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 Monica Reis-Bergan on Personality Psychology

An Interview with Psychologist Monica Reis-Bergan

Monica Reis-Bergan, Ph.D. is Professor and Assistant Department Head of Psychology at James Madison University. She specializes in the personality psychology.

Kendall Hewitt:  Hi everyone. Thank you for joining today for this installment of The Seattle Psychiatrist Interview Series. I'm Kendall Hewitt, an interdisciplinary research intern at the Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice, specializing in anxiety disorders.

I'd like to welcome Dr. Monica Reis-Bergan today. Dr. Monica Reis-Bergan is a professor and assistant department head of psychology at James Madison University. She's an expert in the field of personality psychology, health psychology, and addictive behaviors, and has written several articles on the topic, including The Impact of Reminiscence on Socially Active Elderly Women's Reactions to Social Comparisons, and Self-esteem, Self-Serving Cognitions, and Health Risk Behavior. Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying health and personality?

Monica Reis-Bergan:  Hi. Well, first of all thank you for talking with me today. My interest in personality really comes from the opportunity to teach personality at James Madison University. In my research field in health and social psychology, personality is often a variable that's measured and sometimes just controlled for to see how different interventions might impact individuals. Over my time at JMU, I have really learned to love it as a teaching domain and also use it in my research, especially more recent research looking at health and social media.

Kendall Hewitt:  Perfect. So, would you give us a little description of what personality psychology actually is and why it's interesting to researchers?

Monica Reis-Bergan:  So, personality psychology is a relatively large and yet small area of psychology. So, it's large in that it impacts so many different disciplines in psychology, but it's small in that the researchers and theorists that focus on it and would focus only on it are very tiny. So, within personality, we talk about what is personality, and even looking at the definition of personality as something that different theoretical viewpoints don't always agree on as far as what it is. But in general, when we talk about personality, we're talking about some kind of enduring characteristic behavior pattern. As I like to tell my students, it's something that you know the person has and is often very difficult to change.

In terms of why is it interesting to researchers and really anyone, it's that for whatever situation you might have or even research paradigm, we recognize that people are coming with their own individual differences, and one of those individual differences is these elements of personality. So, trying to assess what that is, and then also, can you change it, and then the impact it has is what makes this such a great field.

Kendall Hewitt:  Awesome, thank you so much. And I know we've talked a little bit about what personality psychology is, but in the way of categorizing personality, that's changed over time in my understanding. So, can you expand a little bit on that topic a little bit more and explain what system we use to categorize personality psychology today?

Monica Reis-Bergan:  Well, I think that I would say that if you look at how do we categorize, and I think you're using that kind of making types or quality approach, it is changing and it will continue to change. As I tell my students, what they're studying today could be very different than what they're going to find in 2050. As we develop our assessment tools, we develop the ability to look at things in more and more detail and look at those differentiations. Each domain of personality also has a different way of thinking about it. So, if you look at a psychoanalytic perspective, you're often talking about types.

If we look at it from a trait perspective, the Big 5, HEXACO model, what are the models of the future in that sense? And then also, as culture changes, we start to develop different personality variables that we think are important. So, 30 years ago, we wouldn't have had a measure of FOMO or something of that nature. So, I think it's really important, especially when we look at personality, to have a contextual understanding of what do we have today, how do we think about it today, and that will be different tomorrow.

Kendall Hewitt:  And then how are you able to use your knowledge of personality psychology in the real world? Do you often find yourself analyzing others around you and using your knowledge to understand them better?

Monica Reis-Bergan:  That's a good one. In a sense that I think I'm always thinking about people, but I'm not sure that's because I'm a personality researcher that I would do that. I think we all naturally think about people and notice differences in people. I think that's why it's very interesting for people to try to create a type or a characterization of a particular type of person. My orientation is much more a social psychology with a personality perspective. So, I'm always looking at the social environment to see what factors I think might be related to why a person is displaying a certain behavior that they have. So, I'm not as true personality as some people might be in that sense.

Kendall Hewitt:  And then what is one piece of your research that you've found the most interesting in your time when looking at personality? And is there any research questions or topics within research for personality that you want to explore more?

Monica Reis-Bergan:  So last year, and we're in the process of working on this manuscript now, I worked with an honor's student that was very interested in TikTok, and to be honest, she thought TikTok was terrible for people, and that's a different conversation topic. But what it led to was really good conversations about what are some of the factors that might make... what are some people who might be impacted by TikTok more positively or negatively? And the personality variable that we chose to study was social comparison orientation, and this is the individual difference variable in terms of how much a person compares themselves with others in their environment, just more generally.

Specifically, the study that we did looked at TikTok engagement and young college women, and so how much they clicked on, they liked, those kinds of things to different kinds of TikTok material. And what we found was that individuals who engaged in TikTok, so liked, all of those things, in addition to having high social comparison orientation, meaning they were more likely to compare with others, had more of the negative body eating disorder types of symptoms associated with TikTok. So, while we couldn't say that TikTok was bad for everyone, we could say there does seem to be a relation between TikTok engagement and this personality variable on this outcome variable, so.

Kendall Hewitt:  That's super interesting. Is there anything that you hope to research in the future within the personality field?

Monica Reis-Bergan:  So, some current studies right now are students that are looking at super fan behavior. So, the idea that 20 years ago we would've maybe read a book about someone, but now, influencers, celebrities, we have almost daily information about them, especially if you're someone that's scouring multiple social media sites and other kinds of information. So, what types of people are more likely to develop these parasocial relationships with celebrities or influencers? And specifically, are there certain personality indicators that might make some people more likely to be super fans?

Kendall Hewitt:  That's very interesting. I'd be very interested to read that research in the future.

Monica Reis-Bergan:  We just finished data collection and we did find among our college students that about 50% identify as super fans or “stans”, I guess, is the word.

Kendall Hewitt:  Got it.

Monica Reis-Bergan:  So, we found that super interesting,

Kendall Hewitt:  Very interesting. And then going into that, many children and adolescents these days are using BuzzFeed quizzes or magazine quizzes to find what their personality type is. How do you feel about that and how accurate would you say that those are?

Monica Reis-Bergan:  So, as you know from my class, I really believe that if we're going to have a measure, we really need to look at the reliability and validity of that measure. And that's often a pretty painstaking process in psychology to make sure we have enough types of validity evidence to really have faith in our measures. So, a lot of the measures you're going to find on TikTok or BuzzFeed or wherever are not going to be particularly valid. However, I think that there's a lot of value in talking about personality and talking to your boss or your friends or your family, just about the enduring characteristics, the behaviors that you perceive for yourself to be stable, that is valuable self-knowledge.

We do know that our own perceptions of our own personality have what we might call causal force. Like, if I think I'm really friendly, I'm more likely to go and do things that I think friendly people do. And then if other people think I'm friendly, they're more likely to select me to be in clubs and organizations. So that self-knowledge piece, even if it's not the exact correct number, maybe you're really a 35.7 instead of a 23.2, but just the knowledge that you have about yourself I think is very valuable.

Kendall Hewitt:  So, do you think it would be beneficial for people to actually take valid and reliable quizzes to know what their personality type is?

Monica Reis-Bergan:  I mean, I do think that especially that's part of that metacognitive self-discovery if someone's so inclined. However, I honestly think people can live happily ever after without ever knowing their score and extraversion as well. So, I think it really comes down to a lot of psychology is when you have a problem, let's explore what the problem might be. In that case, I think personality is a great thing to look at what kind of enduring beliefs, cognitions, behaviors do people have, especially that don't seem to change based on situations, as a great way to see how can this be an issue, likewise people who are striving to be better, to also have that self-reflection. But I don't think it's necessary.

Kendall Hewitt:  And then how popular and accessible do you think the study and research of personality psychology is compared to other psychology disciplines such as social psychology? I know you mentioned that earlier. How accessible do you think that personality psychology is to the general public?

Monica Reis-Bergan:  I'm going to start or stage back from that question. I think personality research is almost everywhere because a lot of your clinical research, your I/O research, your health research, they're including personality measures in them, because as they try to look, they're going, and we're going to account for this individual difference. We're going to measure this difference. We think this difference might be important. So, it really transcends far beyond personality journals per se. So that's number one. But as far as the general population, I do think that the language we use in personality is so universal, and so it comes from language in part.

We talk about, where did our traits come from? They come from the differences in people that we notice and then we create a word for that difference. And then we have that word in our language. Allport used the dictionary to help determine what kind of traits people might have. And I think that happens in every culture, not just the English language. We want to notice and identify those people that we want to seek or we want to stay away from. So, I think it's there whether it's always in the language that researchers or theorists use, maybe not. But I also think FOMO is a great example. Fear of missing out came in part from culture as a variable that people notice this person has this fear of missing out. Okay, let's develop a scale to measure it.

Kendall Hewitt:  Yes, that's really interesting. I feel like there's always new scales coming out. You mentioned that personality psychology is always going to consistently change. And I want to take a step back, could you explain your education and career path that brought you to where you are today? And if someone were to take a similar career path, what advice would you give them?

Monica Reis-Bergan:  So, as I mentioned at the very beginning, I don't necessarily consider personality psychology as part of my professional identity. I'm really more of a health social psychologist. In the part of my college degree, obviously, I took a personality class. We obviously measured personality in almost all of our studies, but I didn't think of myself as a personality psychologist because I wasn't... At that time, I felt like because I wasn't trying to understand what personality was, instead I was using personality to ask other questions and being like, this might impact these people in a different way than it would impact people with a different personality per se. And that's really how I think about myself today as well. I appreciate personality, I love teaching it but to try to actually understand it from just the sole study of personality, I'm really more interested in how it's related to other kinds of behaviors like social media, health, substance use, those kinds of things.

As far as advice to other students, I think I tell all of my students to look and see what you're curious about and realize that those curiosities can change. And personality finds itself in a lot of different domains, whether it's cognitive, it can be I/O, it can be all of these different areas that students might be curious about, and then think, oh, what personality individual difference might be important to study? So, personality is really nice to teach because I feel like students have a lot of different opportunities of which to interact with it and may pursue it more depending on the opportunities they have.

Kendall Hewitt:  And once you finished your bachelor's degree, did you go straight into a master's and then straight into a PhD, or how did that fit into your life?

Monica Reis-Bergan:  So yes. So, I went directly from my undergraduate degree into a PhD program of which I got my master's degree as part of that, and all of them at the same school.

Kendall Hewitt:  Oh, wow. What was that like for you? Did you enjoy doing the master's along the way programs and finishing your PhD that way?

Monica Reis-Bergan:  Yeah. So, I was a little bit strange in that I was an elementary education major, who then had a double major in psychology that started as a minor, and I actually was planning to teach and I also happened to be doing research, a paid research assistant, and it just came about that I was so curious. It was in the early '90s and some of the questions about HIV/AIDS datasets that we were working with and just questions about people's health cognitions was very curious for me. And so, I just started doing the lab work and then I happen to have an extra class, so I took an advanced statistics class and then they were like, oh, have you considered graduate school? I'm a first-generation college student, I really hadn't. And then it was like, well, apply to graduate school. And so, I didn't really have the knowledge, skills, or experience to really scope out schools and think about it in that way. I was very fortunate that I had people that saw in me that this might be a good career path.

Kendall Hewitt:  Very nice. And then once you graduated from your PhD program, did you go right into teaching psychology at a university and just begin research through that?

Monica Reis-Bergan:  So obviously, you do a lot of research in graduate school. And in my case, I also did quite a bit of teaching. So, my first personality class, I actually taught at community college while I was working on my PhD and teaching at the university. So that was a lot to do, but I loved teaching personality. It's such a fun topic to teach and students are so excited to learn about it. So, a little different experience than my teaching statistics that they're not always so thrilled about. So definitely, I was looking for an academic home where I would have the opportunity to teach, as well as the opportunity to do research and work with students in that way. So actually, when I got here, I really hoped I would teach social psychology because I love social psychology. But I've been here for 23 years, and that class has always been filled by another faculty member, and so I just keep teaching personality very happily and health psych and research methods and statistics. I guess my position at James Madison is what cemented and really made me appreciate even more personality.

Kendall Hewitt:  That's very interesting. And you've mentioned, so as a health and personality expert, are there any tips that you would give college students or research excerpts that you believe would be beneficial for everyone to know?

