking to her about her work with caregivers and caregiver burnout. So, before we get started, Dr. Shah, can you please share a little more about yourself and what made you interested in working with caregivers?

Ami Shah:  Yes. Thank you for the lovely intro, Adithi. So, my journey to becoming interested in working with caregivers was a bit roundabout. I initially started off thinking I wanted to work with kids, and as I began to work with individuals clinically in training, I recognized there was a large gap at that time in terms of older adult care, and then when I did my fellowship... I'm sorry, I had done research prior to that at the VA in caregiver interventions for older adults that have dementia. That was the first time I was exposed to and recognizing there was a big gap in terms of, we were working on a research project at that time, it was a phone intervention, long before we had Zoom, and we were working on a phone intervention to provide emotional support for caregivers of veterans that had dementia at that time. And from that, during fellowship, we continued to do caregiver work in the same capacity, primarily as well caregiver interventions for veterans, again, that have dementia.

So, that was the capacity I started, and now most recently, I work at a skilled nursing facility and I'm seeing folks who are caregiving a number of older adults. So whether it's primarily, it's secondary to, say, a fall. Perhaps it's chronic falls, it's chronic pain. Sometimes it is cognitive decline. So, there's a number of caregiving capacities. That's sort of the capacity, so the capacity and context I'll be talking about is primarily in working with adults and older adults.

Adithi Jayaraman:  Perfect. Thank you. Yeah, and then on that note, can you provide us a working definition of what caregiver burnout is and how common it is in the States?

Ami Shah:  Yeah, I think that's a great question. Caregiver burnout I think is, it may go through waves, and sometimes it doesn't. So, it really depends on a number of factors. It's quite complicated, actually. When we think about caregiving someone at a certain point in time, say for example, I'll speak to individuals I see currently, if you're caregiving someone that perhaps fell once, it depends on the nature of the injury. The context is always critical in any of these situations. If it's a one-time fall, depending on their age, their premorbid functioning, the caregiving capacity could be more acute and short term, and so perhaps it really may not necessarily disrupt or impact someone's functioning as much.

What becomes a bit more complicated is, depending on the nature of the injury, but also understanding the caregiver's individual life and responsibilities, including their own health, caretaking other folks. So, burnout, really the word burnout, I think it's important to understand at a single point in time, what is the experience of the person they're caretaking and what is the experience of the person that is doing the caretaking? Of course, as we all know, burnout is essentially saying, at a certain point of time, someone is perhaps giving more than they're able to at a certain point in time, which can of course contribute to feeling distressed.

I know with, for example, caregivers of dementia, at large, again, this is generalized... I'm trying to think back. I think 60% at some point report experiencing some sort of, quote, unquote, "burnout", and sometimes as much as 40% may experience clinical depression. And so sometimes it can be a depressive episode, which can be normalized to, well, what is going on at that point in time? So yeah, I would say even more than the commonality, it's important to understand the context at a certain point in time.

Adithi Jayaraman:  Thank you, thank you. And then in terms of, you kind of alluded to this, but what are some of the main concerns or themes that you've seen in your work with caregivers and the general caregiver population?

Ami Shah:  I think one of the biggest factors is thinking about more of the structural. So, depending on, again, the context here of caregiving, in the sense that if someone is prepared mentally to care-give X, Y, Z person, there's time to plan. So, for example, I see a number of folks here, it's a skilled nursing facility, folks are here for physical rehab, oftentimes due to a fall, multiple falls. So, they've been here more than once. So, if the caregiver has time to think about, for example, if they're planning on being discharged home as opposed to a skilled nursing facility, perhaps that lessens the, quote, unquote, "burden" of responsibility, where they can call insurance, make sure the house is safe for return. So, in more the physical or structural capacity.

Oftentimes, what happens is folks are not always prepared. Sometimes insurance, I would say more than 80% of the time, determines how long someone is staying at a facility, which then can directly, indirectly affect caregiving if they are also, again, aging themselves, working, have other responsibilities, personal responsibilities. It creates this increased stress for everyone that's involved. I think another thing too in terms of caregiving, again, in the capacity of primarily older adults that I see, is finance. Things that we don't necessarily talk so much about. How are we going to finance certain things if insurance doesn't cover it? If there's multiple kids, family members, money is one of the biggest topics that come up. And time. Who's going to care-take so-and-so, and to what capacity, if it's not in a skilled nursing facility?

Another thing is, which comes up quite often in working with older adults, is what they call decision-making capacity. If there's sort of two major, and I'm speaking about it broadly, if so-and-so, Mr. Smith is unable to make decisions for himself, first of all, how are we determining that, and what decisions? So, say Mr. Smith, he recovers from rehab, he's like, "I'm ready to go home," and there's questions about his cognitive capacity. Who's making those decisions about where he goes next? How are those decisions being made? It's not always that clear cut, I'll tell you that. It looks pretty on paper and in textbooks, but in reality, things are moving fast.

So, considering also that individual, Mr. Smith's sense of autonomy in this process. If so-and-so has decision-making capacity, is able to, to some extent share an awareness of why they're in a facility, what they're being treated for, that then directly, indirectly affects caregiving capacity. Are we allowing Mr. Smith the opportunity to say, "Hey," and this comes up a lot, "I would rather just go home"? And they're saying, "I'm not sure we have the time or ability to care-take." Then what? If someone has the ability to speak for themselves and the caregiver is saying, "I'm so overwhelmed," what do you do?

These are family conversations that oftentimes I think bring about a lot of tension for the caregiver, anyone involved with caregiving Mr. Smith. So, I think that comes up quite a bit. And the autonomy part, is caregiving means helping someone to get through X in some capacity, and I think with that, sometimes Mr. Smith may lose his voice at times, assuming he has that capacity. And even if he has, say, mild cognitive decline, he still has feelings. So, it's thinking about how... Caregiving, it goes two ways. Caregiving also means recognizing, preserving someone's autonomy, and it's little sometimes, right? It's allowing someone to eat on their own or maybe they make a little bit of a mess, and it's not the end of the world. So, I think those are big themes.

Adithi Jayaraman:  Yeah, it shows caregivers go more beyond just caregiving physically, but also emotionally, spiritually, mentally, and that's definitely a large feat to hold.

Ami Shah:  Oh yeah.

Adithi Jayaraman:  Perfect. Thank you. And then in terms of caregiver burnout, can it be prevented, or what are some steps that a person can take to reduce it or to prevent it coming on?

Ami Shah:  That's a good question. I think it's quite complicated, again. To your first point, can it be prevented? I guess that's like saying anything else that could be prevented, is who knows? If we were to think about it, if it's something that's more abrupt and sudden, someone caretaking, say someone falls and then they're working and they're not expecting their mom, for example, to fall, and suddenly they're in this capacity, there's a shock factor, one. Emotionally coping with, "Mom fell, oh my gosh. Maybe I'm aging as well." Again, context on both ends.

In that moment, I think number one is seeing if you can have at least someone to talk to in that moment in time. If it's a friend, family, a therapist, it doesn't matter. In some capacity, having a place that isn't mom, because you're both going through this thing together and perhaps you both need an outside person or professional, that would be my opinion, others may say otherwise, to kind of walk through that. And number two, the structural, which is calling insurance and making sure, because a lot of the distress comes from, "Is this covered? Is this not? What do we need to pay for?" A lot of stress comes out of the finance, like I was saying before. So, the stress can be by educating yourself on the insurance policy. These are very real stressors that come up.

So, I would say prevented, who knows? It depends on what you're going through at that time. I have some caregivers who, before they even fell into the role of caregiving or perhaps chose to be a caregiver, they already had a therapist. They already had a solid group of friends and a spouse, partner, whatever, and they tend to perhaps at least emotionally feel a bit more sound. So, I think the prevention part, it's a tricky question, because I think at large, we need to do a better job with understanding what contributes altogether with folks' distress, even before they're in the caregiving capacity.

Oftentimes, a caregiver capacity can exacerbate existing stressors. If someone has a history of depression, for example, and then they come into this caregiving capacity, whether it's suddenly or even over time, depends on the severity of it, how stable mentally are they feeling before taking on this pretty large responsibility? It's almost like caretaking a child. I'm not sure if that answers the question, but...

Adithi Jayaraman:  Yeah. No, makes sense.

Ami Shah:  Yeah.

Adithi Jayaraman:  Yeah. No, thank you.

Ami Shah:  Yeah.

Adithi Jayaraman:  I think that's very interesting. I think that even the finances you brought up, that's something I think that not many people talk about, and I can only imagine how much, if you're abruptly placed in that role and you have to figure out the whole healthcare system in a few days.

Ami Shah:  Right. It's a nightmare.

Adithi Jayaraman:  Yeah.

Ami Shah:  It really is, because even if the caregiver is in the healthcare field, I mean, it took me at least two years with time to really understand health insurance and how it works. These are things that even if you're in school as a mental health provider, we're not taught how to. And insurance, it's all about billing, and that then directly, indirectly affects caregiving. If insurance isn't going to cover certain services, such as physical therapy, which comes up a lot, physical therapy, is Mr. Smith better going to a facility that offers that? Is that covered? That then affects the caregiving quality of life, and for Mr. Smith. So, that's a difficult job.

Adithi Jayaraman:  Yeah, definitely.

Ami Shah:  You know?

Adithi Jayaraman:  Yeah. There's a lot of infrastructural forces that are-

Ami Shah:  Oh, sure.

Adithi Jayaraman:  Yeah.

Ami Shah:  Yeah.

Adithi Jayaraman:  And then in terms of once a person is no longer a caregiver, do you tend to see that they normally just bounce back, or there's some rebounding or burnout continues? What have you seen post that caregiver position?

Ami Shah:  That's a good question. I'm not sure I'm equipped to even answer that, because I'm not necessarily seeing folks post-caregiving. I primarily see them when they're in the moment.

Adithi Jayaraman:  In the moment. Mm-hmm.

Ami Shah:  If I were to imagine some folks that have taken on caregiving as their sole responsibility, I imagine if Mr. Smith ends up and it's sort of this informed decision where they've discussed it and he has that capacity to make a decision and agreeable to it, I imagine things might be a lot lighter, in this sort of picture-perfect scenario. Which is great. Doesn't always work that way. So, maybe I said this a million times, but the context is important at that time. So, again, burnout is a certain point in time. It doesn't necessarily mean they feel that way at all hours of the day.

Adithi Jayaraman:  Yeah. No, that makes sense. And you mentioned how a lot of preexisting mental health concerns get exasperated by this caregiving position. So, when you treat caregivers, do you oftentimes, it goes beyond just talking about caregiving, goes into some of their root fears or concerns that are brought up by the responsibilities they have as a caregiver?

Ami Shah:  That's a good question too. I'm trying to think back to when I first started doing the phone interventions. Well, it was part of a research study, I should add. The research study is about focusing on caregiver distress, so we did talk about, it was primarily about caregiving as opposed to even, are you saying even going beyond the caregiving and talking about their own needs?

Adithi Jayaraman:  Yeah.

Ami Shah:  Yeah, that's a good question. In the capacity that I've seen folks for caregiver distress, not so much. More recently, I did speak to an individual who was caregiving her husband who had aphasia, but this individual already had a therapist, and so it wasn't my place to sort of-

Adithi Jayaraman:  Oh, yeah. Yeah.

Ami Shah:  So, we just focused on the spouse. But I think the times that, I'm trying to think too, there have been times where I've suggested they speak to someone. It depends on the capacity and the setting you're seeing someone in. So, for example, when I was at the VA, it was a research intervention. It was protocoled. It was a bit more like session one, session two. That's not reality all the time. At the nursing facility I work at now, obviously the patient many times is the primary focus, and if they're unable to, in this case, this gentleman with his aphasia was having trouble with speech, is when I sort of went to the caregiver and to kind of see the best way to support him. So, again, our focus was on him.

Adithi Jayaraman:  Yeah.

Ami Shah:  And she also had shared she had someone. But it's certainly, to your point, it's a great idea, I think to explore. And this is more short-term acute care.

Adithi Jayaraman:  Yeah, yeah.

Ami Shah:  I seem them one to five times. This isn't long-term therapy.

Adithi Jayaraman:  Exactly, yeah.

Ami Shah:  And a lot of times in these settings where you're meeting caregivers, it may be in a hospital setting. Not always. Perhaps I'm just speaking to my own experience. If you're in a setting where you're allowed to and you're able to, and again, see someone beyond just the patient, you can explore if it wouldn't be conflicting to see the caregiver as well, or perhaps even provide them resources if you're unable to for whatever reason. So, yeah.

Adithi Jayaraman:  Wow. Thank you. And just one last question. How has your work changed post-pandemic? Have you seen some significant changes in the caregiver field and just generally mental health-wise in regards to caregivers?

Ami Shah:  I think that question is a great question, and it's complicated, because I think post-pandemic, it's hard because there could be a number of factors. I'm not sure I can just pinpoint the pandemic as the only factor, but I think as human beings, which then of course translates to caregiving to some extent, and with increased use of technology and social media, think of climate change, I mean, there's obviously all the things happening in our world, there's sort of this increased, I should say decreased distress tolerance capacity as human beings.

And so for example, in the setting that I'm in, sometimes when someone wants something, whether it's the patient or the caregiver, they want it now. And yes, of course, there's certainly, if it's an emergency, it's a crisis, that's understood. That's a given. But it's sort of a top-down effect. It's that all of us are experiencing this sort of vortex of, "You need to get this done right now or else," in some ways, because of inflation. But things are more costly now for folks. So, if things are more costly, then I'm going to have less time to spend caretaking Mr. Smith, and then Mr. Smith gets less from me as his daughter, then that sort of creates that trickle effect. So, the economy, the environment, I think perhaps we're just sort of aiming for good enough. Perfection is sort of an illusion here. So, as long as we can say, "Hey, am I doing enough today? Am I able to at least accomplish what was necessary to get done today?" and just leave it there.

Adithi Jayaraman:  Yeah, definitely. And I think that mindset just applies to all of us and-

Ami Shah:  Yeah.

Adithi Jayaraman:  ... the capacities we're functioning in. Yeah.

Ami Shah:  Absolutely.

Adithi Jayaraman:  Definitely. Well, thank you again so much for your time. I really appreciate you being part of our interview series. Yeah, and I'll leave it there. Thank you again, and best of luck with your future endeavors.

Ami Shah:  All right. Thank you.

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

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

Psychotherapist Rachel Kuras on Integrated Therapy

An Interview with Psychotherapist Rachel Kuras

Rachel Kuras, Psy.D., LMHCA is psychotherapist at Seattle Anxiety Specialists. She provides therapy for individuals and families, and helps clients of all ages - including children. Her clinical work focuses on: trauma, attachment, gender & sexual diversity, family conflict, grief, anxiety, depression, and ADHD.

Kate Campbell: Hello, everyone, and thank you for joining us for this installment of The Seattle Psychiatrist Interview Series. I'm Kate Campbell, a research intern for Seattle Anxiety Specialists, PLLC. We are Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us Dr. Rachel Kuras, a licensed mental health counselor associate who recently began working with the Seattle Anxiety Specialists as a psychotherapist.

Since graduating with a doctoral degree in psychology from Pacific University, Rachel has trained in trauma-focused cognitive behavioral therapy, acceptance and commitment therapy, and attachment therapy and commitment regulation. Prior to joining SAS, Rachel completed an internship through Idaho Psychology Internship Consortium, where she provided in-person, individual psychotherapy for children and adolescents, comprehensive neuropsychological assessments, and comprehensive diagnostic assessments. Welcome to the interview series, Rachel, and thank you so much for joining us.

Rachel Kuras: Thanks for introducing me, Kate.

Kate Campbell: Of course. So before we get started, can you tell our listeners a little bit about yourself?

Rachel Kuras: Yeah, so my name is Dr. Rachel Kuras, formerly Rachel Rower. I changed my name this year. I grew up in Tacoma, Washington, and I was a graduate from University of Washington Tacoma campus, where I majored in psychology and obtained a minor in global engagement. Directly out of undergrad, I pursued my doctoral degree from Pacific University in Hillsboro, Oregon. And the fifth year of that program was an internship in Idaho, where I worked at Pearl Health Clinic, as you already described. So a lot of what I'm saying is repeating what you already said.

But yeah, aside from pursuing my degree and being a student for most of the time that I've existed, I really love my pets. I have a cat who is a calico polydactyl cat, meaning that she has extra toe beans, so she has thumbs, which is really fun. Her name is Pickle. And then I have a dog who just turned six last week, and her name is Daisy. And I spend a lot of time with them. I'm a huge animal lover. And I really enjoy backpacking and hiking, which unfortunately I haven't done very much in the past five years. Graduate school takes up a lot of time and energy, but I'm getting back to it.

When I graduated high school, I worked in Yellowstone National Park as a room attendant for a summer. And I really enjoy going back to Yellowstone, spending time in the Tetons. But at heart, I'm a Pacific Northwest person. So yeah, I like national parks. I enjoy playing music recreationally. I sing recreationally. I also like gaming, but I'm kind of a cozy gamer. My favorite games are Animal Crossing, Mario Party and Stardew Valley.

Kate Campbell: Yeah, no “Call of Duty” or anything along those lines.

Rachel Kuras: No, I like games where I can catch fish and garden.

Kate Campbell: That's awesome. And I love that where you went to school for undergrad is where you are now a psychotherapist. So that's really cool that you continue to get to work in the same area. And on that note, I think it's just a cool thing to be able to see different parts of the Pacific Northwest, but I was wondering, what's your favorite part of being in the Seattle area now?

Rachel Kuras: I have been so grateful to be in Seattle. Growing up in Tacoma, Seattle was a north neighbor. So I spent a lot of time here growing up, and I missed Washington very dearly when I was away. Right now, my favorite part of Seattle is my neighborhood. My childhood best friend lives just like a five-minute walk away from me. So I've been moving around and away from home for a while, and now I have a best friend close by. So I've been enjoying going on walks with our dogs and just spending time in a neighborhood near people who I grew up with, which is really nice.

I also love Olympic National Park. The Olympic Peninsula is just magical, and the Puget Sound. I remember growing up, I heard stories from my dad about whales coming through the Puget Sound in the past, and I was like, "Oh, that would be so cool. I want to see a whale so bad," but not like whale watching. I want to just see a whale by chance. That sounds funner. And now they're back. They're coming through the Puget Sound, so I'm hoping to get to see them. But yeah, I love the ocean and I love the mountains, and the Pacific Northwest has it all.

Kate Campbell: Oh yeah, that's awesome. That's what I miss about the Pacific Northwest since moving back to the East Coast, so I totally know what you mean. So I was wondering what else got you interested in being a therapist? So you talked a little bit about loving where you grew up and being happy to be back in the area, but what else in terms of your experience growing up made you interested in therapy?

Rachel Kuras: Yeah, that's a big question that I could probably talk about for hours. I think to narrow it down a little bit, I had a lot of experiences growing up that really highlighted the importance of mental health literacy and access to mental health services. My experiences of being human and my experiences of suffering have fostered an interest in what it means to be human. And I really value every person that I work with sharing their individual experiences with me.

So ultimately, I have struggled with mental health myself, and mental health struggles significantly impacted my family growing up. And I saw multiple therapists as a teenager, and there was one in particular who really inspired me, and I was like, "Oh, that's who I want to be when I grow up." And I did it. So I think having access to quality mental health services is something that I'm really grateful for and I was very inspired by. And mental health is something that impacts literally every human. I think that, that did inform my interest in child and family work and in trauma work, with my own experiences growing up.

Kate Campbell: Awesome. Thank you so much for sharing. I was wondering, so what areas or disorders do you specialize in?

Rachel Kuras: So, I have the most experience working with people who have experienced childhood trauma, so post-traumatic stress disorder (PTSD), and other specified trauma-related disorders, and also anxiety disorders, like generalized anxiety, social anxiety. I've worked with lots of kids experiencing separation anxiety, and I've worked with a few people experiencing selective mutism, so kind of the whole anxiety disorders chapter of the DSM. And right now, I'm currently working on increasing my competence in obsessive compulsive disorder (OCD). So trauma and anxiety have been my main focus, and I am expanding my competence working with people who have been diagnosed with OCD.

Kate Campbell: And it's interesting, because I feel like a lot of the times therapy is hardest for people that have anxiety and your OCDs, because opening up about those kinds of disorders make people feel extremely vulnerable. And then getting to know a new person, especially a new therapist, there sometimes can be a wall up. So I was wondering, what's your treatment approach when you're going into those kinds of situations when you first meet a new patient?

Rachel Kuras: I use a person-centered, integrated approach to treatment. I have training in multiple treatment modalities. I was really lucky to work with a lot of people with a lot of different perspectives and experiences. It's a long sentence that I've strung together to try to summarize my approach. I am an attachment-oriented, trauma-informed, cognitive behavioral, acceptance and commitment, and existential therapist. So that's a lot of different treatment modalities. My approach is to meet someone and go from there. Everybody has commonalities between our experiences, but we also have things that are unique to our own lives.

So I like to start with a conversation. The therapeutic alliance is at the core of my approach, because we know through research that the therapeutic relationship is one of the most important determinants in terms of the outcomes of therapy. So if we want positive treatment outcomes, the relationship is what's most important. And as you were saying, Kate, relationships are vulnerable, especially living with chronic anxiety. So my approach is to start by building comfort, to start by getting to know each other. I'm a feedback-informed therapist, meaning I solicit feedback often, and I try to integrate client feedback actively into my approach. So my approach is pretty flexible. I like to tailor it to client needs, but I also really enjoy acceptance and commitment therapy and existential therapy.

So that was a long-winded way of explaining what it means to be an integrated therapist. But yeah, I draw from a lot of different treatment modalities. I view suffering as a central part of being human. Everyone suffers. And it's a challenge to figure out how to build a relationship with suffering and with being human that feels authentic and genuine. So I like to provide support to people in increasing the amount of internal empowerment that they have over their lived experiences. So I like to help people build a relationship with life, build a relationship with their experiences of anxiety, and find ways to connect with the present moment and exist in a way that feels less laborsome. So I like to acknowledge the role that suffering plays in our lives, and inevitably suffering is there. It's just a matter of how do we think about suffering, how do we interact with our suffering?

Kate Campbell: Wow. That's really awesome. It just sounds so individualized. There's cultural competence, it's empowering. There's just so much wrapped up in that. So I think it's awesome, just all the different facets that you incorporate into your style and your approach, so thank you for sharing it really is amazing to hear.

Rachel Kuras: Thank you. Yeah, I think it can be a little overwhelming to summarize at times. I'm also very interested in liberation psychology. Liberation psychology is an area that I've been trying also to increase my competence. And within liberation psychology, there's this idea that what each individual needs to heal is already within them. So the role of the therapist is to help someone find that within themselves. It's not my job to give advice or to provide answers. It's my job to, if your life is a trail and you're walking on it, to walk with you for a moment and to observe with you and explore that with you. Yeah, so I do really value that individual experience. And I think that there's different value in different treatment modalities, but there's also a thread that connects a lot of them. So I like to see that thread, see where they meet, and try to integrate it in a way that works for my clients.

Kate Campbell: That's super cool. I'm excited to look up liberation therapy after this just to learn more about it. That's really interesting. So on that note, how is your approach with working with children, and what's your favorite thing about getting to work with that age group?

Rachel Kuras: My approach is sitting on the floor. I'm on the floor a lot. I'm coloring a lot, playing lots of games, doing lots of art, and exploring through play. I think that kids are so fun and funny. I'm laughing a lot. It brings out a youthfulness and a playfulness in me that I really enjoy cultivating in the therapeutic space. It's hard for me to really articulate how it's different from working with adults, because I think that all adults were kids once. So there's aspects of working with kids that mirror working with adults, but kids have never been adults. So there's a lot of emphasis on cognitive development and behavioral skills.

And I focus a lot on attachment relationships, working with kids. Another thing I enjoy about working with kids is that there's a lot of wiggle room in terms of their cognitive development. There's more neuroplasticity in childhood, meaning that there's more give. As we grow into adulthood, we often become more rigid in our behaviors and our beliefs and in our worldview. And we're digging deep into the roots of what's going on, whereas with kids, it's not as deeply rooted because there hasn't been as much time for-

Kate Campbell: Within their formative years, yeah.

Rachel Kuras: Yes, exactly. So I think that there's a lot of hope and playfulness. And I'm just honored when I work with kids and families to be a part of that development. And I think these things are true working with adults as well. It's just kind of less at the center of therapy. Yeah.

Kate Campbell: Yeah, I could definitely see that. And then also the family aspect, I assume that when you're working with kids, the parents are going to have a heavier involvement than, say, a spouse would be necessarily, if it's an individual.

Rachel Kuras: Yeah, that's a good point. Working with kids is working with systems, is working with family systems, is working with school systems, is working with the foster care system. So I think that I've also really valued the experiences I've had providing services to kids, in that they give me a big picture of what's happening in the world. I didn't mention this previously, but I take a systemic approach to therapy. So I like to view our internal daily struggles within the context of larger systems. And with kids, you can't avoid that at all. With adults, sometimes one-on-one work, systems is just as important. And since you're not doing as much collaboration necessarily, you're not thrown into that systemic involvement in an individual outpatient setting with adults as much as with kids.

Kate Campbell: Yeah, that makes a lot of sense. And I know that over time there may be different changes in the way that you would approach both your therapy with children and adults. So I was wondering, what was your favorite part about your initial training, and then how has your perspective changed over time with that, both with different age groups, or how you have to approach your end goal when you're working with each patient?

Rachel Kuras: Yeah, so my favorite part about my training is people. I'm trying to think of the best way to word this. I feel very honored throughout my training to have been trusted by the kids and families that I've worked with, and to see some really pivotal moments of growth, amongst some really pivotal moments of suffering and pain and setbacks and stuckness. I've really enjoyed seeing kids learn about their brains and their bodies and how it works and what's happening when they have an emotion.

And I think a lot of the time when talking to kids, we don't always realize how much they're retaining, but one of my favorite parts of ... I worked with a kiddo for a long time. And I wasn't quite sure if what I was saying was landing. And then at one of our last sessions, it was like they basically described to me what happens in your central nervous system when you're feeling afraid and how they know in their body when their central nervous system is starting to get activated. So I really enjoyed those moments of like, “Yeah, you get it.”

Kate Campbell: The light bulb. Yeah.

Rachel Kuras: “You get it and you're benefiting from it and you're applying it.” And I think sometimes we underestimate kids' ability to do that. So yeah, I really valued seeing those moments of growth. And there was another part to your question, right?

Kate Campbell: Yeah. It was just what was your favorite part about your initial training, and then how has it changed a little bit?

Rachel Kuras: It changed over time. I think that I was a graduate student at a very unique time. The COVID-19 pandemic hit during my first year of practicum. So I had been working with people for about six months and then everything went online. So I think the events that have occurred during my training have really emphasized the importance and the need for mental health services, for quality mental health care providers. And it's been exciting to see more people talking openly about mental health, where in a time where when I was a child, even with my own experiences, it wasn't something that was very openly talked about. We didn't have a lot of information in my family and my neighborhood and my community about what was going on.

So it gives me a lot of hope and excitement to see the stigma around mental health decreasing. I don't think that it will disappear, but it's changing. So I think the things that have happened while I've been in grad school have really emphasized the importance of mental health care, and I feel very honored to be a part of that process. Did that answer your question?

