Psychotherapist Nica Selvaggio on LGBTQIA Mental Health

An Interview with Psychotherapist Nica Selvaggio

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

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

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

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

Jennifer Smith: Wow.

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Wow.

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

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

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

Jennifer Smith: Yeah, absolutely.

Nica Selvaggio: Thanks. And if anything-

Jennifer Smith: Oh, I was just just saying-

Nica Selvaggio: Yeah, go ahead Jen.

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

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

Jennifer Smith: Yeah, which is unfortunate.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith: Right.

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

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

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

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

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

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

Nica Selvaggio: Yeah, thank you.

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

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

Jennifer Smith: Right.

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

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

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

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

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

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

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

Nica Selvaggio: Thank you for having me.

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

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

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

Psychologist Ann Haynos on Eating Disorders

An Interview with Psychologist Ann Haynos

Ann Haynos, Ph.D. is a an assistant professor in clinical psychology at Virginia Commonwealth University. Her research specializes in destructive excess goal pursuit and restrictive eating disorders.

Ananya Udyaver:  Hi! Thanks for joining us today for this installment of The Seattle Psychiatrist Interview series. I'm Ananya Udyaver, a research intern at Seattle Anxiety Specialists. I'd like to welcome Dr. Ann Haynos, an assistant professor in clinical psychology at Virginia Commonwealth University. She's an expert on the field of neuroscience and clinical science with an interest on the phenomenon of excess goal pursuit that leads to destructive health outcomes. Her research is primarily focused on restricted eating disorders and how they can become consuming and life-threatening. She's written several articles on the topic, including “Beyond Description and Deficits: How Computational Psychiatry Can Enhance an Understanding of Decision Making in Anorexia Nervosa” and “Moving Towards Specificity: A Systematic Review of Cue Features Associated with Reward and Punishment in Anorexia Nervosa.”

So before we get started, can you please tell us a little bit more about yourself and what made you interested in specifically studying restrictive eating disorders?

Ann Haynos:  Sure, absolutely. So just briefly about myself, I guess. So I am new faculty member here at VCU. I just started last August, and before that, was on faculty at the University of Minnesota for several years. And so a lot of the research I'll be talking about was actually performed in Minnesota. I had gone there as part of my training and stayed on with my lovely colleagues to go into a faculty position there. So more generally about my background, I've been working in the field of eating disorders for a long time, since I was, I suppose an undergrad.

And along the way, have also become interested in some sort of intersecting fields like those pertaining to emotion regulation, reward, neuroscience, and have taken so those bits of training and integrated it into the work I'm doing. So as you mentioned, I do a lot related to the clinical neuroscience of eating disorders, but I also have a treatment arm of the research I do. And the hope is that our lab integrates both. So as far as how I got interested, I think the thing that really drew me to the eating disorders field was some early experiences. I grew up in sort of the DC metro area and went to a small all female school there. And when I was there, my graduating class was something like a class of a hundred, and we had a disproportionate amount of people affected by eating disorders in my class. I would say... Maybe the average estimates of how many people are affected by anorexia nervosa or something like 1%. And I would say, just based on my knowledge, something like 10% of my graduating class probably met criteria for anorexia nervosa.

Ananya Udyaver:  Yeah. Wow. That's a lot...

Ann Haynos:  And some of these people, I was quite close to and could see really upfront the devastating effects of these illnesses and would often get disheartened about how people would think about eating disorders in the lay public as sort of a disorder that might be something about wanting to look a certain way. And I could just tell people, based on firsthand experience, that it was so much more devastating to the people and the families affected by it. And then also as part of that experience, I saw some of the people I knew who were struggling with eating disorders got treatment and got better and seemed to recover without as much effort. And then some people really struggled to find the treatment that worked for them and continued struggle with their eating disorder for many years. It just really struck me that we needed more options for people, especially those who don't respond to initial treatments. So that's sort of what sparked my initial interest.

Ananya Udyaver:  Yeah. That makes a lot of sense. Okay. Well, I read a little bit in your most recent article about excess goal pursuit and how that can affect psychiatric illnesses like anorexia nervosa. Can you please explain what this means and how it pertains to your study and understanding of anorexia nervosa?

Ann Haynos:  Yeah. So sort of the background on thinking about anorexia as a disorder of excess goal pursuit is... A lot of studies in psychiatry and in psychology tend to look at places where people with psychological disorders or mental health problems have deficits in some sort of ability, right? For instance, the assumption would be all of us should have self-control and people might have problems with self-control, and that could lead to different sorts of problematic behaviors, like say drug use or something like that. Or maybe everybody should have the ability to manage their emotions effectively and people with psychological problems might have problems with doing that.