Monica Reis-Bergan:  I don't know that I have a really great answer to that, but I think one of the things from teaching personality, and I'm just going to talk a little bit about my final project in my personality class, is that I have students who are already so interested in people, do a psychobiography project, and in that psychobiography project, they study someone in depth and then they think about how the different personality theories, which are pretty different from one another- you have a psychoanalytic theory, you have a phenomenological theory, you have trait theory, you have social cognitive theory- really fundamental different ways of thinking about what personality is and how it impacts people, to take those different lenses and look at one person. And when we look at the reflections from that assignment, what I find is that a lot of students start to realize that you have this person and this behavior, and it can really be interpreted in a multitude of different ways.

And I think that, that appreciation I think is what's important. So, when you see someone and they're behaving in a certain way, one of the questions might be why, and that why really depends on the view or the lens or the perspective that you're looking at. And the next steps really depend on the perspective you're looking at. So, I think it's important for students and people to be open-minded in that process of, there's not just one answer, they don't have a personality type, they're not an X person, for example, but let's look at it from all these different perspectives.

Kendall Hewitt:  Very interesting. And then lastly, is there anything else you'd like to share with our listeners today?

Monica Reis-Bergan:  Personality just is this great phenomenon. I always tell students, it's within the person. You can't go to the store and buy a new one. It's not like a backpack on the first day of school. And so, I think we will continue to be perplexed by what it is, to see how it changes. The more we learn about biopsychology, the more we learn and study how... biological functioning, the connection between mind and body, we might even learn more about personality from that. And then at the same time, our cultural world is changing, looking at how COVID could change locus of control and those kinds of things. So, I think it's just a really great and exciting place to study and to think about.

Kendall Hewitt:  Well, thank you so much for joining us today and giving all your insight. I hope our listeners enjoy!

Monica Reis-Bergan: All righty. Thank you.

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

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

Psychologist Rebecca Shiner on Narrative Identity & Personality Disorders

An Interview with Clinical Psychologist Rebecca Shiner

Rebecca Shiner, Ph.D. is Professor of Psychological and Brain Sciences at Colgate University. She specializes in the intersection of personality, clinical, and developmental psychology.

Sara Wilson:  Hi, everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Sara Wilson, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

And today I'd like to welcome with us clinical psychologist, Rebecca Shiner. Dr. Shiner is Charles A. Dana Professor of Psychological and Brain Sciences at Colgate University. Dr. Shiner is recognized for her pioneering research at the intersection of personality, clinical, and developmental psychology. In addition to the books Handbook of Temperament and Handbook of Personality Development, she has written extensively on the assessment causes and consequences of personality disorders in youth. So before we get started today, could you please let us know a little bit more about yourself and what made you interested in studying personality development and its implications?

Rebecca Shiner:  Okay. Yeah, thank you so much for inviting me to do this, Sara. I'm really looking forward to it. I got interested in studying personality development when I was in seventh grade. I'm not sure if you want me to go back this far, but anyhow, I will tell you briefly the story. So when I was in seventh grade, I had to write my first term paper, and it felt like a very big deal and very serious. And so I went to the library looking for sources of inspiration, and I came across a book that was a children's book about Freud. And so it covered all of Freud's theories in age-appropriate levels of description. It went and talked about the anal stage, the oral stage, the Oedipus complex, all of that. And when I read it, I thought, "Oh my gosh, this is amazing. I can't believe that no one ever told me about this."

And I was just completely captivated. There was something about taking seriously the idea that there's continuity across the course of people's lives, but also that people change over time that just grabbed me. And so I wrote my term paper on Freud, and that really has been my passion ever since. And so when I got to grad school and I realized that I could actually study people's development over time, that I could look at longitudinal studies where they follow the same group of people and I could look for traces of continuity and change, I decided that that's what I wanted to do.

Sara Wilson:  That's beautiful. I love that.

So in a recent talk you gave about narrative identity in the context of personality disorders in adolescence, you've discussed three levels of personality over the course of our development. Could you introduce each of these to our audience?

Rebecca Shiner:  Okay, sure. So personality is more than just people's personality traits. So I think often when people hear the term personality, the first thing they think of is personality traits. And that really is an essential part of our personality. So our traits are the ways that we tend to be at least somewhat consistent across situations and across time, and they summarize general ways that we have of interacting with the world. A good example of a personality trait that everyone knows, I think, is extroversion versus introversion. But another trait that's really relevant to clinical psychology is neuroticism, which ties into Freud. And also really what it reflects is our individual differences in how much we're prone to experiencing negative emotions like anxiety and irritability, vulnerability, and so on. So those are traits, and those emerge early in terms of our temperament. Some of the traits even emerge within infancy, although they change considerably over time.

Okay, so that's the first level, level one. Then the next level is level two. And level two, it has different names. Sometimes it's called characteristic adaptations, but level two has to do with tendencies that we have in terms of what we're trying to accomplish and the goals we're pursuing, the ways that we're motivated in our daily lives. So for example, people vary in terms of the goals that they have for themselves. So for one person, it might be deeply important for them to connect with other people, and then another person might have really strong motives for achievement, or you may have different goals depending on the context you're thinking about. So that's level two, and then that emerges elementary school age when kids start to be more able to control what they're doing and are able to really act as motivated young people.

And then finally, the last part is level three, it's narrative identity. And so that's what we're going to be focusing on today. This does not emerge until adolescence. And narrative identity has to do with individual differences in the way that we make sense of our lives, in terms of the stories that are important to us that we use to tell who we are and what we are about, how our past is connected with who we are in the present and the future. So we vary, very much in terms of the way that we narrate or tell the stories of our lives.

So a good example would actually be the story that I told you about why I decided to study personality development. That was a narrative describing how I came to be excited about this area of research, and we could analyze it in terms of different themes that pop up or how the emotional language in it is positive versus negative and so on. So we all grow in terms of the stories that we tell. As I said, it starts in late or middle to late adolescence, and then it's something that we're really working on over the whole course of our lives.

Sara Wilson:  Yeah, so interesting. Yeah, that example's so good too.

Now, where does a personality disorder come into all of this, and why is narrative identity relevant? What is a personality disorder?

Rebecca Shiner:  Okay, okay. So yeah, we'll start by talking a little bit about what a personality disorder is. Personality disorders are distinguished from other psychological disorders that people might have in a couple of different ways. The key features of them are that people are experiencing persistent difficulties in terms of their sense of self or sense of identity and/or, in most cases, and, they're struggling with different aspects of how they're relating to other people. So it's a fundamental disturbance in both the sense of self and in the sense of relatedness to other people. And so clearly identity is part of that because some of the disturbances in the self have to do with disturbances in the person's sense of identity, in terms of how they understand themselves, say across time, or how they see themselves in terms of their self-esteem and so on. There is a very big burst of interest right now in trying to understand how narrative identity relates to personality disorders because people haven't really been studying that directly until I would say the last five years or so.

Sara Wilson:  Yeah, I think that this topic is so interesting, especially narrative identity, just because you have, in some sense, so much agency over the active construction of this self, and then at the same time, it's like a working schema that affects the self directly. So it's like this feedback loop.

Rebecca Shiner:  Yeah, I agree. I think it's an exciting area to research because I think there's... And it's exciting from a clinical perspective too, because I think there's more of a sense of potential for making significant changes in narrative identity, in part because it's likely to be less heritable and is really evolving over time. So yeah, there's the potential for change there.

Sara Wilson:  Yeah. One thing that I was very curious about was how does narrative identity differ from our actual real identity? And I don't even know what that means, I guess.

Rebecca Shiner:  No, no, it's a great question because I think that there are different ways of conceptualizing identity. So very often when people think about identity, they think about it in terms of just how we see ourselves in terms of our role, in terms of our sense of vocation. So for example, a person's identity may involve their race or their sex or their sexual orientation. It may involve the kind of occupation that they have or their status as being a married person or a parent and so on. And those aspects of identity are fundamentally important to who we are as individuals, but they're distinct from narrative identity because narrative identity really has more to do with how we tell the stories of our lives. So you could be someone who has exactly the same sense of identity across all of these dimensions as another person, and yet your narrative identity is still going to be distinct to you because it's going to have to do with your own history and how you make sense of how your earlier experiences have impacted who you are now.

Sara Wilson:  Now, as you have conveyed in a lot of your work, feeling a lack of agency over your life can really be the root of enduring mental health and personality problems. But then on the flip side, it might also come with this immense pressure to define who we are and take action because our narrative isn't going to write itself. And I was curious how, from your point of view, we should go about reconciling this kind of tension that comes with narrative identity.

Rebecca Shiner:  Yeah. So let me say a little bit about what agency is and how that links up because I think that these ideas can be very abstract and hard to understand. When people share a story from their past, those stories that they tell, you can actually look at them across a bunch of different dimensions. And when people are doing research on narratives, what they do is they ask people to tell the story about something significant, for example, a turning point that helped establish their sense of who they are. So you can take those stories and you can code them along dimensions that typically characterize stories that people tell.

And so one of the really fundamental dimensions that you can look at, or you can at least look for in any narrative is a sense of agency. That is considered a motivational theme that gets at how people understand themselves in terms of how they're moving through the world, how they're motivated. Agency has to do with having a sense that you are the director of your own life. So you tell your story in a way where you're in control of the things that are happening to you, and you are active rather than just being a passive victim at the whim of your circumstances. So you're making things happen, you may be growing and changing and so on.

And agency has turned out to be one of the most important aspects of the way that people tell their stories, because across a huge number of studies, looking at a lot of different outcomes, having a stronger sense of agency, being the author and the director in your stories, it's linked up with all kinds of well-being. So a greater sense of satisfaction with life, lower levels of different psychological symptoms like depression and so on. So it seems to be really good and really positive in general.

Yeah, one other important finding that's been found by John Adler, he did a study where he was looking at the narratives that people wrote after they had therapy sessions, so while they were in the course of therapy. And people who produced stories after each therapy session that were characterized by stronger agency tended to be the ones who are getting better over the course of therapy too. So it actually seems to be not just a correlate of doing well, but seems to be an active ingredient that helps people to do better. But your question is about a sense of agency, how we go about creating that. Is that what you're asking? I want to make sure I'm answering the right question.

Sara Wilson:  Yeah, and also maybe are there any caveats or trade-offs when it comes to just this pressure to define who we are. As we're shedding more light on it in a clinical context, I was wondering if there's any trade-offs to agency?

Rebecca Shiner:  Yeah, that's a great question. I think that if it's agency that's being forced by someone else, it's not really agency at all, because that would be... If a person is feeling a kind of pressure to be agentic, in a way that is undermining the very essence of what it means to have a sense of agency because it's action that's initiated on your own and where you see yourself as freely choosing to act and to do things in your life. I don't know of any studies that have found a negative relationship between agency and well-being. There are definitely studies where it's not related to the outcomes that they're looking at.

Sara Wilson:  This is very interesting. It's a very promising finding with the therapy sessions and the really tangible effective role of narrative identity and meaning-making and agency being very interconnected with our belief systems.

Rebecca Shiner:  Right. And I think it's important to note too that it's not like people are consciously... Normally, people aren't consciously necessarily deciding that this is how they're going to tell their story. I think they could. They could. But in most of these studies, it just seems to be a process people aren't even necessarily aware of. And so the people who tell those stories with a sense of agency do turn out to be doing better.

Sara Wilson:  On that note, what is the role or importance of meaning-making and why is there this focus on the client's relationship to their beliefs, narrative therapy, and in other therapeutic techniques more broadly?

Rebecca Shiner:  Yeah, that's a great question. There's a whole separate line of research that's about meaning-making in life and purpose in life that in general finds that it's really an essential component of wellbeing. It's not the same as being happy, for example, but it's another really important sense of thriving in the world. So meaning, being able to make meaning out of your experiences, I think especially negative or traumatic experiences I think is fundamentally important. People can make meaning in different ways. They can make meaning by pursuing something that they feel called to do. They can create meaning by doing something in service of other people, for example. But narratives also give us a way of making meaning, because it's our way of trying to understand how the things that have happened to us have affected us, and how our own choices and ways of navigating the world also are impacting the way that we're doing right now.

I think narrative is another important contributor to a person's sense of meaning. So for example, if someone has had something very painful, very traumatic happen to them, one way of trying to make sense of that is to try to understand the impact of it and to really find a way to weave that into the story of your life rather than having it be just this standalone, horrible thing that has happened. So there's something very powerful about the process of trying to understand the impact and how perhaps you can carry that with you moving forward. That is really helpful, and I think that that is part of what can happen in the process of therapy.

Sara Wilson:  I think that this is so fascinating, especially because it's not really the content necessarily of the narrative or your belief and/or your story that's changing, it's the meaning around it and the organization of it, and I guess the degree of how attentive you are to certain things, how integral they are to you, which relies a lot on your relationship to this content.

