social anxiety

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

An Interview with CEO Ruth Stronge

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith:  Oh, Walter!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jennifer Smith:  Thank you.

Jennifer Smith with Jenny the donkey. (left)

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

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


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

Psychologist Katherine Walukevich-Dienst on Substance Abuse & Social Anxiety

An Interview with Psychologist Katherine Walukevich-Dienst

Katherine Walukevich-Dienst, Ph.D. is a post-doctoral fellow at the University of Washington School of Medicine. She’s an expert in the field of substance abuse and social anxiety, particularly among young adults.

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

I'd like to welcome with us today psychologist Katherine Walukevich-Dienst. Dr. Walukevich-Dienst is a post-doctoral fellow at University of Washington School of Medicine. Dr. Walukevich-Dienst specializes in alcohol and cannabis use and co-occurring mental health problems among young adults. She's written several publications on the topic, including using substances to cope with social anxiety, associations with use and consequences and daily life, and hours high as a proxy for marijuana use, quantity and intensive longitudinal designs.

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 substance abuse and social anxiety?

Katherine Walukevich-Dienst:  Absolutely. So thank you so much for having me. I could talk forever about this topic, so feel free to interrupt me if I go on and on. So I guess my journey kind of starts back when I worked at an anxiety lab at the University of Miami, and it was focused on anxiety across the lifespan. So we did a lot of work with kids and teenagers and young adults as well. And what I noticed, especially when studying people with social anxiety is that a lot of these individuals, teens and young adults in particular, mentioned using alcohol or cannabis to cope with their social anxiety. So that led to me to applying to grad school to work with my mentor, Dr. Buckner, who is kind of the queen of when it comes to research with social anxiety and substance use. Substance use doesn't occur in a vacuum, and it doesn't really ignore any type of person. So I was particularly interested what made these individuals, who are socially anxious, more vulnerable to using substances.

Tori Steffen:  Okay. Yeah, that's definitely a really interesting topic to study, so it's very cool that you found a great mentor for that.

Katherine Walukevich-Dienst:  Absolutely.

Tori Steffen:  Yeah. So I guess getting down to basics about our topic, could you explain for the listeners why social anxiety typically develops and how it tends to present itself?

Katherine Walukevich-Dienst:  For sure. So that's a really big question, especially with how it tends to develop, so we haven't narrowed down in research the one thing that tends to lead to social anxiety. And it's kind of a combination of a bunch of different things, including your genetics, your childhood history, experiences in adulthood, how you cope with things, among other susceptibility to other diagnoses among other things.

So people with social anxiety... Social anxiety is really common, and most people feel socially anxious in at least some situations. I know that I feel particularly socially anxious when I give a talk in front of a big group. And part of social anxiety is worried about fear or worry about what other people are thinking of you, and mainly that people might be judging you negatively, or that you might act in a way that's embarrassing, or that other people might see that you're anxious.

The important thing with that is that social anxiety, while we all experience that, people with social anxiety disorder experience that a lot of the time in a lot of different situations. So additionally, it is getting in the way of living the life that they want to lead. So while I am socially anxious in this one situation, people with social anxiety disorder might be anxious in a lot of different situations, and it's really getting in the way for them. They're really bothered by it, or it's causing problems in their life. For example, they really want to have a promotion at work, but find a really hard time speaking up in meetings, because they're so worried about being judged. So they end up getting passed over for a promotion over and over again, because they're not willing to speak up in those moments.

Tori Steffen:  Right. Okay, awesome. Yeah, thank you. That's a really... Paints a good picture for how social anxiety presents itself as a disorder, and then just in common. So that's really interesting. Well, in what ways are substance abuse and social anxiety connected?

Katherine Walukevich-Dienst:  So substance use and social anxiety have kind of a complicated and puzzling relationship, and this is part of the reason why these years later I'm still interested in this topic and I feel like we still have a lot to learn. So people with higher social anxiety don't actually tend to use substances more often than people with lower or no social anxiety. And in some cases, the research has shown, particularly with alcohol, like young adults with higher social anxiety drink less. However, what we do see pretty consistently in the literature is that people with elevated levels of social anxiety experience more problems or negative outcomes related to their use, even though they're not drinking more. So some of the research that I've done on this is trying to figure out, in particular context or situations, is it how people are drinking and when that are leading to these greater problems, even though they're not necessarily drinking more or more frequently than their non socially anxious peers?

Tori Steffen:  Okay. Yeah, that definitely makes sense. How would you say that alcohol use typically influences the way that one experiences social anxiety?

Katherine Walukevich-Dienst:  For both alcohol and cannabis, it tends to boil down to expectancies. And both alcohol and cannabis can reduce anxiety. So a lot of people expect that both what we call tension reduction expectancies. "If I drink, or if I use cannabis, I'll feel more relaxed, I'll be less stressed out, and that will make it easier for me to socialize with other people." There's also kind of that social facilitation expectancies. "I can only be in this situation when other people are drinking if I'm drinking too, and that will make it easier for me to have these conversations."