Kate Campbell: It definitely did. It actually carries really well into my next question, because you talked about how much the conversation around mental health has changed and just some of the generational differences. It's really nice to see that kids feel more open talking about some of their struggles. But I was just wondering, so what are some of the ways that you think that the psychology community can continue to grow? You did already answer some of the ways that you've seen it transform over time, but if you have details on that too, I'd love to hear too.

Rachel Kuras: Yeah. I think that there's been an effort to expand access to resources, even just with telehealth, being able to go to therapy from home. Yeah, so access to resources, I think there's been a push for that to increase. I think that will continue to happen. And the COVID-19 pandemic and other large-scale events that have happened over the past 10 years and really over the course of human history, but just viewing this snapshot, it's something we all experience together. So I think that it's been beneficial to have a sense of humanness, to connect in our humanness as a society, whether that's between therapists and client or on a larger scale. I've seen a lot of efforts towards connection and towards valuing ourselves and valuing each other. And I hope to see that continue. And I think it will.

Kate Campbell: Yeah, it's kind of ironic that COVID-19 brought us closer together, but in a weird way, it did too.

Rachel Kuras: Yeah. And I think for a lot of people, it really emphasized the importance of social connection, because working with kids, I mean, the effects of the pandemic have been incredibly destructive on people's routines. And for kids, not going to school is a huge thing. These really essential interactions that were once there weren't there anymore. So I think it, for me, has made me value our connections. And not that I didn't before the pandemic, but it just gives a different perspective and urgency around maintaining connective relationships that cultivate growth and love and acceptance of each other.

Kate Campbell: Yeah, absolutely. And as a final question, do you have any words or advice that you would like to say to our listeners?

Rachel Kuras: Yeah. I think that if you are seeking therapy services for yourself or for a family member, I encourage you to try it, right? Even if there's fear about how it might go, dive in, be vulnerable. There's so much value that each individual person has, and I think it's easy to lose sight of that and feel disconnected from that, and it's easy to be hard on ourselves in this society. So, if you are feeling like you would benefit, even just from having a space to come and be witnessed and be heard, I encourage you to seek out therapy services, try it. And yeah, be vulnerable. Talk about mental health. Don't shy away from subjects just because they've been taboo. Yeah. I think that's it. Be open, dive in, be vulnerable.

Kate Campbell: Yeah, absolutely. Thank you for those words of encouragement, Rachel, and for joining us in our interview series. Hopefully, everyone can take something from this, and thank you all again for joining us.

Rachel Kuras: Awesome. Thank you, Kate, for having me. I'm really  grateful for this opportunity.

Kate Campbell: Of course.

* For those interested in working with Rachel, click on our appointment page to see her current availability.

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

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

CEO RUTH STRONGE ON BUILDING RESILIENCE & REDUCING ANXIETY VIA DONKEY EXPOSURE THERAPY

An Interview with CEO Ruth Stronge

Ruth Stronge, MA is the CEO of Snowdonia Donkey Sanctuary. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. She specializes in helping children, teens and adults build resilience and mitigate various anxiety disorders at her farm sanctuary.

Jennifer Smith:  Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us Ruth Stronge, CEO of Snowdonia Donkey Sanctuary, located in Bangor, Wales. She has a master's degree in environmental and development education, and a master's degree in clinical and health psychology. Ruth was a primary school teacher by training, and with the founding and development of Snowdonia Donkeys, she has been able to combine her passions. Before we get started today, Ruth, can you tell our listeners a little bit more about yourself, and how the rescue organization got started?

Ruth Stronge:  Hi. Well, thank you for inviting me. Yeah, I would say I have a passion for donkeys, and I have always loved donkeys. Maybe about 12 years ago now, there came an opportunity for me to get two donkeys, and I got two little donkeys. I kept them with my daughter who had a pony, and my children were older, my daughter had a pony, and our son was at the village, so we never rode our donkeys. We always took them for walks. And for me, spending time with those donkeys before work and after work were just the best time of the day. I would do it before I'd go to school where I was teaching, so then I was ready for school. And then on the way home, that would be my downtime of reflection. It went on from there and people, our friends that we knew said, "Please, can we come and walk the donkeys with you?"

And then we would bump into people with our donkeys, and they would say, "Oh, it's been ages since we've seen a donkey." And then, people just wanting to come and spend time with our little donkeys. It grew from there in as much as I wanted a donkey to ride, so I got another donkey. And then a group of friends, when we were out walking the donkeys, we were talking and decided if we could help any local donkeys, we would do that. We set up a small charity, and that was just 10 years ago now, a small charity to help local donkeys, and that's how we began, really.

Jennifer Smith:  Wow. That's great. Your website has a large banner that states, "Rescuing donkeys and changing people's lives," and I think that's a pretty moving statement, and I'd like to talk about some of the work that you do there. One of the first courses that you developed was for vulnerable adult learners, so that they could help build confidence by working with the donkeys. Can you tell us a little bit about that? How can caring for donkeys help someone?

Ruth Stronge:  It was a chance meeting with another organization, and telling them about the looking after the donkeys we do, and how volunteers were coming to help us, and how we were working with just giving people opportunities and time to spend time with the donkeys. And it was an organization in the center of Bangor who worked with adults, providing them with opportunities for support if they had mental health difficulties. And I invited their manager to come out and see the site that we worked on, and go through some of the activities that we did of how we managed our donkeys, which was following a simple routine in a quiet place, and basically just really being quiet around the donkeys, and being around each other, explaining to people how some of our donkeys are not used to people, and how we have to approach them, and how we read their body language so that we can support them in the best way.

And it was that opportunity and those conversations that allowed us to run a small program of one afternoon a week for people to come spend time outside with the donkeys. Initially, our volunteers and staff had done all what we would class as the "donkey work", so they'd done all the cleaning out, and the working out, and the feeding. But then just giving people time to brush a donkey and learning which brushes to use, how you would approach a donkey, basically reading body language, as well, of an animal, and giving them the story of the animal, and finding their character was the start of all that then, really. And for some of the people engaged with us, they became more and more interested, wanting to come more often, be more involved with what the animals needed for their welfare needs. And one of the really important things that we took from it was that it was a conversation piece for people. They had something to talk about with other people, what they had done.

Jennifer Smith:  Wow. Oh, that's great. And just for our audience to know, I actually met Ruth when I went for a tour of Snowdonia Donkeys, and it was really fabulous just getting to spend time with the donkeys, and I have to say there is something very soothing about it. Just brushing them, like you said, just petting them, just having that quiet moment, it really is nice. And going for a walk, and seeing beautiful scenery with them is a wonderful thing. I think you've stumbled upon, and definitely have built, a beautiful organization.

Ruth Stronge:  Oh, well, thank you for that. But I would say it's how I want to spend time with my donkeys. I know it works for me. And sometimes when I'm talking to people, if we're explaining the kind of work we do, and with our young people as well, and I would have to say it isn't for everyone, and that's okay. If you are more interested in fast moving things, and you are boisterous, and you are running around, then we are actually not the right place for you to be, because you would frighten the donkeys. And it's a case of, okay, let's take a step back. And our donkeys and our organization is very good at supporting quiet, anxious people, because that's the way we look after our donkeys in a quiet way, building confidence, following routines. And partly that has just evolved, but also my training as a teacher, I was an early years teacher, so the routines and the structures that we put in place to take away too many decisions initially for people were simple things like which donkey you're going to work with.

Well, if you've got a pink brush in your hand, then you are going to be brushing the donkey that's wearing a pink head color. The one in the picture behind me is wearing a pink head color. So you would know, she would have pink brushes, a pink bucket for her feed, and if you were going for a walk with her, she would have a pink lead rope. It sounds simple things, but it takes away anxiety from people if they don't have to ask questions. Some things are just pointed out for them, and next time they come, that routine is built upon.

Jennifer Smith:  Wow, that's wonderful. Through a partnership with Adult Learning Wales, you run an accredited course on animal care, which focuses on supporting young adults. Can you speak about what that entails, and how can young adults psychologically, emotionally, and socially benefit from that course?

Ruth Stronge:  Again, you realize as you do these other, things happen by meeting and talking to people. Behind the scenes, the young people that we work with, or the adults, for them, they don't always know where the funding comes from as enablers to deliver sessions for them. So behind the scenes, it's a bit like a jigsaw puzzle so that they can have the best opportunities. And if they are interested, they can stay as long as they can if we can afford them to stay, and to progress their development. So Adult Learning Wales are a national organization here in Wales that fund accredited and non-accredited courses for people over 16, and we had been delivering some courses that it called engagement courses, which were non-accredited. But working with some of our other young people who had come through us from another grant program which allowed them to do one-to-one sessions with an adult and a donkey, basically just being in a nice quiet environment, having someone to talk to if they wanted to, or just spending time with a donkey.

We were looking for a next step for some of these young people when we identified that for a vast majority of them, they hadn't engaged with the education system at all. They had, whether it be anxiety built on after COVID, or for whatever reason that they had, not been in the education system, so there were no exams, and there was nothing on paper for them to take their next steps. With the program that we had delivering one-to-one sessions, we then built on that, offering them some small group sessions, which for us would be no more than four or five at the most for a few weeks. And then Adult Learning Wales, because myself as a trained teacher, I can be a tutor for them, I approached them and said, "I have this group of young people, who some would like to go to formal college in the future, but I want to be able to acknowledge the progress they've made. And also once the summer holidays comes for some of our other young people, what do they do for six weeks?"

And I wanted them to be able to come and work with us, but we didn't have any funding to enable that to happen. So Adult Learning Wales helped me find a couple of, we would call them entry level modules, so not too high, but requiring some academic input on animal care. We would do things like how to muck out, and how to brush an equine. And the young people that we had focused on having come for one time, one session a week as an individual, and then as a small group, were then asked to apply, we knowing that they would always get on the course, but to give them a formal leading to it, to apply us for a fortnight, coming every day to take part in practical activities and record those activities using photographs and written work so that they could then submit it for an accreditation from one of our organizations, Agored Cymru which accredits their work and then they can build on that.

That was a journey. We've been plotting a journey for some of those young people, and they themselves wouldn't know who had funded their journey, but behind the scenes, we were able to do that. And for our funders, that's interesting as well, because they like to see that it has an impact, which it certainly does.

Jennifer Smith:  Oh, that's really fantastic that you help people to transition in that way.

Ruth Stronge:  And one of the things you asked was about their anxiety and their social skills, so that because they had had those small steps before they got to something that we called education, but we often didn't use that term, then we were trying to look at adding one new thing every time they came. If they were all familiar with the setting, then one-to-one was their first step, be familiar with the setting. The next change would be to work with a small group of people, and then to come every day for a longer period, so trying to increase that confidence, and reduce the anxiety as they took on new things, then.

Jennifer Smith:  Oh, wow. Yeah, that's similar to exposure therapy, correct? And like you said, to lessen their anxiety, the social anxiety and such, that's wonderful.

Ruth Stronge: By the time they got to the accredited side, brushing a donkey was what they would do automatically, so it wasn't the new thing. The new thing may have been recording or talking about what you'd done. So yeah, it's those small steps, and just building on that was really important.

Jennifer Smith:  Ah, fantastic. You also offer one-on-one sessions for those with additional learning needs. What types of conditions is this specifically geared for, and who can benefit the most from these sessions? Would it be people with social anxiety like you mentioned, or general anxiety, or anything else?

Ruth Stronge:  A lot of people with either social anxiety or general anxiety, and we do quite a bit with people with autism as well, who have communication difficulties. Communication difficulties on the side of struggling to verbalize their needs, or anxiety, or shyness, or selective mutism. And again, through following those routines and building that confidence, we've worked with quite a number of young people in that way to increase their confidence. And again, hopefully moving from one-to-one sessions onto small groups. For some of the people that we work with, it isn't always appropriate to do that, but if we can, we can do that, or we would then change or build on the activities that they're doing, so they are being more engaged in different activities. Some of our work, we also work with young people who may have learning disabilities, and may have reduced cognitive abilities, and again, we would match the donkey to their needs.

Some of the autistic people we have worked with are very sensory, some of them like to throw things around, so sawdust moving around the place obviously isn't appropriate for all our donkeys. And so, we've got some donkeys who are very chilled, and don't mind those things happening. But I would say where I find most pleasure is working with people with anxieties, and shyness, and quietness, because to see them make that progress, and to be able to talk, even to their families, about the donkey that they've worked with is just amazing, really.

Jennifer Smith:  Wow, that's wonderful. In terms of the people who have the mutism, as you said, or if they're on the spectrum and not very, or nonverbal, have you noticed where they do become more verbal, or this therapy isn't really applicable for that? Have you noticed a change?

Ruth Stronge:  We do notice a change, yes. And for us, it's trying to not put them into situations where they become more anxious, or it's not putting them in those situations where it makes it more difficult for them to speak. Just by following those routines every time they come, and building a rapport with one of our support workers, and especially with the donkey, then we found almost that the donkey acts as that diversion, that there's someone else, so there's something else to talk about, to be involved with. And then our staff are very much aware of the sensitivities of some of the people we work with, and wouldn't then ask them direct questions. They are very good at supporting the people to shine, and to build on the skills they've got, so almost praising them in a positive manner, using the language of support, and making suggestions together to do things is the way that we tend to build on people's development.

Jennifer Smith:  That's fantastic. And this sounds so perfectly suited for you and your background. It's really wonderful that you've been able to develop this.

Ruth Stronge:  It has just been amazing. Yeah, I feel very privileged to be able to do that, and also then to look around at the other people that I work with and say, "Yeah, I couldn't do it all myself," because there's not enough hours in the day, but we have some lovely members of staff who themselves have maybe been through some of our systems as well, and are able to talk about how working with the donkeys, and following the routines, and just being out in the fields with them doing field work, and then having something to talk about to people. Because we have visitors coming to see the donkeys, and they've got something that they can talk about that they've achieved, they know about this donkey, in a supportive environment. There would always potentially be a member of staff or a key volunteer who would be around, if we saw them faltering or being more anxious, could then step in and support, so that they didn't have extra worries themselves then.

Jennifer Smith:  That's fantastic. Can you tell us about the program that you run with the BBC Children in Need? What is it, and who does it serve?

Ruth Stronge:  Okay. BBC Children in Need is a national charity, a national grant-giving charity here in the UK, and we've had funding for quite a few years from them. And our program for them has always been targeted at young people, so for them, that's under 18, who have social and communication difficulties. And that can be, from our point of view, I guess it started with shy people and quiet people with anxiousness, and that's how we've kept on going with that. We offer them one-to-one sessions for an eight-week period of an hour with an adult and a donkey, in a quiet period of our week. And then, if they are keen to carry on, then we offer them small group sessions for a longer period. So that, again, a bit linking what you were saying back to the exposure therapy, they are quite familiar with the donkeys and the donkey routine when they've done the one-to-one sessions for six to eight weeks, and wanted to come for longer.

The only thing that is different then is there may be more people around. The staff tend to be the same, so they've got familiar people to support them. They know the donkeys. It's just extra new people, then, and that seems to work quite well. And those groups then go on as they get older, and we've had some people with us for quite some time now, so we've moved to being volunteers, or we call them supportive volunteers. Again, they are supported by key staff, funded by Children in Need, familiar adults who know or are aware of their own personal needs. But the older young people then, one of the targets is to take our donkeys to a local agricultural show, and show the donkeys to be part of something bigger, and that works really well. We do that as a day out, so they take the donkeys out for the day.

The show is a four-mile walk to get to, so they have to come the day before and get the donkey ready for the show. Then they have to come early on the day it's happening, walk the donkey to the show, be in the show ring. They will have spent quite a few months actually preparing for all this, but that is on those following through, and that's what we aim for them to be part of, so that then, again, following the journey with Children in Need, then they can be active volunteers then, in some respects giving something back to us, as well as their own lives then.

Jennifer Smith:  Wow, that's a fantastic cycle. Like you said, people get help, and then they help others, and it's just a wonderful thing.

Ruth Stronge:  It's really important for me behind the scenes, to provide that route for people. And I guess that's not just my teacher background, but also the psychology side of it is where do you go? Where is your journey on it? And I would say that I actually do that for all the donkeys as well. They all have a learning journey, too, and targets that I need them to achieve, and things that they can be good at, and stuff like that. But if the young people or the adults coming to us on the one-to-ones are making progress and want to stay with us, then we discuss with them those journeys we would like them to be able to take, if that's what they want, and how we can best support them on that.

Jennifer Smith:  Wow, that's wonderful to have those specific goals to try to reach for, if they're able and want to. One thing I saw on your website was that there was a video showcasing the experience of Zoe, who is 16 years old. Can you tell our listeners a little bit about what she experienced in life, and why time at the sanctuary has been essential to her mental health? And this is just one story, but I think it really signifies what your sanctuary can do to help people.

Ruth Stronge:  Yeah. Zoe has been with us for quite a few years now, and when she first joined us, as with all our children funded through BBC Children in Need, we asked them to be referred to us by a professional working with them. That could be a school nurse, it could be a teacher. We have something we call CAMHS over here, which is Children and Adolescent Mental Health Services so that we had some kind of filtering system, and we'd sent information to our school nurses and CAMHS, and also I often will give talks to the local authority, and give them some examples so that we work with the right people, so that we can have those best outcomes for ourselves, and for the people we work with. And Zoe was referred to us by CAMHS. She had moved to Wales just before COVID time, it was. She'd moved to Wales with her mother.

It was a one-parent family, and moved to quite an isolated place in Wales, as well. Quite in the countryside, quite remote, but didn't go to school, so was homeschooled as well as moving to a new place with one parent. And so Zoe came to us doing one-to-one sessions for her eight weeks. We had to let Zoe know before she came which donkey she would be working with, which adult would be there, reassure her that the adult would be waiting for her when she got there, again, to remove all those anxieties. And we actually sent her, before she came to us, a picture of the donkey she would be working with, so that she had some knowledge of what she was going to be doing. We knew that Zoe liked animals, and this was a good opportunity for her.

After her one-to-one sessions, she wanted to carry on coming, which was wonderful. And so, she joined a group that stayed for more, so she came from morning session again, five or six children at the most, with adults that she had met. But again, those preparation time and the information, so she knew what was coming, who she would be working with. Zoe had quite a lot of anxiety, as it sounds like, obviously when I'm presenting that to you, quite a lot of anxiety. And her anxiety would not only manifest before she came, but also during sessions, as well. If there was going to be something new happening, we would tell her beforehand.

There would be a lot of demonstrations. If it was maybe learning how to tie the donkey up, then a lot of demonstrations, let her do it without being watched, because she found that very anxious to be watched, or if she felt she wasn't achieving it, or couldn't get it right. A lot of support for Zoe in that way, repeating, and again, positive reinforcement, the things that she had done right, and then taking those small steps.

Zoe came when we were talking before about the two-week course. Last summer, Zoe came on that course for two solid weeks and she had never been... She was 16 then. She had never been in education since 11. That was the first time she'd ever done anything like that. In order for her to get support at college, which she then managed to go to college on the basis of having spent a fortnight with us and could demonstrate to college that she could commit to something, and was able to do that.

She had to have a psychology report, an educational psychologist's report. And what I personally found quite touching, and also quite a big responsibility, is that we were actually the only outside organization involved with that child, because she was homeschooled, didn't attend anything. There was nobody else to talk to the psychologist about her needs, and how best she learned. I spent a lot of time with the team that would've been supporting Zoe when she moved on to college, with the local authority, explaining how we supported Zoe. And again, I would say had I not been in the profession I was, I wouldn't have liked to have taken it on. And fortunately for me, the psychologist who was assessing Zoe, I knew her from school. She used to be my Ed Psych in school, so it was like, oh, that's great. We knew the language we could talk, which was really useful.

Having set that up for Zoe, and then her doing the two-week course, she was keen, and as she said in the little video clip, she was keen to start college, and excited to start college. And she has now just completed her first year at college, and has had really good attendance, a few ups and downs along the way, as most teenagers would do, but was very pleased to have finished her first year, and be accepted into the second year. We are just so pleased for her.

And the time with the donkeys, when you listen to her talking about it, she has a favorite donkey, and that's the donkey she's drawn to every time she comes, and the conversations that she would have with that donkey to help her work through some of her anxieties, and also helping him to work through some of his, because sometimes, we ask our donkeys to do things they don't necessarily understand. And it is those conversations that are helping the children or the young people that we're working with understand why we're doing this with the donkeys, and how do we teach them to do that, enables them themselves then to think about themselves, and how they can move forward as well.

Jennifer Smith:  Oh, wow. I recall also in the video, and correct me if I'm wrong, that Zoe was initially homeschooled due to bullying, and she developed some severe depression. And it sounds like because of the social support that you offered her as an adolescent, which is really critical to maintaining good mental health, that she was able to really develop great resilience. And, like you said, now she's in college, whereas before, it sounded like her life was almost at a debilitating level, where she was unable to really just get out there and function with others.

Ruth Stronge:  Yeah, it is amazing when you listen to what she says that we were the only place she would come, and then small number of people around her was all she could cope with. She wouldn't talk to anybody else. And some of the young people that we work with in BBC Children in Need who did that video always ask us can we give them a case study? They'd asked before, and Zoe wasn't ready to talk, because, and this is something we've had on a couple of occasions from our young people, when I come to the donkeys, this is special and I don't want anybody to spoil this, so I don't want to tell people at school, because that isn't a nice place where I want to be. This is my safe space.

For Zoe, on a number of fronts, it was very brave of her to talk about, not just what she had been through, but then almost that this is what she does, and she loves what she does, and she's a wonderful advocate for it. But it was an incredibly brave thing for her to do. And the amount, like you say, her resilience, and how far she has come is all credit to her. She's worked really hard.

Jennifer Smith:  Oh, fantastic. And the donkey that she likes is Norman, am I correct?

Ruth Stronge:  No, that's Walter. It's Walter.

Jennifer Smith:  Oh, Walter!

Ruth Stronge:  She likes Walter, and she says they have the same birthday. They're exactly the same age. Yeah, he's her favorite, and she does have a special relationship with him. He can be, as most animals can sometimes, he can be quite cheeky, and she won't stand any nonsense from him. One of the wonderful things that they did with this group of donkeys, and she was in charge of Walter, is one of the walks, I know you went on one of our walks, and one of the walks that we do, there's a little bridge going over a small stream, and if we could cross the bridge, we can go on longer walks.

But Walter couldn't cross the bridge. He just couldn't cross over this bridge, because of the running water underneath it. He was quite frightened. And for long, I'm saying years here, we would stand and look at this bridge. And one day I was on site, but I wasn't leading the group that Zoe was with. I think there was four young people with one of our other members of staff. And apparently, they'd gone out for a walk, and I knew they were due back at a certain time and they were late coming back.

As you do, I was worrying, where had they all gone? The parents were arriving, and they all came back laughing, but very late. And I said, "So, where have you been?" And Zoe said, "Well, I just said to Walter, 'today is the day we're going to cross that bridge. Sometimes, we have to do things like that. It's hard, but we can do it.'" And she got him to cross the bridge, and they all went over the bridge and could go for a walk. But he couldn't come back over the bridge, so they had to walk the long way round. They were all laughing. These young people were just howling with laughter that they've managed to do this with Walter, and Zoe had been wonderful and got him over there, but he said once was enough.

Jennifer Smith:  Oh, that's wonderful. And what a fulfilling experience for her to be able to get across, at least that one time.

Ruth Stronge:  He will go now. Next time, he was fine. He was just once was enough on that day. Because we do say to him now, "Zoe, are you going over the bridge?" and she says, "Yes, and we're coming back over the bridge, too."

Jennifer Smith:  So Walter had his own exposure therapy, it sounds like.

Ruth Stronge:  His own exposure, but for her, when she was saying to him like, "Walter, we look at this so often, we are going to do this bridge now." And that was just like, yeah, you are an amazing young woman to be able to say, yeah, I'm going to do this, and do it for herself, and for him. So, yeah, it's lovely.

Jennifer Smith:  It's very empowering. That's wonderful. Thank you. During the pandemic, you started a Long Ears Listening Project. I know donkeys have long ears, but what is this project?

Ruth Stronge:  Long Ears Listening is really all my passions all in one place, which was quite a privilege to do. As an early years teacher, when I left school, I knew I still wanted contact with young children. We do a lot of work with young people and with adults, but young children is an interest I've taught all my life in the early years, we would call it here in the UK, and outdoors and environmental education is my other interest.

When I left school and worked with the donkeys full time, when the pandemic came, we have a lovely patch of woodland that we manage, and it was used a lot during the pandemic by people visiting. I would leave activities and resources in for people to use, and then when we could meet together, we started a formal parent and toddler group for parents, and it's outdoors in the woods, and the donkey comes every session and carries some of the resources. With a focus on language and literacy through storytelling, then, we have a group of parents who meet every Monday morning and share time together. And whilst it is an emphasis on language and literacy for them, it's also a time for them to get together and just be outdoors enjoying themselves, and giving their babies and young children exposure to nature, access to animals, in a friendly, supportive environment.

Jennifer Smith:  And the benefits of nature therapy, or ecotherapy, like you said, just spending time in nature, and then you're with an animal, and then there's the reading... It's just beneficial on so many levels.

Ruth Stronge:  It's been a fascinating journey, that one, as itself has developed, too. And we have a small number of songs that we now use every time we meet in Welsh, so that we are then doing that bilingually for them. And they are about donkeys, obviously, so we do a few counting rhymes that we have. If you've ever met early years teachers, they'll sing to anything, a song, a counting song or anything like that, to a familiar tune, so we've made up a couple of songs that we sing about donkeys to start it off, and just a relaxing place for them to be out there. And they all have a little activity bag, which would have some sensory activities in, and a book. And again, that bit started with COVID when we couldn't share resources the same, so everyone had to have their own resources, and we actually just kept that up. If the child is not old enough to walk around, they've still got activities that they can do and interact with their babies with, then.

Jennifer Smith:  Oh, that's great. This has been extremely informative, and I think this time has unfortunately flown, for me, anyway. As we wrap up, is there anything else that you'd like to share with our audience about the sanctuary, or anything else mental health related at all?

Ruth Stronge:  Yeah, I think one of the things that it makes me realize is that I started it probably by accident, and because I know the benefit I got from being with the donkeys, and stroking them, and mucking them out before and after school, and then part of my work, making time to be out of doors in nature was so important to me, personally. And to be able to offer those opportunities to other people that, as you said, I went back to Uni to do my clinical health psychology degree, because I'm thinking, I don't want to just be the person that says, "I know it's good, and it really is nice." I wanted to embed it in the research, really. And we still work with Bangor University to try and get the psychology students to use as case studies. And for us, it's often another pair of interested hands as well.

But we're really keen that the work we do is the best it can be, not only for the people we work with, but to give the work that we do with donkeys, who often get quite a bad press, or are often looked down upon, and they're very hardworking animals, to give them a value as well. Because it just doesn't happen by accident. If it looks from the outside that it's easy, then sometimes, I think, well, actually that means we're working really hard, and it is working well. But behind the scenes, all that theory, and the small steps, and the thinking about how people need to move forward, and how we can help them do that is important. And I guess I would also throw in as well that for our staff and volunteers, we try to make time for them always to have what we would call "donkey time," so that they have their own mental health moments where they can just be with the donkeys, and enjoy doing those things and being in the moment with them.

Jennifer Smith:  Oh, that's wonderful. For our audience listening, for those of you who are local, or plan on traveling to Wales or the Bangor area, we're definitely going to link up in the interview so people can check out your website. Also, learn about different ways to support your group, sponsorship opportunities. I know you have some wonderful little knitted donkeys. I forgot to bring mine. (*photo at bottom of page)

Ruth Stronge:  I forgot to leave one out as well. Yeah, should have done that.