Rebecca Shiner:  That's right. I think that's right, because it doesn't necessarily mean that you have to change the content of what you believe, but through the stories that you tell yourself about what you've experienced, it may affect the way that you can imagine yourself moving forward into the future.

Sara Wilson:  Yeah. One study of yours that I was very curious about your paper, “The Relations between Narrative Identity and Personality Pathology among Clinical Adolescents: Findings from a Multi-Ethnic Asian Sample”, this was the first study to assess the links between themes of narrative identity and personality disorder domains in a clinical adolescent sample. Could you explain the study a little more to our audience, why you chose the participants you did, and just your findings more broadly?

Rebecca Shiner:  So this is a paper... The first author of this paper is Amy See, who at the time that she did this study was a PhD student at Utrecht University in the Netherlands working with Theo Klimstra, who is a colleague of mine whose studies actually identity development in adolescence. Amy See herself was from Singapore, and so she was very interested in trying to look at whether the narratives of adolescents are linked with their emerging personalities and particularly personality difficulties that they might be having. As I mentioned, adolescents, teenagers are really in the very earliest stages of starting to develop their narrative style and are really starting to have a richer sense of what are the most important episodes from their lives.

What Amy did was she recruited a clinical sample. These were teenagers who were being seen at the largest mental health clinic for adolescents in the country. And so she asked them to write about a turning point that they had experienced. And a turning point is a specific kind of narrative where you ask the person to share something, to share an experience that they've had that really informed the way that they understand themselves, that really changed the way that they perceive themselves. So she asked them to write about that, and then she also asked them to fill out a questionnaire about difficulties they were having in terms of their personalities. So these were not young people who were diagnosed with personality disorders, they were having clinical struggles, and they were just reporting on personality difficulties they were having.

So the most striking finding from it was that there was a particular dimension of those narratives that was related to personality difficulties that the young people were having. And that dimension is one I haven't mentioned yet, which is communion. Communion is a motivational theme similar to agency that describes how much the person tends to talk about positive, loving, close relationships with other people, with friends or romantic partners. If you're looking at a sample of adults, it may also be caregiving relationships or any sort of feeling of connection with other people.

And so what we found in this paper is that the teenagers who were having more personality difficulties tended to express lower levels of this kind of positive communion with other people in the turning point stories that they told. We're not sure which came first. We don't know if it may be that they were having problems in their relationships, and so then that's reflected in their narratives. It could be that the way they tell stories was affecting their mental health, for example, by making them more depressed. I thought, if it's okay, I could share a couple really short narratives from that study because I think it will make the findings a little more concrete. Is that okay?

Sara Wilson:  Yes, we would love that!

Rebecca Shiner:  Okay, so here's a first turning point narrative from one of the teenagers. "I was diagnosed with depression one year ago. I was not myself and caused a lot of problems for my family. After a number of sessions with the psychologist, I started understanding myself better and why I behaved the way I did. This made me change my mindset, and I told myself to enjoy life more. I am now feeling happier and approach life in a more positive manner." So this person is talking about learning and growing through the process of therapy, but they're also suggesting that they had been having a lot of problems with their family. But they're talking about this positive connection with the psychologist and this more positive mindset that came out of it. So they're expressing a sense of communion.

In contrast, here's one from a participant who expressed a low level of communion. "So I was sexually abused by a family member a few months ago. It made me feel hurt, horrible, and disgusting. I now flinch when someone touches me, and I hate this feeling. This has made me less trusting of others, including my family." So you can see this is a turning point for this young person when asked to think about an experience they had that really changed their sense of self. They describe something that's really painful, and they talk about that painful experience of abuse leading to them not trusting people anymore. So you can see this clear distinction in terms of that theme of communion there.

Sara Wilson:  Yeah. And whether the turning point itself is articulated in positive or negative terms.

Rebecca Shiner:  Right. Yeah, in this case, there's a clear difference in the overall tone of those two narratives that you can see there. But I think it's interesting too, this is an Asian sample, and so in general, Asian cultures tend to be more collectivistic and to have a stronger focus on interdependence across people and stronger need to think about the group rather than just the individual. Whereas a US sample, for example, is more individualistic. So it would be really interesting to know whether the pattern would replicate in a Western sample where maybe communion is not so clearly linked with problematic personality traits.

Sara Wilson:  Yeah, Because I noticed in your results that communion was perceived as more a significant dimension in that sample in particular, as opposed to agency.

Rebecca Shiner:  Right, which is an unusual finding actually. Agency is more consistently associated with wellbeing in general than communion is. There are a lot of studies where communion is just not related to whatever positive outcome measures you have. And so it raises questions about whether maybe this is a cross-cultural difference that I think would be worth studying more.

Sara Wilson:  Right, yeah. It also definitely raises the question of how narrative identity is highly convoluted by nurture and just your social situation and upbringing. So it's subject to change I guess.

Rebecca Shiner:  Yeah, absolutely. I think narratives are a place where culture plays a big role because different cultures have different preferred ways of telling stories. US samples have a very strong preference for redemption narratives where things start out bad, but then by the end of the story, they turn out to be positive. We love a good redemption story in the United States. And that's not always necessarily a positive thing, but it's a clear cultural preference that we have.

Sara Wilson:  Yeah, it's so interesting because it's not real in some sense, it's very socially and culturally dependent and context relevant, but then at the same time, it manifests itself in very real situations. It very much changes your belief systems.

Rebecca Shiner:  Right. That's right, but the outcomes may vary again, depending on the culture. So I think it's important in thinking about narratives to not assume that narratives that are positive in one culture are necessarily going to have positive outcomes in another.

Sara Wilson:  One more study I wanted to talk about. Can you discuss a little about your study exploring narrative identity and PTSD symptoms in veterans? I was especially curious about the finding that even if patients experienced a loss of control during traumatic military experiences, it may be possible to help them find ways of narrating their life in more agentic terms in the present through the process of therapy.

Rebecca Shiner:  Yeah, let me describe that study. This was a study that was actually inspired by one of my honors students at Colgate, and this is before I really had done much narrative research. So I had a student who wanted to study veterans for his honors project, and he wanted to look at PTSD. And so we hit it on the idea of asking veterans to tell us about their most stressful experiences that they had had in the military. And we wanted to look at whether their way of narrating those really stressful experiences was predictive of whether they had PTSD symptoms or not. It's really interesting because in a lot of the literature on PTSD, there's the assumption that the memories themselves are highly relevant to developing PTSD or not, but they're not looked at in terms of narrative identity, they're more looked at in terms of whether the memories are fractured or fragmented or not.

But we thought that it seemed likely that the narrative style, the way that people tell the stories of those really stressful experiences would be highly relevant to whether people have PTSD symptoms or not. So we collected stories about the most highly stressful military experience in a sample of veterans. We found that, in fact, there was a link between narrative identity and PTSD, so specifically the veterans who told these stories in a more agentic way and also with a stronger sense of growth tended to have lower levels of PTSD symptoms. So I think this is really, really important because it suggests that, again, those memories are important because they become part of a person's narrative identity. There may be ways of working with those memories to help people to begin to narrate them in a way that is going to bring some relief to them.

It's really interesting to me that the treatment method that has the most evidence for its effectiveness for treating PTSD is something that's called prolonged exposure, which is where the person with PTSD is asked to tell, in as much detail as they can, the traumatic experience that they have had that has left them with PTSD. So they have to recount in great detail everything that they can remember about that experience. Which is obviously extremely difficult and painful to do, particularly the first time. And then they're asked to retell this story and actually to listen to recordings of them having told the story themselves. The contention is that the reason this is working is because it's exposing them to the story or the memory of something that they have been trying very hard to avoid having direct contact with.

And I believe that that's true. I believe that it's exposure that helps them put aside the avoidance that is playing a really important role in why that model works for helping people get over traumatic memories. But I also expect that there's something about the retelling of that story that helps people to actually gain a sense of mastery over it. And I think it would be really interesting to actually do a study where you looked at whether those stories change in terms of whether the person feels a greater sense of agency in the retelling of the story over time.

Sara Wilson:  This is such amazing research, really, and such important implications, and it's just starting to be tapped into its full potential. Yeah, I totally definitely agree with you. I think it's very good work that you're doing.

Rebecca Shiner:  Thank you. I feel very lucky to have had people who are willing to let me collaborate on this kind of work with them.

Sara Wilson:  When you discuss this epistemic gap in clinical theory regarding personality disorders, I think it's interesting that you cite one of the reasons for this deficit in knowledge to be the desire to protect youth from stigmatizing diagnoses. How might a diagnosis in any domain, I guess, actually contribute further to poor narrative identity? How can we go about this maybe more carefully or be more sensitive to this in therapeutic practice?

Rebecca Shiner:  Yeah, it's a great question. Historically, there's been a lot of hesitancy to use labels of personality disorders for teenagers. And in fact, the diagnostic manual, the DSM has encouraged clinicians to be cautious about using personality disorder diagnoses for people below the age of 18, even though it's recognized that these personality patterns start earlier in life, so they don't just emerge out of nothing when a person gets 18. And this has been because in the past, people saw personality disorders as being chronic and very hard to treat, like once you have a personality disorder, you are destined to have that personality disorder forever. And that seems too stigmatizing to apply that to a young person.

However, it turns out that there are a bunch of mistakes that have been made in those assumptions. It turns out personality disorders are amenable to treatment. It turns out that they do naturally change over time even without treatment. And it turns out that personality disorder problems actually may be at their worst during adolescence. And so that suggests that there may be value in at least thinking about personality disordered patterns in young people like paying attention as a clinician to whether the young person you're working with has problems with their sense of self and identity, or chronic problems and how they're relating to other people.

That being said, I have a lot of sympathy for this concern about using personality disorder diagnoses on young people. And that is because as we've talked about, teenagers are in the process of developing their sense of narrative identity. They're only just beginning to figure out what are the important stories from their lives, how do their past experiences affect who they are now? And so there is a great risk, I think, actually in giving them a label that would lead them to formulate a sense of identity that is going to be really pathological, that is going to discourage them from feeling hopeful about change.

And I'm especially concerned about this now because on social media, there has been this profusion of teenagers and/or young adults self-professing that they have personality disorders, particularly borderline personality disorder. And there's a strong tendency for people almost sometimes to almost relish having this diagnosis that makes them feel special or celebrates their sense of being a victim in a way. This has become rampant on TikTok with mental health in general, young people posting TikToks about their diagnoses and so on.

And so this is something that I have actually been gradually rethinking for myself, because in the past, I have encouraged clinicians to think about personality disorder diagnoses for young people and to very carefully present that information to young people. But I think that as those diagnoses have been promulgated in social media, I am beginning to see more and more the potential risks that are associated with that, especially because of young people's emerging sense of identity and the way that that diagnosis may play a part in how they're crafting the narratives of their lives.

Here's where I'm at on this at this moment. I may change my mind again, I still think it's vitally important to be paying attention to those core personality disorder features for people who are working with teenagers to really pay attention. Is this a person who's struggling with intimacy, is struggling with how they see other people? Do they tend to view other people in a black and white way, for example, that might characterize borderline tendencies? Is this a young person whose sense of identity is so profoundly unstable that they're having trouble beginning to navigate decisions about what they want to do after high school and so on?

So I think those are things that clinicians should be paying attention to and should develop some competence in learning how to treat, because those problems are significant for a large number of teenagers with clinical problems. On the other hand, I think that there's a really important role for being cautious about giving a personality disorder diagnosis. And I think it's important to be careful in how that is articulated to the young person. And I think explaining it in the kind of language that I've been using, it's likely to be more helpful, that these are ways of seeing the self and seeing other people interacting with them that are profoundly important, but also open to change so that the young person can start to develop narratives about who they are that are both realistic and more healthy.

Sara Wilson:  Yes. Yeah, I think that expressing a critical sensitivity to narrative identity and the reality of it in therapy especially, will inevitably strengthen the therapist-patient relationship just because a lot of traditional therapeutic practices stigmatize the client's point of view as something that's disordered or subjectively inaccurate. But instead of discrediting the content of the narrative itself, the narrative therapist helps to consciously separate the story from the client and sees narrative identity as a construction over which we have agency that's separate from our core.

Rebecca Shiner:  I agree. Although I think that there's a place too for reality testing in the sense that I think that the best narratives are in contact with reality, but are also healthy. A narrative identity that is entirely positive, but disconnected from a person's actual reality is going to be a problem perhaps in a different way than a narrative that's unduly negative, if that makes sense, yeah. So I think that it's important for the person's sense of identity to be both flexible and reality based, and ideally positive because there's the potential for change there.