The thing with expectancies is that there's no kind of magical properties of alcohol or cannabis that makes you funnier or makes it easier to talk to people. It's really, a big part, the expectancies. There's been a lot of research done on that that is really interesting. So those are the two main reasons, or the two main expectations that people have is the social facilitation and the tension reduction as well.

Tori Steffen:  Okay. Yeah, that's really interesting about the expectancies. And your article about substance abuse and social anxiety compared alcohol-only days, cannabis-only days, and then co-use days, and then how that impacted social anxiety, or coping with it. So could you explain a little bit about your findings around that for us?

Katherine Walukevich-Dienst:  Absolutely. So I was lucky to work with this really large dataset from my post doc mentor, Dr. Christine Lee, where we measured 409 young adults, we measured them multiple times a day for two weeks at a time over a period of two years. So basically, we had a lot of data on these people.

Tori Steffen:  Yeah.

Katherine Walukevich-Dienst:  And while these people weren't selected particularly for social anxiety, there were high levels of social anxiety in the sample. Particularly, a pretty large number of individuals met the cutoff, clinical cutoff for social anxiety disorder. And what we looked at it was to see, on days people use substances to cope with social anxiety are those greater risk days for experiencing negative consequences, using more, and experiencing more positive consequences as well. So a lot of the literature has looked at negative outcomes or negative consequences, but we do know that people get positive things, or there's positive outcomes from drinking or using cannabis.

So what we found is that on days that people used substances to cope with social anxiety, they drank more, they experienced more negative consequences and positive consequences as well. So regardless of whether they were actually meeting criteria for social anxiety disorder or not, based on the measure that we had. So it was a high risk day for all people, regardless of social anxiety, which was kind of an interesting finding.

We also looked at the item level, which positive and which negative consequences people were more or less likely to experience. And what we found is that on the days that people used to cope with social anxiety, they experienced more likelihood of positive consequences, like feeling like they were more sociable, and not so much the negative consequences on those days. So it may be that they're saying, "Okay, this is great. I felt more sociable, I was able to express my feelings more easily." So they drink more, or used cannabis more often. And then it's using it kind of more often for those people in particular, or the way that they're doing that, that might be causing these problems.

Tori Steffen:  Right. Okay. Yeah, that's definitely interesting for the comparison of alcohol and cannabis use. So that's good to know. When measuring substance use, does the amount of alcoholic drinks per day or hours high have a significant impact on one's experience of social anxiety?

Katherine Walukevich-Dienst:  So I think that's a really good question as well. And I think it kind of boils down to how alcohol and cannabis work in the body. So for alcohol in particular, we know a lot more about alcohol and what the dosing looks like and what the response looks like for alcohol than we do cannabis. But we often think in young adults in particular that the more you drink, the better that is. So like, "If I have 10 shots, that's better than having just five over a longer period of time." But what we actually see is that there is this kind of we call it the biphasic effect, whereas people drink more, you get to this certain point where you're feeling the really good effects, but if you keep drinking, that actually gets worse and you start to experience some of those negative effects, like stumbling over your words, feeling dizzy or feeling nauseous, not remembering things. And that people tend to, in that moment, be like, "Oh, shoot, I need to drink more to feel good again." But once you hit that point, you can't.

And although we know less about cannabis, we do know that cannabis causes anxiety and can cause anxiety, especially in high THC or acute doses, which a lot of people use high THC products. So the more you use, even though it feels like the more you use, the less anxious you'll feel, sometimes the more you use, there's that sweet spot, and then you'll feel pretty anxious afterwards.

So I think the takeaway from that is more isn't always better, particularly with anxiety, and particularly with alcohol and cannabis.

Tori Steffen:  Right. Yeah. That's so interesting how your study looked at the nuances of people's experiences and exactly breaking it down, "Here's the positive effects, and then here are the negative effects." So yeah, that's all super interesting information. Have you found that socially anxious young adults are at a higher risk for substance abuse?

Katherine Walukevich-Dienst:  Again, that question is tricky, but it can be, yes. They're more likely to experience problems related to their use. And some people have done research finding that it's actually people with moderate levels of social anxiety, not necessarily clinical. Although, clinical levels are associated with worse outcomes. It's the people in that moderate range who might be going to the social situations, that might be putting themselves at risk, that are experiencing the most consequences and are the heaviest consumers of these substances. Because in some ways, social anxiety might be protective in that they might be avoiding situations where drinking or cannabis use is happening because of their social anxiety. Or we've also looked at finding that some people tend to use alone. So social anxiety is a big risk factor for using alone or by yourself.

Tori Steffen:  Yeah. That definitely makes sense as far as maybe keeping you from wanting to socialize.

Katherine Walukevich-Dienst:  One of the things about the study that we were talking about a little bit earlier that I found interesting is that the one negative consequence that came out significant for cannabis use days was on days people used to cope with social anxiety, they were more likely to feel antisocial or want to avoid other people. So even though they were using to cope with social anxiety and these other reasons, because of their cannabis use, they reported feeling more socially anxious and more avoidant-

Tori Steffen:  Yeah.