Jennifer Smith:  Yeah, different ways to support you guys and this wonderful mission that you're doing, that's helping both donkeys and people in a really wonderful cycle. So, again, thank you Ruth Stronge, for speaking with us today. And tell Jenny the donkey that I said hello. That was my friend that day. And we wish you all the best.

Ruth Stronge:  Thank you very much for the opportunity to talk to you, and we would love to see people over here. It'd be amazing.

Jennifer Smith:  Thank you.

Jennifer Smith with Jenny the donkey. (left)

A souvenier “knitted donkey” from Snowdonia Donkeys posing for a picture near the sanctuary in Bangor, Wales. (right)

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

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

Social Psychologist Sharon Goto on the Mental Health of Asian Americans

An Interview with Social Psychologist Sharon Goto

Sharon Goto, Ph.D. is a Professor of Psychological Science and Asian American Studies at Pomona College. She specializes in Asian American psychology, cross-cultural psychology and issues of intergroup relations.

Kaylin Ong:  Thank you today for joining us for this installment of the Seattle Psychiatrist Interview series. I'm Kaylin Ong, an undergraduate student at Pomona College, and a research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us Dr. Sharon Goto, Professor of Psychological Science and Asian-American Studies at Pomona College. Dr. Goto has a PhD in social psychology with minors in industrial and organizational psychology and quantitative psychology, and has also published several papers within the field of Asian American and cross-cultural psychology.

So before we get started, can you please let us know a little bit more about yourself and what made you interested in studying Asian-American psychology?

Sharon Goto:  Thanks, Kaylin. So happy to be here. I’ve taught at Pomona College in Asian American psychology and Asian American studies and psychological science department for over 25 years. Currently, I am chairing the Department of Asian American Studies, and I have been teaching a class called Asian American Psychology. That is one of my favorite classes to teach along with some other classes. It's been really fun to see how the field has changed across the years. I also do research and my research is generally trying to understand how bicultural individuals navigate different cultural worlds, different racial worlds, and trying to understand the psychological processes related to that. And in addition to that, I guess, let's see, my pronouns are she/her, and I have a lovely family, my husband and two daughters who are currently home right now back from college and my two adorable stray cats. So happy to be here.

Kaylin Ong:  Yeah, thank you so much. So your research explores the prominent role that culture plays in self-construal. Can you explain what this means and talk about some ways you studied this in the lab setting?

Sharon Goto:  Yeah, so self-construal is a way that people kind of define or think about themselves. So it's a series of different theories about that and there's been a lot of empirical work on it. And it's slightly different from the way that Freud, for example, would learn about them, the self and just sort of through introspective techniques, it's more empirically driven. So there are some theories that talk about the difference between the ought self, the ideal self, the actual self. There are some distinctions between the public self, the private self. What I'm really interested in is the differences in the distinction between the interdependent self and the independent self. In some ways that I studied or has been studied and I study as well is we look at, for example, just simple self-report, for example.

So, you could ask a person to measure the level of interdependent self-construal. How important is it to include other people when you're trying to make a decision for independent self-construal? It's really important for me to make decisions on my own, agree, disagree, how much agree to that. So that would be different ways to tap those using self-report measures.

And the reason why it's such a big deal to look at interdependent independent self-construal when you're looking at cross-cultural research is because it actually predicts a lot of variance in behavior and attitude. So it really turns out to be super important when you're looking internationally, globally as well as within a particular culture. And there are also more experimental ways to understand self-construal, like using electrophysiological measures and trying to understand the way the brain is processing information differently based on their cultural orientation of interdependent versus independent self-construal. So it's not alone. There are many people who have come before me. It's really, I think, a super interesting construct that has really stood the test of time.

Kaylin Ong:  Yeah, that sounds really interesting. I think cross-cultural psychology is such an interesting field and has so much depth. So yeah, thank you so much for sharing. So on that, cross-cultural research often uses the phrase collectivist versus individualist to talk about, for example, cultural differences. Can you explain what these two terms mean and also give some examples of how this might manifest itself in human behaviors and attitudes?

Sharon Goto:  Yeah, so if you're not familiar with the terms independent and independent self-construal, you might be familiar with the terms collectivism and individualism. So that's probably a more well known, maybe more interdisciplinary approach. It was probably one of the entrees into psychology about how culture was first studied. And it does look at the amount of importance the group carries over the individual. So collectivism is more cultural level and individualism is more cultural level or aggregates of people level constructs. So groups of people can be more collectivist in nature, more group oriented or more individualistic in nature or more self-oriented or individually driven. And it turns out some important things are, for example, the way that rewards are distributed. It's very interesting. It varies very much by collectivists versus individual orientation, for example, in terms of how people think reward distribution is fair or not.

So, for example, collectivists might be very happy if rewards are distributed equally within your group. So, everyone gets $5 and that feels good. Versus individualists might tend to be more what's called equity based. So, they want to earn their money, so they're really okay if some people that do more work get $10 and other people that don't do the work get $0. So, it's a different way of distributing and a different way of really defining what is fair. And it's really interesting that the very notion of what is fair is actually culturally driven and understood by collectivism versus individualism, for example.

Kaylin Ong:  Thank you. I had a quick question. So collectivist versus individualist. I think a lot of the times I've associated, for example, collectivism with East Asian cultures or just eastern cultures in general, and then Western cultures are a little bit more individualist oriented. Would that be correct or accurate to say?

Sharon Goto:  Yeah, so there have been a lot of studies that have done, starting with Hofstede’s original studies, looking at the amount of collectivism versus the amount of individualism in different nations. And you're exactly right. So East Asian cultures tend to be more collectivists and less individualistic. And Western European, North American cultures tend to be more individualistic and actually more individualistic than basically the entire world. So very much outliers. And I do want to say that although it's important to understand the idea of individualism and collectivism at the aggregate level, there's analogous to interdependent and independent self-construal at the individual level. So collectivism tends to be comprised of people that have high interdependent self-construal individualism tends to be comprised of people that have high independent self-construal. But it's also really important that you have that distinction because just because you're in North America doesn't mean that you're necessarily individualistic. You could have very strong interdependent self-construal tendencies as well. Does that make sense? So it really allows for that's not just so essentialized that you really do have a broad representation.

Kaylin Ong: Oh, thanks for the clarification. Okay, next question. So, one of your most recent publications focuses on cultural priming effects on the N400. Can you explain for our listeners what the N400 is and why it's been an essential component of your research?

Sharon Goto:  Yeah, so the N400 is like a time locked event related potential. So basically what you do is you attach these fancy electrophysiological equipment to the scalp, which people have probably seen. And based on surface level activity, you have some insight in terms of the brain processing, the neural processing that's going on. So basically, what we do is show you stimuli and about 400 milliseconds afterwards, you are getting some gauge of semantic processing, which is the amount of sense making a person is doing.

So, for example, if I were to tell you ‘The boy gave his dog a bone.’ Okay, that makes good sense. Versus, ‘the boy gave his dog a bugle.’ That's a little bit more confusing, and there's probably a little bit more processing that's going on to make sense of that. So it turns out that the semantic processing of information can vary by culture, and it's a more dynamic way to understand cultural differences, particularly for example of bicultural people who might move in and out of different cultural frames. It's also very sensitive, and that's why we have tended to use it in our lab.

Kaylin Ong:  Right. That's very, very interesting. So in your lab, do you collaborate with the neuroscience department or neuroscience students, for example?

Sharon Goto:  Yes, absolutely. So our lab is called the Cultural Race and Brain Lab, and I'm one of the professors and also Professor Richard Lewis who has an appointment in neuroscience. And our students are a combination of people that are in Asian American studies and psychological science and in neuroscience, all interested in culture and the brain.

Kaylin Ong:  Oh, great, thank you. So, you've briefly studied the role of discrimination on the mental health of students of color, and as a professor with a background in organizational psychology, how do you see your findings as being relevant today?

Sharon Goto:  Yeah, that was an interesting sort of study that I had done with a student actually as a senior thesis at Pomona College. Pomona College students are amazing. So it's been known that discrimination is a stressor and it leads to negative mental health outcomes. And what we wanted to do is we wanted to look at the mechanism for that. So we were wondering if one of the mechanisms of being in a stressful organizational setting, so either educational or workplace setting, if that would lead to more psychological distress. And if the mechanism or the reason why that might be the case would be what's called depletion of self-control.

So, the idea is self-control. There is a limited amount of self-control we have. It takes energy to maintain our self psychologically and physiologically. And whenever there's a stressor, it kind of depletes it a little bit, and one of those stressors could be consistently being in a hostile environment or an environment where you have to be wary. And what we showed empirically is that, yes, for students of color being in a psychologically stressful environment, for example, a classroom setting in a predominantly White institution can lead to psychological distress. And the mechanism for that is depletion of self-control.

So, self-control is really interesting because you could also learn to build it up a muscle, you could exercise it, but at a particular time you're using a lot of energy, if that makes sense and that's why you have the depletion.

Kaylin Ong:  That makes a lot of sense.

Sharon Goto:  So yeah, I think that's particularly relevant now with the racial tensions and it's definitely whether you're in education in the classroom or in the workplace or whoever it might be, if you're in a setting where you're thinking about these issues, you're worried about issues related to discrimination, then it's probably taking a little bit of a mental toll and cumulatively it could have a negative effect on your psychological distress.

Kaylin Ong:  And the next question I think is a little bit related to that. So why is cultural diversity important in the workplace setting? And have you done any sort of research on this topic as well?

Sharon Goto:  Yeah, so that's one of the reasons that I really got into this area, just looking at the demographics, I understand that workforce diversity, just diversity in our society in general is only going to increase. And to pretend it's not is just probably not the most productive way to go. So, counter to what some of the recent Supreme Court decisions have been that have made decisions against the role of affirmative action, there's a really long-standing tradition of empirical tradition: understanding that diverse work groups do better in many ways. They come up with more creative solutions. If you have enough time to work together, people are very satisfied with their interaction within a diverse setting. There's really fantastic outcomes that come to play. So it's really, really super important.

And although I haven't done research looking at, for example, diversity and group performance for example, I do indirectly look at it because I'm looking at how bicultural individuals might interact or be in a workplace with culturally different or racially different others. And I'm trying to work from a model where it's not necessarily an assimilationist model. So, where you have to become completely like those people in the workplace that you're seeing, shed your language, shed your cultural values and shed your cultural behaviors. But rather what are ways that those cultural differences benefit the workplace and what are ways that being different from others can be enhancing and not self depleting? So that's what I do.

Kaylin Ong:  I think especially as a student, and obviously Pomona College is a very liberal institution and it's very, very diverse and I feel very grateful to be surrounded by just such a diverse crowd and so many diverse students of color. But yeah, I think just because of the affirmative action and just the recent events, I mean, I guess surrounding that and the dialogue, I feel like it's particularly relevant today for students.

Sharon Goto:  Yeah, it's really interesting. I mean, there really is a trickle-down effect in terms of the way people think about each other and what their goals are. And so I'm really hoping that this time is a time where people just really keep the conversations and communications going.

Kaylin Ong:  So it's clear that the COVID-19 pandemic has had profound impacts on mental health across the globe and research states that Asian Americans in particular have been affected by the pandemic more than other racial groups. And so I wanted to ask you, in what ways have they been affected more and how would you potentially explain this finding?

Sharon Goto:  Yeah, so I am a little bit less interested in the comparative experiences of the COVID pandemic across different groups, but I have seen a lot of research that was looking at the effects of the pandemic on Asian Americans in particular. And you really do see faring worse during and after the pandemic. So it's really due to health related stressors, economic related stressors, social stressors, like racial discrimination and the pandemic, that physiological, everything is a stressor that has affected, in particular, some people within the Asian American community more than others. So I think those are just things that need to be looked at more carefully.

Kaylin Ong:  I think the social determinants of health in particular are very, very interesting and sometimes they get overlooked. And so I also wanted to ask a follow-up question. Do you consider, for example, historical trauma at all and in your research, or I guess what is your take on that in implementing a broader scope of history and the historical traumas or generational traumas that Asian Americans have faced?

Sharon Goto:  Yeah, I think that's something that is really so important. It's actually one of the reasons why I got into this area in the first place. I was really taken by my Asian American psych class as an undergrad that Stanley Sue taught and really wondering within my own personal family, what would be the negative impacts of internment, which my parents had both faced in terms of long-term consequences.

I haven't looked at it directly as a research question, but some people have Donna Nagata and University of Michigan, and I think empirically you're seeing it more and more in research. I would love to adopt some frameworks and some theories about it. What's really interesting is we just finished a study looking at older adults and help seeking within the Asian American community. So it's a community based sample. We're wondering about how the COVID related incidents, both due to the virus and also due to increased racial discrimination and violence really has affected older adults, and in turn, whether or not and how they help seek or not.

What was really interesting is yes, so there was some reluctance, some stigma as you might imagine, but also people would come up to us after and they would say things like, "Our community," or, "I've been through so much before that this..." They wouldn't say is nothing, but, "I know I can make it through this." So it was really personal testimony and resiliency that I wish that... Maybe it will be our next study. I thought it was so very interesting. It wasn't outside the kind of questions we're asking, but you could really see it as the strength of the community.

Kaylin Ong:  No, I think that's a very, very interesting topic because I'm also Asian American and my grandparents, they lived through the Great Depression, they're very old now. But they were saying very similar things where it's like they've been through a lot and they're very, very resilient and it's just unlike anything our generation has experienced. And so that difference in generational knowledge and generational experience and also help seeking behavior and health seeking behavior is very, very interesting to me just because I feel like there is a fine line between older individuals who are reluctant to seek help even when they may need it. And so it's just that line between they're very resilient, but at the same time, I feel like more outreach maybe needs to be done, especially because the pandemic has affected older populations, especially my grandparents and my great aunts and uncles who are still around. So yeah, it's very personal, but very interesting.

Sharon Goto:  Yeah, yeah, very personal, very interesting and really super important. So there's more people that do this kind of work. We always need more people to do this kind of work.

Kaylin Ong:  Yeah, it's very, very interesting to me. So my next follow up question, it's pretty general. What can be done to potentially address the declining mental health of Asian Americans throughout the pandemic?

Sharon Goto:  I mean, think it's about making sure that people have the resources that they need. One thing that we did find is that the older Asian Americans were likely to seek help from friends and family, surprisingly equally likely from law enforcement, just in case there were race-based situations, but much less so statistically, significantly less so for mental health resources. So trying to get the mental health resource piece together, it's been long standing in the community based on stigmatization and access and that sort of thing, but particularly stronger now. And what's interesting in our data, it suggests that when people are thinking about seeking help, the collectivism piece comes back. So thinking about how I am seeking help now from friends and family will help share my experiences so they will know what happens.

So the old adults in my sample, they were really thinking about younger people too, setting a good example. They're wondering if other people are going to be available and willing to listen. They're wondering about whether the police are going to be available, if they ask, reach out. They're also asking questions about the social norm around help seeking. That was also really big. So really looking differently than other samples that are less probably interdependent self-construal would probably look at our sample, which you would guess was very normatively driven, very collectively driven. So I think what can be done would be to do things like attack the problem of stigmatization, show role models of people who have sought help from mental health and have done better.

I remember in graduate school, for me, mental health help seeking was not something, not a tradition in my family that we really talked about. I remember there was a graduate student that was a little bit older than me that I really looked up to, was profoundly smart, had their act together so much, and then she would talk about how she would see her therapist, and I thought, "Ah, maybe that's the ticket."

So role modeling, more communication, more availability, more help to access the resources if they want to seek mental health. That would be a big step: resources. That would be a big step I think of in terms of, right, you could do now, right?

Kaylin Ong:  Yeah, I think the Asian American community especially, there is a mental health stigma and asking for help and reaching out for help. It's definitely a barrier. And it comes from a lot of personal experience, and I'm sure you've had very similar experiences as well. And yeah, I think it's cool that it's this collective experience that we have and it's something that we can overcome together through collective help and just an increase in resources, like you said.

Sharon Goto:  Yeah, absolutely. You could probably link it to one of the, again, once again, that some of the collectivist values of not wanting to be a burden on other people. If you think about a really tight group, then you know, want to try to hold your own, other people don't have to worry about you. And so, it is a little bit driven by that.

Kaylin Ong:  And then moving on to our next question. So before the pandemic, what were the biggest mental health challenges typically faced by Asian Americans?

Sharon Goto:  Before the pandemic, I think you would hear about differences or difficulties in acculturation or adjustment, immigration adjustment or acculturation adjustment, discrimination, racial discrimination, and also stereotyping. So having to live with one way or the other, the model minority stereotype is a big stressor on the community. So, I think those were things that would appear in the literature before the pandemic.

Kaylin Ong:  Yeah. Could you elaborate a little bit more on the model minority myth for listeners who haven't really heard of that term?

Sharon Goto: Yeah. So, the model minority myth stereotype is the idea that Asian Americans, and it  was originally with East Asian Americans, but also now extended to South Asian, Southeast Asian. It just is a really strong stereotype, very persistent. They are the model. They don't need anything. There's something about their culture that's special. They work hard, they don't complain. They do their work, they don't need any extra resources, they don't need any help. They figure it out themselves and they do a good job.

So on the surface, the model minority myth sounds really fantastic. "Oh, yes, I am a part of a model group." But there’s really a little bit more difficult of a read in it. So if you dig down a little bit deeper and you see when the stereotypes started to occur, I think it's not an accident. And many others think it's not an accident that it started to be more popular during the civil rights movement. So when other groups were really asking for more justice for them, so African Americans and Chicanx populations were really asking for more justice for their own situation, then, then popular media, politicians, et cetera, were saying things like, "Well, we don't need to change our structure. Our institutions look at the Asian Americans. They're doing really well." And that's really the beginning.

So, it really did then, and it does now, it really creates a wedge with using Asian Americans as a wedge group to divide people of color. Does that make sense? So, to deny that racism exists in our institutions.

Kaylin Ong:  Right. And I think that goes a little bit back to what we were talking about with affirmative action. I think there's a very interesting stratification between different minority groups now, especially Asian Americans sort of being grouped with White Americans as opposed to all other minority groups in higher education. And I think that has so many implications right now. And so it's interesting to see how things come back and things are very interconnected right now.

Sharon Goto:  Yeah, I think that's a really good point. So yeah, with affirmative action stuff now in educational settings, you have to, and it's really been a rough place for Asian Americans to continue to build their coalition among Asian Americans, because yeah, the umbrella of Asian Americans are very diverse, different ethnicities, different languages, different experiences within educational settings. And so I think particularly if you think about in workplace settings, extending that to workplace settings, and all of a sudden it's all gone in terms of the model minority and everybody and needs a little affirmative action. I know that I benefited very much from some mentorship that was based on race. Yeah.

Kaylin Ong:  Very interesting issues.

Sharon Goto:  Yes, yes.

Kaylin Ong:  All right, so just wrapping up, do you have any other advice or anything else you'd like to share with our listeners today?

Sharon Goto:  Well, Kaylin, I wanted to thank you for really doing your research, asking really super good questions and bringing this important topic out to people that might be listening or thinking about these issues or maybe wanting to know a little bit more, benefiting from a little bit more. So thank you for that. My message would be that our communities are really rich. There's a lot of strength in our communities and in our families. And so I think the best thing during hard times would be to really lean into the strengths.

So if you need help from people that have always been there for you, that would be the time also to ask for some assistance. And the flip side of the coin is if you're in a position where you're seeing someone else and they may not be asking you explicitly, but you think that maybe you could share some stuff, some time just listening, maybe some advice, some resources, or just really just being there for someone. I think that would be my best advice. Very simple, every day things, just the humanity that we have for each other, I think would be, and really relying on our cultural strengths, would be the best advice.

Kaylin Ong:  Yeah. Thank you so much. Yeah. And on that, thank you so much just for being willing to answer my questions and sharing your knowledge. And I think it's so important to be generous with our time and share stories and listen and whatnot. So yeah, thank you for joining me today, and I wish you the best in the future.

Sharon Goto:  And right back at you. Thank you so much. Appreciate it.

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

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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.

Consultant Leon Seltzer on the Effects of Childhood Self-Shame

An Interview with Consultant Leon Seltzer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ecologist Lance Risley on Mitigating the Phobia of Bats

An Interview with Ecologist Lance Risley

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Great.

Lance Risley: If we have time.

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

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

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

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

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

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

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

Lance Risley: Yeah.

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

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

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

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

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

Lance Risley: Yes.

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

Lance Risley: In that sense. Yes.

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

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

Jennifer Smith: Okay.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lance Risley: Really?

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Absolutely. Yeah.

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

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

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

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

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

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

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

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

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

Jennifer Smith: Right.

Lance Risley: Enjoy them. Yeah.

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

Lance Risley: All right. Thank you.

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

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

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

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

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

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

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

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

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

Psychologist Travis Osborne on OCD & Hoarding

An Interview with Clinical Psychologist Travis Osborne

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

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

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

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

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

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

Travis Osborne:  Yeah, for sure.

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

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

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

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

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

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

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

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

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

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

Travis Osborne:  For sure.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Travis Osborne:  Yeah, for sure.

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

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

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

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

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

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

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

Professor Irina Zlatogorova-Shulman on Leadership Influence & Employee Wellness

An Interview with Professor Irina Zlatogorova-Shulman

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

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

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

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

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

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

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

Tori Steffen:  Yes, please.

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

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

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

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

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

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

Tori Steffen:  Absolutely.

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

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

Irina Zlatogorova-Shulman:  Sure.

Tori Steffen:  Okay. And how effective would you say are those wellness programs in producing a positive impact on an employee's overall mental health?

Irina Zlatogorova-Shulman:  Again, I kind of covered that information in my previous response. And I would also say that people in leadership positions can do above a lot more than just wellness programs. They can create a positive atmosphere and welcoming environment for their employees. So, as they participate in wellness programs, they also notice how their leaders behave and follow those examples. For instance, if they see that their managers participate in wellness programs, they can also more likely to enroll and participate in those initiatives, versus if they observe that their managers are reluctant to participate in programs and see it as a waste of time, they may also choose not to participate in those programs.

Tori Steffen:  Okay. Sounds great. Have you seen anything in the literature in regards to maybe anxiety or depression in relation to wellness programs?

Irina Zlatogorova-Shulman:  I have seen a lot of information related to authentic leadership styles that followers and mental health. Would you like me to cover the leadership style that is authentic leadership style for your listeners?

Tori Steffen:  Yes, please. If you could explain authentic leadership as a style for our listeners, that would be great.

Irina Zlatogorova-Shulman:  Okay. Well, authentic leadership is a specific style that leaders display based on their moral values, their beliefs, and their behaviors. Those leaders, authentic leaders, play a critical role in creating positive organizational cultures and ethical work environments. Authentic leaders are generally in tune with their emotions. They're passionate about their mission and adaptive to changes. Authentic leaders also convey self-confidence, self-discipline, self-knowledge. They clearly express their thoughts and they're able to choose and listen. So two years ago, I was invited to present information on authentic leadership style to the Society of Human Resources Management, SHRM, and many HR managers admitted that although this style sounds wonderful and is attractive, it is challenging to be authentic at some places of work due to their organizational culture.

Tori Steffen:  Okay. Yeah, that's interesting, bringing in the aspect of the company culture as far as leadership influence. Great. One thing that your research discusses is the ways that authentic leadership can impact individual sense of wellness and productivity. Could you describe for us how this might work in an organizational setting?

Irina Zlatogorova-Shulman:  Of course. So, leaders with authentic qualities can definitely promote positive relations and effective commitment. They can empower their employees. And in an organization that attempts to create a climate that promotes employees' involvement and engagement, authentic leaders serve as role models. They convey appropriate behavior based on their moral values, and overall individuals in leadership role greatly influence how they can demonstrate and share similar goals with their followers through leading by example. And in multiple studies, even outside of my research, the authenticity of a leader was found to be effective in preventing employees' burnout. Plus, since the authentic person can listen patiently with understanding and without judgment, employees feel much more compelled to approach them without feeling being judged or feeling retaliation. When followers identify themselves with authentic leaders, they are also more likely to develop self-advocacy, self-esteem, confidence, optimism, passion, hope, and resilience to job-related stressors. They can also become more engaged.

Tori Steffen:  Great. It sounds like authentic leaders would have a lot of great qualities and be able to lead by example in an organization. What are some of the different types of leadership styles and how might they impact employee wellbeing and productivity? Have you seen any negative ones out there that you might be able to speak about?

Irina Zlatogorova-Shulman:  Oh, thank you for asking this question, Tori. So, scientists and theorists are still arguing and trying to identify the best leadership style and practices that would eliminate the negative trends related to employees' health at work. Overall, since the beginning of research on leadership, the paradigm shifted and reflected significant changes in leadership progression from total dominance by leaders to group decisions, and from the power of leaders to values of groups, and from leaders' goals to group visions. So, if you look at leadership as a continuum, you would see autocratic style in one side and authentic servant leadership style on the other side. The leader's roles change from active to passive. And out of all leadership styles. I would say that the autocratic leadership styles could potentially negatively affect employees' morale, productivity, and wellbeing depending on the work environment. Autocratic leaders tend to make decisions quickly without input from others, and usually when they're pressed for time. This can lead to subordinates experiencing work stress, anxiety, lower wellbeing, and most of the research on autocratic leadership has shown that subordinates dislike managers use this leadership style they call the micromanagers. And they experience more job stress when being managed by such individuals. They also have lower levels of job satisfaction.

Tori Steffen:  Okay. Yeah, that's definitely important to know how the different styles might have an influence on those factors, so thank you.

Irina Zlatogorova-Shulman:  You're welcome.

Tori Steffen:  Your research was also investigating a correlation between leader involvement and employee enrollment in wellness programs. Could you explain for us your findings about that relationship?

Irina Zlatogorova-Shulman:  Sure. During my research, I collected data about employees' participation in the wellness program and compared it to their management enrollment statistics, and I found significant positive correlation between leaders and employees' enrollment in wellness programs. I think there are three factors that could explain that correlation. First one was transparency of a self-tracking and reporting system that companies use to monitor everyone's participation. In some cases, employees could see if their managers enrolled in the program or not, including their CEOs. The second one was positive correlations could also indicate that individuals had higher personal commitment toward their health and wellbeing if they saw that their leaders are also committed to their health. And finally, surprising finding was that employees and their managers were motivated by financial incentives to participate in wellness programs. For example, when one company introduced financial incentive of up to $560 per year for all employees, including top leaders, the wellness program's enrollment and participation rates went up from 17% to 57%.

Tori Steffen:  Wow.

Irina Zlatogorova-Shulman:  I hope these information examples answer your question, Tori.

Tori Steffen:  Okay. That's great to know. Definitely a big jump there in the enrollment, so that's great. What else might leaders be able to do to promote employee wellness and productivity levels, maybe besides the high involvement in those wellness program enrollment?

Irina Zlatogorova-Shulman:  Yeah, I touched a little bit on this before, but to promote employees' wellness and productivity leaders can also create a welcoming, inclusive, safe, and pleasant work environment. Several research studies that I reviewed during my dissertation confirmed that authentic leadership style influences the positive emotions of their followers and directly impacts employees' engagement and turnover rates. In those work settings where employees can voice their concerns without fearing retribution, they feel more secure and less likely to leave. Also, in my research on wellbeing, I found that flexible work arrangements can improve employees' morale, increase their engagement and lower turnover. For instance, more and more organizations are now considering creating flexible working arrangements for their employees, such as hybrid work, telecommuting, remote work, condensed work week, flex time, part-time, shift work, or even job sharing. So here are some additional ideas.