Sara Wilson:  Yeah. Thank you so much for joining us today. I really think that this is such an important concept right now, especially as so much research on the self is emerging and in our relationship to selfhood, what is the self? And there's obviously so many levels to it with so many pressing implications and very real importance for who we are and for wellbeing. So I think that this is very, very important research and a very cool concept. Is there anything else you would like to share with our audience today, Dr. Shiner?

Rebecca Shiner:  I had one last thought that I wanted to mention. There's a brand new study, it actually hasn't been published yet, but it's been accepted for publication, that was looking at this construct of the hero's journey. This is a popular motif that a number of people have recognized that the most loved stories across many different cultures seem to take this form of the hero's journey, where the person begins in the dark, but then they feel this calling to leave their safer childhood home, and they venture out and they find a mentor and they have to battle the foes that may thwart them and so on. So there's a particular form that this hero's journey story takes.

Anyhow, this study has found that there's actually value in telling your own story as a hero's journey and being able to see your life in terms of that pathway from a maybe sheltered existence, but moving forward into facing your foes and your challenges and being defeated, but then continuing to move forward. This was a series of studies that showed that actually adopting that kind of sense of your own story as a hero's journey, it's good for us, and maybe it gives us courage to face the things that are inevitably going to be painful and difficult.

Sara Wilson:  I wonder, do you think that we inherently value that as an intrinsically good narrative organization, or do you think it's maybe very convoluted by cultural norms, what we've been accustomed to?

Rebecca Shiner:  Yeah. Right, that's a great question. I think that part of the impetus for studying this is that this is a very common narrative format across historic time and across place. There's something about this kind of story that deeply appeals to all of us and suggests that there may be something universally, humanly relevant about it.

Sara Wilson:  How would you suggest that someone goes about trying to develop their narrative identity?

Rebecca Shiner:  Yeah. I have a few ideas. One is I think reading good books is a good way of doing it. Actually, over Thanksgiving break, I have gone back to... I pulled out one of my childhood books that I love very much called A Little Princess. It's like a classic, classic girl's book. Anyhow, and just reading it actually makes me really... It actually follows the hero's journey pathway. And I realized how much I internalized that narrative form as a kid when I was reading it.

So anyhow, I do think there's a place for watching good movies and reading good books and so on to have a sense of the narratives of other people's lives. I also think that there's really good value in well done therapy. I definitely think some therapies are better than others for developing a sense of narrative. I think all therapies do it, but I think for people who are trying to gain more of a sense of understanding of themselves, I think some of the more traditional therapies like psychodynamic can be especially useful. I think journaling. I really think anything that has to do with self-reflection and deep thinking about yourself.

Sara Wilson:  So interesting.

Rebecca Shiner:  Very useful, yeah.

Sara Wilson:  How many layers there are, and how many different ways there are to get in touch with yourself and make real change. Yeah, I've been very interested in the concept of self throughout my psychology and philosophy major at Colgate. And the more I study it, the more I'm just blown, mind blown. It really is such an incredible concept. It's just unbelievable how much there is to it. And the more I study it, the more I'm just dubious of what it even is, what it even means. The research is just so interesting. And I think it's so relevant nowadays, especially right now with so much more research going on with regards to what mind is and major developments in neuroscience. And I think that this very much deserves to be paid attention to, especially in neuroscience and the mechanisms behind this. It really is just unbelievable.

Rebecca Shiner:  It's fantastic that you've been able to study it. Yeah, my hope is that people will be inspired to learn more about it. I highly recommend anything that has been written by the person who developed this concept, who I should have acknowledged at the very beginning of this interview, who is Dan McAdams, a psychologist at Northwestern, who really I think pioneered the... Who was drawing from a lot of existing traditions within psychology, but really helped to pioneer the empirical study of narrative identity. So I commend anyone looking up Dan McAdam's work.

Sara Wilson:  Thank you so much for joining us today. It was such a pleasure to talk with you. This was Dr. Shiner.

Rebecca Shiner:  Great questions, yeah.

Sara Wilson:  Of course. It was so amazing.

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

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

Psychologist Sandra Parsons on Social Psychology & Depressive Realism

An Interview with Social Psychologist Sandra Parsons

Sandra Parsons, Ph.D. is an Associate Teaching Professor, the Director of Undergraduate Studies, and the Director of Pedagogy in the Department of Psychological Sciences at Rice University. She specializes in the various aspects and components of groups in society, such as decision-making, identity and competition.

Jack Eisinger:  Hello everyone. Thank you for tuning in. My name is Jack Eisinger, and I'm a research intern for the Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'm here today with Dr. Sandra Parsons who graduated from Miami University with a PhD in social psychology, and is currently a psychology professor and RA at Rice University.

She has won three George R. Brown Awards for superior teaching, and has done research on human decision processes, executive coaching, and information sharing. Dr. Parsons, before we get started, can you tell us a little about yourself and what got you interested in social psychology?

Sandra Parsons:  Sure. So I've been at Rice for about 12 or 13 years. It's fuzzy on the exact dates, because I started as a sort of a patch hire and that turned into a full-time position. And I've been teaching both in Houston, and also before that in Baltimore, and before that in Columbus, Ohio for about 30 years, which is hard to believe since I'm only about 30 in my head.

I really got interested in social psychology because people are so weird. People are so strange and unpredictable, and I was always asking, I wonder why people do that and why are people like that?

And I was also interested in trying to figure out how we could diffuse some pretty common misunderstandings among people, some things that come up over and over again that are problems in groups of people. And so when I was talking to my research advisor, an undergraduate, I told him I wanted to go to graduate school in psychology and he said, "What kind?"

And I remember being shocked that there wasn't just the one kind. I'm not sure what I thought happened to all the professors in the world who taught all the different kinds of psychology, but I think I had some conception that everyone was a clinical psychologist and then they had expertise in different research areas.

Anyway, he said, "You could be a social psychologist and study this all of the time." And I said, "Okay, well that's what I want to do." So my interest in psychology has been since forever, but specifically social psychology since about middle way through my undergraduate years. So here I am.

Jack Eisinger:  That's really cool. And by the way, before coming to college, that's also what I thought, you just went to grad school in psychology.

Sandra Parsons:  That's right. I had no idea.

Jack Eisinger:  Somewhat common. All right. So let's get into the questions. Question one, of your published studies finds the impact of professional coaching on university students. I was hoping you could explain a little bit to our audience what leadership coaching is, and is it something that is practical and useful for the everyday college student?

Sandra Parsons:  Absolutely. So we're really lucky, because this study actually took place at Rice University in partnership with The Doerr Institute. And so we have incredible resources, incredible funding with professional coaches who teach undergraduates how to develop their leadership tools, the idea being that everyone can be a leader.

Though I have to say we are very specifically talking about Rice University undergraduates. So it's not literally everyone in the world can be a great leader, but really focusing on the kinds of students that we have in this kind of institutional space.

So the professional coaching really is about looking at the literature on successful leadership tools, and helping students develop their leadership goals. So with The Doerr Institute specifically, it's very much tailored towards what kind of leadership roles students are interested in, what kind of leadership skills they want to develop, what kind of personal goals they have taking into account their culture of origin, but also the culture that they want to practice more leadership roles in. Because the way that you successfully lead is of course bound by cultural expectations and cultural norms.

And I would say that absolutely, this is something that is practical and useful for everyday college students. I think that it is fairly rare for one to be in professional spaces where there's no leadership. There is almost always some opportunity. Even if it's just the leader of your very small team at whatever level of job that you're doing, there are different tasks that come along where someone has to sort of take charge. And so I think having all of our students have some ability to harness those skills and refine those tools to better lead is wonderful. It's a tremendous asset.

Jack Eisinger:  Yeah, I definitely agree, and I definitely have met some of the people that may have participated in those studies, and I definitely agree with that assessment. My next question, regarding teams and social psychology, what are some suggestions you have for those teams? Whether it's business teams or just as something as simple as college students working on a class project. What are some ways that people can foster a better experience and have more positive outcomes in these situations?

Sandra Parsons:  I love this question because it really gets to the heart of one of the things that I went into my graduate schooling thinking I wanted to know more about. I talked before about how people were weird, which is clearly a driving force. But the other thing that I was really focused on is why is it that we do so much group work and yet still haven't figured out how to do it well? And so I studied a lot about how could we make that experience better.

So I think that number one, you have to define what the roles are in the group, so who's going to be in charge of what. There are some ways that tacitly develops. So that develops not necessarily on explicit understandings, though in my opinion, it's better if you spend some time being explicit about that. Because if you leave it to unspoken estimations of what other people are going to do, it takes much more time to develop those efficiently.

But also, what is the product going to be and how will people be held accountable for that product? Because one of the things that we know that happens is that when groups of people get together, it's very easy to imagine that other people will take on the bulk of the task. And we call that social loafing, the idea that if there are many of us doing it, then all of us can kind of relax a bit.

And the usual way of doing business in a group like that is to have a group product that just pops out the other side and is assessed by some external force like your professor, or the customer buying the product, or whatever it is, with little attention to who in the group was responsible for which parts of it. And when it's set up like that, then that means that people can take advantage of the shared workload and not put in their all.

So I think having some rules of holding each other accountable, either within the group where everyone agrees that these are how we're going to hold each other accountable to these, or asking the outside entity like your professor to set up some sort of a rubric or expectations about how to define whose work was what.

I also think it's important to think about, is this even a group task? Why are you doing this in a group? And I think for the group to understand why they have come together to do this product or this project together is vital.

So for example, one of the things that we assume is that a group will do a better job on a task. That if we put lots of heads on it, we'll have an even better outcome. But that's assuming that there's some either really hard lift, something that one of us couldn't do by ourselves because it's just too much work to do alone, or because we need lots of different people thinking about it differently.

And so we've already talked about the first problem. If we're doing it all together because we know that it's just a really hard lift for any singular person to do, then we better make sure that this is something we can each contribute to and be held accountable for each of our individual outputs.

If it's the other thing where we're coming together because of a diversity of skillset, then we need to make sure everyone knows in that group who is really good at what. If we don't do that, we run the risk of having everybody focus on the shared information and not talk about the stuff that they're uniquely qualified to talk about.

And so we really waste that resource, and that can potentially slow down the process and also tamp down the creativity and uniqueness of the product that you're trying to get, which is really actively working against having a group of people do it.

So trying to figure out, who's going to be responsible for what? How to maximize individual output, making sure that it's a group task, and also agreeing on how you're going to communicate about. They're all absolutely vital. And I think that those pieces of advice suit all kinds of situations. Classroom, outside of classroom, business context, really anytime you get a group of people to do something.

Jack Eisinger:  Yeah. No, that's a really good answer. I've definitely been on both sides of social loafing, both in school and in jobs.

Sandra Parsons:  Absolutely.

Jack Eisinger:  So I completely agree with that. No one really wins usually in those situations.

Sandra Parsons:  That's right. And it's such a shame, because group processes should be a really good tool for getting something done. We have so many big tasks that we have to do, and having more people work on it absolutely means more buy-in. People feel like they're involved in the process.

And so we want to continue to use groups for sure. But if we're not utilizing them to the best ability based on what we know, then like you said, nobody wins. It's just an unpleasant process and you end up with less than fabulous product. It's certainly less fabulous than it could have been if everybody had been doing their best work. So it's something we need to think about whenever we're in groups.

Jack Eisinger:  To continue with groups, in teams or groups, can you talk a little bit about in group competition or in-group threats, and what would be the best way for people to handle these situations in the healthiest way possible?

Sandra Parsons:  Absolutely. So I often talk about in-group versus out-group threats, usually talking about how we develop our identities in part around the people who are in our groups and by what we are not. And so we develop this strong in-group bond, and it is sort of implied whenever we're in a group that there is some out-group that is different from us, and also by definition not quite as good as us. We prefer our in-group members over our out-group members generally speaking. And there's lots of research with that in-group bias.

So then when we start looking at, well, what happens when there's actual competition from inside the group, which we know happens of course, or some sort of threat to identity that comes from inside the group.

Because it is a somewhat unexpected source of conflict, it can be very devastating. So if you think about how you know that you and your people are cohesive and connected, and you know that you're in us and that those are thems, and one of the things that makes you a good us is that you were willing to fight for resources or compete for resources with the other us against the other thems, that's kind of a comfortable space to be in, because we're used to that conception of things.

So when someone threatens your membership or when someone competes for a place within the group, it can be kind of scary because it threatens your idea of this cohesiveness, and it threatens your idea of what makes the us different from the thems.

So it can be particular threatening, and particularly insidious and difficult to deal with. And I think the best way to deal with that is to have honest conversations and to understand why it is that it's so anxiety provoking to have that threat come from someone you thought of as an us or part of your in-group.