And one of the things I started to find when I was doing research on folks with anorexia nervosa, and I'm sure this is true of other clinical populations too, this is the area I worked in the most, is that I would find certainly some areas where there were deficits or problems and certain abilities, but I also found places where I was seeing actually distinct strengths in abilities that we usually think of as good, like the ability to inhibit impulses and work towards long-term goals. Society usually thinks that's a good thing. And so I would see the strengths. And the problem is a lot of times, those strengths get missed because people are so busy looking for the weaknesses that might lead to mental health problems.

And one of the things that concerned me about this bias towards looking at these sort of deficits or relative weaknesses that might lead to mental health problems is that there is a possibility that certain things that we really encourage as a society, like self-control, like the ability to focus on a goal very narrowly and intently, if taken too far, could actually cause some problems. But we encourage those things as a society. And so one of the ways I've begun to conceptualize anorexia nervosa is this may be a disorder where people with this disorder are doing what society has told them to do. They are pursuing a goal. And specifically, they're pursuing what is often a socially sanctioned goal, which is weight loss. They just keep going and going past when most people would stop. But I think it can be very confusing if you're told, "This is the right thing to do and this is a thing that will be rewarded," and then at some point people say, "Oh, no, no, no, stop doing that thing." Right? And so that's how I started pursuing that area of research.

Ananya Udyaver:  Okay. Makes a lot of sense. And it's really interesting, the idea of goal pursuit and how you also have to consider patients' strengths and not just their weaknesses when you're looking at disorders like this. So when you talk about computational psychiatry in your research, what does that entail, and how does it relate to treating anorexia?

Ann Haynos:  Yeah, I'm smiling because it's such a complicated... It's an umbrella term, and it's very complicated. I think a lot of people who even work closely on areas related to computational psychiatry get a little confused about exactly what it means. So basically, the field of computational psychiatry developed mostly out of partnerships with neuroscience. So over time, mental health fields have been more and more drawing off of some of the tools and theories that neuroscientists have been using to look at things at a much more fine-grained level, like how brain circuits work. And one of the things that neuroscientists have learned is that there are different ways that our brain makes mental calculations to solve different problems. So you could have a problem in front of you, like there are different types of reward in front of me. Which should I pursue? And there are many different mental calculations that should go into how you make that choice.

So you could mentally calculate, what is the cost of pursuing option A over option B? You could calculate the relative reward of these different options. You can calculate, how much do I know about option A, option B? And all of us do this throughout the day in living our everyday lives. If you think about where you choose to get a sandwich for lunch or whatever, you're usually doing some sort of probably quick, but mental calculations, weighing out familiarity, effort to get someplace, how much things cost, et cetera. Now, the idea of computational psychiatry is that sometimes those mental calculations can be either over applied in certain situations, or applied insensitively, or otherwise just go awry, and that can lead to mental health problems. So again, taking the example of the mental calculations that go into getting your lunch sandwich, let's say you are always selecting the deli downstairs, except that costs a ton of money and you don't have a lot of money.

Well, suddenly that's a problematic way of making that mental decision because it's leading over time to bad outcomes. You just don't have enough money in the same ways we can make mental calculations that can over time lead to mental health problems. So some of the... One example from my work in anorexia is we're starting to see some evidence that people with anorexia nervosa make decisions... They form preferences very quickly and stick very rigidly to their preferences about things. So that can translate to, if you have decided that the thing you really care about pursuing is weight loss, maybe you may be quick to jump to that as a solution to certain problems, and it might be harder for you to stop and say, "No, I need to do a different thing at this moment."

Ananya Udyaver:  That makes a lot of sense, and that was a really great analogy with the sandwich.

Ann Haynos:  Maybe it's just cause of lunchtime and I'm hungry.

Ananya Udyaver:  Yeah. Okay. So I guess you kind of answered this question in this sense of what is the difference between under responding and over responding and how an individual can recognize that type of response within themselves.

Ann Haynos:  And so when you refer to under responding and over responding, are you talking about to rewards?

Ananya Udyaver:  Yes, or to...

Ann Haynos:  Okay.

Ananya Udyaver:  Yeah.

Ann Haynos:  Yeah. Okay. So as far as rewards go, all of us want to seek out things that are going to be pleasant or enjoyable or give us some payoff in life, right? And there are some problems that can arise with mental health where people over respond to rewards, generally speaking. So let's say, for instance, this is something that could lead to impulsivity. If you were just saying like, "Ooh, food, ooh, drugs, ooh, sex," whatever, all the rewards, that's going to lead to not making sensitive decisions about also the cost of those behaviors.