Tori Steffen:  Awesome. Those are great to know. We personally do remote work and flex time, and I definitely find that that helps with work-life balance, so that's great. Do you work on any other research projects or maybe activities that relate to the topics of our discussion today?

Irina Zlatogorova-Shulman:  Yes. I am currently researching data and findings related to mindfulness practice. Mindfulness refers to a mental state or focus on the present moment while noticing and accepting all feelings, thoughts, and bodily sensations. So, in the past two years, I've been participating in educational seminars and workshops on mindfulness. This topic is getting more and more interest because it can be applied to any field, any area, from businesses to schools, and from arts to sports. I was very grateful to lead one training session at Southern New Hampshire University and deliver a presentation to our faculty about how mindfulness can be integrated into the online learning environment for our students. I also did an educational zoom session on mindfulness related to financial health for one of the investment firms and their clients. And now, I'm working on an article for Silent Sports Magazine on how athletes could integrate mindfulness techniques into their training and improve endurance and performance. Finally, I'm teaching yoga and meditation classes. I'm a certified yoga instructor at the local park district, and I see more and more people becoming interested in these activities, mindfulness, meditation, yoga, and relaxation techniques because they find those helpful in enhancing their emotional wellbeing and building individual resilience to stress.

Tori Steffen:  Great. Those are all really nice topics to touch on as far as mindfulness, and I can see how it would be very helpful for students, athletes and teachers too.

Irina Zlatogorova-Shulman:  Yes.

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

Irina Zlatogorova-Shulman:  Yes, I would like to share some final thoughts. When employees are unhappy with their jobs or workplaces, they start searching for different opportunities. And with the COVID-19 pandemic, many people began reevaluating their life commitments and where and how they spend their time and talent. Now, many organizations struggle to attract and retain their most productive workers. However, they can stop employees from leaving by creating and promoting a healthy culture. It all starts at the top, at the senior management levels. And I know I'm repeating myself by saying this, but the leadership influence on employees mental and physical health is significant.

Tori Steffen:  Absolutely. Well, great. That is amazing, helpful information. So thank you so much for joining us today, Dr. Z., and contributing to our interview series. It was really great speaking-

Irina Zlatogorova-Shulman:  Thank you very much for participating, for inviting me to participate in the session. I appreciate.

Tori Steffen:  Absolutely. It was really great speaking with you today, Dr. Z.

Irina Zlatogorova-Shulman:  Thank you, Tori.

Tori Steffen:  And I hope you enjoy the rest of your day.

Irina Zlatogorova-Shulman:  Thank you, you too.

Tori Steffen:  Thank you.

Irina Zlatogorova-Shulman:  Bye-bye.

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

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

Psychologist David Rosmarin on Spirituality & Mental Health

An Interview with Psychologist David Rosmarin

David Rosmarin, Ph.D., ABPP is the founder of the Center for Anxiety (New York & Boston) a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin specializes in the relevance of spirituality in one’s mental health.

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

I'd like to welcome with us today psychologist, David Rosmarin. Dr. Rosmarin is the founder of Center for Anxiety, which has offices in both New York and Boston. He's also a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin's research at Harvard focuses on the relevance of spirituality to mental health. At Center for Anxiety, his team uses a combination of cognitive behavioral therapy (CBT) and dialectical behavior therapy, also known as DBT. These approaches are used to help patients struggling with moderate to severe symptoms of anxiety, depression, and other concerns.

Before we get started, could you please let us know a little bit more about yourself, Dr. Rosmarin, and it sounds like you have two different aspects of your career, the spirituality and then the anxiety piece. Are these related?

David Rosmarin:  Well, first, thanks very much for having me on your program and I'm really happy to be here. They can be related for some individuals. Spirituality is an interesting variable. It's the kind of thing that most people in mental health don't get a lot of training in, and my program of research seeks to remedy that, to give clinicians tools to be able to assess for and address aspects of spiritual and religious life when it's relevant, which is more often than you would think, but it's not for all individuals.

In terms of anxiety, sometimes it's relevant and sometimes it's not. Center for Anxiety doesn't practice spiritual psychotherapy per se, unless individuals need specific spiritual and religious supports. I would say it is somewhat unique about our practice that it's a domain that we're not uncomfortable to address, unlike a lot of others. But it's not the only unique thing about Center for Anxiety.

Tori Steffen:  Okay. Very interesting. Well, getting down to basics, could you explain for our audience what spirituality is?

David Rosmarin:  Sure. Spirituality is any way of relating to that which is perceived to be sacred or set apart from the physical world. These kinds of beliefs are pretty common. In the United States, 80 to 90% of the general population has some sort of spiritual beliefs, and more importantly, in mental health settings, there's data to suggest that more than 80% of patients, even in some of the least religious areas of the United States, utilize spiritual ways of coping when they are distressed by mental health concerns.

Tori Steffen:  Okay, perfect. Thank you for explaining that for us. What are some connections that you have found between spirituality and mental health?

David Rosmarin:  Sure. Like any domain of life, it can be positive or negative, and spirituality is no different. In many cases, people have spiritual resources, and they might think that their faith gives them a lift. It might help them to deal with depression. It might protect them against certain things like substance abuse or alcohol abuse or suicidality. There's some very strong research to suggest that completed suicide is substantially less among people who have certain types of faith. It might give them a sense that they can get through difficult periods of life. We've seen some evidence here at McLean and elsewhere that when individuals have spiritual and religious resources at the beginning of treatment, that can help them to reduce quicker through their treatments even if the treatment has nothing to do with spirituality, interestingly.

On the other hand, though, it can be a source of strain, I mentioned. It can definitely be negative, and a lot of individuals struggle with their faith. They might think, why am I dealing with depression again? What's God doing to punish me? What did I do wrong? They might feel guilty or estranged from a faith community. They might feel bad about certain feelings they have; they might have certain conflicts which are sometimes very serious. To be able to discuss all of these, the positive and the negative and all points in between is just part of being a good psychotherapist, frankly.

Tori Steffen:  Okay. Yeah, it seems important to know about the spirituality piece, especially when you're treating patients with suicidality and it's great to know that that can help too. Well, could you describe for us how the methods of both CBT and DBT work as those naturalistic treatments for anxiety?

David Rosmarin:  Sure. You mentioned my career has two parts to it, and I would say there is some connection and overlap, but a lot of it is really disparate. At Center for Anxiety, we use a combination of cognitive and dialectical behavior therapy, which is somewhat innovative in the treatment of anxiety disorders. Most individuals treating anxiety concerns would really stick more to cognitive behavior therapy. But these days, anxiety, as I'm sure you're seeing out in Seattle, a lot of individuals come in with some pretty severe symptoms. They might have self-injury, they might be debilitated by their anxiety or other symptoms that they have. There's also high levels of what we call comorbidity where people have co-occurring anxiety with other concerns, whether it's substance abuse or depression, as I mentioned before, or any number of issues, obsessive compulsive and related disorders and these concerns and the complexity and the severity that people have today, they really, we have found can benefit from a broader toolkit of strategies that we can provide in psychotherapy to them, and that's why it spans both cognitive and dialectical behavior therapy in the practice.

Tori Steffen:  Okay, great. That definitely helps introduce our topic today with CBT and DBT. How effective would you say are both approaches, CBT and DBT in treating those symptoms of anxiety, depression, suicidality?

David Rosmarin:  Yeah, that's a scientific question and fortunately we have research to study it. Center for Anxiety has a research protocol and all patients at all sessions are administered measures, and we track over time their progress. We a couple years ago did an evaluation of our IOP, our Intensive Outpatient Program, which are individuals who needed three or more sessions per week.

One of the things that's unique about Center for Anxiety as I mentioned before, is that we provide really a higher level of care than just standard once a week outpatient. Individuals coming in with a lot more severe concerns and symptoms, I'd say about 50% of our patients at this point, require IOP, Intensive Outpatient Program or treatment, IOP we call it, and our data was very positive. We saw substantial reductions and clinically significant reductions in anxiety and depression for substantial decreases in those symptoms over the course of treatment. In fact, none of the patients in that study had an increase in their anxiety or depression over the course of treatment, which I think was particularly encouraging given the severity that they had when they came in.

Tori Steffen:  Wow. Yeah, that's definitely good to hear that there's those treatments out there to be able to help with those symptoms. Have you seen any limitations that might prevent the treatment of anxiety, depression using those?

David Rosmarin:  Being in an outpatient setting, one limitation is the cost of treatment. Unfortunately, with the era of managed care, and I'm sure you have a similar situation out in Seattle, these are out-of-pocket services, and it does limit the people who can come, which is really truly unfortunate. One advantage though that I think we have, and one way of addressing this is we do have a training program and many of our trainees are learning these techniques and they are able to be accessible at lower fees. Also, some of them move on to different sites which can provide services to individuals using insurance or having no insurance at all. I do feel like we're having an impact on the field more broadly, but in terms of our actual caseloads, that's a very significant limitation.

Tori Steffen:  Okay. Definitely makes sense. Well, your research discusses the ways that CBT and DBT involve behavior activation and mindfulness. Could you describe how those might work for audience?

David Rosmarin:  Yeah, so DBT is a broad set of tools, principles, really, and tools to help individuals struggling with severe levels of distress, moderate to severe levels of distress. One of the core tools is called mindfulness, that was the word that you mentioned. Mindfulness means being attentive to the present moment and not being judgmental of oneself. One of the things that happens is not only do people feel depressed or anxious or have other symptoms, but they judge themselves for feeling anxious, depressed, and that judgment instead of simply being anxious or being depressed and allowing oneself to feel that way, that judgment of oneself and negative perception of that feeds in and actually creates more of a surge of adrenaline. It suppresses dopamine, serotonin, other neurotransmitters and individuals are more likely to struggle substantially when they judge themselves. Mindfulness is a training of simply allowing oneself to be in the moment and to experience whatever they're going through without that critical eye.

Tori Steffen:  Okay, great. Thank you for explaining that for us. Your research was also discussing how psychoeducation plays a role in the treatment. How might that work to address those symptoms for anxiety and depression?

David Rosmarin:  There are a lot of basic facts around anxiety and depression and other symptoms that people don't know. For example, if you're feeling depressed, you probably will not want to engage in this much activity because hey, you're feeling sad, you're not enjoying things as much. You're struggling to have the energy and your sleep might be dysregulated. However, to the extent that people simply keep a schedule, even if they're feeling depressed, their depression can and often does remit.

Scheduling an activity which is supposed to be so to speak, pleasurable, even if it isn't, can actually be a part of that. Going to an exercise class, simply going for a walk, lacing up one's shoes, getting out of bed, not sleeping during the day. This is what we call behavioral activation, which is actually in some ways invented in Seattle in your backyard over there and certainly came to be a tour de force in the world of behavioral psychology in Seattle. But in any event, this is a concept that we can just educate patients.

Another one is with anxiety, the more you avoid, the more anxious you will be. If you're afraid of something and you avoid it, you're going to become more anxious of it, not less, even though it feels better in the moment. These are basic concepts that have been clarified through the literature, through experimental science, through clinical science, and they're grounded in theory that patients and anybody just needs to know. So, sometimes just some basic info can go a long way.

Tori Steffen:  Okay. Yeah, that definitely makes sense how important psychoeducation can be. Are there any other approaches than CBT or DBT that individuals can utilize to combat those symptoms?

David Rosmarin:  Yeah, one of the DBT approaches that we really love is called distress tolerance. People often think that one of the goals of treatment is to reduce the amount of distress they're experiencing, and to some extent that's true, but to a larger extent, one of the goals, a better goal, I would say, is to increase the amount of distress that we can tolerate. There's a big difference between trying to reduce my distress versus trying to increase my capacity to withstand distress, and when we think about it the other way, the increasing our distress tolerance in of itself, we're not expected to never be distressed. It's not a surprise when we're having a really rough day and the goal then becomes to weather the storm as opposed to getting the weather to change. As we all know today, climate's very hard to predict and to control, not that we shouldn't try, but we can and certainly should learn to tolerate more with the situation that we have, especially when it comes to our emotions.

Tori Steffen:  Okay, awesome. Thank you for sharing that. While CBT and DBT are best and ideally done under the treatment and guidance of a licensed mental health professional, what are some things one can do on their own to potentially reduce or lessen some of those symptoms of anxiety or depression?

David Rosmarin:  I'm thinking about another DBT module called emotion regulation and simply the idea of being aware, for example, on a scale of 0 to 10, how stressed are you right now?

Tori Steffen:  Myself, I would say maybe a four. Not too bad.

David Rosmarin:  Four, not too bad for a mid-morning west coast kind of vibe. I get that, even though it's a Monday. That's great and you're aware of it right away, and maybe that's because you're involved in the field. Other people will fumble, I don't know, is it high? Is it low? I don't have a baseline. Simply being aware of how sad you are, how anxious you are, and throwing a number to it. If you don't want to throw a number to it, at least is it high, is it medium, is it low?

Being able to share that with someone, that's another factor in emotion regulation. Being able to just communicate how you feel to other individuals, whether it's a professional, as you mentioned, or a friend. Whether it's a post on Twitter, hey, feeling a little bit sad today, whatever it is. Then these kinds of things, it's important to maintain awareness and then to recognize also that we can shift our emotional states. Sometimes you might all of a sudden feel really dysphoric and sad and part of that we can't necessarily control, but we might be able to indirectly influence that. Listening to reggae music, right? Hard not to bop. Going for a walk, calling up an old friend, eating ice cream. But sometimes those can have negative effects, as well. Being aware of our emotional states and how what we do affects those, that's really the core of emotional regulation and that's something everybody can benefit from today.

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

David Rosmarin:  I guess I'll share this, that we're living in very challenging times. People have higher levels of anxiety and depression than ever before in history for a variety of reasons. It's very real, these concerns, and they have very significant and real effects on people's lives. Our phones are ringing off the hook. The other day, I think they're 22 intakes that came in and that's very significant for a modest practice of our size.

I think it's important for people to know that they're not alone today, that if they're struggling, there's plenty of other people that are there. More importantly, that there are treatments that really are helpful, and in not a lot of time. I mean, our treatments will often see people 5, 6, 7 sessions and see a decrease. They might stay on longer to target other aspects of their mental health, but A) people are not alone and B) there is hope to be had and a lot of hope, so I think those are probably some important messages to get out there.

Tori Steffen:  Definitely important to keep a positive perspective on things, so that's very helpful. Thank you so much. Well, it's been really great talking to you today, Dr. Rosmarin, and thank you again for joining us and contributing to our interview series.

David Rosmarin:  Thanks for having me on your series.

Tori Steffen:  Thank you very much. Hope you have a great day.

David Rosmarin:  You too.

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

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

Author John Purkiss on The Power of Letting Go

An Interview with Author John Purkiss

John Purkiss is the best-selling author of several books, including:“The Power of Letting Go: How to Drop Everything That’s Holding You Back” and “Brand You: Turn Your Unique Talents Into A Winning Formula.” He is an expert on the notion of “letting go” while utilizing mindfulness to improve performance and mental well-being.

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

I'd like to welcome with us author John Purkiss, who joins us from England today. Mr. Purkiss is the author of several books, including “The Power of Letting Go”, he began his career in banking and management consultancy. He now recruits senior executives and board members, he also invests in fast-growing companies. Before we get started today, can you let our listeners know a little bit more about you and what motivated you to write “The Power of Letting Go”?

John Purkiss:  Certainly. Well, thanks for inviting me. So what happened in my case was... like a lot of people, I got the message that if I was intelligent and hardworking, then everything would be fine, so I did that until I was 26, so I went through economics degree, banking, consulting, MBA and it all worked extremely well. And then, I was diagnosed with clinical depression, which nearly killed me, so that was my wake up. I now see it as a blessing, it was like the beginning of the destruction of the ego. But from a medical point of view, it was very bad news so that's when I realized. What I was offered, electroconvulsive therapy, Freudian psychoanalysis or pharmaceuticals. I didn't do the electrical thing but I did do the Freudian psychoanalysis and I did do the pharmaceuticals. And then, I just thought there has to be another way so I started searching for other options so that's how the journey began.

Preeti Kota:  Can you describe the Vedic tradition that inspired the concept of letting go?

John Purkiss:  Yeah, certainly. While I was searching around, I read lots of books. Everything from Californian self-help to Eastern philosophy. And what I found was pretty much everything points back to the Vedic tradition. So Veda simply means knowledge, it's a Sanskrit word which means knowledge. As you may know, science also means knowledge, scientia. The difference is that Western science is largely based on looking outwards, doing experiments in laboratories and social experiments. Whereas, the Vedic tradition is more of a download, so it's looking inwards. And people downloaded things thousands of years ago, which are now being tested in laboratories. So the Vedic tradition goes much faster because it doesn't have the empirical process, but it seems to be leading to very similar conclusions.

Preeti Kota:  How do you find the balance between letting go and giving up?

John Purkiss:  I don't give up. I think giving up is completely unhelpful. Answer, no balance. Letting go is not giving up. I don't recommend giving up.

Preeti Kota:  I feel like when people are trying to start to let go, they are afraid of giving up.

John Purkiss:  Yes. Well, it might be helpful if I distinguish between the two. So giving up is, you just stop trying and you lose hope. Well, you might just hope that somehow things will work out, which they might, but it's powerlessness, it's like, "I have no power, I can't do anything so I give up." And in some situations, I suppose, that could work, actually. I mean, I've never done it, but I've heard about it, if someone attacks you and you just give up, then they kind of loosen their grip, so there are situations maybe that works. But letting go isn't that at all. Letting go, at least as described in the book and in the Eastern traditions, letting go is... what you're actually doing is letting go of your ego.

So if I describe it this way, in the West most of us have been brought up to believe that we are the body-mind. So Eckhart Tolle to talks about this in “The Power of Now”, for example, he talks about the body-mind. And I studied economics. So economic, psychology, finance, arguably even engineering, medicine, there are so many disciplines which are based on the idea that you and I are body-minds. And we're trying to get what we want and avoid what we don't want, so like a brain and a body.

And so when we let go... If that's how you see yourself, it may feel like, "Oh, I'm giving up now, because I'm not trying anymore." The Eastern traditions of which the Vedic tradition is largely the origin is saying, "Your brain and body are part of something extremely intelligent, which is running everything all the time. And when you let go, you stop trying to figure everything out using your brain, and you basically tune into this universal intelligence, which is running everything."

And I think, if you've been brought up as an atheist, that's very hard, because you have this strong belief system that there's nothing beyond human intelligence. Whereas, if you've been brought up in any of the spiritual tradition... I mean, I was brought up as a Christian, at least when I was ill, I had some understanding that there was something extremely intelligent that was running everything. And then, when I let go, I very quickly began to tune into it. And then, things started to work out. I mean, one example is your body, even if you don't think about it, your body will run itself. In fact, most people interfere with their bodies and stop it from running correctly. But if you don't do anything crazy, your body will run itself without any intellectual intervention.

Preeti Kota:  Yeah. So, you're mentioning the ego, so a little bit on that. How does our ego affect us, particularly our mindset?

John Purkiss:  Okay. There are two definitions of ego. Two main ones. The one which is most common in the West is the Freudian definition, which is... I'm sure you know, you have the super ego, the ego, and the Id. And the Id wants to do kinds of crazy things, and the ego regulates the Id, and stops the Id from doing stupid things. So the ego is useful. I mean, ego is a Latin word. It simply means I. So that's the ego in the West. In the East, the ego is not helpful at all, because what the... for example, the Vedic tradition is telling us, is that you are not the body-mind. How should I put it? You are supreme consciousness. You are the consciousness which is running everything.

So the guru who I follow, he says, "I'm not here to convince you that I'm God. I'm here to convince you that you are God." So the message of the Eastern traditions is you are divine, and ego is hugely unhelpful because ego is when you start seeing yourself separate from the divine, from the cosmos. So clinical depression for me was an extreme example of that. I felt completely separate and desperate. I felt separate from everybody and everything. And I was running around trying to solve problems and I wasn't tuned in at all. And of course Freud died, I think, in 1939, that's very recent. The Eastern traditions have been talking about the ego for millennia. So two totally, completely different view points.

And I think, you used the word, mindset, is that right? Yeah. So mindset. So in the West we have this idea of the mind as a thing. The mind is like some box. And we try and fix the box using medication or using maybe some therapy or self-help books or whatever, that's the idea. Whereas, the mind in the Eastern traditions is more like a process. It's a series of patterns. And you can do this on your own, or you can have professional help. If you look very carefully, you can start to see all the patterns, the really unhelpful patterns which are causing the mess, I think. And so the definition of the mind is different. So the West, I would say, sees the mind as a thing, and the East sees the mind as a process.

Preeti Kota:  Okay.

John Purkiss:  Yeah. Or processes, as you would say in the US.

Preeti Kota:  How is the ego formed?

John Purkiss:  I don't know. I don't know what Freud's view was on the formation of the ego. So my guru is called Sri Nithyananda Paramashivam, the way he describes it, which I talk about in the Power of Letting Go is he says, "The ego is made up of incompletions." So for example, when you are a small child. Small children are generally blissful, and then, occasionally they cry when they're hungry or something. And then between the ages of two and seven, we have painful experiences. And those painful experiences form the ego. So for example, I'm sure you've had this experience, if you're in a meeting or a conversation and the other person suddenly gets annoyed with something you said or something that happened, it's because some pain pattern has been triggered. And that's the ego.

And I mean, in the West we tend to say, "So and so has a massive ego because they think they're superior to other people." For example, they might suffer from poverty when they're small, when they grow up, they have lots of money. So they have an ego relating to money, that's a common. But you can also have an ego, which makes you feel inferior to other people. So some people who feel inferior to other people, they actually have massive egos on the eastern definition because they have so much pain in their system, which they accumulated between two and seven. But it's still ego. It still makes you feel separate and it still causes suffering.

Preeti Kota:  So they project the opposite.

John Purkiss:  Unfortunately, ego, we project it all over the place. So if you have some pain pattern about racism, or unfairness, or dishonesty, or something, you project it onto other people, you start accusing other people of that. Yeah. So it causes chaos, unfortunately.

Preeti Kota:  How can you simply follow your intuition when you have a fear that you might be making the wrong decisions?

John Purkiss:  Okay, that's a good question. So my favorite definition of intuition is immediate insight without reasoning. So you have an insight. For example, you might have an insight that you should call your mother or that you should turn left, whatever it is. And that doesn't require a massive thought process. You just act on it. And real intuition comes out of love. It's guiding you to do the right thing. There is a thing called false intuition. So we just talked about the ego, these accumulated pain patterns. What can happen is that, false intuition is you have a reaction to something or someone, and it's coming from pain. And so it's not really intuition, it's just a pain pattern asserting itself.

For example, you might see someone from another ethnic group walking down the street and immediately avoid them, because you have some pain pattern. Or, you might see a dog, or a cat, or a spider, and it triggers some pain pattern. That's not intuition, that's just a pain pattern getting triggered. We'll talk about it later, but if you use the correct technique, you can remove those pain patterns and you stop getting triggered. And then, your intuition operates freely because you're not getting triggered the whole time, you're just seeing things as they are. And you have a feeling about what you should do next.

Preeti Kota:  Yeah. So how do you let go of the fear?

John Purkiss:  Well, the completion technique removes the fear. So we can talk about that now. So in chapter three of the book, I describe a technique called Completion. It's been trademarked, it's now called the Science of Completions. So I learned it eight years ago from Swamiji behind me. That's why I went to India to meet him. And it's very simple. I'll give you an example. So my first day at school when I was five, I arrive at school and I have this accent. So I don't know if you know, this is the accent which the BBC sells to foreigners. This is the export version of British English. I mean, the BBC in the UK uses all kinds of accents, but when they're talking to foreigners, they tend to use this accent, which is what I grew up with.

And when I was four, we moved about hour and a half, two hours north of London. And the accent there is different. So it's my first day at school and I'm five years old. This is my first day in the world without my Mum and I arrive at the school and I want to make friends. And they don't make friends, they just laugh at me. And someone says, "You're a bloody nutter, you're crazy." And I feel really bad. So that's how the pain pattern starts. So, Swamiji calls it, self doubt, self hatred, self denial. So the self doubt is, "I'm unacceptable." There are all these patterns. "I'm unacceptable. I'm a failure, I'm trying to make friends, but it's not working. Other people don't support me."

Then all those patterns start developing. As far as I can tell, it all happened within five minutes. And everybody has this before the age of seven. I mean, in some people, it can be something that seems far more traumatic or less traumatic, either way it happens. So when that happens, you then live the rest of your life based on those patterns because we suppressed the pain. So what happened in my case is I grew up in Lester, in the Central England, and after a while I realized that nearly all of my friends were not English or they were not White English people, they were Indian, or they were Jewish people from Central Europe, or they were Ukrainian or whatever they were, Irish.

And I was aware that I had this feeling that I was an outsider. I wasn't in the football team, soccer team, I felt like an outsider. And then many years later, I realized when I met Swamiji, I realized I had this pattern of, "I'm unacceptable." So I ended up hanging out with all the other people who felt unacceptable. And it was, in a way, it looked beneficial because a lot of us went to Oxford and Cambridge. I mean, because we didn't get any love from the other people. The only way to get on was to work hard. So we all worked hard and went to Oxford, Cambridge and did all this stuff.

But there's still this underlying pain pattern, which is, "I'm unacceptable," which is very bad news in terms of relationships, business, all kinds of things. And so the technique is incredibly simple. The technique is... I become five years old. I've got my mirror here. I've got this mirror that I use every day. So I become five years old. And I look at myself in the mirror, I'm talking to the person in the mirror, and I relive intensely those first few minutes at school.

So, I allow all those suppressed emotions to come out. So in my case it just feels bad and eventually it starts to die down. There have been cases, I mean, some people cry, some people throw up, they vomit. But basically this pain is stored in your body. And what happens is if you do the reliving intensely... and you can relive any episode in your life, what I find is, at some point it feels almost like an electrical charge has left my body. And what I'm left with is an empty memory. So it's a memory, which I can go and find a book in a library, but it's not a memory with an emotional charge, which is running my life.

Preeti Kota:  Okay.

John Purkiss:  And for me, it's such a powerful thing because, I mean, one of the really great things about it is you then become nonviolent. So much violence in the world is people being triggered, right?

Preeti Kota:  Yeah.

John Purkiss:  And then attacking each other, either mentally or verbally, so if you're not triggered, you won't fight people.

Preeti Kota:  That's true. So I guess you've already touched on this, but what are pain patterns?

John Purkiss:  Yeah, it's a good question. So pain pattern, that's a simple word. The Sanskrit word is samskara, like a scar. Swamiji uses the word incompletion. So one way to describe it is, in an ideal world, if you were completely conscious all the time, you would have a painful experience and you would live it from beginning to end. Or, a happy experience, so let's imagine you have a happy experience, you live it completely, and then it's finished. You've done it right, you've completed it. Or, you have a painful experience and you allow yourself to feel all of the pain. And then you complete the pain and then it's finished.

But what happens in reality is... By the way, British men are experts at this, is we have a painful experience and we don't like the pain, so we suppress it and we pretend everything's okay. And that suppressed pain is now stored in our bodies. I often do this. Well, I can do it with you if you want. You don't have to tell me the experience. But can you think of the most painful thing that happened to you before the age of seven?