I think it's also useful to think about your definition of your in-group. Why is that your in-group, why is that important to you? Why is that part of your identity formation process? And then perhaps use that to reconceptualize what that in-group threat means.

I say this because I know it's not always going to be easy to just say, "Well, let's just talk about it and resolve it, and then we'll all be fine again." The resolution might be that we have to redefine how we think about ourselves. Maybe we decide that we aren't really part of that group in that context, and we have to redefine where the boundaries are. And anytime we're doing that, that is going to be anxiety provoking and difficult, and we just have to give ourselves the time and space to have those conversations and decide, can we both still be in the group? Is this some irreconcilable difference? Do I need to think about my identity differently? Do I need to maybe join another group with respect to this task?

The good thing about in-group and out-group memberships is that they are often very fluid, that they're based on some expectation or some either internal or external expectation, or situational factor that's malleable. So we can decide to change the membership or we can decide to reconceive how we think about things.

Jack Eisinger:  Yeah, it can be a difficult thing to balance. The larger the group, typically the more power that group has. But at the same time, the larger the group gets, the more divisions there are going to be over little idiosyncrasies or bigger things.

Sandra Parsons:  Absolutely. And the more potential there is to see factions within a group. We recognize when we're in a group how heterogeneous the group is, and we tend to think that the out-group is very homogenous. But that heterogeneity while wonderful within our in-group, we also have to appreciate that's going to be the source of conflict sometimes, because we aren't all the same. We aren't all going to think about things the same way.

Jack Eisinger:  Right. Just to transition to teaching a little bit, what is the biggest takeaway you want your students to have in your social psychology and positive psychology courses?

Sandra Parsons:  So we'll start with the social psychology. So usually, it ends up being that I meet students early in their four years for my social psychology class. So I'm usually talking to first years and second years, with a few older students sprinkled in who are trying to get distribution credit.

And so I have the opportunity to talk to them at the beginning of their four years of college, which is a really exciting time. There's a lot of change and a lot of potentially tumult going on, where they're trying to find their way and trying to figure out who they're going to be in their new, more adult lives.

So one of the things that I want to make sure my students know is that in many cases, they have the power to change the situation. So social psychology is all about how the situation affects the way we think, feel, and behave. And that means that when we get into these spaces where there's conflict, or misunderstanding, or frustration even leading for example to violence, that those are coming out of situations that we've socially constructed, that we have somehow agreed as a group on the certain ways of doing things. We have certain normative reactions. We have certain expectations about what others are going to do.

And because they're socially constructed, that means that they can be socially reconstructed. So if something isn't working, we can decide collectively to change those situational variables to create a new situation that better serves us.

So specifically, thinking about times when we see conflict between people. It's often because there's some misunderstanding. I see the situation one way, and you're seeing the situation a totally different way. And once I understand your perspective, I can understand your behavior. So if we can come to some shared understanding of you're reacting to your construal of the situation over here, and I think it's supposed to be like this. And when you don't do it right, I get mad.

But what if we came to it with, "Okay, here's what I thought the ground rules were. This is what I thought was the environment we were interacting in. And I want to hear more about what you thought, and then we can come to a compromise."

One of the things that I worry about is that this makes it sound like it's very Pollyanna. "All we have to do is just change our expectations and the world will change." And obviously, I don't think we're going to get rid of all of the world's strife just by changing the way we construct things. I also think there are some cultural barriers where we can't just say everybody has the agency or the power to change the situation. That's just not true either.

But I do think that opening up students' minds to the idea that they don't have to go with the flow the way that the flow has been constructed before, but they can create a new flow. We get to create new places for us to be in. And especially at this age with this exciting group of students, you all will have the power. You do have the power.

So looking for ways to change those understandings and clear up misunderstandings I think is a really, really powerful tool that students can have and that humans can have to make the world a more harmonious type of place.

I often like to use the example of queuing cultures versus massing cultures. So there's some cultures where we stand in line, and then there are others where we kind of crowd around for our turn for something. And if you're from a queuing up and you think that you're supposed to stand in line for something, and you go to a place where they're crowding around, can be very frustrating, because you're wondering why aren't they doing what they're supposed to do? Why are they taking mine before? It's not their turn, right?

Likewise, if you come from a crowding place and you go and you stand in line, you're wondering, "Why are these people standing in this long line? Why don't they just crowd around and grab what they need?"

And you can see there's a lot of conflict there, because both sides are like, "What are you doing? You're not doing it right." But if you just explain to the other group, "This is what I can see the situation to be," and the other group is like, "Oh, this is how I thought it was supposed to be," then you can at least understand each other and understand where the differences are coming from, and potentially really tamp down that anger response that causes so many problems between people.

So long story short, power to change the situation. I want students to understand that they're not just being pushed along through their daily activities without any agency.

Positive psychology is actually fairly similar in terms of a lesson, but what I want people to understand first and foremost is that the goal of positive psychology is improved wellbeing. That does not mean improved happiness in the sense that everyone should be skipping through the tulips, and singing and dancing. I think about Shiny Happy People from the R.E.M. song, which is a reference probably most people don't get anymore, but I'm like, "I'm going to keep talking about it until everyone knows who Michael Stipe is."

The goal is not shiny, happy people, and that shouldn't be the goal. And I think that we are sold, especially in western societies, that is the goal. And then if we're not feeling happy in the sense of skipping through the tulips, that we're not doing the right kinds of things and something has to change.

So with positive psychology, I want people to understand that happiness is a very broad multi-tiered or multi-pillared kind of conception that has multi-facets to it, multiple facets to it. And it involves connection with other people, certainly positive feeling, meaningful work, connection, all sorts of really rich and interesting things that come with effort.

So the takeaway message for positive psychology is to reconceive happy as a much more complex construct that it has lots of pieces to it, and that it's changeable. That we do have the power to change our wellbeing, but it's going to take effort.

So it is not that we are going to magically either be happy or not happy, and if we're not happy, we have to keep trying to find this magic pill that will make us happy again. It's that we need to conceive of happiness differently, and then very consciously choose activities that support more of the good stuff. And so actively working on that, just like you would exercise every day or eat good food every day. It's not something you do once and then you checked it off your list. It's something every day, you have to pay attention to and nurture.

Jack Eisinger:  Yeah. I think if I had to combine the two into one, social psychology and positive psychology, it's the need to break down the things that happen in your life. That it is not so simple that you just can follow the flow of the group, or that you're just going to do whatever you want or just feel like, and you're going to be happy. That there are things that you need to consciously think about and put effort into.

Sandra Parsons:  I think that's absolutely right, Jack.

Jack Eisinger:  All right. Okay, perfect. Question number five. Can you talk a little bit about stereotyping? Why do people do it? Is it an automatic process? And what are some ways that individuals... And I was particularly interested as well in governments. What can they do to try to combat this practice?

Sandra Parsons:  That is a very interesting and provocative question. So let me take it apart one at a time. So let me talk about stereotyping.

So stereotyping is when we decide that there are boxes that people or things can fit into. Clearly, what you're thinking about is people stereotyping. So let's talk about that. That we decide that we know what people are like, based on certain kinds of features, we can put them in these different categories.

And it is necessary. It is automatic. It is part of the way that our brain makes order out of a lot of what would be chaotic information if we didn't do otherwise.

So we are in some sense what's called cognitive misers. We want to figure out the easiest way to tackle the largest amount of information possible, and our brains are constantly trying to organize those things into chunks of information.

If we didn't do that, the world would be full of way too much information. We would have trouble functioning even in the most simple tasks, because everything would be new to us constantly, and disordered, and uncomfortable, and not very pleasant.

And so what we do is we make these categories of people. And then once we know what we think we know about people, these stereotypes, then those help us decide how to behave. So we create these stereotypes, we create these boxes, put people in those based on some very quick judgment that we have, and some very little information often we have about those people in those groups. And then we behave and act towards them to reinforce those stereotypes.

So having stereotypes is not actually the problem, and it's a good thing it's not a problem because it is an automatic process. We're not going to be able to get rid of stereotyping. It's something that we do naturally.

The problem comes of course, when we have these assumptions that lead to discrimination and to prejudice. So it's when we have negative stereotypes, and also that we believe that they're immutable, that it's unchangeable, and that there is a fundamental difference in a group of people that is insurmountable, and that we can't be convinced otherwise.

And this actually goes back to the discussion we were having before about in-groups and out-groups. We think we know something about the out-group, because we have a stereotype about them. And so whenever we see behavior from an out-group member, we imagine that that supports the stereotype. And it's very hard for us to remember times when it refutes the stereotype, and have that stick where we start to alter the stereotype. Usually we dismiss it or we say, "Oh, well that's a unique member of that group. That's weird, because they're not like all the rest of them."

So then we get to the juicier part of your question, which is what can individuals, and then what can governments do? So I'll start with the easier one.

What individuals can do is be aware of that. So having a stereotype is not, like I said, necessarily in and of itself a bad thing. But we have to be very consciously aware and checking ourselves, how are we using that stereotyped information to guide our behaviors?

And we also have to actively seek out alternative explanations and information. It's again, a very effortful process. It is going to mean that we can't always take the comfortable, quick, easy route of just making an assumption about something, and that we have to constantly seek out others, make sure that we are not just always trying to prefer the comfort of people we think who are like us, but we have to seek out people actively who might be different from us.

And so then when we start talking about, how do we have governments be a part of that? I think it starts getting a little trickier because we have to think about what we think, what is the role of government, and how much hand does government have in our day-to-day interactions? So it's a little bit of a political question I think.

I think that we know from data, from research that when people are zoned to certain areas, if there are certain areas that have certain resources, that the areas that have more resources are going to be places where people with more resources can live. And to the extent that privileges certain groups of people in society, that is encouraging this prejudicial and discriminatory behavior. We definitely can't have that.

So I guess one of the things you could argue is that governments would have to make sure that they weren't providing resources to some groups over others or in certain locations over others.

And again, I think that goes back to a political conversation is I'm not sure... We're going to have really different ideas about how big the government could be and how far its hand should reach. But in some utopia, you would have governments enforcing only regulations and resources in ways that did not systematically privilege certain groups over others.

Because when we do that, we know that that causes strife between people. You can't just put people to together and hope that they solve their differences. When people are put together without some sort of environmental, situational variables in place, they actually reinforce those stereotypes, and things become worse between groups of people.

So providing opportunities for people to interact with people who are different from them or interact with people with whom they don't normally, or actively putting people together who have negative stereotypes about each other. With some things in place, like figuring out a common enemy that they share. It's actually a really effective way of bringing groups together.

But also helping people, facilitating people figuring out how they're more alike than they are different. So some sort of governmental programs that encourage sharing resources across stereotypically adverse groups or opposed groups would be one way that they could do it.

Anything that's going to encourage people to get out of their little echo chambers where they think they know everything about a different group is something that will encourage the breaking down of these prejudicial and discriminatory practices. But we're never going to get rid of stereotypes.

And frankly, they're shortcuts. They're useful. And so it's going to help me know... For example, if I have a stereotype about college students, then when I meet a college student, I don't have to think for very long what we're going to talk about, because I know they're going to be stressed right around Thanksgiving, because that's right before exams. If I know they're a third year, I know they're going to be looking for jobs. I have a stereotype about what kinds of things are going to make them anxious, and I'm going to immediately be able to talk to them about those kinds of things.

And that's good, because that makes for easier conversation. It makes for less stressful interactions. And so again, I know I'm repeating myself, but in as much as they are positive in making life smoother, they're going to be continuing to be part of our process.

Jack Eisinger:  Yeah. It seems like if we don't make assumptions and we don't see the same person every single day, it could be pretty hard to talk to them. And then also for your government answer, politically, what should the government do? But what could the government do? Making people live together, and sharing resources, and making sure those are equal, like you said. Utopia, which I think was the right way to word that.

Sandra Parsons:  Yeah. Yeah. I think in theory, it would be a lovely place to live where there was no competition for resources, or the only competition was where you had a perfectly self-sustainable unit where everything was equally accessed. I think we're probably describing a type of government that has been tried and failed before, but in our perfect-

Jack Eisinger:  Not necessarily with fully economic resources.

Sandra Parsons:  Right, exactly.

Jack Eisinger:  Okay, so just to transition back to class, I remember in social psychology, one of the biggest takeaways I had... And it was something that we didn't talk about for a super long time, but it really stuck with me, was when we talked about depressive realism. And that when people who are depressed sometimes do not have the "elevated" versions of themselves that a lot of other people do.

And so I was hoping you can explain for our audience a little bit more about depressive realism, why it can develop, and what are some ways for a psychologist to determine that in a potential patient or other person.

