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.

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.