Preeti Kota:  I don't really remember.

John Purkiss:  Okay. All right. The most painful experience you can remember at all doesn't have to be before seven.

Preeti Kota:  Okay.

John Purkiss:  Right. How old were you?

Preeti Kota:  Maybe 15.

John Purkiss:  15? Okay. So can you feel the pain of that experience now without telling me what it was?

Preeti Kota: Yeah.

John Purkiss:  Okay. And where is that pain in your body?

Preeti Kota:  I think in my mind.

John Purkiss:  In your mind. But where? Can you point to it? You can feel the pain. You're 15 years old. You can feel the pain. Where is it? Is it in your head or where?

Preeti Kota:  Yeah, I think in my head.

John Purkiss:  Okay. All right. So in 99% of cases, when I ask people that question... I say, "Okay, think of an event, feel the pain. Where is the pain?" 99% of cases, people can point to the pain in their body. They know where it is. It can be in their heart, it can be in their chest, or their stomach, wherever. But the point is it's been stored. Swamiji calls it muscle memory or bio memory. But the point is, it's not some abstract thing. I was in management consultancy for a while. I once asked this question as a former management consultant, and he said, he could feel the pain, but he didn't know where it was. Which strikes me, maybe that's very intellectual person, but most people like 99% of people, they can find it in their bodies, right?

Preeti Kota:  Yeah.

John Purkiss:  So the pain gets stored. Swamiji uses lots of analogies. My favorite one is, he says, it's like putting a carpet on a wound. So imagine you have a wound and it's all horrible, and then instead of treating it and disinfecting it, and you actually just put a carpet on it, which makes the whole thing worse. And that's what most of us do. We just suppress it because it's painful. And completion is removing all the pain. So the wound heals and then we would become whole, then you're fine.

Preeti Kota:  What is flow and what are its benefits?

John Purkiss:  I'm sure you know, there's a famous book called “Flow” by Csikszentmihalyi. Are you familiar with him? The Hungarian psychologist who invented the word flow. So it's a very thick book. I would say, for me, flow is a symptom. I mean, the state of flow has lots of benefits. So people experience flow when they are completely immersed in some activity, usually they really enjoy it. In my case, photography. If I'm immersed in photography or writing or something like that, there's a feeling of flow. You're not agonizing or analyzing, you're just enjoying the process and it happens very naturally.

But I would say, for me, that flow is more like a symptom. So maybe we'll get onto the topic of unclutching, as well. But if you are complete and you are unclutched, then flow happens naturally. One way of describing it is you become one with existence, or one with the cosmos. And so everything's happening very naturally. And you may have read about this, there are American football players, for example, who say that, when they're in a flow state, everything slows down. There's almost no thought involved and everything just happens really smoothly. But for me, there are ways of getting to that. It's a result rather than something you just do. Sorry.

Preeti Kota:  What are the benefits of it?

John Purkiss:  The benefits of flow are... of being in that state, are little or no stress, things happen very easily, relationships are easy, it's very productive. I mean, I have times when I can just sit down and write a thousand words in an hour or two. And a book is only 40,000 words. So yeah, I mean, flow is a fantastic thing. I mean, yeah, it's definitely good for your health. It's good for productivity, good for relationships, good for creativity. Yeah, definitely.

Preeti Kota:  Okay. How can people with anxiety or depression who are stuck in negative thought patterns about the past or future start to let go?

John Purkiss:  Okay, well there are two techniques. One of which I mentioned before when we were preparing for this. So we'll deal with them in a minute. So one is completion, which I've just described. So if you keep practicing the Completion Technique, you'll remove the negative thought patterns. And what happens is, that those repetitive negative thoughts start to die down. So for example, if I have a cognition from my first day at school that I'm a failure or that I'm unacceptable, if I complete that incident and remove that pain pattern, then I won't have thousands of negative thoughts about being unacceptable or being a failure, so that's one thing. You can remove the cause, which is the pain pattern. The second thing is... and this is a wonderful technique which fits beautifully with completion. This second technique is called Unclutching, which I didn't write about in the book I'm going to write about it in the next book.And I sent you a video. So there's a six minute video and a one hour video, which you can share with everybody. But the principle is very simple, unclutching is very simple. So, are you familiar with mindfulness?

Preeti Kota:  Yeah.

John Purkiss:  Yeah. Okay. So mindfulness has become huge in the West, and it also comes from the Vedic tradition. But mindfulness, there are various ways to do it, but my experience of mindfulness was... So I'm present, I'm sitting here quietly, and then I have a thought and I get distracted by the thought and my mind follows the thought, which morphs into another thought, and another thought, and another thought. And what I need to do is bring my attention back to the present. So that can be by putting my attention on my breath or the end of my nose or whatever, or the sensation of my hands on the table. There are all kinds of things I can do to bring my attention back to the present. And that works. I mean, I did that for six years and I talked about it in The Power of Letting Go. For some people that works perfectly well. Steve Jobs did zen meditation, which is similar, for decades. Unclutching is even simpler.

So what happens is... so Imagine you're sitting there and you have this negative thought, you now have a choice, you can either engage with the thought or you can unclutch from it. So if you engage with the thought, you might for example say, "That can't be true. Or, Oh dear, here's that thought again." Or get distracted and start thinking about whether or not that thought's true. A whole thing. You'll be there for hours. You can either engage with it and allow that to happen, or you can unclutch. Swamiji invented the term. Unclutch means, "I choose not to engage with it." It's a bit like, a small child is pestering you and you ignore the child.

So this thought comes up and you have the choice not to engage with it. Right?

Preeti Kota:  Yeah.

John Purkiss:  You just unclutch, you just step back mentally. You step back from it. And my experience as a Westerner is, initially, it felt to me like incredibly lazy. Surely if I have a thought, I should engage with it, and I should analyze it, and I should deal with it, and address it, and bladi, bladi, blah. Yeah, but then you're going to be in this mess. So what I do now is if I'm doing something and I have a negative thought... which can happen. I'm winning some business or working on a book or something I have a negative thought, I can just choose not to engage with it.

Preeti Kota:  Do you just distract yourself?

John Purkiss:  Sorry?

Preeti Kota:  You just keep distracting yourself?

John Purkiss:  No, don't distract about it. It's just a choice. Okay. I mean, we can do it now. You sit there, a thought comes up, you don't have to engage with it, you don't have to think about it. You can just notice it. And then, after a while it'll go away and another thought will come. And you don't engage with that one either. You don't think about it. You don't analyze it. You don't find evidence to contradict it. You don't suppress it. It's like bubbles in a fish tank. "Okay, there's a thought." And I encourage you and anyone listening to this or watching this to do this is, if you unclutch what you will notice is... Okay, so I'm doing something and I have a negative thought and I unclutch from it. Within a few minutes you'll find there's some other thought. And they are like bubbles in a fish tank, because... the way Swamiji describes it is, we create shafts.

So one thing we do is we have a painful thought or experience and we connect it to other painful thoughts and other pain. And we create this narrative like, "I'm a loser," or, "I'm a winner," or, "I'm a good father," or "I'm whatever, I'm a victim." We create this whole narrative. Whereas in reality, these thoughts are separate and unrelated. So if you slow down a film of bubbles in a fish tank, they're all separate, they're unrelated, right?

Preeti Kota:  Yeah.

John Purkiss:  So if you start treating our thoughts like that, if we just unclutch from them, they start losing their power over us.

Preeti Kota:  That's a good metaphor, the bubbles.

John Purkiss:  It's the simplest one. Yeah. I mean, that's the way Swamiji describes it. And I find that I still have negative thoughts. Sometimes I'm doing something really ambitious and I have a thought about how it's not going to work or it isn't working, and I just unclutch. I just carry on doing what I'm doing. Right?

Preeti Kota:  Yeah. I feel like that prevents you from spiraling then.

John Purkiss:  Yeah. Otherwise, you're going to spiral. Well, you're going to waste loads of time. You're going to feel terrible. You may go and say something to somebody which causes you a problem. Instead, all you need to do is unclutch. The metaphor, I didn't understand it first. In the US, I think you call it a stick shift gearbox in a car. So I know you have mainly automatic gear boxes. But with a stick shift gear box, the clutch enables you to disengage. So, basically the gears aren't running and the motor isn't driving the car anymore. It's a bit like that. You're having all these thoughts and you just disengage and you stop engaging with these thoughts which are coming up. And then the thoughts die down. And then you can start working. And when you start working, you may need to think, but you're thinking constructively. You're not just responding to random thoughts.

Preeti Kota:  How do you build faith or trust in the idea that good things will happen when you let go or surrender? What do you do with the thought? What if it doesn't get better?

John Purkiss:  So if you've been brought up in one of the big spiritual traditions, certainly the Asian ones, so Hinduism, Buddhism, Jainism, Daoism, all of those traditions say that there's something extremely intelligent, which is running everything. They all say that in different ways. And the Vedic tradition specifically says, "This intelligence is blessing you all the time." It's beneficial. It's benign.

What we are doing is we block it. We block with our our egos. Our body is trying to run itself very efficiently and healthily, and we do crazy things. We put crazy things in our bodies which stop that from happening. So, that's those traditions. And then, we've got the Abrahamic traditions, which come from Abraham. So you've got Judaism, Christianity, Islam, which have a different view of God, but you've still got an intelligence which is running everything. So in my case, as I mentioned, I was brought up as a Christian, although I didn't understand what was going on, especially when I became ill. I did have this understanding there was something intelligent running things.

I think the difficulty is if you are an atheist. And as I understand it, there are two types of atheists. So one type of atheist is you don't believe in deities, you don't believe in a God because you haven't seen any enough evidence or whatever. Which for me is completely fine because you're being empirical. I mean, I just see how amazing nature is, and for me, that's pretty solid evidence. For some people that's not enough. But okay, so you might say, this world has been operating for 4.5 Billion years perfectly. But that's not enough evidence for me. Fine. It's okay. I think the real problem is … you can at least say by the way, when I was clinically depressed, one of the psychiatrist I talked to, he said, "Look at the animals. They're not running around being depressed, they're just getting on with things." And I do that.

But there's what I would call maybe militant atheism, which is being convinced that there is no intelligence running everything. And for me, that's completely unscientific viewpoint. I don't know. Are you familiar with Karl Popper?

Preeti Kota:  No.

John Purkiss:  Karl Popper was a very influential philosopher of science. And what he said was, "For a statement to be scientific, it has to be capable of being falsified." There has to be a means of proving it wrong. So for example, if you say the earth is flat as a hypothesis, there are ways of proving that wrong. But if you say there is no God, how do I construct an experiment to prove that's wrong? You see what I'm saying? It's an unscientific statement, but there are people who are absolutely convinced that there is no God and there's no intelligence running it and running their lives. And I would say, well, A, that's unscientific. B, I would suggest it's probably ego. And C, it makes life very difficult because if you are absolutely convinced of that, everything falls on your shoulders. It means the only way for you to be happy and successful is for you to do everything using your brain and your body.

And maybe that’s why … I mean, I don't know if you know the history, but after the Soviet Union ended, lots of people, Eastern European people came to the UK. And I've met lots of people in the West, as well. But I've met a lot of people who were atheists who were brought up as atheists. It's like atheism was a religion in the Soviet Union. And in those countries like Poland and all those. Well, Poland has a lot of Catholicism. Let's say Estonia, Latvia, Lithuania, a lot of these countries they were taught atheism at school. And a lot of them are really depressed because they've been brought up to believe that the only way to do anything is using your brain and your body. And when that doesn't work, you're stuck.

So for those people, I would just say, I invite you to entertain the possibility that there's something extremely intelligent, which is running your body, which is running nature. And if you tune into it … To answer your question, when we let go, we start tuning into all of that and life gets much easier. We're not holding onto this idea that only my brain and my body can solve everything. Does that make any sense?

Preeti Kota:  Yeah.

John Purkiss:  Okay.

Preeti Kota:  So what are daily practices people can do to realize the power of letting go?

John Purkiss:  Okay. Well, what I do is, as I mentioned, I did mindfulness for six years. Then I learned transcendental meditation, which I've been doing in 20 years. I've done it twice today. And that is wonderful. I mean, it removes nearly all of my jet lag. For those who haven't experienced it, when you let go during transcendental meditation, you go into this state called Turiya, which is the fourth state of consciousness it is also from the Vedic tradition. You experience pure consciousness without any thoughts. So it's blissful and it's deeply restful.

And in terms of letting go, this was one of my early experiences of letting go was, if I have a problem or I need to have some creative idea, frequently it comes during or after transcendental meditation, because what you're doing is you're switching off your mind. You hear a mantra, you go into this state of pure consciousness, and then solutions to problems or ideas, they just come because what you've done is create a massive gap between thoughts. I mean, the gap could be up to 20 minutes. I mean, it might be just a few seconds. So, that transcendental meditation is great. Unclutching, which I've just described is also great.

So here's a really practical thing for anyone listening is, imagine you want to do something but you don't know how, and you're worried about it, you might be worried about it. So if you get really clear about what you want to create, and you can write it down, you can have pictures, whatever you want. First thing, is make sure that it's something you want to do. It's a genuine desire. It's not something you've borrowed from somebody else. It's loving. It's going to be for everybody's benefit. So it's a genuine desire. Now what you do is unclutch, so do that unclutching exercise, very simply, just disengage.

Actually, you can do this, write down on the paper. Your mind will tell you all the reasons why it can't happen. So if you pick something you want to happen and write it down, your mind will tell you all the reasons why it can't happen. Just write those down. And then, when you see all the reasons why it can't happen, that tells you where you need to complete, where you need to relive the original incident. It's like software. You've got all this software telling you bad things. So you can use the completion technique to remove all those negative patterns.

And then, when you unclutch, so what I do now is I want to do something I don't know how, is I get really clear about what I want to happen, and then I unclutch. I disengage from thinking. And then I have a flash of intuition, which tells me what to do. So having been brought up as a Christian, I would just ask myself, "Please guide me." It's in The Power of Letting Go. When I got completely stuck, I asked to be guided to the right job or business. And I was guided to the perfect job. What I do now? I mean, because Swamiji is 44, so now I just ask him to guide me. But essentially I'm letting go of the thought process asking to be guided, and I unclutch. And then I suddenly have an idea, I need to call this person, or send an email to that person, or go to that place. So you start functioning out of intuition instead of agonizing about everything.

Preeti Kota:  Yeah. Those are great useful techniques, I feel like, that are easy to implement.

John Purkiss:  Yeah, I mean they're not mine. I just found they're the easiest ones to do. And they work.

Preeti Kota:  So do you have any parting words of advice or anything else that you'd want to share with our listeners today?

John Purkiss:  If you like reading, please read The Power of Letting Go. If you don't like reading, well it's on audiobook, as well. The other thing is I would definitely take a look at Swamiji's videos on YouTube. If you type in Nithyananda, which is N-I-T-H-Y-A-N-A-N-D-A, if you type in Nithyananda... By the way, it means eternal bliss. At the end of his satsangs, his talks, he always says, "Be blissful." So step number one is be blissful. So if you type Nithyananda and unclutching into YouTube, you'll see the videos where he explains unclutching. If you type Nithyananda and completion into YouTube, there's a 20 minute video where he talks about how to use completion for health, wealth and relationships.

Preeti Kota:  Okay.

John Purkiss:  And in fact, any problem that I have, I just type Nithyananda and whatever. Like, Nithyananda and diabetes, a video will come up.

Preeti Kota:  Amazing.

John Purkiss:  So that's a great resource for people to use.

Preeti Kota:  Okay, great. Well, thank you so much for your time today and I really enjoyed hearing all the advice and strategies on letting go.

John Purkiss:  Well, thanks for inviting me. And if anyone wants to contact me, it's johnpurkiss.com. I've got a form on the internet.

Preeti Kota:  Thank you so much.

John Purkiss:  All right.

Preeti Kota:  Thank you.

John Purkiss:  Thank you very much. Thank you.

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

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

Psychologist Julie Erickson on Aging & Anxiety

An Interview with Psychologist Julie Erickson

Julie Erickson, Ph.D., C.Psych is a Clinical Psychologist at the Forest Hill Centre for CBT in Toronto, Canada and adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto. She specializes in the treatment of anxiety disorders in older adults.

Tori Steffen:  Hi, everyone. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, a research intern at the Seattle Anxiety Specialists. We are a Seattle based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today Clinical Psychologist, Julie Erickson. Dr. Erickson is an adjunct faculty member for the Department of Applied Psychology and Human Development at the University of Toronto.

She practices at the Forest Hill Centre for CBT in Toronto, Canada. She's an expert in the field of anxiety disorders and has written several articles on the topic, including “Anxiety Disorders Late in Life: Considerations for Assessment and Cognitive Behavioral Treatment”. As well as “Associations Between Anxiety Disorders, Suicide Ideation, and Age in Nationally Representative Samples of Both Canadian and American Adults.” Dr. Erickson is also planning to publish a CBT workbook for older adults with New Harbinger in the fall of 2023.

Before we get started today, could you please let us know a bit about yourself and what made you interested in studying anxiety disorders in older adults?

Julie Erickson:  Yeah, absolutely. Thanks for having me. I live and practice in Toronto, and maintain a pretty steady clinical practice and I do some teaching as well. In terms of what got me interested in this area, so it actually started way back in one of my first jobs when I was a teenager. I worked in the recreation department of a nursing home. As part of that job, I was helping facilitate different recreation programs for residents, and noticed that it was the same group of people coming to recreation programs all the time.

It tended to be a group of people that were maybe more optimistic. They tended to be more social. They also tended to be the same group of residents that had more people visiting them. Relative to other residents, who were maybe a little bit more withdrawn or isolated, maybe a little bit more pessimistic or had fewer visitors. Just seeing the contrast made me curious. Why did some people tend to thrive and do quite well, as they got older and were in nursing home care, versus some people really have a more difficult time?

Ultimately, wanted to understand some of the psychological and social factors behind aging well. How to help people live better lives as they grow older and to be more fulfilled. As part of that, how to manage the anxiety and the stressors that can come up for people in late life. Ultimately, this led me to the field of clinical psychology and the intersection between that and gerontology.

Tori Steffen:  Okay, great. Thank you. Would you say that older individuals experience anxiety similarly to younger people?

Julie Erickson:  Yeah. I would say generally speaking, there's probably more similarities than differences. The similarities being maybe focusing on worst case scenarios, feeling agitated or restless, having difficulties relaxing, struggling with indecision or doubt, difficulties concentrating, so a whole host of similarities. Where some of the differences might be though, might be the types of symptoms that end up getting endorsed. Older adults can tend to report more physical symptoms of anxiety or at least report those predominantly.

One of the first things they might report to their family doctor, could be the physical symptoms like upset stomach, or having a racing heart or shortness of breath. As opposed to going to their family doctor and saying, "I'm worried about what people are thinking about me in social situations." That's one difference. The other difference might involve more of the content of the worries that older adults have. That's going to be a little bit different than younger adults. It's less focused on things like academic success, or career building or parenting.

It tends to be a little bit more focused on things like changes in your physical health or mobility, caregiving concerns, or even identity shifts that might be happening because of things like retirement. The surface nature of the worries will be a little different, as well as sometimes the types of symptoms that older adults report.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Would you say there are any limitations that you've found that might prevent the treatment of anxiety disorders in older adults?

Julie Erickson:  Yeah. There's several unfortunately, and several big ones that can get in the way of older adults getting treatment for anxiety disorders. The first one relates to something called mental health literacy. This relates to someone's ability to recognize the symptoms of a mental disorder. Knowing where to get information about mental health concerns, and knowing where and how to get help. Some research suggests that older adults tend to have lower rates of mental health literacy relative to younger adults.

That might be one of the things that prevents them from detecting that part of what I'm experiencing could be a psychological issue. It also might prevent them from knowing there're effective treatments out there and knowing where and how to get help. That's one of the first limitations. The second more has to do with a systems issue, so lack of access to qualified, geriatric mental health professionals. There's an undeniable shortage of us who specialize in treating older adults. That can certainly make it quite difficult to get qualified help.

Thirdly, also probably a societal or systemic issue, stigma. Some older adults may come from a generation or social or cultural background, where going to see a psychologist or a psychiatrist is only when someone is really sick. It still might be shrouded in a lot of their shame. That can be something that really gets in the way. Then finally, I would flag ageism as a potential issue that gets in the way of getting treatment. Sometimes symptoms of mental health conditions in late life can be missed by healthcare professionals.

They might be very well-intended, but maybe more inclined to look at some of the symptoms that older adults might be presenting with, as more attributed to a physical problem as opposed to a mental condition. It's not just maybe healthcare professionals, but also older adults themselves can hold some ageist types of beliefs. They might be inclined to see older adults as less capable of changing. If they hold that belief, which is an ageist stereotype, that can really defer them from seeking treatment as well. A whole host of different things that can get in the way of older people getting help.

Tori Steffen:  Right. Yeah. Those are some great points, as far as limitations go. Your research discusses the ways that CBT can defer among the younger and the older patients with anxiety disorders. Could you explain the differences for our audience?

Julie Erickson:   Absolutely. There's a few that I'll highlight. The first has to do with the pacing of treatment. It's important to know that with CBT, in particular with older adults, things might take a little bit longer for a number of reasons. It's longer to gather maybe a personal history from an older adult client. There's lots of background information to get. Depending on the client's experience with therapy, you may need to devote some extra time to socializing them to therapy. So they have more of a working understanding of what this is, what to expect as you engage in treatment.

There's also an issue of pacing if you're working with someone with cognitive impairment. Or even an individual with normal age-related changes in cognition, you might want to slow down the speed at which you're talking about interventions or introducing new things in session, or even consider having shorter sessions. I'm thinking for people who might have medical conditions that make sitting or sustaining their attention for full hour sessions more difficult. Pacing is one first thing to consider that would make treatment a little bit different with older adults.

The second issue relates to being more attuned to medical issues and how these might be likely to impact your conceptualization of a client and also treatment. Given that a sizable proportion of older adults are experiencing either chronic, physical health issues or more acute issues, there's likely going to be an interplay between some of those symptoms and the anxiety that they're reporting. For example, I had an older adult client diagnosed with tachycardia, and subsequently developed panic attacks every time she had an irregular heartbeat.

Doing a careful assessment and asking about physical health issues is particularly important, so you understand how this might be impacting an older adult in your treatment with them. Another potential difference and an issue to keep in mind, stems from cognitively how an older adult is doing. Cognitive issues require some assessment, even if it's just a brief screener at the outset of treatment. Just to take into consideration how that might impact treatment, and to consider how to best pace and deliver content.

Age-related, cognitive decline is pretty normal and primarily affects things like your short-term memory, your word finding, maybe speed of processing. This may or may not require any alteration in your treatment. But if you're seeing someone who's maybe got a cognitive impairment that's related to dementia, maybe they've got mild to moderate types of dementia. This is going to require some tailoring, in terms of your pacing, but also lots of use of memory aids, right?

Handouts, writing things down, even audio recording sessions, so clients can help retain what you're talking about in session.

Tori Steffen:  Okay.

Julie Erickson:  Then finally, what I'd flag in terms of how things look a little bit different with older adults, has to do with just the types of themes that might come up in treatments. There might be more themes to pay attention to around loss, right? Grief in a bunch of different forms, whether it's of people or of roles in your life.

Or grieving mobility, or functionality or independence. But also themes of isolation, identity changes, or even dealing with regrets. Being attuned to just some of the developmental concerns that can emerge in late life, I think is particularly important with older adults.

Tori Steffen:  Great. Thank you. Thank you for that. Then I know we spoke about it earlier, the somatic symptoms that older adults may experience. Can you explain what types of somatic symptoms that they typically experience and why that might be?

Julie Erickson:  Yeah. A lot of the somatic symptoms older adults experience, would be some of the typical ones we would see in early life as well, around whether it's upset stomach, or just feeling on edge, or restless or even elevated heart rate. Even things like feeling sweaty or short of breath, in cases like panic. Some of those somatic symptoms will look very similarly. As far as to why they might present more with some of those somatic symptoms. Well, we don't know for sure. There's a couple possible explanations.

One of which might be that there could be either biological or psychological, or social factors that influence how anxiety disorders are experienced or present, or seem more prominent in late life. It seems reasonable to expect that the types of symptoms that people might present with can change as one grows older. Due to things like different medical conditions or just age-related changes in things like sleep or emotion and how people experience it. It could just be that there are developmental changes in how anxiety disorders present.

But the other possible explanation relates back to something that I was talking about earlier around lower rates of mental health literacy in older adults. If older adults are less aware of what some of the different symptoms of anxiety disorders are, they may underrecognize some of the symptoms, for example, some of the cognitive symptoms. May be less likely report some of those symptoms, if they don't know that's in keeping with an anxiety disorder. If that's actually the case that this is more of a reflection of let's say a cohort effect, right?

That it's this generation of older adults who lack mental health literacy, we might expect to see that as younger generations of adults now as they get older, that they would be more aware of and more likely to endorse a greater array of anxiety symptoms. So we'll see, and probably research will have more to tell us in the coming decades about some of these age-related differences.

Tori Steffen:  Yeah. That'll be interesting to see the changes as time goes on and people grow older. Are there any other approaches than CBT, that older adults can utilize to combat the symptoms of anxiety disorder, maybe fear of aging?

Julie Erickson:  Yeah, it's a good question. The challenge is that there's probably relatively less therapy outcome research for older adults, compared to other age groups and most of it tends to focus on CBT. But if we look outside of this modality, there's some support for approaches like motivational interviewing or problem-solving therapy to have some success with older adults. One other approach that might be more useful and maybe more unique to late life.

Maybe more helpful too in dealing with issues like fear of growing older, or fear of aging or coming to terms with one's mortality, is the practice of reminiscence and life review, so reminiscing therapy. And while we all might reminisce about the past and recall the good, the bad, and the ugly of our lives, this is particularly important for older people as a developmental task. Older people use the process of reminiscing to help create meaning and integrate life's events.

Maybe even have a heightened awareness of things like the finiteness of life. And to work to create meaningful roles for themselves in their later years, which can be challenging given that society largely pushes older adults to the sidelines. This practice of reminiscence and life review has particular relevance to older adults, who might struggle with fears of growing older or come to terms with what that means for them.

Tori Steffen:  Okay. Yeah, that definitely makes sense. Your article also mentions that the presence of cognitive impairments. We were talking earlier, dementia as an example, can make it more difficult for older adults to engage in CBT as a treatment for anxiety.

Would you mind just explaining this a bit more? Do you think CBT could ever be a suitable treatment option for an older adult with a cognitive impairment?

Julie Erickson:  Yeah. Yeah. Cognitive impairment can vary in late life. There's a certain degree of cognitive change that's normal as people get older, like declines in short-term memory, forgetting names of people or forgetting where you left an object, or walking into a room and not remembering why you walked in there for. That's all pretty normal, versus dementia is not considered a normal part of growing older.

Dementia's an umbrella term for a wide variety of different conditions that can include things like Alzheimer's disease or vascular dementia, or Lewy body dementia. They can come with more severe difficulties with memory, attention, speed of processing, language. It can be much harder for these folks to learn and retain new information, especially as the disease progresses. Now, it's not to say though that older adults with dementia can't benefit from CBT, but it really depends what stage of the disease that they're in.

There is research to suggest that if you're in the more mild to moderate severity range of dementia, that you can still benefit from this type of approach. But you want to ensure that your CBT protocol maybe is streamlined and simplified, in terms of the level of complexity. And to make sure there's ample use of memory aids. Things like handouts, keeping written notes of what's happening each session, and having the client keep their own notes as well, audio recording each session.