Sandra Parsons:  I love this question. So the other side of that is rose colored glasses, which has to do with the self-serving biases that we have. So the idea is that most of us, if we're mentally healthy, are walking around with a little bit elevated version of ourselves in our heads. So I referred to these self-serving biases. We bias the information that we believe about ourselves and that we think other people have about us, that's a little more positive than reality.

So for example, we think people think that we're a little smarter than we actually are, or than they actually think... We think they think we are a little smarter. We think they think we're a little more attractive, a little more clever, a little better dressed, all of these things. In fact, when we look at pictures of ourselves, one that's just us and the other one's a little enhanced, we think the enhanced one is a better picture, it's more accurate.

So the rose colored glasses are actually useful. They protect us from the harsh realities in the world, and they allow us to go out in the world and be a part of things, and continue to explore, and take risks, and be vulnerable, because we're somewhat protected. We think we're already doing pretty well. And so I'm going to extend myself in these spaces, and it should probably go pretty well because hey, I'm a pretty good-looking, smart, clever kind of person, and everyone thinks that about me.

It's when you are depressed that those glasses come off. So it's less about depressive realism developing, and it's more that you are taking away that self-serving bias, and you're being more realistic about the way the world sees you.

So it's realizing that when you're not mentally healthy, when you're a little depressed, mildly to more than that depressed, that the world really isn't spending that much time thinking about you. And that when they do think about you, they are not assessing you as positively as you hope that they are.

So I'm glad that you didn't spend a ton of time thinking about this, because when you do, it becomes in and of itself kind of depressing. It is hard to go out into the world constantly and put your best self forward without that illusion. And so it is a protective mechanism and it's one of the things that keeps us healthy. And so we shouldn't spend a ton of time tearing it apart.

Now, I think the interesting point that I think is probably behind this question is that when we're thinking about this illusion, we do have to think about the healthy version of that versus the unhealthy version of that. So we don't want to be delusional, and we don't want to be unable to accept very true and accurate criticism of self. We have to be able to learn from our mistakes, and we have to have people who can give us that negative feedback and that we will take it in.

So one of the things I would say is that when we... And again, based on research, we know that people who have an inflated sense of self that's not based on any reality, that's actually problematic. So an inflated self-esteem not based on real attributes is problematic.

So I think one of the things... And this is outside my field, but one of the things that I think clinical psychologists would want to do is to figure out, where is the illusion and the self-protective rose colored glasses turning into something more detrimental, something that's delusional? So where the line is between self-serving bias versus delusional thoughts about self or grandiosity is going to be a clinical question, I think with some sort of assessments.

And then I think for the average person who we aren't concerned has delusions, knowing that they have somebody who has their best interest in mind, who can give them realistic feedback, that they will be able to take in without having that in-group threat that we talked about is going to be really important.

So it's the difference between somebody who believes they're so spectacular, that to believe anything else is going to be crushing to them. Versus somebody who in general, thinks they're pretty great and a little better than the average bear, who has a parent or a best friend or a partner who can say to them, "You are really great, but there's this one thing that we need to talk about. You're really a terrible cook, Sandy. You really can't actually cook." Or, "You think you're being gregarious and you're actually being annoying in these spaces. You need to stop talking so much," or whatever. It is the thing that you think is really charming about you, that other people may not think is super charming.

And being able to trust that information and say, "Okay, the threat's coming from inside the house, but it's okay because I trust you." And in order to continue to have that positive feedback loop, we do have to make changes when necessary. So that's okay. Yeah, but it's hard. That's tough.

Jack Eisinger:  Yeah, that's exactly what I wanted to get into, just the different spectrum from depressive realism to rose colored glasses, and the fact that not only are humans weird, like you mentioned. And I also think we can also be relatively unaware of ourselves all across that spectrum. And so like you mentioned, which is perfect, having that person that is able to tell you those things is just the crucial, most important thing to making sure that you don't stray too far.

Sandra Parsons:  100%.

Jack Eisinger:  One side or the other to the point that it would cause some detrimental effects.

Sandra Parsons:  Absolutely. I think you said that really well. I think you do have to have that person. And the other thing that's true about wellbeing is that one of the best predictors of wellbeing in a person is whether they have social support. And part of social support is someone who can say the good, the bad, and the ugly, who can say, "You really are all these things a little better than the average bear, but in this one area you're"-

Jack Eisinger:  Social support isn't all support. Yeah, it's a little bit of pushing you in inward direction.

Sandra Parsons:  Absolutely. A little bit of realism spiced in there is good.

Jack Eisinger:  All right. And now to go the opposite direction of realism, I want to ask you a few, I don't know, not theoretical, but just questions that aren't so grounded in the curriculum. I was curious, what is the most misunderstood thing about social psychology in your opinion?

Sandra Parsons:  I love that question. So I think that when people hear that we're going to study how other people affect the way we think, feel, and behave, they're like, "Oh, you mean you're going to study everyday knowledge, like stuff that we already know all the time?" And that's something that social psychology has a bit of a chip on its shoulder. I think psychology in general does, but specifically social psychology, because the thing that we're studying is in fact the thing that most of us are doing all day long. We're trying to figure out why are people the way that they are, how can I understand how they are, so I can control it, and I can react to it, and make things turn out the best way possible?

And there's various versions of that, but that's kind of the big thing, is how can I be in this world and understand what's going to happen so that I can predict it, so that I can react to it and get things my way? Basically in a nutshell.

And so I think what people misunderstand about social psychology is that it is not just the study of everyday behavior. That there's a scientific method to it, that the reason why you think something is true may be totally wrong. Not that it leads you to the wrong reaction to it, but the processes behind it are wrong.

And so social psychology can help us tease out those theoretical implications and theoretical predictions in ways that are surprising to somebody who doesn't study social psychology. I'm going to give you example, but I think some people might see that and say, "Well, who caress? If it leads me to the same conclusion, why do I care what the process is?" And that's somebody who just isn't interested in studying social psychology.

I think we're always going to have... My husband studies the brain and cancer cells, and I don't want anyone to have cancer. And as long as he can figure out how to prevent it, I don't really care how we got there.

So here's an example. People talk about personality all the time and they say, "I know how she I because I know her personality." And what a social psychologist would say is, "What you really know is how that person expresses their personality in the context of the situation you see them in."

And so I'm not saying that they're wrong. You probably do know, not as well as you think you do, but it doesn't matter. People think that they know how other people will behave in certain situations based on personality. And when I point out to them, "You really only see that person in a very narrow band of situations. It's the situation that's driving the behavior, not the personality." And they're like... So I think that's something that's exciting to think about, because for me, that changes the way I think about what personality is. I want people to understand that when you use that word, you mean something different than what you think you mean.

I think that's cool. Some people don't care, but then they don't have to be social psychologists if they don't want to be. Right? So that's I think-

Jack Eisinger:  No, that's cool. I remember taking your class and hearing that. But even still to this day, even though I have that mental note of that distinction, when I'm talking with people, I'll still sometimes refer to them both as personality, even though I know the difference. It's a harder thing to say.

Sandra Parsons:  Yeah. And even though we all know what we mean, in my head when people say that, I'm like, "Well, I don't know." That's personality or situation. And what makes it interesting to me is that means that it's more changeable than people think that it is. Because I think if I could get you in a different situation, I get you to have a different kind of response to that.

Jack Eisinger:  So then is that...

Sandra Parsons:  Right? And like you said, people are often really unaware what's driving their behaviors. And so to me, that's powerful, because to me I think, "Okay, well let's get you out of this situation that I think is driving you to do something that I don't think is good or healthy or equitable, or the way I want it to be selfish. Let's move you into a different location, in a different situational space. Let me change the factors, and then let's see how you behave and see if it turns out better for all of us."

Jack Eisinger:  I really like that answer. And then in a similar vein, if you had to create a class about an under focused area of social psychology, or positive psychology, or really any topic that you're interested in, what would you want to teach about?

Sandra Parsons:  To figure out how to best teach people how to utilize the skills and the tools that we have. I think people don't harness what we know about social psychology in ways that get the best outcomes done. And so very specifically, how do we present information to people in a way that will make them more likely to accept that information?

So this class would be something like a social movements class, or how to improve the public service announcement. Every time I see people talking about a problem that they see, and I think to myself, "I wish that they'd talked to a social psychologist about that because I could help you solve that problem." Not me personally, but social psychology. How do we persuade people to do things? How do we frame messages that can be the most useful?

So it'd be all about that. It's like how to deliver messages, how to harness expertise, how to use what we know about the way people think and feel to get them to do the more healthy thing, the fairer thing, the more just thing. That's what I would do. And I-

Jack Eisinger:  So kind of like the more communicative aspect, the more practical way of getting things done.

Sandra Parsons:  Yes. Even just thinking about Covid-19 rules and regulations, let's use what we know about persuasive messages, and what we know about different audiences for different types of behaviors, and tailor multiple different messages. And I feel like we just got one message. "This is what you're supposed to do." And then of course the other side is, "This is what you're not supposed to do."

We can talk to both of those groups with social psychology, we just have to tailor the message appropriately, and I don't feel like anyone did that. And so that kind of thing, like composting. How can we present composting to a diverse group of people, or cessation of smoking, or better alcohol use rules? It can apply to anything, but how do we harness that communication and what we know about message framing, and audience effects, and all of that, and make it more effective?

Jack Eisinger:  I don't know how classes are made, but I would definitely take that.

Sandra Parsons:  Would you take it?

Jack Eisinger: Yeah, that does sound very interesting. And then that's pretty much the end of my questions. I just wanted to ask, is there any advice or takeaways you want to share with the audience in a conclusion?

Sandra Parsons: Take a psychology class. I think everyone should have to take at least one psychology class. I think it makes us better human beings. Also try to remember that...

You know what? Here's my takeaway. Fundamental attribution error. I want the world to know that when you think someone does something, and you think that they are something, a jerk or not a nice person because you don't like what they did, try to imagine that there's some situational effect that's leading them to that behavior, and make a more gracious attribution about the person instead of immediately jumping to the assumption that they're not very nice or jerky.

Jack Eisinger:  Yeah. No, that's definitely my biggest takeaway from social psychology, fundamental attribution error. It's ingrained in my mind now.

Sandra Parsons:  Good. I'm so glad. We need to be nicer about our assumptions about other people, and give each other the benefit of the doubt in the same way that we give ourselves the benefit of the doubt when we do something that we wish we hadn't done.

Jack Eisinger:  Put on some slightly rosier colored glasses for other people as much as we do ourselves

Sandra Parsons:  There we go. That's right. I love that.

Jack Eisinger:  All right. Yeah, so that's pretty much the interview. Thank you so much for taking the time to participate. For you and any of the other viewers, feel free to check out the Seattle Anxiety Specialists website, and I hope you all have a great day.

Sandra Parsons:  Thank you so much. It was my pleasure. It's good to see you.

Jack Eisinger:  Of course.

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

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

Psychologist Stephen Oross on Bias & Cultural Humility in Health Care

An Interview with Psychologist Stephen Oross

Stephen Oross, Ph.D. is an Associate Professor of Psychology at Kutztown University of Pennsylvania. He specializes in experimental psychology and cultural humility in healthcare.

Ryann Thomson:  Thank you for joining us for this installment of The Seattle Psychiatrist interview series. I'm Ryann Thomson, a research intern at Seattle Anxiety Specialists. And I'd like to welcome with us Psychologist Stephen Oross. Dr. Oross is an Associate Professor of Psychology at Kutztown University of Pennsylvania. He is a scholar in the field of experimental psychology, and has published several articles within his career, including, “Studies of Brain Activity Correlates with Behavior in Individuals with and without Developmental Disabilities”. As well as “The Impact of Acuity on Performance of Four Clinical Measures with Contrast Sensitivity in Alzheimer's Disease”. As well, Dr. Oross has had extensive experience working with the World Health Network as well as previously having completed a visiting fellowship at Massachusetts General Hospital. Before we get started, can you please tell us a little bit more about yourself? What made you interested in experimental psychology and what led you to become a professor?

Stephen Oross:  Well, thank you, Ryann. Certainly. I actually became- It's a longer story, but I'll condense it. I actually became interested in psychology and decided to be a psychologist as a sophomore in high school. And largely it was due initially to an interest in clinical, child clinical to be specific. I had read some books on autism. I had an aunt who had been diagnosed with mental retardation. And so, when I went to college, my plan was to be a child clinical psychologist. And so, I did my undergraduate work, and while doing that, did a bunch of volunteer and then some paid work interacting with individuals with different developmental disabilities, including some time as a residential house manager at a group home for children with autism. So, I honestly thought that was the direction I was going to go. But as an undergraduate, I also began doing some research with a couple professors at the University of Dayton. And some problems with the clinical end that I saw and the excitement I had with research led me to pursue the experimental degree.