Katherine Walukevich-Dienst:  ... which is pretty unfortunate.

Tori Steffen:  Man, yeah, that's good to know though, that it can have those kinds of effects, especially if you're wanting to use cannabis to treat social anxiety, but it can have those reverse effects.

Katherine Walukevich-Dienst:  Absolutely.

Tori Steffen:  Yeah. Well, another article notes that smoking to manage anxiety can be targeted as a false safety behavior. Can you kind of explain that for our audience?

Katherine Walukevich-Dienst:  Yeah. So a false safety behavior is basically anything that we do that helps us feel, in the moment, less anxious or safe. So for example, non substance related false safety behaviors, particularly for people with social anxiety, can be only going places when you have a person with you or that you feel comfortable with. So this might look like only going to parties if you have that one friend who you know feel comfortable going with you, or only going places if you know that you'll have your medication with you. And if you have your medication, or if you have your safety emotional support water bottle or whatever thing, that makes it okay to go.

But when it comes to substance use as a false safety behavior, this can look like only going to social situations or being in situations where you are able to consume substances either before, during, or after to help manage social anxiety. And kind of targeting a false safety behavior means to first identify it and then try to fade it out. So try to go a longer period of time without using, or start to go maybe the first 20 minutes of the party you go and you don't use, and then you decide at that point, "Do I want to use and how much?" Or decreasing the amount that you use over time. So eventually, the idea is that you're not doing it anymore, this behavior anymore, to manage anxiety. So you may still use cannabis, you may still drink, but the goal is not to do so to manage anxiety.

Same with a safety behavior, like going somewhere with a friend. Right? Of course, you want to spend time with your friends, but if it's only to help you manage your anxiety, or in part to help you manage your anxiety, we want to reduce that part, so you're spending time with your friends because you want to and not to help you feel less anxious.

Tori Steffen:  Right. Okay, awesome. Yeah, that definitely breaks it down really well. Thank you. Well, other than engaging in substance abuse, how can young adults cope with negative symptoms related to their social anxiety?

Katherine Walukevich-Dienst:  So part of what alcohol and cannabis make tricky when it comes to social anxiety is that they do a really good job of making people feel less anxious in the moment, and pretty immediately too. But by... I keep using this example of being in a party setting, but by going into a party setting only while intoxicated, you're never really learning and your brain is never really learning like, "Oh, I'm actually okay here." Or, "Yeah, I said that something that was really embarrassing, or I couldn't figure out what to say, and that was okay." And that it's really not learning that these situations, while uncomfortable, you can survive them and you will be okay. And that the more that you do them, the more comfortable you feel. We call that habituation. So what substances do is they act as a way for us to avoid confronting that cycle and tolerating that discomfort that comes initially when you're in a new situation, or when you're in a social situation that makes you feel particularly anxious.

So with treatment, in part, what we argue for is, “Just do it,” which sounds really easy, but is really hard in practice. And instead of using substances to avoid, try to approach some of the things, little by little, that you feel produce anxiety or make you feel socially anxious. Start with something on your list that feels a little bit easier, and then maybe work your way up to some harder situations. But see what it's like to be in a situation without substances and try that a couple of times, get some more data on what that looks like, because for people who tend to do this, they haven't been in those situations very often without substances.

Tori Steffen:  Right. Yeah. It sounds almost like ERP a little bit.

Katherine Walukevich-Dienst:  Yeah.

Tori Steffen:  Are there any specific types of therapy like that that can be beneficial for treating social anxiety and substance use?

Katherine Walukevich-Dienst:  The good news is there is. So once you identify these things, one of the treatments is cognitive behavioral therapy for social anxiety, which includes exposure. So exposure is like what you're talking about with ERP. So coming up with a hierarchy of situations, that behavior piece is coming up with a hierarchy of situations that make you feel anxious, and working with a therapist to gain both cognitive skills and behavioral skills to experience and expose yourself to that anxiety.

So for example, if somebody says that they feel socially anxious about giving a presentation and the only way that they feel less anxious is by using cannabis before, the first exposure might be giving a presentation to your therapist, and the second without cannabis, and saying, "What's the worst thing that could happen here?" I'm telling myself I'm going to sound like an idiot, or I'm going to sound like I don't know what I'm talking about. What would be the worst thing about that? And coming up with a response like, "Even if these things happen, it will be okay," or, "I'll probably be embarrassed for a bit, but I'll get over it." Even having that more balanced way of thinking can be helpful. And it's not going into the situation saying, "I'm going to do amazing, and nothing's going to go wrong," because that's not necessarily helpful either if something does go wrong. It's finding a balance perspective, and then putting yourself in that situation.

So then what the therapist might assign for homework, an exposure homework, is then to do that in real life. So to set up a presentation, do it in real life without using substances. And if this sounds scary, it's because it is. And part of this is that you might feel really, really anxious at first. But I've done a lot of treatment with people with social anxiety and substance use, and it's pretty amazing how confidence grows in these different situations, and not necessarily their confidence in performing well in these situations, but their confidence in their ability to tolerate the anxiety and discomfort that might come from these things.