Things of that nature, as much as you can do to help the client remember and encode the information you're talking about in session, the better. You might be able consider involving significant others in the client's life to help assist with remembering information. I'm thinking of one client in particular, who after our sessions, she would often talk to her daughter. And would talk to her daughter about part of what she learned in her CBT session that day.

Then part of that was just to help her remember and consolidate what she's learning. But also, to bring her daughter into the loop so her daughter's more aware of what's going on in her treatment. Those are some of the things to keep in mind that might still help an older adults with dementia, let's say, benefit from CBT.

Tori Steffen:  Great. Yeah. It's good to know that it can still be helpful for older adults with those cognitive impairments. The case study outlined in your article, showed that older adults who experience regular panic attacks can improve such occurrences with the help of CBT tactics. Could you speak a little bit about this and what may help with that?

Julie Erickson:  Yeah. Yeah. Let's start with in its simplest form how we conceptualize something like panic disorder. Most simply, panic disorder is a fear of fear. Where individuals who might be experiencing normal or benign physical symptoms of anxiety, become quite fearful of these sensations because they start to assume that they mean more catastrophic things, like having a heart attack or being on the verge of fainting, going crazy or losing control.

When anxiety symptoms are viewed in that way, of course, it's very distressing and can typically result in avoidance of activities or situations, or things where people think that those physical symptoms might be activated. They might start to avoid things like cardiovascular exercise, caffeine, or even things like taking the stairs. With some of those avoidance behaviors, this can really reinforce and even magnify some of the fears that people have around those physical sensations of anxiety.

It can sometimes be the case that for older adults with panic disorder, the onset of those difficulties can go alongside other medical issues, like the tachycardia example I discussed earlier, or even GI conditions. The onset of these medical issues can make people more hypervigilant to changes in physical sensations, to be a bit more anxious or on edge about them. Now, when you're doing CBT for panic with older adults, the overarching goal is to help people learn that the physical sensations that occurred during panic are uncomfortable but not dangerous.

They don't actually need to try to actively control these sensations, that they'll dissipate on their own. Part of how we do this is by cognitive restructuring, so helping older adults to change their minds about what these sensations mean. With some older adults, they've had pretty longstanding beliefs about what these sensations mean, that they're crazy or they're unable to control themselves. Good psychoeducation is going to help people start to shift the perception of these symptoms.

Now, the other thing though that's really going to go a long way, is doing interoceptive exposures, which is basically making active, intentional efforts to try to mimic the sensations of panic. In doing so, is going to allow people to learn that these sensations aren't going to result in some catastrophic outcomes, like going crazy or having a heart attack. We'll often encourage people to do things like breathe through a straw for one minute and plug your nose. Run on the spot as quickly as you can or purposely hyperventilate for 30 seconds.

Doing that repeatedly is going to help people start to learn that these are at most, uncomfortable but not actually dangerous feelings for me. Now, the thing that's maybe more important if you're doing those interoceptive exposures with older adults, is to make sure that you inquire about any medical conditions that might contraindicate some of these exposures or require you to adapt them. For example, there's some cardiopulmonary conditions that you might want to avoid.

Certain forms of interoceptive exposures where you activate either cardiovascular symptoms or respiratory symptoms. Likewise, if you've got individuals with asthma or COPD, or renal disease or seizure disorders, some of those folks are advised not to do certain forms of exposures that involve breathing through a straw or inhaling more CO2. For this, don't work in isolation. Check with your older adult's primary care physician to get clearance to do some of these exercises.

Well, collectively, some of the cognitive work and the exposures in CBT for panic, can really go a long way into helping older adults reduce the frequency of those panic attacks, and ultimately, to feel more confident about their abilities to deal with anxiety.

Tori Steffen:  Great. That's great to hear that those tactics can help with panic disorder and definitely good. I know that CBT is best and ideally done under the treatment and guidance of a licensed mental health professional.

Are there anything things that older adults can do on their own to potentially reduce or lessen those symptoms of anxiety?

Julie Erickson:  Yeah, absolutely. There's a number of important things that they can be doing. One of the first things I'd encourage older adults to do, is to try to be a detective with their anxiety. By that, I mean trying to make note of a few things when they feel anxious. To make note of where and when they tend to feel more anxious. Is it before trips to the doctor, while driving, before traveling? To also identify what thoughts that they may be experiencing at the time that they feel anxious.

What if I get into an accident? What if my doctor gives me terrible news and the like? Also to make note of what behaviors that they engage in when they feel anxious, whether it's avoiding driving or researching physical symptoms online. Making note of those different things can help understand the full picture of your anxiety and how it shows up in your life. That can ultimately help you be better situated to interrupt some of those usual things that go on when we feel anxious.

The second thing I think older adults can do is to talk to themselves like they would talk to a loved one or a close friend who was feeling anxious. If we had a loved one who was worrying about an upcoming medical appointment, we'd probably try to understand, to empathize and even to comfort them. Oftentimes, if we can do that for ourselves, that just tends to feel better and helps us feel a little bit better situated to cope with feelings of anxiety that might be coming up.

The third thing and final thing I'll mention that might help older adults in dealing with anxiety, has to do with experimenting with doing the opposite to what your anxiety pushes you to do. If you notice that your anxiety tends to make you want to avoid things like socializing, exercising, or trying new things, try to attempt to gradually face and overcome some of these fears by doing the opposite. If you notice perhaps that your anxiety makes you overdo things.

So over-come it, over-prepare for things, over-research, experiment with scaling back on some of those things. And people can find that if they change their behavior when they feel anxious, many of their feelings of anxiety can reduce over time. Those are some of main things I would encourage older adults to do, who feel anxious.

Tori Steffen:  Great. Thank you for sharing that. I'm sure it's helpful information and definitely relates to mindfulness and exposure therapy as well.

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

Julie Erickson:  Yeah, sure. I always like to plug some optimism for growing older. As much as there can be some negative stereotypes of aging and fear surrounding the process of growing older, there's also a lot to look forward to. The later years of life can bring a lot of freedom from responsibilities that were present earlier in life, so like child rearing or building a career.

Older adults acquire a lot of wisdom and emotional maturity that tends to peak in later life. Alongside that, they tend to have more clarity about the people and the things that are most important to them and tend to spend their time accordingly. As much as there are considerable challenges to growing older, there are a lot of upsides and things to look forward to.

Tori Steffen:  That's great. I love the optimistic perspective on that. Well, thank you so much for joining us, Dr. Erickson. It's been really great speaking with you today. Thank you so much for contributing to our interview series.

Julie Erickson:  You're welcome. Thanks for having me.

Tori Steffen:  Thank you. Have a great one.

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

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

Therapist Claire Jack on Autism Spectrum Disorder

An Interview with Therapist Claire Jack

Claire Jack, Ph.D. is an Anthropologist and Therapist based in Scotland. Dr. Jack specializes in working with women with Autism Spectrum Disorder and has published “Women with Autism: Accepting and Embracing Autism Spectrum Disorder as You Move Towards an Authentic Life”.

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety specialists. We are a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us anthropologist and therapist, Claire Jack, who joins us from Scotland today. Dr. Jack received her Ph.D. in anthropology and has subsequently trained as a therapist over 10 years ago. In her late forties, she was diagnosed with autism spectrum disorder and has sought to help others understand more about this often challenging disorder. Before we get started today, can you let our listeners know a little bit more about you and what made you interested in becoming an anthropologist as well as a therapist?

Claire Jack:  Okay. Yeah, actually, I suppose for me the two things link up really quite a long time ago. When I was 18, I started to train as a psychologist, I started to do my degree in psychology. For various reasons, it just wasn't really the right course for me. I shifted to archeology, so I've had a long route to get here, which led on to anthropology and history because, obviously, anthropology and archeology are quite closely related. I think there was just always that interest in how people work, how they communicate, so very much was studying that within anthropology.

I really got into therapy from my own personal experience. I had a really bad driving phobia and I had had hypnotherapy a long time ago, which was reasonably successful, but not fully successful. I had an incredible hypnotherapy session for my driving phobia and that just made me want to train. I trained in that, I did counseling, I did life coaching. That's it, really, I've been working as a therapist now I think for probably nearly 15 years and I've had a training school for 10 years, so I combined the two.

Jennifer Ghahari:  Great. Can you explain to our listeners what autism spectrum disorder is?

Claire Jack:  Okay. Autism spectrum disorder is a developmental disorder, so that means that you're born with the condition. When we're thinking about it, we can really think about three levels of autism, we've got level one, level two, level three. I think it's really important to remember, it's a huge spectrum, so very big spectrum of experience.

People with level one autism, that's what I've been diagnosed with, that's equivalent to what used to be called Asperger's syndrome. I think in 2013, you no longer have an official diagnosis of Asperger's. That is roughly equivalent to level one autism. People with level one lead independent lives on the whole; average or above average intelligence. They have symptoms, I think it's important not to downplay how difficult level one autism is, but most people can lead a certain completely independent life.

Level two autism, we're talking about people that maybe need some kind of assistance, might struggle to be lead independent lives.

Level three is often associated with learning difficulties; it might include people who non-verbal.

It seems like it's such a big spectrum that you almost think what have people, say like me, who's leading a completely independent life, with someone who has special needs and a lot of help, what have we got in common? It's really thinking about the traits. People with autism, we have sensory issues, difficulties processing sensory stimuli, communication and social difficulties. We might have difficulties with restricted interests. Emotional regulation difficulties are really common as well. Across the spectrum, people have these traits that they share in common.

Actually, I don't have anything visual that I can show this on, but I think when we think of a spectrum, we often think of a linear spectrum, from good to bad or difficult to easy, but actually, if you think of it as a pie chart and think of the symptoms and think, well, somebody might be much more affected in terms of communication difficulties, but maybe less affected in terms of restricted interests, or they might have difficulties with eye contact, but less emotional regulation difficulties. Instead of thinking of it a spectrum, we can think that people have really diverse experiences within autism as a whole.

Jennifer Ghahari:  Wow, great. Thank you for explaining that and the different levels. Unfortunately, without more information known about autism among the general public, those without it can often feel frazzled or annoyed at some of the ways it may present in people. It's fairly common to hear notions like, "Why can't they stop doing that? Why don't they act normal?" Can you explain what it's actually like to experience autism? What does it feel like?

Claire Jack:  Yeah. I suppose, first of all, there's not a choice in it. You are experiencing the world differently and you're processing the world differently, so you can't think yourself out of autism. I think that's the first thing for other people to remember. Actually, although I'm autistic myself, I come into contact with autistic people and we don't all necessarily get on together, so I can see it from both sides. An example might be, I do a lot of teaching, I teach students, and sometimes my autistic students need me to really explain things in a huge amount of detail, I need to spend an awful lot more time going over things, they might take things that I say very literally so I have to go over that, and just I end up spending a lot more time with them. I can understand that they need that time, but I can see that that could be frustrating for somebody else.

Yeah, and to come back to your question, it's important to know that when something is happening for somebody autistic, it tends to be happening in a really extreme way and there is nothing that they can do about that. For instance, when I was a child, because I think a lot of people learn about autism because they've got maybe autistic children, when I was a child, I was very well behaved; never, ever misbehaved. That was what I wanted to be like, I just wanted to be a really well-behaved kid. But if I was triggered, I was a monster; absolutely, I was horrific.

One time in the hospital, I was there for an operation, I attacked all the nurses, I got all the medical equipment, I threw everything everywhere. I scratched my mum so badly that she still has the scars. I was five, but there was no controlling me. It wasn't a choice; I never would've attacked like that. I think that's just really important to think, because autistic people have to process things in a different way, you have to understand it is different. It's not the same, no matter how they might present most of the time to somebody.

Jennifer Ghahari:  Great. You mentioned triggers, could that be something like lights or smells or sounds?

Claire Jack:  Absolutely. I think when I'm thinking about triggers, I'm usually thinking about emotional triggers and sensory triggers. What you're talking about is more in terms of sensory processing. An example might be going to the supermarket and dumping your bags because you can't be there any longer, or a huge one for me is people scraping their plates. As a kid, I couldn't stand, especially if we had unglazed plates in the house, that noise, I just couldn't be in the room. Even as an adult, I've learned to cover it a bit, but that kind of thing, I experience it very, very deeply. It's like a physical, horrific pain. Both my sons have that sensory thing as well, they're exactly the same.

Emotional triggers can also be a huge thing as well. I think often, if you're not being understood or you're not being listened to, maybe somebody's given you too much information. I had a client recently, a student, and she was just getting too much information that she wasn't able to take in and had a complete meltdown. I think those are two really big triggering things for autistic people.

Jennifer Ghahari:  Great, thank you. On your website, you mentioned that males and females with autism actually present differently. Can you explain the differences?

Claire Jack:  Okay. Well, I think there are a lot of similarities, in terms of the traits, there are really big similarities, but women tend to camouflage or mask their autism. We know from a really early age, girls tend to be driven to be more social than boys. That goes from neurotypical girls and autistic girls, but there is this drive. They want to engage a bit more, little autistic girls than little autistic boys, so they find ways of trying to appear "normal" so that they pass. For that reason, girls tend to be awful lot better at making eye contact, at having conversations, at just blending in.

Also, in terms of things like interests, there seems to be a difference. The classic, what we might think of, collecting Star Wars toys or little trains or something that boys might do, collecting things, girls often become really obsessed with other people. It could be crushes, it could be bands, film stars, even a best friend.

Again, they tend to go under the radar because they're presenting very differently to boys. They still have the restricted interests, still have the social difficulties, still have all of it going on, but it tends to look really different in girls and boys.

Jennifer Ghahari:  In terms of comorbid mental health conditions, what do those with autism tend to experience? Is it anxiety, depression, things like that, or any other?

Claire Jack:  Yeah, absolutely. They tend to have really high levels of anxiety and depression. What the research shows is that that tends to be linked to the degree of camouflaging. It's not necessarily linked to how autistic you are, how severe your autism is, but how much you try and cover that. Again, women tend to maybe have worse mental health than men and that tends to be linked to how much they mask it, because when you're masking all the time, it's absolutely exhausting. It's a strange just doing anything because you're putting on such a constant act. That's a big reason for the certain mental health issues.

Suicidality is also a really big problem with autistic people, higher levels of suicidality and also more of a likelihood that it's followed through on as well. A lot of autistic, well, I don't know a lot, I'm possibly using the wrong term, but certainly some autistic people are misdiagnosed with things like bipolar disorder as well, because meltdowns can seem horrific, it can seem like a bipolar episode. Some of the extreme behavior that autistic people present with as well can sometimes be misdiagnosed as bipolar. Some people do have autism and bipolar, but the misdiagnosis is something that comes to light quite often as well.

Jennifer Ghahari:  When we diagnosis this, is it a psychiatrist, a therapist?

Claire Jack:  It's usually a psychiatrist, sometimes clinical psychologist will diagnose, for a full clinical diagnosis. Therapists, such as myself, might offer a nonclinical diagnosis. I suppose one of the reasons certainly that I offer that is just the problems that people have getting a full clinical diagnosis. The wait times can be huge, the expense can be really extreme, and so sometimes people might go to someone like myself, even as a stop-gap, so that they have something to work with whilst they're waiting a couple of years for a diagnosis.

Jennifer Ghahari:  Oh wow; years.

Claire Jack:  Yeah, absolutely. Yeah, I don't know about every country, and obviously in the UK we have the NHS, so it's a free diagnosis, but that can certainly be up to a couple of years waiting. It's a massive wait.

Jennifer Ghahari:  Which could lead, as you said, to the anxiety and depression.

Claire Jack:  Absolutely, yeah.

Jennifer Ghahari:  Wow. In terms of treatment, how would autism spectrum disorder typically be treated, from a therapeutic standpoint?

Claire Jack:  I think this is a really interesting question. The recognized treatment for autism is applied behavioral analysis, ABA. To be honest, it's not something that I've had and it's not something that I'm trained in, I'm no expert in ABA, but basically, it's... I'm trying to think of the best way to describe this. It's aimed towards people maybe having a more productive, and again, inverted commas, “normal” life. It's quite a rewards- and punishment-based therapy, as far as I know. It's not particularly popular within the autistic community, because the autistic community are of really working towards accepting autism and accepting yourself. But certainly, I think it's very common amongst autistic children, trying to almost train them to be less autistic. Like I say, it's not a very popular approach within the autistic community.

CBT can be effective, but I think what's really important is you need to go to somebody who understands autism. I've been trained in CBT and I do work with CBT, but it doesn't necessarily work with autistic people unless you really recognize the limitations, because trying to push yourself and change your beliefs and come up with new behaviors can be really impossible for people with autism. What I find is that a lot of people who have been down traditional therapy routes just haven't got the help that they need at all. A lot of them have talked about therapists, and actually I've had this experience looking for past trauma to explain what I'm experiencing, because it can present in a very similar way, and actually there's maybe nothing particular in the past that can explain what you're experiencing now.

There are autistic therapists out there. I think just having that level of understanding from a personal perspective and being able to educate your clients, I find with autistic clients, I'm educating them a lot more than I would with other clients and that's a hugely important part of therapy. But to me, therapy is all about accepting yourself, it's accepting you're autistic beginning to work to take the pressures off and work with, I don't like to call it limitations, differences. Just think, yeah, I'm different in this way, but this is a solution for it. It's all about acceptance.

Jennifer Ghahari:  Oh, that's fantastic, thank you. In terms of self-care tips, are there any that you can recommend that people can try at home or just on their own without any therapy?

Claire Jack:  Yeah. I think one of the big problems people with autism have is emotional regulation. The worst effect of that is when people have meltdowns, which can be absolutely horrific. It can involve leaving your house, putting yourself in danger, breaking things, putting other people in danger, they can be horrendous. But there are signs at some point that you are probably heading from meltdown, so it's really important to begin to recognize your own signs. They don't come out of nowhere.

You might just recognize you're a bit tired, some people might stim, so it could be touching their face or rocking backwards and forwards or pacing, or even talking a bit loud, there will be something. If you can think about it as an emotional regulation timeline, you can begin to recognize that actually you need to stop and don't go to the supermarket. I'm mentioning supermarkets because I hate them, but don't go to the supermarket if you're starting to talk a bit quickly. At that point, you start to rest. I think that's a huge tip, start to think about a timeline and what you need.

Also, you need a recovery time. I think this is, again, autistic people are different. They take ages to recover from a meltdown. It might be hours, it could even be days. You need to think, “Do I need to rest here, do I need to avoid something?” There's a theory that lot of people use, called “spoons theory”, and it was actually developed by somebody with I think it was chronic fatigue, it was some kind of chronic illness. It's a great way to think about self-care. You need to think, “I have X amount of spoons this morning, so I've got 10 spoons. I'm not going to get anymore, when they're gone, they're gone.” I can think, “Right, I've got a meeting, that's two spoons, I've got the school run, that's going to be three, but I don't get any more at the end of the day.” You might actually only be starting with six. It's a real check in with yourself and thinking, I don't have limitless capacity, because fatigue is a huge thing as well.

I like to think of it in terms of pebbles, because I live by the coast. Literally, you have your pebbles. You can even take a pebble out with you, but you just don't get anymore. Again, without being negative or trying to think about limitations, it is a reality check, that you do need to look after yourself or you could end up being exhausted and frazzled and have a meltdown and all of these other things.

Jennifer Ghahari:  Yeah, I think you bring up a good point. I think a lot of people without autism don't realize how bad a meltdown can be, number one. Yes, people can witness it, but then, like you said, the recovery can be hours or days. Autistic people really need to do self-care. If they can't go to an event or if they're wearing noise-canceling headphones, it's not because they want to look stylish or interesting, it's because they actually need to do this for their own health.

Claire Jack:  Yep, yep, absolutely. I know a lot of my clients love noise canceling headphones and some will wear them in the house. I was talking to someone recently, big family, including stepchildren, and just the noise at dinner time was just too much to cope with, and she started to wear these. Her family thought it was amusing at first then they accepted it. It just made such a difference. Yeah, but yeah, it's not about trying to look for attention or anything else, it is about trying to keep yourself safe.

Jennifer Ghahari:  That's great. I'm glad that client found that way to do it.

Claire Jack:  Yeah, it's amazing. I think once you accept it, the solutions you come up with are really inventive.

Jennifer Ghahari:  This has gone by pretty quickly. I always think that's a good sign of a good interview. Usually, we wrap up our interviews by asking if you have any parting words of advice. I'm actually going to ask you that twice. First, do you have any parting words of advice that you'd like to offer for those diagnosed with autism disorder?

Claire Jack:  I think it's a really difficult thing at the beginning to come to terms with, particularly for adults. I think it's different if you've maybe known since you were younger, and certainly the way parents impart that knowledge to their children is really important. But I think just if you find out a bit later in life, as most of my clients have, you've got to be really patient with yourself. It can be scary, you can think, “My life's going to be limited, I can't have the career I want, can I have a family?” Yes, you can do all of these things, but you maybe need to just find different ways of managing it, but it really doesn't have to limit your life in any way.

To me, it's something that it can really open up doors and it can open up new ways of thinking and being once you've begun to accept it. I think that's the really important thing. If you keep battling against, it's always going to appear like this terrible thing that's going to hold you back, but if you can accept it... Autistic people tend to have different ways of viewing the world, they maybe have different talents, they might be particularly good in some areas, so once you can accept all of that, then you can lead this incredible, rich life. It might be slightly different or it might work in slightly different ways, and that's completely fine. I think it's accepting that that's completely fine.

Jennifer Ghahari:  Do you have any words of advice for those without autism that you want them to be aware and cognizant of?

Claire Jack:  Well, I think first of all, the client base that I work with, you wouldn't know they're autistic. I think some people think they're giving a compliment by saying that, “You don't look autistic at all,” which is actually really frustrating because they don't see what's happening in the background. When I went to my GP initially to ask for a referral to a psychiatrist, I was just completely knocked back on the basis that I can have a conversation, I can smile, I can look somebody in the eyes. I'd done tons of research and I really tried to explain why and what was going on for me, and it was, "You don't look autistic." I think it's terribly important, if you're not autistic, don't judge somebody, because you don't know how much effort they are putting into something.

It's also, I think, really important to recognize it's real. Most of the people that I work with tend to be really lucky in terms of their partners. I think autistic people are often drawn together anyway, but even if there is a non-autistic partner, most of my clients have had a lot of support, but I have had some clients who've had a really horrible experience from husbands and partners who will not believe that they're autistic and it doesn't seem to matter what they say. Even when they get a full diagnosis, they will not believe it.

I think if somebody has a diagnosis, even if they haven't, even if they're self-diagnosing and have done the research, what they're experiencing is very real. Just because you don't understand it doesn't mean it's not real. Again, just thinking about autistic people having to be inventive with some of their solutions is a great opportunity for partners, children, parents, to be inventive with the autistic person as well, be open to it. Accept if they don't want to do something, they don't have to do that thing. You can probably work around it, you can come up with a different solution. If they don't want to come to your family party, fine. Do they have to go? Probably not.

It's about, I guess, looking at societal norms, which very much are made to fit neurotypical people. This is where I'm going into my anthropology bit here, and I'm thinking, well, do we have to adhere to these norms, and why would we? I think, again, it's a great opportunity, but people have to be really open to accepting their loved one or colleagues or whoever has autism and thinking I can either treat this in a way that's going to stress this person or I can support them, because this is absolutely real for them.

Jennifer Ghahari:  That's really great. Thank you so much. Dr. Jack, it's been wonderful talking with you today and we really appreciate your contributions to our interview series.

Claire Jack:  Thank you.

Jennifer Ghahari:  Have a good day.

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

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

Atmospheric Researcher Kyle Hilburn on Wildfire Anxiety

An Interview with Atmospheric Researcher, Kyle Hilburn

Kyle Hilburn, M.A. is an atmospheric researcher and research associate at the Cooperative Institute for Research in the Atmosphere at Colorado State University. He specializes in the use of technology to study natural disasters, such as wildfires.

Theresa Nair:  Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us atmospheric researcher, Kyle Hilburn, who is a research associate at the Cooperative Institute for Research in the Atmosphere at Colorado State University. Kyle has a Bachelor's Degree in Atmospheric Science from the University Of North Dakota and a Master's Degree in Meteorology from Florida State University. He was recently a presenter at NASA's Earth Science Applications Week, where he discussed the most recent breakthroughs in the use of NASA satellites to assist emergency responders in tracking the directionality and impact of fires. Thank you so much for joining us today. Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying meteorology?

Kyle Hilburn:  Thank you, Theresa. It's my pleasure to be here with you today. Growing up in Minnesota, I was fascinated by the weather for as long as I can remember. Minnesota has plenty of crazy weather to observe. I will admit that as a young child, I was afraid of loud noises. And so, thunder caused me distress. Some of my childhood interest in lightning was motivated by that. Even though I couldn't control it, I could at least understand it. And that helped me deal with the stress more effectively. I find it incredible that despite millennia of meteorological observations by humans, we are still learning new things about the weather.

For example, when I was in high school, the first photographic documentation of sprites was captured, which are electrical discharges from the tops of thunderstorm clouds. There are undoubtedly many new discoveries still to be made in meteorology. What makes new discoveries possible are advances in technology for observing the atmosphere. And while the public may joke about the accuracy of weather forecasts, there have been steady improvements in weather forecasts over the last 30 years, coming from increased computational power, more sophisticated weather models, and more observations.

It wasn't until I was living in Northern California that I had personal experiences with wildfire, and I realized its important role in the Earth atmosphere system. The growth rate of wildfires rivals that of thunderstorms. The first fire I witnessed relatively up close was the Valley Fire in 2015. It grew from 10,000 acres in the first six hours and 50,000 acres in the first 24 hours. Within two weeks, it had burned 76,000 acres. When fires become large enough and hot enough, they even begin to create their own weather, capturing the physical coupling between fires and the weather is an important theme in my current research.

Theresa Nair:  That's incredible. I mean, I think sometimes we don't realize how quickly fires can spread. Some of the comparisons that you're giving us are amazing. We don't realize that it can spread even faster than a storm.

Many of our audience members are in the Pacific Northwest where wildfires are becoming a growing concern. Since the time you began researching atmospheric behavior, are you noticing any significant changes to wildfires, either in frequency or behavior?

Kyle Hilburn:  Yes. What I've observed and what multiple studies confirm is that wildfires are becoming more frequent, they're growing larger, they're exhibiting more extreme fire behavior, and the fire season has gotten longer. And with population growth in what's called the wildland-urban interface, there are more people with greater exposure to wildfire risks. And it's not just droughts and fires that are becoming more frequent and more extreme, but heavy precipitation seems to be becoming more common as well.

For example, the six 1-in-1,000-year precipitation events that occurred in August in the United States or the recent flooding in Pakistan. This leads to the concept of cascading natural hazards, where heavy precipitation falling after a fire can cause erosion, debris flow, and have impacts on watershed, ecology, and water quality. This recently occurred with tropical storm Kay over Southern California. This cycle of drought, fire and flood is surprisingly common. And the National Weather Service actively monitors for these situations.

Throughout most of my career, the concept of attributing extreme weather events to climate change was considered impossible or at least dubious science. However, with advances in computing power, one can now simulate extreme events with and without the human influence on the climate and thus attribute those events to climate change with some level of confidence. This attribution is being performed almost in real time today.