I went to Vanderbilt University for my experimental psychology PhD. I stayed there, did a couple of postdocs, one in sensory perception, one on mental retardation and developmental disabilities. And stayed there actually even longer than that as a research faculty member. While doing that, I had the opportunity to do some teaching. And I supervised a student as she worked on her PhD. I was the doctoral advisor. And those experiences led me to believe that while I wanted to do some research, my interests were more aligned with teaching. So, I did stay in a research position for a number of years before coming to Kutztown and then beginning the path I'm on now that led me here.

Ryann Thomson:  Really interesting. That's great. I'm glad you had such a different variety in your background before you came here. That's really nice to hear.

Stephen Oross:  Yeah, actually I think it's important to do that. I think it's been beneficial in thinking about how to teach.

Ryann Thomson:  So, to begin, I wonder if many people have heard the term cultural humility. And could you possibly define what that is and why it's so important when we're treating clients?

Stephen Oross:  Yeah, cultural humility, you're absolutely right. Not as many people are familiar with it as I would expect. But it was introduced in the late 1990s. I believe it was 1998, by Melanie Tervalon and Jen Murray-Garcia in a journal article. And what they were trying to do was to respond to some national mandates to improve multicultural education among physicians. And what they identified was a multidimensional approach with three primary components. The first was to emphasize the importance of self-reflection and lifelong learning. And I'll come back to this point. But second was a recognition that in healthcare settings including mental healthcare settings, there's an imbalance of power. The care provider dominates the services and the care that's needed. And often the patient or client gets ignored at some level. Certainly we're paying attention to the symptoms, but not always looking at their background, and the mindset and experiences that they bring to the healthcare setting.

And lastly, they identified the importance of institutions, not just individuals, but institutions to model these principles of reflection, and lifelong learning, and acknowledgement of power imbalances. So, it's a very dynamic process. And it emphasizes the fact that when people enter into healthcare settings, there's a lot of unknowns about them. And what we need to do is to acknowledge the differences, and the similarities, and the perspectives that people bring. Why it's important, it's clear. There's lots and lots of data to indicate that healthcare providers bring a number of biases into treatment. Some of these biases are explicit and some are implicit biases. But the biases that people possess can negatively affect the care that's provided and the adherence to the treatment plan on the part of the patient. And cultural humility is an approach to try to get past these biases and to incorporate the knowledge that patients have into their treatment.

Ryann Thomson:  So, in your experience, what are some barriers that the Western medical system and mental health field face when trying to implement this idea? And how should professionals go about trying to address the challenges effectively?

Stephen Oross:  Sure. There are potentially a lot of barriers to implementing what seems like a fairly simple concept in many ways. One barrier, for instance, is that academic training, whether it's in medical profession, or a psychologist, or psychiatrist, really does emphasize becoming an expert on a topic or a domain. In some sense we know we don't know everything, but we still act like we know everything and have been trained to think that way. It's potentially a problem to get providers to recognize the fact that we don't know everything, and we have to provide care and conditions where there's uncertainty. Both uncertainty on our end about perhaps the type of treatment that might be called for and uncertainty about the patient's responses and their actions that would affect how well treatment works. So, that's one.

A second that's very prominent is time. Much of the training that's occurring, it's happening for professors in academic settings, physicians in a more applied settings, mental health providers really looks at a very time limited training program. I know I have to go through a series of trainings, but they're once a year and they're kept maybe an hour long, roughly. And cultural humility is not an approach that can really be taught in a single, very time limited session. It's a ongoing process. This is the lifelong learning component that is emphasized. You are trying to develop a mindset that is awareness about yourself and awareness of the individual you're working with. But that knowledge, and the awareness, and how it impacts interactions is going to be continually changing. So, you can get an orientation to cultural humility, but you really have to be practicing it on a regular and continual basis. And I think a lot of the training is capped to be short because of the other time demands that are placed on individuals. And that can be a barrier.

One other from my perspective is that it is often the case, quite often, particularly mental health care, that we're talking about an individual providing the care rather than a team. And if you have individuals rather than a team that's working collectively, it is more likely that certain biases can creep in. So, cultural humility, training and awareness becomes especially important in that context. How you can effectively train or educate people to work on cultural humility varies. I mean, I did just a quick search and there are lots of institutions that talk about training cultural humility. And I noticed that many of them have a big emphasis on self-reflection for the provider, thinking about the provider's cultural background, and ideas, and expectations.

But there's not as much that I could find talking about power imbalances, and certainly even less on how do you make an institution become aware of the cultural background and biases that are inherent in that institution. So, I think the training efforts can be done, but it's got to be a bigger, more collective effort to highlight the three primary principles of cultural humility. And we have to as providers then start recognizing that we have to live with uncertainty. Rather than always thinking we're an expert, we have to recognize that while we know a lot and certainly can bring that to bear in treatment programs, we don't know unless we search for it like cultural humility wants. We don't know how well each of the clients will respond to a treatment plan. What are their other activities from their religious beliefs, their cultural beliefs, their fact of their people possessing different genders, different sexual orientations, how all that is going to affect treatment.

And we have to, when we accept that uncertainty, recognize that we're not going to be all knowing. We're going to have things we're not aware of. But if we recognize that, and work with individuals and allow for input from the people we're working with, we can help to mitigate these power imbalances. We can gain more information on the types of approaches that clients are willing to bring to treatment, what they might adhere to, what they might not want to adhere to in a way that isn't often captured when there's a a unidirectional, here's the treatment, here's what you do independent of the client. I think that's what we really have to consider.

Ryann Thomson:  Yeah, I really liked the team aspect, because I know you personally have a unique experience as you're a heart transplant recipient. So, I know you've talked about having a team approach to your personal healthcare. So, looking back on that experience as well as professional, do you see any more of these strategies being invented? And if not, what can they do for patients in the future to better that?

Stephen Oross:  Yeah, if I think about my own situation, including the heart transplant and then other aspects of personal and professional lives. I've actually been fortunate. I have to acknowledge that I come from really a position of privilege in healthcare settings. Coming in as a white male with some advanced educational training, and now with at least some money in health insurance, it really affords me an opportunity to select who I want to care for me. It allows me to have a little face validity when I talk to the healthcare professionals and question why certain things are being done. And I don't tend to have a huge power imbalance between myself and the healthcare providers.

And I found particularly in the transplant setting, interesting to think about because you have to go through a bunch of screening, obviously medical, but also psychological screening prior to being approved to get a transplant. And one example that I thought of as I was preparing thinking about this interview was that while talking to the psychiatrist, a question came up about how depressed I may be or how suicidal I might feel, and whether or not I've ever had those feelings. Because frankly, the healthcare system, if they're providing you with a transplant, something like a heart, they want it to succeed. They want to have it put in somebody who's not going to intentionally damage the gift that they've been provided.

But my beliefs on suicide are not typical for many people. So, when I was asked about that, I remember explicitly thinking, well, I could give the easy story and say, "No, I've never thought about it. I've never been depressed." Quick, easy answer, and we're out. But it would be a dishonest answer because the heart issues I had started many years prior. And when they first happened, they were sudden and surprising. And I did go through a depressed period, and that did lead me at times to think about suicide. And I went to a Catholic university, University of Dayton. I was raised as a Catholic. But I never accepted the idea that suicide was necessarily a bad thing. There are many cultures that accept suicide as a reasonable approach under some conditions. And I in fact had to debate suicide, the pro side when I was an undergraduate.

So, I remember thinking, "Going to tell them this, and this may disqualify me for the transplant," but I had to be honest. And what I appreciated was they didn't have this immediate reaction of saying, "Wait a minute, you've thought about suicide at one point?" They explored the conditions under which, why did I think that? Why did I come to this belief system? And to me, that is a reflection of the cultural humility perspective. So, I really appreciated it at that time. And it highlighted in a personal way, the importance of adopting an approach where they're willing to listen to me, they're willing to explore more deeply why I am holding certain perspectives.

So, that was a very helpful component of being prepared. The downside, I've noticed a couple occasions in a couple settings where I don't feel that providers (and I'll talk about employers a little bit as well) adopted a cultural humility perspective. So, after the original damage to my heart and I had to go to varying cardiologists, there was one in particular who my wife would accompany me because I had, at the time, was using a wheelchair and had to use a wheelchair to get around. And this one doctor in particular would always direct their questions and provide information to my wife who was sitting in the exam room and barely looked at me. Despite the fact that even though he wasn't looking at me, I was the one providing the answers.

My wife has been extremely helpful as I went through this process, but she is not as knowledgeable about the health condition I had. She wasn't as knowledgeable about the damage to the heart and what I might have to do. She wasn't as knowledgeable about the medications I may have to take or other treatment plans. And yet this physician kept insisting on talking to her as if, because I had this serious heart attack, that I was incapable of responding and taking care of myself. And that was an instance where there was certainly not a cultural humility perspective. There was no real attempt to understand what I possessed, what abilities, knowledge, background I had. It was, I'm going to dispense the information to the person who looks less impaired.

It was an instance when I was like, this person's clearly not trained in a way that I think would be conducive to better healthcare. And I left their care. It was unacceptable to me. I encounter it also, not intentionally sometimes, but with individuals who want to talk about the transplant and what the consequences have been for me. Because even though I might be asked what it's like to have a heart transplant, the conversations often turn quickly to their knowledge of transplants or their knowledge of somebody else, and not really looking at what I bring and what my perspectives are and how I'm handling this. So, it's a case where I see myself being minimized, if you will, in these discussions.

I see it institutionally. Most recently at my university at Kutztown University in several ways. I won't belabor the point. But one I thought was particularly relevant when you asked the question concerns the need for medical notes when you have sick days. As a heart transplant patient, I'm immunosuppressed. I'm going to get sick. Varying types of bugs are going to affect me. The team knows this. We've gone through what I'm supposed to do, how to treat the symptoms. At what point should I contact the team? At what point do I wait it out? But Kutztown University and probably others, has a policy that if I'm sick for three days or more, I have to provide a note where I've gone to see a doctor. Well, I don't necessarily see a doctor in three days. My team knows that, that I know I'm going to be sick. It happens, it drags out for a few days. I don't necessarily have to see a doctor.

But the institution has decided that three-day policy that I have to have a doctor note. Little attempt to understand anything about the individual in this case. They're not looking at it as, why do you not have a note? Why does your team allow this? No real dialogue about the conditions and the background that I bring that might affect how and what kinds of demands they want to place on me. So, when we talk about institutional accountability with the cultural humility perspective, I think these are some of the kinds of examples that I've encountered anyway.

Now, how do you get people to be more aware of cultural humility and what ways should people train for this in the future? I'm sure we'll talk more about this. You certainly have to get people to engage in the self-reflection and the lifelong learning component. You have to get healthcare providers to recognize that they need to learn more about themselves so they know what their backgrounds and biases might be. And then they have to be interested in learning and continually learning about the individuals they're working with. And there are some training programs to do that, but I think that's a huge step, the self-reflection and lifelong learning approach. The power imbalances, we know they're there. There's certainly training to make people less willing to have those imbalances.

I am not a 100% sure what kinds of training can be available at the institutional level. The medical institutions I've interacted with most, as far as I can tell, really haven't done any kind of institutional accounting for cultural biases and adopting a cultural humility perspective. I can say that I felt that my transplant team did do that, but in other healthcare settings, both with myself and other family members that I've went to, I don't see a lot of that at the institutional level. So, looking for specific training programs for each of these three components is going to be crucial. And it's hard to mandate how that's done because it has to be a very personal reaction on the part of the providers. And every institution has a slightly different background and mission. So, the awareness that cultural humility is a perspective that should be adopted, a willingness to go look at what other types of efforts have been made at other institutions would be a first step.

Ryann Thomson:  So, within this conversation, I know I personally have heard more about cultural competency. And I think you're touching on some of the ideas that differ cultural competency and cultural humility. So, how does knowing the difference and implementing both, I would say, enhance treatments of patients?

Stephen Oross:  Sure. And I think that's a good point to bring up here. The perspectives that have often been taught in institutions are ones that call themselves looking at cultural competence. And there's nothing wrong with this. It's just that cultural competence approaches are training efforts to make people more aware of cultural differences, but they really think of the training as an endpoint. And what I mean is there's a set of facts that are taught in the training about people who have differing types of backgrounds. It is, in some sense, a training to teach about the belief system that is assumed to be held by individuals from different backgrounds.