Tori Steffen:  Right. Yeah, that's amazing. That sounds so important to know the difference between that and treatment, so very cool. Well, do you have any final words of advice or anything else that you'd like to share with the listeners today?

Katherine Walukevich-Dienst:  I think final word of advice would be, if this is something that you're concerned about for yourself, start just paying attention to it and gathering some data, paying attention to, "What do I expect from using cannabis and alcohol in social situations? And am I actually obtaining those rewards?" So if I expect that using cannabis will make me funnier, or more enjoyable to be around in a social situation, does that actually happen? And does that happen every time, or just some of the time? And I think starting to gather that data can be really helpful in making different decisions potentially about using in those types of situations, or your need to.

Tori Steffen:  Yeah. Awesome. Well, thanks so much for sharing that advice, and thanks so much for sharing your knowledge with us today, Dr. Walukevich-Dienst. It was really great to talk with you.

Katherine Walukevich-Dienst:  All right. Thanks so much, Tori.

Tori Steffen:  Thank you. And thanks, everybody, for tuning in.

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


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

Psychologist Andres De Los Reyes on Adolescent Social Anxiety & ADHD

An Interview with Psychologist Andres De Los Reyes

Andres De Los Reyes, Ph.D. is a Professor of Psychology at the University of Maryland. He's an expert in the field of adolescent psychology, social anxiety and ADHD.

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

I liked to welcome with us today, Psychologist Andres De Los Reyes. Dr. De Los Reyes is a professor of psychology at the University of Maryland in College Park, as well as the Director of the Comprehensive Assessment and Intervention Program. Dr. De Los Reyes is an expert in the field of clinical psychology. He's published over 100 articles, including “When Adolescents Experience Co-occurring Social Anxiety and ADHD Symptoms,” “Links with Social Skills when Interacting with Unfamiliar Peer Confederates,” and “Multi Informant Reports of Depressive Symptoms and Suicidal Ideation Among Adolescent Inpatients.”

Before we get started today, Dr. De Los Reyes, could you please let us know a little bit more about yourself and what made you interested in studying social anxiety, ADHD, and other mental health issues among adolescents?

Andres De Los Reyes:  As you mentioned, I've been at the University of Maryland for some time now, about 15 years. In that work, I spent a lot of time thinking about the most accurate ways of assessing various kinds of mental health concerns with a particular emphasis on those concerns, where when we try to get a sense of symptoms and associated impairments... Obviously, because we're often assessing children and adolescents, we're seeking input from not only the clients themselves but also significant others in their lives, like parents and teachers and sometimes peers. We focus our attention a great deal on those domains, where when we ask these questions, we oftentimes get very different responses depending on who we ask. That's a common byproduct of assessments of social anxiety, of ADHD.

The work our group has conducted, and the work of many other labs all over the world, really have led us to believe that although there may be some circumstances where these assessments are telling us different things because perhaps one or more of the informants aren't nearly as useful reporters as they might be, under the grand majority of circumstances, when we administer assessments to understand things like ADHD and social anxiety, we're often using well-established instruments, and we're also often asking people, informants, who mental health professionals have relied on for decades to assess behaviors. So under a variety of circumstances, there may very well be reason to believe that rather than these differences in results reflecting something artifactual about the measures we administer and the scores we obtain from these informants, it might be actually something really important. In particular, the specific contexts where adolescents, children might be experiencing concerns like social anxiety and ADHD.

It turns out that in both of these circumstances, in both of these domains, social anxiety and ADHD, the symptoms and associated impairments can move around considerably across various social environments that impact the lives of those we assess, the peers with whom they interact, the teachers who are serving as instructors in their classes, the parents who look after them and in fact are often initiating their services. So, I tend to choose domains like ADHD, like social anxiety because I think not only are they places where these discrepancies and results happen often, but if we learn more about these discrepant results, then we also learn more about the actual domains themselves.

Tori Steffen:  Right. Wow. That's really profound. I can definitely agree with you there how it's important to understand the differences, especially when assessing for the two of those domains. So, thank you for explaining that for us.

Well, getting down into basics about our topic, what age range describes an adolescent?

Andres De Los Reyes:  A very wide one. Even just a definition of what counts as an adolescent is a topic of considerable debate among mental health professionals, among developmental scientists. Adolescence can begin within some definitions as early as 12 or 11, and can stretch out as far as, within some definitions, the early adulthood years. There may be various factors that one might consider when thinking about where adolescence as a developmental period begins and ends.

But germane to the work that we do, we tend to focus on what some scholars might consider the mid- to late-adolescence period, so that period between the ages of about 14, 15, 16, 17, where developmental research and theory would posit that the people we're trying to assess are undergoing significant amount of changes in their biology, in their social environments. They see a lot of new environments, novel environments they oftentimes are not necessarily accustomed to encountering earlier on in development, like the development of romantic attachments, the development of time spent outside the home, outside of the immediate observation of caregivers who, as I mentioned previously, are often initiating care.