On the other hand, you could have a problem related to overall under-responsivity. So that might look like what you might see, for instance, in people with depression, where nothing really interests me, nothing's that rewarding. Not just like, oh, I don't care about the food, sex and drugs, but I also don't care about talking on the phone with friends or watching a movie. And that would be a really clear example of overall under responding. Your brain is just not gravitating towards any rewards, which is problematic because you need your brain to want to do some things in order to function in the world.

The other thing we tend to see in eating disorders specifically, and I'll talk about anorexia nervosa here, is that some disorders are associated with over responsivity to some rewards and under responsivity to others. So one of the things we found in anorexia nervosa is that... And not just us, a lot of research. This is summarizing a lot of researchers findings, but people with anorexia nervosa tend to show a lot of under responsivity to rewards that the average person would find enjoyable, like winning money, seeing pleasant videos, or having social interactions, but tend to respond to rewards related to their eating disorder, so things like exercise cues or weight loss cues, or engaging in eating disorder behaviors. And that imbalance is also a problem. Because if you only have these sort of problematic weight loss things that make you feel good and nothing else really makes you feel that positively, then you're just going to keep going for the same rewards over time, even when they're problematic.

Ananya Udyaver:  Right. Yeah. That makes sense. Okay. My next question was actually about rewards and punishments, but I feel like that question was kind of answered by your last response. Yeah. So do you think it's important for individuals suffering from eating disorders to understand the psychiatric basis behind their thoughts and actions? And if so, why?

Ann Haynos:  I find a lot of folks with eating disorders are very interested in understanding sort of the neurobiology and some of the psychological and psychiatric mechanisms that underlie their disorder. At this point, I've run a lot of people with eating disorders through research studies, and they're often very eager research participants, because A, they know how much they've suffered from their disorder and they want to help other people. But B, I think a lot of times people are confused about what's driving their behaviors. They know they're really stuck in their eating disorder behaviors, and they know that they try really hard at times to get out of those behaviors, and it's very difficult. And so I found that by describing some of the neurobiology and other research that has helped to understand how eating disorders function, a lot of times, that can be helpful for people to just understand themselves, and also, I think hopefully can relieve a layer of self-criticism and self-blame.

Ananya Udyaver:  Right.

Ann Haynos:  This is another reason why I've gravitated in my work to towards looking at things that could be strengths that also could be problematic. I think that allows me to say to people I work clinically with, "Look, this set of skills that you're using is great, and if applied in to the right things and in a judicious way. I don't want to get rid of your hardworking nature, your willing to use control and effort. All of those things are not bad in themselves. We just got to attach them to good outcomes, and also make sure you balance it out with the ability to be flexible and give yourself a break sometimes." So I tend to, when I work clinically with people, try to bring in as much of the research as possible.

Ananya Udyaver:  Yeah, I think that's a really great way to motivate your patients to want to do better and get better. So that's really interesting. Okay. And then I read about in your research, the positive effect treatment and as a cognitive behavioral intervention. And I was wondering if you could please more explain this intervention.

Ann Haynos:  Yeah. Absolutely.

Ananya Udyaver:  Yeah.

Ann Haynos:  Oh, sorry. Sorry, I had a little bit of a delay talking over you.

Ananya Udyaver:  It's okay. Go ahead.

Ann Haynos:  Do you mind just saying the second part of your question again?

Ananya Udyaver:  Yeah. Just explaining the intervention and its potential benefits for patients.

Ann Haynos:  Wonderful. So positive affect treatment, I'm really excited to talk about this right now because we're sort of in this pivotal stage with this research that I'll talk more about. But positive affect treatment, which is abbreviated. We call it PAT, but the person who developed it calls it PAT often. But it was originally developed by Michelle Craske at UCLA. She developed it as a alternative treatment for depression and anxiety. And the idea that motivated her developing this treatment is a lot of treatment for people with depression and anxiety is focused on reducing negative emotions.

And we know those work, but we also know that in addition to having high negative emotions, people with anxiety and depression often have low positive emotions, and decreasing the negative emotions does not always lead to increasing the positive emotions. So a good example of this is antidepressant medications often help people feel less anxious, less depressed, but also often have the side effect of making people feel kind of numb, less interested in things around them. So that's an example of decreasing negative, but also just not helping positive emotion at all. So she had really good initial findings from delivering this treatment in depression and anxiety, basically finding that this treatment could reduce depression and anxiety symptoms, as well as suicidality. So we learned about it, and we're really interested in translating it to anorexia nervosa. This is me and my colleagues at University of Minnesota. Dr. Carol Peterson is the main person I've worked on this work with.