Theresa Nair:  That's great. Yeah, I think those types of models are important for answering that question of whether we are affecting the atmosphere or not. In your recent presentation for NASA's Earth Science Application Week, you discussed extreme fire behavior and how some fires are large enough to create their own weather. I know you mentioned it a few minutes ago also in this interview. I was wondering if you could give us some examples of that and discussed what types of phenomenon you observe.

Kyle Hilburn:  A primary example is called a “pyrocumulonimbus” cloud, which is a type of thunderstorm that gets its buoyancy from a heat source, such as a wildfire. This type of cloud has only been widely recognized in meteorology in the last 24 years. There are even examples of pyrocumulonimbus clouds that get strong enough to produce lightning that ignite new fires, such as the pyrocumulonimbus cloud created by the Mallard Fire in Texas. Strong winds cause extreme fire behavior as we saw with the Marshall Fire in Boulder, Colorado. This was just a grass fire, but with winds stronger than 100 miles per hour, this fire was able to get out of control and enter an urban area causing so much destruction. People who thought they live far from the wildland-urban interface found out they are more vulnerable to wildfire risk than they thought. The Tubbs Fire in Santa Rosa, California in 2017 burned from Calistoga to Santa Rosa in just three hours’ time, propelled by very strong Diablo winds. Those winds are strongest along ridge-tops and created tendrils of fire that spread down into the valleys and neighborhoods, reaching within half a mile from my house.

The other ingredient in extreme fire behavior is heavy fuel loading, where the term fuel dispassionately refers to trees, shrubs and grasses. Drought, historical forest management practices, and pernicious species have played roles in creating the dead fuel conditions that we find ourselves with today.

In Lauren Johnson's interview on environmental justice, she described Native American forest practices of thinning trees to control fires. That practice is now referred to as a prescribed burn. Although New Mexico, this year, we witnessed a tragedy when a prescribed burn got out of control and became the Calf Canyon/Hermits Peak Fire, the largest in New Mexico history. The goal of my research is to use sophisticated weather models to provide improved decision support tools for prescribed burns and wildfires.

Theresa Nair:  That's really interesting. There's actually a couple follow ups I think I'd like to ask you on that. So with these weather systems that develop in fires, are some of the tools that are being developed able to begin predicting those?

Kyle Hilburn:  Yes, absolutely. We're able to put together all of the physical processes. And a lot of these have been understood for some time, but it's about having the computing power to be able to run these models fast enough to provide the information to people in the field, dealing with the fire.

Theresa Nair:  Okay, and one other thing. You had mentioned the benefits of controlled burns, but then also the risk if it gets out of control. Given the risk of it getting out of control, does it seem like it's better in general to do the controlled burn or is it maybe different in different circumstances?

Kyle Hilburn:  Yeah. I'm not a forest ecologist, but my understanding is that in general, controlled burns are an effective practice for controlling fuel-loads in forests.

Theresa Nair:  Okay, great. In your presentation, I did attend your NASA presentation, you were discussing the most recent applications for using satellites to assist in responding to fires. Could you tell us about the developments in that area and how it differs from previous methods that were used to track the directionality and impact of fires?

Kyle Hilburn:  Satellite remote sensing has been used to detect thermal signatures of active wildfires for over 20 years. Recent developments have improved the spatial and temporal resolution of the observations. For example, currently, the highest resolution satellite sensor with publicly available data has pixels that are 30 acres in area. However, that satellite is on a low Earth orbiting satellite, about 500 miles up, which only observes a given location twice per day. In contrast, geostationary satellites currently provide updates as fast as 30 seconds, but because they're so much farther from Earth, 22,000 miles up, they have pixels that are 1,000 acres in area.

So, part of my research concerns combining these observations from different sensors to get the best of both approaches. Over the coming decades, we will get new sensors and satellites with even finer spatial resolution and faster temporal refresh. These are being designed right now. While small satellite constellations and unmanned aerial vehicles will offer new observing approaches.

The other major development is how we forecast fires. Older models treat fire as an uncoupled system where you have wind blowing over a fire and they use simple assumptions to predict the fire spread based on the wind, but in those models, the fire does not in turn affect the winds. In my research, we're using a fully coupled model. Its name is WRF-SFIRE, which has physical processes in the atmosphere, the fire, and the vegetation coupled together and interact as they do in the real world. This is the only way that you can have fire that creates its own weather. Examples of fire atmosphere interactions include fire-induced winds that can further dry fuels and smoke shading that could inhibit air mixing. Uncoupled models do not represent those types of physical connections. I discussed more technical details about physical processes of WRF-SFIRE in my NASA Earth Science Applications Week presentation, and I've provided the link. (Kyle’s presentation starts 1 hour 32 minutes in.)

Theresa Nair:  That's great. Thank you. And that sounds like incredible research being able to combine all of those different factors and get more accurate predictions about how the fire will actually behave. Are these recent developments in the use of satellite data and the work you've been talking about, are they solely intended for the use of professionals and disaster responders, or is this knowledge that's available to the general public?

Kyle Hilburn:  I would encourage the general public, not to attempt to interpret forecasts from fire models for the same reason your doctor encourages you not to obsess on WebMD. You need to be a trained meteorologist to be able to understand the characteristics of the particular forecast system in order to understand what those forecasts mean. On the other hand, there are websites that provide information on fires, smoke, and weather that are suitable for the public, and I'll provide you links. You should also look for information at your state and local levels to get the information that is most specific to you.

Theresa Nair:  That is great. And we will be linking to all the resources that Kyle's talking about in the transcribed interview below. So if you're watching this interview or if you're on the podcast listening to it, there was a transcription available that we'll have all of the links that he's discussing. Let's talk for a little bit about the relationship between wildfires and mental health. You have extensive experience dealing with wildfires, both from a personal perspective and a professional perspective. When people find out that they may potentially be in the path of a wildfire or that they're in the general proximity of a fire, what steps do you believe would be the most helpful in dealing with the anxiety that might arise from that situation?

Kyle Hilburn:  Well, recognize that a fire doesn't need to be particularly close to cause major impacts on life and various impacts can last days to weeks to months. Even when a fire is 30 miles away, its impacts can make it feel very close. The smoke from a nearby fire can produce a suffocating sensation in a matter of seconds to minutes, which is anxiety provoking. The sky can darken, turning day into night and falling ash can produce an “end of the world” feeling. The smoke can make outdoor exercise impossible, which removes a potential coping mechanism, and it can trigger PTSD in people who have lived through previous fires. Having to leave everything behind at a moment's notice, not knowing what you'll come back to is incredibly stressful. And the aftermath of a fire in an urban setting looks like images from a war.

I've experienced living near fires in Santa Rosa, California, and Fort Collins, Colorado. The Cameron Peak Fire near Fort Collins started in August 2020, and it wasn't 100% contained until December. Fortunately, I was not directly in harm's way with any of these fires, but I still experienced some anxiety. The thing that produced the most anxiety for me was the lack of specific up-to-the-minute information given how fast conditions can change. While messages go out from emergency managers to people currently in evacuation zones, being close to, but not in an evacuation zone can be frustrating because it is hard to get the hyperlocal up-to-date information you want.

So, when confronted by wildfire hazards, one way to deal with the anxiety is practicing mindfulness by which I mean observing your environment and your thoughts about it. Some questions you can ask yourself, is the smoke aloft, or is it near the surface? That can make a big difference in terms of impacts on whether your air quality is healthy or not. How dense is the smoke visually? What is the color of the smoke and how does it affect your perception of the sun or the moon? What does the smoke smell like? Is it spicy and pungent like fresh wildfire smoke, or is the smell more muted? Indicating the smoke has traveled some distance. Is there falling ash? What is the wind direction?

By remaining mindful, you can avoid black and white thinking about the fire. You can observe that its impacts vary from day to day and over the daily cycle. And you can see that like everything, it comes, and it goes. Emergency managers also recommend staying observant in wildfire conditions, which they call maintaining situational awareness. So, staying aware has benefits both to your psychological state and your physical safety.

Another strategy for dealing with the anxiety, turn your focus outwards and practice gratitude for the wildland fire crews responding to the fire incident. Wildland firefighters work extremely hard, and they deserve our appreciation and support. Also, there may be evacuees who need support, but please listen to your local officials and make sure you don't get in the way of their response efforts.

One issue I've experienced during fires is obsession over the latest observations. I found I have to ask myself, is there really any new information? And, when do I expect new information? To keep myself from spiraling into an obsessive-compulsive cycle of refreshing websites repeatedly when fires are nearby. Finally, preparing for wildfire hazards can give you comfort and can make a big difference when the worst does happen. So, I've provided links from Ready.gov, CAL FIRE, and the Red Cross, discussing steps you can take to be prepared.

Theresa Nair:  That's great. And I think we've probably all been in situations where you're repeatedly refreshing that website, trying to get the latest news. Following up on that. You mentioned the importance of not only staying up to date with those resources, but also your own observational skills, keeping an eye out for things, like whether the smoke is closer to the ground or further up, whether there's ash falling from the sky. If somebody notices that their situation is changing, but maybe there aren't any alerts yet saying to evacuate, should they kind of follow their observational signs that they've observed or should they wait to receive specific instructions from authorities?

Kyle Hilburn:  That's a difficult question and it will depend on your own personal feelings about the situation. Things like ash can be transported for many, many miles, and aren't necessarily an indicator that you're in imminent danger. I would definitely recommend that people listen to their state and local authorities and to emergency managers. They will let you know if there is an immediate risk to your safety. But if you're uncomfortable, you can make the choice to leave at any point, if that makes you feel better.

Theresa Nair:  That's true. It never hurts to be more cautious, right? Are there any further developments in tracking or responding to wildfires that you think might be helpful for our audience to know about? And are there specific tools you would recommend for those who are concerned about fires in their area?

Kyle Hilburn:  Yes, I would recommend four websites. First is the AirNow website, which provides information about air quality. In particular, the quantity called PM 2.5, which measures the concentration of particles smaller than 2.5 micrometers, which is a key indicator of the severity of wildfire smoke. And whether it's healthy to be outside. Keep in mind that air quality sensors represent the conditions at a specific point and conditions can vary dramatically with your location. Second is the InciWeb website, which provides information on active wildfire incidents for the United States. You can click on specific incidents and read more information about the current situation and the outlook.

Third is the CIRA SLIDER website, CIRA is where I'm located, which provides access to satellite imagery of fires. When you go to that site, it defaults to the GeoColor product, which is very good for looking at smoke plumes during the daytime, because smoke generally has a darker color than clouds. Under “Product”, you can select fire temperature or natural color fire, and then zoom in on your location. There are color bars at the bottom of the image that tell you what each color means. Under add map, you can add cities, roads, and county boundaries, and other information to see where the fire is located. Keep in mind that clouds and even heavy smoke can obscure the heat signatures from fires. And finally, the National Weather Service at weather.gov is an excellent resource for the official weather forecast coming from human experts with local knowledge and to learn whether there are any watches or warnings for your area.

Theresa Nair:  This is some great recommendations. Thank you. And once again, for our audience, we will provide links for all of those in the description. So if you didn't quite catch that, you can just look at that on the transcript and they'll be there. As an atmospheric researcher who specializes in creating weather prediction models, do you have any other parting words of advice or anything else you'd like to share with our listeners?

Kyle Hilburn:  Well, nature is very restorative for the soul. Florence Williams described nature therapy, such as forest bathing in her interview. And so it is extremely distressing to see nature burning down, but we must remember that fire exists as part of a natural duality between creation and destruction. There are artists such as Erika Osborne, who are exploring this duality and human's relationships with fire. But the increasing rate of changes in our environment is very distressing and climate change anxiety is real. And so, I've provided a link discussing that. Thank you again, Theresa, for this opportunity to discuss managing wildfire anxiety.

Theresa Nair:  Thank you so much for speaking with me today and taking the time to participate in our interview series.

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

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

Psychologist Jonice Webb on Childhood Emotional Neglect

An Interview with Psychologist Jonice Webb

Jonice Webb, Ph.D. is licensed clinical psychologist located in Boston. She specializes in identifying and treating childhood emotional neglect.

Preeti Kota:  Hi, I'm Preeti Kota, and I'm a research intern here at Seattle Anxiety Specialists. And today I'm joined by Dr. Jonice Webb. Dr. Webb is a licensed psychologist whose interests concentrate on childhood emotional neglect. She's a speaker and bestselling author of two self-help books, Running on Empty: Overcome Your Childhood, Emotional Neglect, and Running on Empty No More: Transform Your Relationships. She has increased awareness of the effects of childhood emotional neglect, and trained hundreds of licensed therapists in identifying and treating childhood emotional neglect in their clients. Dr. Webb, would you like to introduce yourself and share a little bit about your research?

Jonice Webb:  Yes, absolutely. Thanks for having me on. So, I am a licensed clinical psychologist located in Boston, and I've been practicing psychology for, I hate to admit it, but probably like 25 years now. And during that time, having worked in a lot of different settings, I noticed that I started seeing this pattern among my clients, and I got very curious. What is causing this particular group of symptoms to appear in people that seemed to have nothing in common? Otherwise they were from different socioeconomic backgrounds, different cultures, different diagnoses, different types of families, and backgrounds, and yet I kept seeing it over and over. And I just got very curious and started trying to figure it out and eventually realized that what I was seeing was a very pure form of emotional neglect that all these people had in common in their childhood homes. And when I saw that and realized what it was, I started doing research among the databases of the American Psychological Association, trying to find research on emotional neglect, specifically childhood emotional neglect in its pure form.

Meaning not necessarily accompanied by abuse, but just, and not physical neglect, but just pure emotional neglect. And I realized that there really wasn't... It wasn't being talked about it. Wasn't being written about it, wasn't being studied. And that's when I realized I needed to write my first book Running on Empty and it's just taken off from there. And so at this point, then I wrote another book and that was in 2012. In 2018, I wrote Running on Empty No More: Transform Your Relationships, which took the concept and applied it further. And I have a blog on Psychology Today and emotional neglect recovery programs on my website. So it's pretty much everything I do now. I'm very passionate about it.

Preeti Kota:  Wow. That's great. So to dive into the questions, can you talk about the process of early childhood emotional neglect, leading to a lack of self-trust?

Jonice Webb:  Sure. So, childhood emotional neglect happens when a parent fails to respond enough to the feelings of their child. And it doesn't have to be zero amount that they respond, but parents who tend to minimize the importance of feelings, or are even blind to feelings. And there are many, many people in this world who are good people who want to be good parents, but who just don't understand that emotions matter so much. So, when they're raising their child, things like just ignoring the child when they're really upset about something, pretending not to see it, or just not seeing it, not asking questions, not being interested in the child's inner life, or what they're experiencing and not responding to that. When a child grows up this way, they tend to get the message that is not necessarily ever said out loud, but is communicated by a lack of asking the right questions, and saying the right things.

So, sort of like if your parents just pretended that your right arm didn't exist, and just acted as if it wasn't there, you would grow kind of ashamed of your right arm. And you would be like, "Why do I see this, but no one else does?" And you'll try to hide it from other people and from yourself. And that's what children do when their feelings are ignored is they get the message their feelings are irrelevant at best, or bad at worst. And then they block them off so that they won't get in their parents' way. They won't have to deal with them themselves. They just sort of build this wall inside their brains, not consciously, it's just sort of an adaptive mechanism so that their feelings are cut off, and this might get the child through their childhood, but it doesn't really work as an adult because we really need our feelings.

Our feelings are the deepest expression of who we are, and they provide us guidance, and motivation, and all sorts of connection and great things that are really important as we go through our adult lives. So people who grow up with their feelings cut off, don't even realize it don't remember anything happening to them that could make them have problems in their adult life necessarily, and end up just sort of secretly struggling with it, and not understanding what's wrong. And that is the essence of childhood emotional neglect. It plagues a lot of people who aren't aware of it.

Preeti Kota:  And is it the parents that have the most impact on childhood emotional neglect, or can older siblings, or friends have the same effect?

Jonice Webb:  That's a great question. It's primarily the parents, because the human infant is wired to need affection, and emotional connection from their primary caretakers, which in most situations are the parents. Sometimes there can be like, I've heard stories of a nanny providing it when the parents couldn't so there could be a substitute stepping in to provide it, but to be deprived of it, it really is to be deprived of it from your parents.

Preeti Kota:  And then do those with childhood emotional neglect tend to be more prone towards any comorbid mental health disorders, such as anxiety or depression?

Jonice Webb:  Yes. First I want to say all people with childhood emotional neglect, which I call CEN, do not... It's not like everyone develops a comorbid disorder. I've seen lots of CEN people who don't have any history of diagnosis and don't qualify for one when I see them. But nevertheless, they're struggling in various ways, but it does make you more prone to both depression, and anxiety. And I think that it's because when you have your feelings walled off, you're not processing them as you go through life, which most people just do naturally, you get upset, you deal with it, and then you've dealt with it. So you move on. But when your feelings aren't, when you don't have that natural connection with your feelings, they just all sort of pool together on the other side of the wall.

And because you're not aware of them and you're not connected to them, they just kind of mix together and they can turn into basically three things that I've seen, depression, anxiety, or irritability. Some people just become very irritable people, and it's because they haven't dealt with their feelings, or they'll end up depressed or they'll end up having anxiety, free-floating anxiety, or anxiety about certain things. And it's because they haven't dealt with their emotions.

Preeti Kota:  Is there a certain factor that makes a person more prone to having irritability, or anxiety, or depression in reaction to the same thing?

Jonice Webb:  I wonder that myself, I wish I knew the exact answer, but I don't, but I can tell you what my hunch is, which is that it depends on the nature of the walled off feelings. If most of your walled off feelings have to do with sadness or loss, I think you're more prone to depression. If most of your walled off feelings have to do with fear, or trepidation, or any of the sorts of fear based types of feelings, you're more prone to anxiety. And if it's more anger, you're more prone to irritability. That's my guess.

Preeti Kota:  Interesting. So, how do you not confuse following, or listening to your emotions as a source of guidance with giving into your impulses?

Jonice Webb:  First, I'll just explain that one of the things I talk about a lot and try to teach people to do is to pay attention to their feelings, and to listen to them. So I think that's what you're referring to here in this question, and to follow them. But that doesn't mean just like knee jerk following, because emotions can be excessively strong. They can be misplaced at times. And sometimes we feel things really intensely that actually are, we're feeling it so intensely because it's touched off something from the past that we haven't dealt with that feeling enough yet. And so that feeling attaches itself to the current situation, and makes you feel you can have big feelings over something that seems kind of ridiculous, or small. And it's because it's just blown out of proportion by the past. So, there are many reasons why we can't just knee jerk trust our emotions.

So, the way it works well is to take note of what you're feeling, process it with your head, meaning, think it through what is this feeling? Because every feeling is a message from your body. So what is my body trying to tell me here, by making me feel angry right now, could it be this, could it be that? And you sort it out with your head, and then you say, should I be angry right now? Actually, yes, I should. Someone just insulted me. What should I do? And then you think it through, and that way your body informs your head, and your head informs your body, and the two work together to make a good decision, and choose a correct action or the most correct that you can.

Preeti Kota:  How do you find the balance of if you are using your head too much, it's like overthinking, but if you're using your emotions too much, it's kind of impulsive?

Jonice Webb:  Yeah. Well I think we all struggle with that, and it really is a matter of just trying to really consciously do this process enough that you get better, and better at it. And we all are going to mess it up. We all do. There's no way to be perfect at this, nor should anyone expect themselves to be. Really for every human being who's alive, it's a work in progress. Getting our brain to work with our body, to get good results is the essence of being healthy, and living well.

Preeti Kota:  And then how does indecisiveness relate to people's inability to trust themselves?

Jonice Webb:  So when your feelings, so our feelings, as I said a minute ago, really inform us, and they're our guide to what we really want, what we need, what we like, and dislike what we care about. It all is communicated to us through our feelings. And so when you're cut off, I think cut off is a strong word. When you don't have a good connection to your feelings, then you don't really have the sort of weather vane that your feelings should be providing you. Your feelings, or the rudder is what I meant. Not a weather vane. Your feelings are your rudder. And so to use a boat metaphor. So it's very important to be able to consult your body, and get answers that come from your deepest self, which is your feelings. And if you don't have a good ability to do that, it's kind of consulting your gut, right?

A lot of feelings occur in our gut. We now know there are neurons in our guts, in our GI system. And there's a reason why you feel things in your gut, but if you're disconnected from your feelings, then you're disconnected from your gut, and you don't end up trusting yourself nearly enough when it comes to making decisions. And you're much more vulnerable, and prone to asking other people, "What do you think I should do? What do you think? What do you think of this? What do you think of that?" And that's a kind of dangerous way to live because people can have all sorts of opinions and it doesn't mean it's right for you.

Preeti Kota:  So then how do you start to trust yourself if you think you're going to make the wrong decision?

Jonice Webb:  Get in tune, get in tune with your gut. And start the process of healing childhood emotional neglect. It really involves getting in touch with your feelings, starting to value your feelings more, and paying attention. I've probably told hundreds of people with childhood emotional neglect, what does your gut say? Let's ask your gut about that question. And it's a foreign, it can feel weird at first, but if you do it, if you keep doing it, and keep paying attention to your feelings and processing it with your brain, it's a matter of practice, and changing old habits and filling them with new ones.

Preeti Kota:  And then how are self-trust, self-esteem, and confidence related?

Jonice Webb:  When you have a good gut sense, and you trust your gut. No one's gut is right all the time. When you trust your gut, you're trusting your feelings, and you're trusting yourself, and you're valuing your own internal world, and your own internal process and sense of self. So when you have that, you trust yourself, and you can feel more confident. And that leads to all sorts of good things, feeling comfortable in your own skin, feeling comfortable around other people. It's the process of overcoming social anxiety, just becoming comfortable with who you are and trusting yourself so that it all goes together.

Preeti Kota:  So, you would say the first, are they kind of linear or..? Like increasing your self-trust, leads to an increase in self-esteem?

Jonice Webb:  Yes, I would say so.

Preeti Kota:  Okay.

Jonice Webb:  Vice versa though. It goes the other way too.

Preeti Kota:  Okay. How do you break the habit of dismissing your feelings to start accepting them?

Jonice Webb:  Yes, that is a whole process. I developed this technique for people to use, it's called the identifying and naming technique. It's in, I think I have it in both of my books, but it's definitely in Running on Empty. And basically it just involves turning your attention inward, and checking in with yourself and asking yourself, "What am I feeling right now?" And then following that up with some other questions that help you identify why you might be feeling it and what it's coming from. And just doing that check in with yourself if you can make yourself do it several times a day, even starting with once a day or at whatever level you can handle.

And it's okay if you come up empty and it doesn't feel like you have a feeling, because a lot of people with emotional neglect have that experience that they ask themselves, "What am I feeling?" And that they come up with nothing. But if you keep doing it, and keep trying to tune in, it's sort of like that process, it's so simple. But what you're doing is you're connecting your brain and your body. And every time that you try to forge that connection, you're chipping away at that wall that's blocking the two off. And even if you don't come up with a feeling, you're making progress and you just have to keep at it, keep at it.

Preeti Kota:  Is that kind of related to mindfulness?

Jonice Webb:  Yeah. It's a mindfulness technique, because basically you're turning your attention inward, and you're putting your full focus on your inner world. And that's something with people with emotional neglect are usually not very good at because they're used to focusing outward. Everybody else is what's important. Everybody else, everything else, the outside world, and this kind of makes you look inside at yourself.

Preeti Kota:  So, how does the need to belong relate to the need to trust yourself? Are they conflicting?

Jonice Webb:  The more you trust yourself... So, interestingly, I'm going to start somewhere else for a second. Interestingly, people with childhood emotional neglect have a proclivity to feel out of place. And they tend to have an almost verging on social anxiety, if not social anxiety. And it's because they feel disconnected from... They feel like when you have your feelings blocked off, some part of you feels something's not right. It's like you're missing something that everyone else has. And I've heard many emotionally neglected people put this into words and say, "I feel like I'm on the outside looking in on everyone else who's really living life." Or "I feel like I'm living in black and white and everyone else is living in color." Or "I walk down the street and I see other people smiling, and laughing, and walking together. And I feel like, why can they do that so easily? It doesn't come easily to me."

And when you're cut off from your feelings or disconnected from your feelings, it can feel like you're different than everyone else, and something is secretly strangely wrong with you. And that makes it hard to feel like you belong anywhere. And it makes it hard to feel like you can be yourself in any social situation. So, you can end up feeling like you need to be a certain way, or do a certain thing, or act a certain way in order to get accepted and fit in, because you just haven't figured out yet that what you need is just to be your true self, which includes your feelings, and your thoughts about those feelings, and that whole process that you're skipping over in your life it's needed in order to be able to be your true self and feel like you really belong and are worthy.

Preeti Kota:  But what about when during childhood, when you don't really have that mindfulness technique in hand, and you feel like with friends, or something and you feel like you want to belong, but you don't really know how to trust your feelings first?

Jonice Webb:  There's no simple answer to that. I mean the real answer, the real, real answer is really work on being your true self. If you are your true self and your friends reject you, it means you're with the wrong people, and that's all there is to it. It doesn't mean you're bad. It doesn't necessarily mean they're bad. It just means you're trying to squeeze yourself into the wrong space with the wrong people. And it's hard to find the right people unless you are being your true self, and showing who you are so that those people can connect to your true self.

Preeti Kota:  How do you change your existing relationships with people who have already learned that you distrust yourself, and therefore don't respect you as much?

Jonice Webb:  Well, I think the most important thing to say about that is that people read each other on all sorts of levels that are not conscious. And we tend to trust people as much as they trust themselves. So, we sense how much someone trusts themselves, and that's how much we trust them, and how much we respect them. And so the best way to help people around you trust you more is to be yourself more, and to show your own true feelings more. And that doesn't mean all the time, just impulsively. It means being in tune with yourself so that other people can be in tune with you. And when people feel truly in tune with you, like you're authentic, and you're being your real self and they're allowed to see who you are, that's when they really value and trust you.

Preeti Kota:  But how do you overcome the possibility of rejection, or invalidation when you show your true self?

Jonice Webb:  It's always possible. And so part of this has to do with believing, with accepting who you are, and how you feel about things. And if there are things about one's self that you don't like, then you can work on changing yourself. You can even change your feelings to be the way to feel about something the way you want. So, in a way we all shape ourselves, but in order to truly shape ourselves, we have to be in touch with who we actually are, what our feelings are, and who we want to be. And so the key really is to tune into yourself, believe in yourself enough that if someone does reject you, you're able to weather that and say, "Okay, I guess that person doesn't value who I really am. Is that someone I really wanted to be in my life anyway?"

Preeti Kota:  And then a lot of people have a self critical part of their self that makes it hard to believe in themselves, so how do you suggest overcoming that?

Jonice Webb:  People with childhood emotional neglect tend to be very, very hard on themselves, and it could be, they had a critical parent and they internalized that. Or it could be that they had zero, or very little feedback about themselves growing up, which is true for many, many people with CEN. And if you're a child growing up and you don't have much feedback coming in, if your parents aren't giving you observations about who they see that you are, if they don't see your deepest self, and reflect that back to you, as a child, you have to fill in all the blanks, and children can develop a very harsh internal voice that's sort of like their creation of the parent they need. And that parent, kids don't really know necessarily, especially if they haven't received it, they don't know how to accept, or they don't know how to talk themselves through a difficult situation or a mistake. So it just turns into the mean parent, "What an idiot. How could you do that?" Talking to oneself the way you would never talk to a friend.