So we think of, like I mentioned before, social anxiety and ADHD as a great place where the assessment issues we care about happen. On top of that, the developmental peer that we focus these assessments on will oftentimes create additional complexities that require further elaboration and interpretation. That's where a lot of our work essentially seeps from, is trying to figure out within the traditional approaches we use to measure domains like social anxiety and ADHD, what additional things must we think about and be developmentally sensitive to when we're trying to apply our traditional assessment tools to assessing these specific domains in this particularly complex period of development?

Tori Steffen:  Right. Yeah. Definitely a lot to consider when defining an adolescent. So, that all is very important. Could you explain for our audience what social anxiety is?

Andres De Los Reyes:  The typical definitions of social anxiety revolve around several different kinds of core features of the condition. One of the big core features is an intense fear or apprehension. Under some circumstances, when the fears are really high in avoidance of social situations of various kinds, interacting one-on-one with somebody, even just going up to somebody and asking them for information or directions, like if you're going somewhere you don't really know where to go, giving presentations in a structured setting like a classroom or an adulthood in a workplace... But one of the common, core denominators that cut across all those situations is that among individuals who experience social anxiety, there tends to be a particular fear, apprehension, avoidance, of unfamiliar scenarios, scenarios that appear novel that haven't been encountered all that frequently, and where people might not have a lot of practice in navigating those situations effectively.

That's one of the big things that we think about when it comes to assessing and understanding social anxiety within adolescence, because like I mentioned before, you have these situations, these scenarios that as you enter the adolescence period you don't have a lot of practice in. One of the big ones that we focus on is in those scenarios where adolescents feel like it's one of their tasks to engage with people they don't know very well, particularly their own age, and try to develop bonds of some kind: friendships, romantic attachments, and then in both those places that unfamiliarity is something new to them, especially when you consider the fact that a lot of these unfamiliar interactions with people your own age are happening where your caregiver, somebody older than you isn't looking over your shoulder to see how things are going. You're doing a lot of this by yourself.

Tori Steffen:  Mm-hmm. Right. Okay. That definitely makes sense, that a lot of uncertainty and fear might be present.

Could you explain for us how adolescents typically experience social anxiety, and would you say that there's any big differences in symptoms among adolescents compared to adults with social anxiety?

Andres De Los Reyes:  This is something we've struggled with a great deal, and it bears some relation or implication to how we diagnose the condition among adolescents, children, and adults. I can focus specifically on the sort of diagnostic considerations you have within one of our predominant systems, the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition.

In the current edition, there's a distinction between the kind of social anxiety that manifests consistently across situations across contexts. So, for many clients there's this sense that the symptoms and their impairments: fears, the avoidance, the apprehensions, are there when you are ordering food at a restaurant and interacting with coworkers and trying to meet new people. You see it everywhere. That can be contracted with at least one other form of social anxiety that we tend to see in clients, and that is those scenarios, those instances in which clients appear to be experiencing symptoms and impairments that manifest in a specific kind of context.

In the Diagnostic and Statistical Manual of Mental Disorders, the DM, that context is typically characterized as a performance-based context, some kind of place where there's a lot of structure and you have a sense of what it's like to give a presentation in front of a group, you know what the rules of engagement are: You have to make eye contact; you have to enunciate; you have to be able to answer questions effectively. What we've been learning in our work is that although adolescents can experience that kind of context specificity that has a look and feel of what you see in adults, we also see at least one other kind of specific form of impairment and where symptoms arise. And that's when adolescents are engaging in the social scenario where the rules of engagement are kind of stripped away. There's no manual to figure out how to navigate parties effectively. There's no how-to guide on the right thing to say when you sit down next to someone on the first day of school. You probably think that you should be friendly, maybe say hi, but what else do you do after that?

So, that lack of structure in our work leads us to believe that although adolescents can experience those kinds of patterns that we tend to see in adults, the symptoms and impairments can manifest in lots of places or in one specific place, we have reason to believe that maybe it's worth considering the notion that because of the novelty inherent in the social experiences that adolescents often have, that even just being placed in a situation where you don't know the rules of engagement can produce the same kinds of symptoms and impairments that we see in that context-specific subcategory that you said that we already have in our diagnostic manuals.

Tori Steffen:  Right. Okay. That's good information to know, the importance of novelty, especially for adolescents. So, that's really interesting.

How are the issues of social anxiety and ADHD and adolescence connected? If the two issues, let's say, that they're co-occurring in an adolescent, does that have more of a negative impact?

Andres De Los Reyes:  In our work, we tend to see that it does. It's a phenomenon that fascinates us. The reason why is because there are a lot of different kinds of features of all of our disorders, all of our diagnostic categories. They all have their own lists of symptoms. What they also have are what we call associated features, or there could even be risk factors depending on whether or not their presence brings about the condition. But many times, when we're thinking about treatment, we're thinking about those aspects of functioning that might not be symptoms, but they could be implicated in how conditions are maintained. It's kind of like whatever started the engine, an associated feature might might keep it going.