And what appealed to us is this treatment is really designed to target the neuroscience of reduced positive affect. So what goes on in the brain, and how can we correct that behaviorally for people who are just under responding to the rewards in their environment like we described before? So what we wanted to do is take everything that works so well for that set of problems, and then we added on some additional components of the treatment that target the over responsivity to weight loss rewards that we might see in anorexia. So the way we talk about this treatment is we tell clients our goal is to grow your life and shrink your eating disorder so that your life is so good that you don't need to rely on your eating disorder to do whatever it was doing for you in the past. So we just finished writing up our initial manuscript of our pilot study for this treatment. And the treatment involves some sort of cognitive behavioral interventions, as well as some mindfulness and self-compassion interventions, all targeting increasing positive emotions outside of the eating disorder.

Ananya Udyaver:  Right.

Ann Haynos:  And what we found is that this treatment was associated with people who went through the treatment, decreased their eating disorder symptoms and increased their body weight, which is what we want for people with anorexia nervosa. And also, unlike other treatments for eating disorders, we saw that anxiety and depression also really decreased...

Ananya Udyaver:  Wow.

Ann Haynos:  ... during this treatment. Yeah, which we were really excited about because a lot of times people will say, "My eating disorder is better, but I'm still miserable." Right? So we're about to publish... Well, we're about to submit that for publication. But the other really exciting thing is we're going to start a new study piloting this treatment for people stepping down from higher level of care after they've had an acute episode of care for anorexia nervosa in residential or partial hospitalization or intensive outpatient treatment. And we're going to be doing PAT and comparing it to more standard eating disorder treatments during that sort of pivotal step down period. And the treatment's virtual, so anybody across the country could participate in it. So if anybody's hearing this and this sounds like an interesting option for them or their clients, hopefully while this is up, we'll be running the study.

Ananya Udyaver:  Yeah, definitely a lot of people that are interested in getting help will be reading and watching these interviews, and this is a really great study that you're doing because I'm sure people will definitely want to join. And that was actually one of my questions, which was, do you have any potential treatment options or a study going on that could help people watching these interviews and seeking help? So that's a really great thing that you're doing.

Ann Haynos:  Absolutely. And I'll just put in one extra pitch, which is, one thing, you could do this treatment study while also doing other treatments. So it can be the only treatment people are doing, but it could not be as well. The other thing is it's completely free. And in fact, people get paid to participate in the research side of things. So this is a good option for folks who might not be able to financially access other eating disorder treatment during their step down period. So if anybody out there is listening and interested, please reach out to our group. We'd be happy to see if you'd be eligible. (email: haynosa@vcu.edu)

Ananya Udyaver:  Definitely. And we'll make sure to put all your information on the website so that they can contact you.

Ann Haynos:  Wonderful.

Ananya Udyaver:  And then just to wrap things up, since we are coming to the end of our interview, as a professor in the field of clinical psychology and a researcher, do you have any other advice or recommendations for our listeners who may be seeking treatment or suffering from a psychiatric illness?

Ann Haynos:  I think first, for anybody who's acutely struggling with an eating disorder or any other psychiatric illness, I guess I would say as a first thing, that I recognize how difficult that is, and it can feel at times near impossible to get the right type of treatment or the right type of resources to help alleviate your symptoms. So I guess the first thing is, I know it's hard. And I guess I also want to instill some hope. We do know that there are... Taking disorders as an example, even among people who have been struggling with their eating disorder for very many years, the evidence overwhelmingly suggests that most people do recover, even if it takes a while to do so. I think we are trying to get better as a field about understanding how to help people with the right treatments at the right time. But I would just always say to keep that glimmer of hope.

I've worked with so many clients who, at the moment when I've been working with them, have been just severely struggling, very uncertain about the directions to go in, not certain if they can overcome their psychological problems, whether that be eating disorder, anxiety, depression. And then I'm lucky enough to have people keep in touch with me sometimes and tell me where they are several years later. And a lot of times, they've built these beautiful lives. I think the other thing I'd recommend is just, to the extent you can, do the research about what are the evidence-based treatments for you. There's a lot of non-evidence based treatments for eating disorders and other disorders out there. And I think a lot of people get stuck in a place of getting treatment that actually is not going to benefit them for too long. And so that would be the other piece of advice. And get a support system to the extent you can, because it's hard to go through dealing with mental illness on your own. And having more supports, even if that's just your therapist, anything can be really helpful.

Ananya Udyaver:  I think that's amazing advice and definitely very motivational to anyone who is seeking help.

Ann Haynos:  I hope so.

Ananya Udyaver:  Yeah, thank you so much for that. But anyway, thank you so much for your time and for your willingness to participate in our interview series. It's been a pleasure speaking with you, and we wish you the best on your future research and hope that you find more interesting things that can help people out there.

Ann Haynos:  Wonderful. Well, thank you so much for having me.

Ananya Udyaver:  Of course. Thank you.

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

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