And so that can be a hard thing to overcome, except that the more that you can value yourself, and listen to yourself the more, and actually deal with your own feelings, then you can also start challenging that voice, catching yourself when you hear it, or catch yourself when you use it. And really start talking back to it, and say things like, "It's not true I'm stupid. Everybody makes mistakes." It really is a critical voice or a critical part of yourself is a really difficult thing to beat back, but it's absolutely not impossible. I've seen many people do it just by doing that whole process I just described.

Preeti Kota:  So I think you've already touched upon this, but what strategies do you have for listening to your emotions and turning inwards specifically any daily habits?

Jonice Webb:  Yeah. Doing that, identifying and naming, I think is the number one thing to do. The technique where you tune in and ask yourself, what am I feeling? And then there are other things you can do once you are identifying some feelings which involve processing the feeling and asking, and I created this technique also called the IAAA, where you identify the feeling, you accept it for what it is. Then you attribute it to a cause, and then you decide on an action. So that whole process pulls your brain and body together to start using your feelings instead of just shoving them away. So, practicing that another thing people can do is try to start identifying what other people are feeling, and if you're too good at that, it's not something to do, it means you're over focused on other people.

But just becoming aware of emotions, watching how other people handle their emotions, watching for emotions and other people, and what they do with them can be very instructive. I call it becoming a student of emotions and feelings. And just starting to... Once you make up your mind, I'm going to learn everything I can about how emotions work, what I'm feeling, and how my emotions work. Once you declare that to yourself, and start tuning in, it's really a great start towards fixing everything that didn't happen for you as a child.

Preeti Kota:  So, would you say, I think we touched upon this earlier, but about balancing between the mind and your emotions, would you say that's like the rational and irrational split or I don't know.

Jonice Webb:  Not necessarily, because feelings are not always irrational and thoughts are not always rational, so I wouldn't put it in that camp.

Preeti Kota:  Okay. And then do you have any parting words of advice or anything else you'd like to say to our listeners?

Jonice Webb:  Sure. I just want to emphasize that emotional neglect, childhood emotional neglect is not something your parents do to you. It's something they fail to do for you. And so it's not an act, it's not something that happened to you. It's something that failed to happen for you. And because of that, your brain as a child, doesn't record it, and then as an adult, it's really hard to remember childhood emotional neglect happening to you, because it wasn't an event. It was a non-event, right? And our brains don't record things that don't happen. So, it's hard for people to know whether they have childhood emotional, neglect or not, but people can go to my website, and take the emotional neglect questionnaire. And that will give them an idea of whether they fall in this camp or not. And when they take the questionnaire, they'll also be a member of my newsletter, and they'll be kept informed of every blog I write on Psychology Today, and every interview I do, and everything I write, and talk about, so.

Preeti Kota:  Great. Thank you so much. I learned a lot about childhood emotional neglect, and I think it's very helpful for people to go back and see how that could have affected them today and definitely has a very influential impact on our daily life. So thank you so much.

Jonice Webb:  Absolutely. Thanks for having me.

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

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

Advocate Lauren Johnson on Environmental Justice

An Interview with Advocate Lauren Johnson

Lauren Johnson, MPH has a graduate degree in environmental science and policy, and is a Climate Corps fellow for the Environmental Defense Fund. Lauren founded the Environmental Justice Action Network at the George Washington University and specializes on advancing environmental justice.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. Today, I'd like to welcome with us Lauren Johnson, who has a master of public health in environmental science and policy, and is a Climate Corps fellow for the Environmental Defense Fund. During her time as a graduate student, Lauren founded the Environmental Justice Action Network at the George Washington University, which is a student-led organization working to address environmental justice issues in the metropolitan D.C. area. In her current fellowship with the Environmental Defense Fund, she focuses on advancing environmental justice through strategic planning, scientific research, data-driven project management and community engagement. Before we get started, can you tell us a little more about yourself and what made you interested in environmental justice?

Lauren Johnson:  Yeah. So, hi. My name is Lauren Johnson. I'm from Northern Virginia, the D.C. area. And I just graduated with my master of public health in environmental science and policy from George Washington University's public health school. And ever since before public health school, even, I fell in love or became passionate about environmental justice issues when I was teaching high school chemistry in Miami, Florida for Teach for America. And there, I was confronted with various systems of oppression, such as lack of literacy, deteriorated infrastructure, school to prison pipeline, and was very disheartened by seeing how our nation's most vulnerable groups of people are treated, and left with little resources and so much instability, to reach their full potential. And that's what motivated me to focus on these issues at a systemic level. And I saw that public health was an avenue of doing so. And brought my passion of environmental justice into public health school, which led to the founding of the Environmental Justice Action Network at GW.

And that was founded by me and about seven other people that were also passionate about environmental justice, but did not see an avenue of expressing it at the school. And even though there's been a lot of mentioning of it, there really wasn't organized effort for students to get involved and give back to their surrounding community, because that's also a central tenant of environmental justice, of having real impacts in communities, and especially communities that are most vulnerable. So we found ourselves in Southeast D.C. doing park cleanups, urban gardens. We also held a lot of webinars, bringing more disadvantaged speakers, such as Indigenous environmental activists or food justice activists, so that we can start elevating these intersectional issues to the forefront, and also challenge traditional environmentalism that does not have these issues in the forefront, but is so needed to us actually reaching our climate goals. So that perspective informs my career work at the Environmental Defense Fund, which I am going to be a permanent member in a couple weeks.

Theresa Nair:  That's wonderful. Congratulations.

Lauren Johnson:  Thank you.

Theresa Nair:  And so going back a little bit to when you started the Environmental Justice Action Network, what types of environmental justice issues did you see in D.C., and how did you decide what was important to prioritize?

Lauren Johnson:  Yeah, so we were starting EJAN, the shorthand for it, during COVID-19. So we were quite limited in terms of direct engagement with people, just for social distancing guidelines and guidelines that the school laid out for that, as well, that we had to abide by. But we saw there was a pressing need with pollution in Southeast D.C., Ward 7 and 8, and how a lot of people did not have proper trash pickup. So we would drive into these areas and just see trash littered everywhere. And you kind of have to keep it in perspective, well, if you don't have proper trash pickup, where are you going to put the trash? So that's when you can't blame the individual, but the system that allows these conditions to persist, and how they are inequitably perpetuated, because we saw some parks that are managed by the National Park Service that was full of trash. When you go to Rock Creek Park, you don't see that. What's the difference between the two areas?

Theresa Nair:  Right.

Lauren Johnson:  I think you can answer that in terms of income and race. So, we saw those issues most aptly and saw that that was a way to socially distance and engage in these types of work. And we also partnered with an urban garden called the Franciscan Monastery Garden Guild, that produces a lot of food to food insecure individuals by donating a lot to food kitchens and pantries. So, we saw those were the main ways we could engage in EJ within COVID-19. But other than that, our activities were virtual; in terms of meeting, holding webinars, and just trying to educate ourselves as future EJ practitioners.

Theresa Nair:  Okay. And just before we continue, I want to make sure, if any listeners are not familiar with the term environmental justice, could you explain a little bit more about what exactly it is and what it means and how it impacts different communities?

Lauren Johnson:  Yeah. So environmental justice came out of the late 1970s where... I believe it was PCB. There was this new industry being proposed to be put in a predominantly Black community, Warren County, North Carolina. And the residents organized extremely well and were able to stop those efforts by literally putting themselves on the line. You look at pictures of that protest and you saw kids laying on the ground trying to stop trucks going into their neighborhood. That's how pressing the issue is for these communities, because literally their lives are on the line, so they have to put their lives on the line to stop it.

And that's what spurred the movement. And since then, in the '80s, there was a report called Toxic Waste and Race that found that the strongest predictor of whether a pollution source is in a community is race, regardless of income is race. So again, I'm talking about systems. That is evidence of systemic racism and how these trends perpetuate all over the country. And then from then, environmental justice became this movement that kept becoming academic. What is environmental racism? Well, just dependent on the environment, you are subject to lack of clean water, polluted air, mold, pest infestations, things that, even if you control for income, affects our predominantly Black and brown populations.

And then that notion just kept perpetuating until in 2021, Biden released an executive order that was pretty much codifying environmental justice at the forefront of their priorities, because prior to that in the 1990s, there was an executive order assigned by Clinton that also recognized environmental justice and how federal agencies need to confront it. But this executive order put it to the forefront with an initiative called Justice40 that says that any Federal... I think energy and infrastructure investments, 40% has to go to disadvantaged communities. So that's really huge, right?

Theresa Nair:  Yeah.

Lauren Johnson:  Because when you want change, you need to have the capital follow with it. So basically, environmental justice captures a lot of things. It captures how people are adversely affected by the environment, disproportionally predicted by race, most strongly; very place-based in terms of the surrounding industries and factors that lead to pollution; cumulatively burden certain communities. And achieving environmental justice means upholding the principle that everyone has equal protection to environmental, housing, criminal, other such laws that affects every aspect of your life. That's the environmental part, expanding the definition of environment for everything that externally affects you. And EJ is about rectifying that.

Theresa Nair:  When we were talking a few minutes before the interview started, you mentioned how systematic engineering can help to solve some of these problems. Would you mind discussing that a little bit, and how systematic engineering could be applied in these situations?

Lauren Johnson:  Yeah, yeah. So this is a new discipline that just kind of happened. When I started working in the Environmental Defense Fund, I saw that someone was doing a similar study that I was, from a systems engineering perspective. And essentially, there are some tools available from more technical disciplines to assess the inputs and outputs of a system, and everything that takes place in the system that mediates or negotiates the resulting outputs. That can be applied to a social context where, for example, I'm doing a study on net zero and equity and justice. And I'm trying to create recommendations for my organization to uphold their equity and justice goals.

So the equity and justice goals are the output. Now, what can the input be? Well, to achieve that, you need to really have resources, meaning time and people and capital to be put in the types of projects that prioritize people-centered solutions that do not perpetuate existing injustices. But if you don't view that from a systems lens, then you could easily result to just blaming individuals, like, "We have some bad actors here. If we get rid of those, we'll be good."

Well, we know that doesn't work when, let's say, a similar issue is police brutality. You know firing a few bad cops is not going to change the system of people being systemically murdered, predicted by race. So in turn, you need to think about things in that lens, and the mental models, the different structures. Everything interacts with each other to produce a certain output. And to reach the output that you want, you need to change everything within the system and outside the system and how it's structured, to reach it.

Theresa Nair:  That's a great point, because I think a lot of times people do just want to blame one person or a handful of people, but it's so much of a bigger problem than that, that it really needs a much bigger solution. If I could do one more spinoff, just because we were talking about such interesting things before I started recording, could you talk a little bit also about the relationship between the environmental movement and environmental justice, and how those two can sometimes conflict a little bit?

Lauren Johnson:  Oh man, I was just having a conversation about this. So it helps to talk about the history. Environmental movement was spurred by... I believe his name was John Muir, who was pushing the national parks movement. And I may be getting this wrong. I also know Teddy Roosevelt was involved in the national park system, but hey. "We're concerned about the environment. It's pretty. Nature. Wildlife. Let's preserve it." Well, who was on this land before? Indigenous peoples. They lived for thousands of years, existing sustainably on the land. So prior to colonization, people are like, "Oh wow, this nature, it's so well kept." That's because people were keeping it. And we're finding now that there's some practices that are ingrained in Indigenous knowledge that we need to start doing, such as controlling fires in forests or cutting some of them down so it's not densely populated. Indigenous peoples figured that out thousands of years ago, and now we're coming around and realizing we need to do stuff like that, because we have so many wildfires now.

So there's always been this tension of people, typically white liberal, "We need to protective the environment. We need to protect our wildlife." That's true. We also need to protect the people that is in that environment. And that's the intersection that is left out, and many others. Gender, race, income, all those things factor into how much you can take care of the environment and how much the environment impacts you. And coming from an environmental justice side to that, there's a lot of tensions because like... we were talking about systems. EJ really pushes for you to confront those issues. And that makes you very uncomfortable with it.

So a lot of people, when they become uncomfortable, they'll shut down and say, "Well, that's not my focus. That has nothing to do in the environment." The environment is everything around you that affects you. So yeah, you should have a stake in all this. And if you're doing environmental work, you also need to talk about healthcare. You also need to talk about housing, the criminal justice system, because these are things that impacts everyone's environment. And we all need to be an equal stakeholder in solving it, because otherwise we can't have a systemic change that is needed to solve the climate crisis.

Theresa Nair:  Yeah, I think that's an important point. You can't really separate all of it. It's kind of the one-health approach, that everything is connected together and it all relates to each other. When you've been working with communities and residents on some of these environmental justice issues, what types of mental health impacts have you seen on the communities who are experiencing some of these disparities or discrimination?

Lauren Johnson:  Yeah, I would say I was confronted with that quite aptly when I was teaching. I decided to Teach for America in Miami, Florida, a very hot and humid place that... I read one site that says that the number one most economic risk to climate impacts. So for the students I taught, one time, I got a grant to do a hurricane disaster preparedness workshop for those students. And somehow during that workshop, we started talking about air pollution. And I ended up asking those students, "How many of you have asthma?" And over half the class raised their hand. That's not-

Theresa Nair:  That’s significant.

Lauren Johnson:  ...random. That's the system at play where you're in these conditions, like I said, hot and humid, you have a lot of mold, you have a lot of pests, you have on top of that industries near you that are affecting your health through air pollution and water pollution. And then now you're compounding that with climate change and sea level rise, extreme weather. All those things are going to heighten those existing conditions there.

And so that's kind of what climate justice is all about. And the ways that we are addressing our climate-related causes, you need to make sure that the people that are most adversely affected are uplifted in that transition because, well, one, usually they're the ones that are least responsible for causing it; just looking upon income, the more income you have, the more greenhouse gas footprint you have. And oh man, I can't even get into a large conversation about how corporations are part of that too, but-

Theresa Nair:  You can feel free, if you like. Yeah.

Lauren Johnson:  But these factors, they compound. And it causes a lot of anxiety. I even had to make a suicide attempt call to report that.

Theresa Nair:  Wow.

Lauren Johnson:  And I mean, these are environmental things, but this also controls people's behavior. If you're in this bad environment and you're also not concerned about education, even though it's a school, that's another thing, you're going to have all these things mentally impact the students that you have. And oftentimes I just had to put on my therapist hat and just be there talking to students, had some people cry on my shoulder, just know that I care about them. And if anything, sometimes that's one of the few times they even heard that, which is also really sad.

Theresa Nair:  Wow, that is.

Lauren Johnson:  Yeah, mental health is very tied into it. But one thing you need to make sure is that climate anxiety has become something very real. It's a very real thing, but that is because this might be the first time you have this existential threat to your livelihood.

Theresa Nair:  Right.

Lauren Johnson:  To keep that in perspective, that has already been a thing for many groups of people in this country, whether it be slavery, Jim Crow, migrant workers, elderly, just people with disabilities. They've already had these existential threats affecting their livelihood. So, you have to recognize your identity and your privilege when you're addressing these issues because you might be like, "Oh my gosh, you need to do something about it at all costs. Everyone just needs to get in line." Well, that's not good enough for a lot of people that's already suffering from occurring conditions. So, you just have to keep things in perspective, even when it affects you mentally.

Theresa Nair:  That's a good point that a lot of groups have been dealing with these threats for a long time. And for some people, this is the first time they're experiencing something like this, but other groups have been dealing with this on an ongoing basis.

So, when people start to feel overwhelmed and feel like these are just huge issues, where do you even start addressing it? What advice would you give for people who are just feeling overwhelmed when they think about these topics? Because we're talking about these major systematic problems, right, that I think the average person feels like there's not really anything they can do much about. So what advice do you give? Like, you seem to be able to stay inspired and feel like you can make a difference. And I think that's amazing. It's one of the reasons I wanted to interview you. This is incredible, how you stay inspired in the face of all this. But I think a lot of people look at some of these topics and they just feel frustrated. So what advice would you give for people who just look at this and they just think, "I can't change any of this"?

Lauren Johnson:  Well, first, I'll say check your privilege, because there's a lot of people overwhelmed for hundreds of years in this country. But also, I'll take a quote from one of my environmental professors at public health school: "You need to find the bubble of people and work that you can influence, and just focus on that."

So, for me, I know that I grew up in a pretty privileged upbringing. And even though I'm a Black woman, I still had a lot of opportunities and came from a two-parent household that also was very stable. So that means I've been able to gain a really robust education. Part of my skillset is talking to White people, so I'll just call that out too. And then also, just thinking about the big picture. So that's why I found that I can make a lot of impact in a big environmental organization because all those skills I had growing up, but I can also keep things in perspective and saying, "Well, I know that I'm quite privileged, but there's a lot of other people that look like me that aren't. And how about I can do what I can to level the playing field, per se, and actually make an impact in doing that at an organization that has international influence?"

Very challenging and difficult work, but I found myself on a team that is designed to do just that. And they're extremely motivated. And what keeps me going is thinking about the students I had in Miami. They are suffering in many different ways. It seems like I might have some skills that can do something about that. And that might be me getting ahead of myself and saying, "I'm going to fix everything." No, no, no. But what I can do is expand the platform I have and try to get as many people on the same page as possible so that authentic and meaningful change does happen as we're addressing the climate crisis.

Theresa Nair:  That's great. And I think you hit on one of the key points, that you work with other people who are also inspired. Finding maybe a group or an organization to work with where people are working towards a positive difference, right, I think that that can help. And then you have also the inspiration of who you want to help, thinking about your former students.

Let's talk a little bit about your work in Texas. I know last year you worked with the North Central Texas Council of Governments to develop a greenhouse gas emission reduction plan that will mitigate risk for underserved communities. Could you tell us about your work there and how underserved communities in that area are being impacted by climate change?

Lauren Johnson:  Yeah, for sure. For sure. So that project you just mentioned took place last summer. And just as a context, Texas is actually divided into all these regional council of governments, and they assist the local governments in making decisions and providing funding. Well, a collection of those local governments approached the North Central Texas Council of Governments, which is the Dallas-Fort Worth area, saying, "Hey, we know climate change is a thing. Why don't you give us this repository of strategies and tools to address it in our own communities?"

So that was the basis for the project, which is looking at all these different plans that were cultivated in Texas or the rest of the country, even some international organizations, of these strategies. Well, I'll say a lot of them are untested though, because a lot of things that we're proposing to solve climate change, they're still in a development phase. But if a government wants to do something in particular, well, then they can... Well, I hope it's being turned into an online repository. I just did the strategies. They can look at some strategies that can reduce some emissions. But like I was saying, you can't leave out the other side of the picture, that there are some people that are burdened by emissions, but more specifically air pollutants. And those are the things that are most concerned.

So I tried to position the recommendations and the strategies around those different pollutions, and know that you can both reduce emissions from these industries, but also clean them up so that surrounding communities are not disproportionally affected. And that was the level of engagement I could have with vulnerable communities with that project. But I also was able to use some GIS mapping to look at the trends of different pollution sources, so whether that be natural gas or oil, power plants or Superfund sites, and look at some data that approximated the distribution of health impacts, whether that be asthma, cancer, diabetes, and then see how the location of those pollution sources interacted with those health disparities.

It was almost very upsetting how much those health disparities aligned with where those pollution sources were. And I used something called the CDC Social Vulnerability Index  that takes into account a lot of social factors like age and race and language proficiency to measure the vulnerability of certain communities. And I found the most vulnerable were right near these pollution sources. And that could just be a highway right next to you. But some of the most burdened communities... There was one in Fort Worth. It had the lowest life expectancy, I believe in the whole state of Texas. And they were actually right across from a hospital, but because it's this really major roadway was separating them and the hospital, they were completely cut out from any healthcare access. And likely the effects of the roadway near them and a number of other pollution issues, that causes them to have ridiculous rates of different diseases, and then caused such a lower life expectancy.

So, when I talk about environmental justice, this really is a life and death matter, and should thus be treated with that urgency, because as we're trying to change our society to affect climate change, you need to make sure that there's communities already suffering, and this is an opportunity to do something about it.

Theresa Nair:  Yeah, sometimes people don't realize what a difference even just living right next to an interstate makes on your overall health, just breathing in that pollution every day. And of course it's usually wealthier people tend to live further from the interstate and aren't impacted as much, right? Something like that can have such an impact on your health.

We've been talking about these environmental justice issues that are in Texas and D.C., and we talked about Miami a little bit. Many of our listeners are in the Pacific Northwest, and they may not know what environmental issues are in their city or even how to find out about that topic. How could the average person who may not be very familiar with the environmental justice problems in their area find out more about some of the problems in their local communities and the disparities that exist?

Lauren Johnson:  Yeah, yeah. So, it's good that I've learned a lot of cities or local governments are really thinking about these issues, especially with the Biden administration setting high priorities for environmental justice and like Justice40 providing funding to vulnerable communities. So, I would say the first resource you can go to locally is check your local government website. See if they have something listing what they're doing about environmental and social issues that are affecting the area. I think that's the best way to get more local base. But if you could quickly search what local organizations are also confronting those issues, like type in "Environmental justice" and your community. You can see if there's any other organizations there that might have some local knowledge.

But there is also a lot of just national organizations and movements that are trying to put these issues into light. And that could just be some of the renowned environmental justice organizations like we have for environmental justice, the Deep South Center for ... Deep South Center for Justice ... Oh, man. I messed this up.

Theresa Nair:  That's okay.

Lauren Johnson:  But this is an organization led by Dr. Beverly Wright in the Cancer Alley area. It does a lot of work there. And even the major environmental organizations too, like I work at Environmental Defense Fund, we're also thinking about these things. There should be a decent amount of resources there to think about it. And also nationally, the EPA, Environmental Protection Agency, DOE, the Department of Energy, they're also putting out resources to think about these issues, but also mapping and screening tools to actually you can go in, type in your address, and you can see the different pollution sources or demographic issues that are coming into play your area.

So for example, the EPA, they have something called EJScreen, that you can do this. The CDC has Environmental Public Health Tracking Program, that you can do this. And if you live in California, the California EPA is really on top of these issues. And you can look to see how they're affecting you through a tool called CalEnviroScreen. So, there's a lot of resources and things sprinkled throughout here, but what we need is a more robust movement of joining forces and understanding we're on the same side of trying to figure things out, and working together to do so.

Theresa Nair:  Yeah, I think that's the important point, because a lot of times people might want to help if they know about it, but they may not even know that some of these problems exist in their neighborhoods, or where the tools are to find out about it. And I will link to some of the tools that you mentioned below this interview as well, so that people at least listening to this interview can find them.

If a person is experiencing anxiety due to living in an urban area, and maybe they're worried about things like the pollution from the interstate, if they live nearby, or heat islands, or they've noticed that they have higher rates of asthma in their neighborhood, some of these topics that we've discussed, what type of advice would you give to them?

Lauren Johnson:  Yeah. Yeah. I would say just really try to figure out what those different things are; like you said, the urban heat island, it could be a lot of allergens that you're affected by, the interstates. Just really understand how all these issues are. And then find people trying to do something about it, because there's a lot of really great local nonprofits that provide free assistance to ... let's say you're in an urban heat island and don't have good AC. Well, there's a lot of nonprofits that have programs funded for you to get that for free. And then that can intersect with healthcare as well. There's a lot of great organizations that may be local to you that can do that as well.

But really the issue isn't individually how we respond to this, the issue is our representatives, the people we elect, pushing policies that can actually do something about this. For example, why isn't it mandated in affordable housing to have AC? Isn't that a necessity nowadays, especially with heat waves and climate change?

Theresa Nair:  Right.

Lauren Johnson:  We need to petition our representatives and senators to do something about it. And if you not just send an email, but if you are able to get on the call online with someone, then I've been told by number of local legislators they will listen to that and try to do something about it, because maybe they have a ballot initiative coming up and are debating it, if you could be someone in the public forum or speaking setting to talk to these people directly. And I would advise, start at the local level too, because those are the people that really are making decisions that impact you locally. You can bring your perspectives up, and they may pivot entirely. You never know. So there are ways to stay empowered throughout this. And really just realize knowledge is power, and you do have something to do about it.

Theresa Nair:  Have you seen that happen? Have you seen someone completely drastically change their mind after being contacted on one of these issues?

Lauren Johnson:  Not directly, but I have heard offline, these are ways to really make an impression, because for example, part of the reason why I fell into EJ is I started working with a nonprofit called Catalyst Miami in Miami, Florida. And they did a lot of free training and resources to empower local residents to talk to their representatives or a city board meeting, and how to do that. A lot of it is just telling your personal stories and how things have personally affected you, and then saying a solution too. They'll be empathetic, but if you don't put anything on the table what to do about it, they probably won't get there either. So you could go there. And like I said, there was a local nonprofit that was training us to do that. And I saw people throughout that program really find their voice, encouraged to talk about these issues, how they affect them, and what is something we can do about it.

Theresa Nair:  That's an important point, because it's true, a lot of times people who make these decisions aren't in the community, and they might make decisions that wouldn't even work for the community. But if community members who are affected themselves are the ones suggesting solutions, then they know that that's the solution that would work best, from their perspective. And then they can at least consider it, whereas they may not even think about it if somebody doesn't contact them.

Lauren Johnson:  Right, exactly. It's very powerful, the storytelling really is. So, I hope people don't lose sight of that because there's been such a push to quantifying things, big data, technical. Well, I'm finding with EJ, the social dimensions of all that is being left out. So that's why I'm training myself to be a social science practitioner, where my current study, I'm talking to a lot of people through ... well, I'm actually doing my own interviews. I'm having a focus group tonight to start talking candidly about these types of issues, and what are some ways we can do them ... well, for me, as a big environmental organization, do something about it, and not leave people behind?

So, there are things. Again, we were talking about, what are things you can influence? Well, that's my sphere. I think about people in communities and try to bring them in the conversation. Well, you can figure that out for you too, whether that be from a more technical side or social side. We need everyone, all hands on deck to meaningfully and authentically address these issues.

Theresa Nair:  Yeah, you're right. That's true. Well, as a professional who's building your career around advocacy and addressing environmental justice issues, do you have any parting words or final things you'd like to share with our listeners?

Lauren Johnson:  Well, I'll say the fight is long, the fight is hard, but it's still worth doing it. And it sounds cliche, my favorite MLK quote, but this one's good, and he's also said a lot of things that are good. They're just kind of whitewashed over time. But this one is, "The moral arc of the universe is long, but it bends towards justice." So if you are fighting for something you truly believe in and truly believe in helping people and pushing us forward as a society that's more fair and equitable and just, we're going to be going to that position naturally as people.

Whether we'll get there fast enough with climate change happening is another question, but things are already moving that direction. So, if you feel like you're the only person caring about these things, if anything, people will come around to it. But the urgency is that we kind of are on a ticking clock now with how worse issues can be if we don't reach our greenhouse gas emission targets. So be urgent, know that these issues matter in our life and death, but try to remember that this fight is worth having at the end of the day, because you can truly improve lives to the better doing so.

Theresa Nair:  Right. That's a great note to end on, that it's worth fighting and that it's worth going through and worth continuing to work towards these solutions. Well, thank you so much for speaking with us today and participating in our interview series. I really appreciate you making time in your busy schedule to meet with us.

Lauren Johnson:  For sure. Thank you for having me. If anyone wants to follow up, I'm happy to put my email address there. I can send that to you.

Theresa Nair:  Okay, great. We'll put your contact information there. And so yeah, if anyone feels like they would like to contact you, we'll provide the information on how they can do so. Okay. 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.