One of those features that cuts across many conditions, but in particular social anxiety and ADHD, is a concept or domain that we call social skills: those behaviors, those elements of how you engage in social situations and make a difference in whether or not you're able to make friends and influence people, and not only make friends, but also maintain those friendships over time. We know that in both ADHD and in social anxiety, one of the key areas of impairment is in friendships, in how many friendships you've initiated or developed, and the maintenance of those relationships over time.

The key distinction that many of us encounter when it comes to social anxiety and ADHD is that although there's those associated features of social skills and friendships in both of the conditions, there's reason to believe that those features might arise in these conditions for very different reasons. So, for adolescents who experience social anxiety, they might experience social skills issues in part because of the avoidance. They experience apprehension, fears about engaging situations. They might not engage in situations where they could get opportunities to make friends nearly as much as other kids who don't experience social anxiety. The consequence of that might be kind of the same thing as you missing out on going to the gym for a few months, a muscle here or there atrophies, and then you get back to the gym and you say to yourself, "I can't lift nearly as much as I used to."

That avoidance might have the effect of perhaps overall reducing fears, so if you don't enter into a situation that you find stressful, you're going to experience less stress maybe, but at the cost of not being able to have opportunities to do positive things that might actually even help the anxiety down the line. So, that avoidance makes a big deal when it comes to social skills and associated impairments in developing and maintaining friendships.

With ADHD, there's reason to believe that within that condition, the social skills issues associated impairments of friendships have less to do with avoidance and perhaps a bit more to do with the fact that among many children and adolescents who experience ADHD, the hyperactivity they might experience might be seen by peers as aversive and perhaps make it less likely that they might want to engage with them in the future.

Now, if it's the case that someone's experiencing both social anxiety and ADHD, are perhaps experiencing social skills issues and associated impairments with building and maintaining friendships for different reasons, and those two different reasons are encapsulated in the same individual, so not just the avoidance, but on occasion, the hyperactivity kicks in; you create some kind of aversive interaction with somebody, maybe they don't want to associate with you as a friend. That might be one of the reasons why we're seeing what we're seeing, at least in our own data, that when adolescents experience heightened levels of both of these conditions at the same time, they tend to be experiencing more of these social skills issues in direct observations of how they interact with same-age adolescents.

That's the neat feature of the work that we do. We collect the symptom data the old-fashioned way by asking a bunch of people about what's going on with the adolescent or how they are thinking, feeling, and behaving, and whether or not those symptoms tell us that somebody's elevated in social anxiety and ADHD. But we're looking at those combinations in relation to how the adolescent actually behaves in our laboratory when we create scenarios that have the look and feel of everyday social interactions between themselves and somebody that we lead them to believe is a same-age peer.

Tori Steffen:  Okay. Yeah. That definitely makes sense. It sounds like really interesting work that you guys are doing to figure that out.

Well, one of your articles mentions that the presence of social anxiety and ADHD can have a negative impact on adolescent social skills. I know that you kind of explained how they might show up symptom-wise. Could you explain for us the impact on social skills in an adolescent?

Andres De Los Reyes:  Going back to this notion that adolescents experience social anxiety might have fewer opportunities to engage socially with people, typically their own age or other people. If they avoid those scenarios, then by construction, they're going to get less practice building the kinds of competencies that we know are instrumental in being able to have healthy relationships with other people. When's it appropriate to make eye contact? When is it appropriate to avert your eye contact? When is it appropriate to initiate a conversation? Is it okay to say hello to somebody when you're having a very deep conversation with somebody else? When is it appropriate to end the conversation and maybe go somewhere else, interact with somebody else? All these kinds of skills, we develop them whether we know it or not, oftentimes through trial and error. Most of us don't read a guide about how to be socially skilled before we go to a party. That's just not what we typically do.

Over time, we figure out what's worked and hasn't, and in that respect, among many of us who can be considered as socially skilled, those kinds of skills are kind of like a really good app on your phone. They fit into the background after they all make sense. So oftentimes, in our interventions for both social anxiety and ADHD, although the approaches we might take to improving social skills might differ, the outcomes have the similar kind of look and feel. We're trying to build up your competencies to be able to make friends and influence people, but the routes you might get there might be quite different.

Tori Steffen:  Okay. Yeah. That definitely makes sense, how it could have an impact there.

Have any significant differences been found in your lab work for prevalence of social anxiety and/or ADHD among girls versus boys?

Andres De Los Reyes:  We don't tend to see too many big differences in our work as a function of gender, but it is just one sample. One thing I can say is that some of the gender and the gender-related issues and how we diagnose these two conditions, depending on the condition, reflect either variations in rates as a function of gender or in features. So as an example, when you assess ADHD in the general population, so outside of a clinic, you tend to see a bit higher rate, 2-to-1 in children, maybe 1.5-to-1 in adults in the direction of males tend to be diagnosed more often than females. But in ADHD, you also tend to see that females are more likely than males to experience symptoms that have more to do with inattention, so difficulty in maintaining attention relative to males. Again, big average differences that we tend to see in research.