There's little in cultural competence training that emphasizes looking for, well, in some sense being taught generalizations rather than stereotypes. Being taught in cultural competence, that this is a starting point for understanding individuals. But you need to interact more carefully, understand the nuances that each individual brings. Not all individuals from varying backgrounds are identical to one another. We tend to think when we say cultural competence, something really along the lines of race or ethnicity. But we have to broaden that perspective, especially if we're talking mental health to consider diagnoses. And one of the problems with diagnosis and mental health is we all know two different individuals identified with the same diagnostic label aren't necessarily acting the same way, don't necessarily show the same symptomology. So, it really is a setup where we need to learn more about the individual patients.

Ryann Thomson:  So, you touched on bias earlier-

Stephen Oross:  Oh. Yeah, sorry.

Ryann Thomson:  Oh, sorry. If you want to keep going, go again.

Stephen Oross:  Well, just briefly. There have been a few surveys in other experimental analysis of cultural competence training. And it works. People get more knowledge about different backgrounds. But it has been shown that it tends to promote stereotypes. And that's something that cultural humility will try to break down by the fact that you're going to be looking for the individual perspectives, belief systems within a framework of their cultural background. I'm sorry to cut you off there.

Ryann Thomson:  No, it's okay. I didn't know if you were finishing that. So, earlier you touched on both of these points, but implicit bias within the mental health diagnosis. And education, obviously holding a really important point. But how do you ensure educational programs and training can at least mitigate or try to mitigate this bias, and make accurate diagnosis and assessments of patients? Or is that even possible?

Stephen Oross:  Well, this is a big question. Let's start with a couple simple points and then build up to this. When we're talking about biases that people bring to providing services, largely talking healthcare here, we have both explicit and implicit biases. So, explicit biases are, we already have certain beliefs about people who come from different backgrounds. And we know this, we hold them, we can state what those beliefs are. Before we've even met the individual. We have certain expectations. And that type of work, I mean that type of bias has certainly been shown to provide a means for having unequal healthcare treatment based on your cultural, and ethnic, and racial, gender, sexual orientation backgrounds.

So, that part can be often taught with some formal training to have people aware of their biases, provide information to show where the biases are misleading, present alternative approaches to thinking about individuals. The implicit biases are a little more tricky because they are ones that people are not aware that they're holding. And if they're not aware that they're biased, it's very difficult to make them aware of the need for training and for changing their perspectives. But in studies that have attempted to look at this, there's been a few studies I remember that were talking about roughly two thirds of individuals who were providing services holding biases. Not that they were aware of it, but they were implicit biases that were negatively affecting groups that are typically underrepresented or marginalized. And these biases can impact what types of treatment programs and plans are recommended for patients.

So, we've seen health treatment disparities, for instance, between White and Black as one example, men and women. Different types of recommendations, different treatment options. One, as I remember prominently because I'm also diabetic, is that individuals who are Black when they experience neuropathy, the condition that a nerve damage that follows diabetes often, individuals who are Black were much more likely than White patients to have to be amputated to have a foot or leg amputated. Whereas White patients were more likely to have more extensive treatments designed to try to restore blood flow to the affected leg or limb. And that's a bias perhaps impacted by an implicit bias of who will follow treatments, what will work, the money, and the time efforts, the diligence in treatment. So, we know that populations who are underrepresented or marginalized are going to be affected by implicit biases. In mental health, this may not be something that individuals at the varying psychiatric institutes want to hear. But they're particularly vulnerable to the implicit biases. And partly I would argue that's because of the DSM itself.

There is a belief that is commonly held that the DSM has a standardized diagnostic criteria. And it does have diagnostic criteria and it can be quite standardized in some instances, little less standardized in others. But there's a tendency to not recognize the fact that the benefit of at least some of the standardization that's present in the DSM matters if providers pay attention to the DSM, and don't use their own judgment that might be more likely to be affected by biases. There are a number of providers have reported in different sources that , yeah they're aware of the DSM-5, they were aware of the changes that came out in DSM-5 compared to previous editions. They have a copy of it. But they argue that they rarely refer to it, that after a certain period of time they know how to diagnose individuals from their own backgrounds.

And the DSM is there, I remember in particular reading one report, where this provider was saying the DSM there is there really just to head off arguments from clients about diagnoses. And that really bothered me when I started reading these types of reports, because that's a perfect scenario for implicit biases about mental health challenges to creep into diagnosis. The DSM, some people and a growing number I would argue, suggest that there are concerns about how reliable the diagnostic categories are used and defined in the DSM. And if we don't have a careful system of diagnosing and identifying treatment plans, the individual biases that we all possess have a greater potential to come into play. We might think certain groups are going to be less compliant and we'll recommend one type of treatment for one group compared to a different treatment for others.

These are the conditions that have to be overcome. And the educational settings, again, I think first and foremost, we have to have awareness of the three principles of cultural humility. Of those, while all are important, I think one that is commonly missed is the self-reflection and the lifelong learning approaches. And there are some training materials out there to facilitate that. But it has to be emphasized that one time training is not going to be sufficient to do this. So, I think the field is right for the varying efforts that have been made across different institutions to facilitate understanding of cultural humility. I think the time is right for an overview, what is everybody doing? And can we pull out best practices that have worked in different institutions and share them more widely. At this point, I still see this being largely run on a center-by-center or provider-by-provider basis, rather than as widespread training as it probably should be.

Ryann Thomson:  Yeah, I've definitely heard some of the changes DSM has tried to make for culture, and race, and things. It's obvious they're trying, but at the same time, how much changes can you make before... There's only a certain point, if that makes sense. Like you said, you have to recognize your bias and self-reflect on those. Definitely a major point, I think. That's important.

Stephen Oross:  Well, especially when the DSM changes over time. So, if I'm a clinician and I've been providing mental health services for a number of years, am I actually paying that careful of attention to the changes that are introduced in subsequent additions of the DSM? I mean, there are many who are diligent and are well paying attention for this. But we know from self-report and a few studies that there are individuals who really are not paying that much attention to the changes. And if they're not, the efforts to become more culturally aware in the DSM are going to be ignored. And it's going to, again, make it likely that biases come into play in treatment plans.

Ryann Thomson:  Well, I want to jump to this technological advancement we've had because of the COVID-19 pandemic. So, telehealth has obviously, especially mental health, telehealth has grown. And in a way has allowed us to enhance our cultural humility, and especially with treating individuals. So, can you speak to how telehealth plays an important role and how our biases can be expanded with increased uses of technology within mental health diagnosis? Or in a way, can it negatively affect?

Stephen Oross:  Yeah, it's an interesting question to address because the technology is so varied that can be applied to providing healthcare services. We can talk about a simple technological advance, the telehealth, as you mentioned. I conduct a number of my sessions with clinicians through telehealth now. Some I have to go in person, but many I can do. Essentially they're a Zoom meeting at some level. And it works. There are concerns, I think about the technology because it's an unusual situation for most people to be conducting health interviews or health sessions through a camera and through a monitor. And I think there's potential there for people to act differently when they're in telehealth settings than they might when they're in person, on both the clinician and the patient end. You're sitting pretty still stable looking at a camera. Whereas in a in-person facility, you're moving around, you might be able to observe things about body movement that you're not going to pick up necessarily with a telehealth interview.

On the other hand, the integration of artificial intelligence can provide some background information about an individual's cultural and background. And that could be useful for writing reports or preparing for visits from the clinicians. I’ve heard, you know, when you start talking about technology, we've already heard of lots of wild ideas. So, I've been hearing more and more about digital twins, this idea that there would be, in essence, a virtual representation of you. And the digital twin would somehow be coded with information about me. And clinicians could interact at times with the digital twin. They could try out different treatments and see how the body in this virtual person responded.

I have a hard time thinking about how that's really going to work because it's simply going to be based on the input that creates this digital twin. And if we're not adopting a cultural humility perspective very well, we're going to miss information that should be incorporated into the twin. Virtual reality therapy we use already in mental health treatment in some cases and it has been proven effective. But how far that can go is still a little unclear to me. I think there's another issue though with technology that we're not really addressing.

The benefits are often proposed to be ones that are going to help people who are underrepresented or marginalized. And the problem is we already know there's healthcare disparities for these populations. We already know lack of money, lack of easy access to facilities, lack of freedom to select different care providers because of healthcare insurance restrictions. We already know that exists. We also know that providing technology through the internet, for instance, not everybody has equal access to the technologies, the internet access, the cameras, the monitors that might be needed to use telehealth.

And so, we saw some of that with COVID-19, where there was an effort to push both educational and health services online. And understandably so. But there were large numbers of groups who were marginalized to begin with, who became further marginalized because of lack of access to the technology that's needed to do this. So, if we're going to push technology into the telehealth kind of world or the virtual reality type of world, and hope that it helps us better understand individuals, it has to start with making sure there's full and unencumbered access to the technology for individuals. And I don't think that exists right now.

We then still have to adopt the perspective that when you've got somebody on a camera, you still have to spend the time to think about how you're interacting with them and how they're interacting with you. How the different backgrounds are going to mesh. Whether we're willing as healthcare providers to, at some level, give up a certain degree of control and recognize that people from different backgrounds won't always accept the treatment plan that we propose. And we have to do a better job of recognizing the power imbalances, living with a little less control at some level. But understanding the client or the patient better so that we can tell them in more succinct manner, more appropriate manners why we're recommending different treatments.

The COVID situation is one example. I don't think we did a very good job with public health and convincing different populations of people of the benefits of vaccination programs. And we see that by the disparities in who's willing to get vaccinated and the percentages of people who are actively fighting or ignoring vaccine protocols. Vaccines I firmly believe are beneficial for most people. But we haven't been able to recognize that not everybody believes that upfront. And how do we either inform them better so they change their mindset? Or how do we adapt to the belief that vaccines in some people's minds are not beneficial? And we're still struggling with that.

Ryann Thomson:  I feel like this whole conversation, it involves every single part of our lives. So, you can take any example from any part and just like, well, here you see it in vaccinations, or in how we approach illnesses, or if we even go to the doctor. It's literally anything you can think of. I think you can see an example of it.

Stephen Oross:  I think you're absolutely right. And my understanding, my familiarity with cultural humility came a little later than when it was first introduced. But I had the belief system already in place from working with people who had developmental disabilities. And the awareness that whatever their clinical label may be, there are variations in the symptomology, and the beliefs, and the behaviors of those clients. I had that perspective. So, when I encountered cultural humility more formally, later, it was easy for me to accept it and to understand it.

And I think that afforded me an opportunity to, as you said, recognize it applies in multiple contexts, not just healthcare settings, not just mental healthcare settings, but in every aspect of our lives we're encountering different people. And we have to understand that we're going to have certain beliefs, we're going to have certain generalizations about people when we first meet them. But we have to get to know those individuals. We have to think, why did I hold my beliefs and are they valid beliefs? Should I change those beliefs? I believe as people become more aware of cultural humility and as we develop more effective training programs for this, it will affect all aspects of our life.

Ryann Thomson:  Yeah, I definitely agree. Now, I know you have a class to teach in 10 minutes. So, is there anything else as a health psychology professor, you want to say to our audience? Any advice or ways to move forward from this conversation?

Stephen Oross:  I think we've touched on quite a bit of this. I think really, from my perspective, one of the most important keys, I guess I would say in a multi-lock system, is that we have to give up when we're providers of services. We have to give up the idea that we are an all-knowing expert. Certainly expertise is important. Certainly academics and physicians are training to understand their domains better and better, and more sophisticated manners. Certainly there's a great deal of knowledge that's possessed by the individuals. But we have to give up the idea that we're all knowing and recognize that there is a dynamic with whomever we're working with. And they are not just a receiver of whatever treatment or information we want to provide, but there's some level, almost a negotiation with the individual that has to take place. And I think that's probably the biggest point that I think of. I'm sure others can have different perspectives. But for me that's the biggest point. Can we recognize this dynamic interaction between patient or the client and the provider?

Ryann Thomson:  I like that you never really stop learning. You always have to keep learning about other people and an open mind about things. That's really nice.

Well, that is all the time we have. And I want to thank you again for talking with this about me. I learned so much and actually a lot of interesting ideas I'm going to look up after this. And I hope we can see you in the future. And I hope you have a nice day.

Stephen Oross:  Thank you. It was my pleasure to do this interview. It was really interesting to think about this and how to present it in this kind of context. So, as I'm talking, we had the time limit, but I'm thinking, "Oh, I could say so much more here." I could say-

Ryann Thomson:  Yeah, I know.

Stephen Oross:  But I enjoyed it, so thank you for the opportunity.

Ryann Thomson:  Yeah, of course. Thank you again.

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

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