In social anxiety, historically what we've tended to see is a gender difference that might manifest in the general population, but once you get into the clinical circumstance, it doesn't tend to be much of a difference, much of a gender difference at all. But what you do see is a kind of variation in the other diagnosis, somebody might meet criteria with as a function of gender. Among females who are diagnosed with social anxiety, they tend to experience a greater number of depressive, bipolar, and anxiety sort diagnoses, whereas males who are diagnosed with social anxiety tend to experience diagnosable conditions that are more externalizing sort of in nature, so oppositional-defiant disorder, conflict disorder, alcohol dependence and abuse or dependence and abuse of illicit drugs.

That latter group, people have been interested in that group for a long time, that combination of social anxiety and substance use disorders. One of the hypotheses people have is what they call a self-medicating hypothesis, this notion that perhaps one of the reasons why people might use substances in the context of something like social anxiety is as a coping mechanism, like a means to reduce your arousal or apprehension to then enter situations and manage them more effectively.

Tori Steffen:  Okay. Yeah. That's definitely interesting to know, and sounds like maybe there's a few gender differences, but overall as far as diagnoses go, not super significant in the differences.

Well, another area of your study classified participants in groups of low social anxiety or ADHD and then high social anxiety. What might the main differences in the severity of symptoms be between the two groups?

Andres De Los Reyes:  The interesting thing about the groups that we observed in our own data is that the group that could be characterized as high social anxiety symptoms, high ADHD symptoms, differed from that other group that could be characterized as low social anxiety, high ADHD, and specifically in those social anxiety symptoms. But where they didn't differ much at all is in the level of ADHD symptoms.

The same is true for that other group that was high social anxiety, high ADHD, and high social anxiety, low ADHD. That group as well might have differed on the level of ADHD symptoms, but not in the level or severity of social anxiety symptoms, which made us pretty excited in that one of the problems or one of the limitations you have to overcome when you do this kind of work is sort of ask yourself, when I think about grouping individuals this way, is the group that's showing concerns on two different domains simply just a more severe form of clinical presentation, or are they just a more severe client when it comes to the symptoms? Is that all I'm looking at that? That it's a 10 to 5 difference on one versus the other? If so, what's the point?

But what made us really excited was that, at least from a symptom severity standpoint, we didn't see differences in those groups that are elevated on one versus another versus elevated on both. What it looked like to us was that these groups are different from each other, from something other than raw symptom count. There's something else going on here, and it might have implications for understanding the phenomenology of the actual clinical presentation.

Tori Steffen:  Wow. Yeah. That's a great finding to come by. Yeah. Thanks for explaining that for us. That's definitely an interesting finding.

Well, actually another finding in your study linked social anxiety in ADHD through impairments or behaviors in adolescents. Can you explain that finding for us a bit?

Andres De Los Reyes:  Yeah. We thought it was important to do. In a lot of our studies, we make an observation, we might find it interesting, but we want to scrutinize it a little bit more and probe it. One of the things we wanted to probe with regards to the findings of this particular study was this notion that maybe the social skills issues that we're seeing, the differences among these groups, are isolated to just this kind of interaction. Do we have any data that sort of speaks to the possibility that these differences might have implications for impairment issues we might see outside of the peer context?

It turns out that we had a survey, the work and social adjustment scale for youth, that provides us with a broad sort of index of psychosocial impairments germane to mental health functioning or at least behaviors that might be indicative of mental health concerns. We were able to essentially replicate the finding we observed with the behavioral data, that when you look at overall indices of psychosocial impairments, that same group, that high ADHD, a high social anxiety group, tends experience overall more psychosocial impairments than the other groups in our sample.

Tori Steffen:  Okay. Definitely good to know as far as what to expect in the experience.

Well, clinically speaking, what psychotherapeutic treatment methods might work best for an adolescent with, let's say, co-occurring social anxiety and ADHD?

Andres De Los Reyes:  The good news with regards to both social anxiety and ADHD is that there are well-established interventions for addressing social skills issues in both of these for these conditions. So, social effectiveness therapy, a form of social anxiety behavioral treatment developed by Deborah Beidell and Sam Turner and colleagues, seeks to focus on improving social competence within children and adolescents experiencing social anxiety and for that matter, adults as well. There's a version of social effectiveness therapy that is developmentally modified or tailored for adults experiencing social skills concerns stemming from social anxiety.

There's a variant of that kind of intervention that's broadly thought of or referred to as social skills training that has been tested for many years among children and adolescents experiencing ADHD. My sense, and this is not something that that's been tested formally in a controlled trial or treatment study, is that addressing these co-occurring issues might involve trying to first assess the associated impairments within a client experiencing both of these concerns at once, prioritizing figuring out which one might be more impairing, and then on the basis of understanding where the priorities lie, which of these might be getting in the way of building social skills competencies in most, starting with one of these two intervention protocols, and then moving on to the next protocol if it looks like further addressing these needs is warranted.

The interesting thing, and this is another thing that hasn't been tested yet, what we tend to see in the treatment literature goes like this: If you try to address anxiety or you try to address ADHD and you're successful in doing it, you'll see reductions in the thing you're targeting, reductions in anxiety, reductions in ADHD, but you'll also tend to see reductions in mental health conditions that are related but conceptualized as distinct from those conditions. So, we tend to see that if we see a reduction in anxiety and we targeted anxiety, we also tend to see a reduction in depression; try to address ADHD and successful reducing ADHD, you're also likely to see reductions in oppositional-defiant disorder or conduct problems or what have you.

The interesting thing here that I don't think has been tested is this idea of if you treat social skills in one of these domains, both lying, by the way, in very different spectra ADHD being a more externalizing-related condition versus than a more internalizing condition like anxiety, might in those circumstances, you see the rare occurrence of seeing a reduction in social anxiety and a concomitant reduction in ADHD, specifically because the core feature that cuts across both of them is social skills.

Well, might this be one of those rare circumstances where you would see a reduction in two distinctly conceptualized diagnostic conditions? That's a question that I'd be intrigued to see somebody probe, and maybe they have the data to probe it in one a large-scale data set of sorts. But suffice to say, that the good news is there are these two classes of interventions available to address both of these conditions, and what might be required in a clinical scenario is figuring out which one to target first and then monitor symptom response to intervention across sessions and then figure out at what point might it make sense to transition over to addressing social skills in their domain versus continuing on with that same one.

Tori Steffen:  Right. Okay. Yeah. That's really good to know, good information, especially to know that treating one issue might actually help the symptoms of another, which is really good information for a researcher.

Well, while all these treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things that adolescents can do on their own to potentially reduce or lessen some of those symptoms of social anxiety or ADHD?

Andres De Los Reyes:  It's important when you're experiencing these kinds of issues to become a good detective of how you're thinking, feeling, behaving. If you start noticing that it's kind of hard to build the kinds of relationships that you really want to have because it is true, and this is the interesting thing about social anxiety and ADHD for that matter, is that when you avoid these situations or you have difficulty maintaining friends, that doesn't mean that you don't want to be in those situations; you don't want to make friends. Quite the contrary. I mean, the research on social anxiety suggests that avoidance doesn't equal, "I don't care." There's that weird push and pull where you don't want to go into that situation, but you actually do really want to have friends. You actually do really want to maintain a healthy relationship, which is a universal feature. It's the rare person that doesn't want to build these kinds of relationships, because they're healthy and they feel good, and being able to have fun conversations and lean on people when times get tough, those are all things that the majority of us value.

So, if I was experiencing these kinds of concerns, I would sort of start asking myself, “What might be getting in the way? What are the things that I notice about myself when I know I want to go meet that person? I know I want to go. I know I really would love to be friends with that person, but I just can't get there.” What seems to happen before I get there? That isn't to say that you need to become your own therapist, far from it. But I think the interesting thing is to think about what information can I start gathering about myself, that once I get there, once I think I have the information I need, I can reach out to somebody who can help me: my parents, a counselor at school, someone who can guide you towards the people who have the experience, the expertise to help you make a meaningful change in your life.

Tori Steffen:  Right. Awesome. Yeah. That's really good advice. So, thank you so much for sharing that.

Do you have any final words of advice for us or maybe anything else that you'd like to share with the listeners today?

Andres De Los Reyes:  Do you have any questions about our work or are interested in learning more? I can be reached on Twitter with the handle @JCCAP_Editor, and feel free to reach out to me at my email address adlr@umd.edu. Thanks so much for finding this work interesting enough to listen all the way to the end.

Tori Steffen:  Perfect. Yeah. Thank you so much for sharing your knowledge. Definitely a lot of good advice and just good things to know about social anxiety and ADHD in adolescents, so we really appreciate you taking the time to enlighten us.

Andres De Los Reyes:  Happy to do it. It was a lot of fun.

Tori Steffen:  Yes, definitely. Well, thank you so much again, and thanks everybody for tuning in, and we will see you guys next time.

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.


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

Psychologist Kevin Chapman on Panic & Social Anxiety

An Interview with Psychologist Kevin Chapman

Dr. Kevin Chapman is the Founder and Director of the Kentucky Center for Anxiety and Related Disorders (KY-CARDS), and specializes in the treatment of anxiety, panic disorder and social phobia using CBT.

Jennifer Ghahari: Hey, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I'd like to welcome with us licensed clinical psychologist Kevin Chapman, who is certified by the Academy of Cognitive and Behavioral Therapies. Dr. Chapman is the founder and director of the Kentucky Center for Anxiety and Related Disorders, KY-CARDS. He specializes in treating anxiety, panic disorder, and social phobia, and has written a multitude of books, book chapters, and peer reviewed journal articles, including “Minority Inclusion in Randomized Clinic Trials with Panic Disorder” and “Clinical Behavioral Treatment of Social Anxiety among Ethnic Minority Patients.” Before we get started, can you please let our listeners know a little bit more about yourself and what made you interested in cognitive behavioral therapy?

Kevin Chapman: Thank you. I appreciate that. Well again, I’m Kevin Chapman, licensed psychologist. I'm originally from Louisville, Kentucky, and again, run the Kentucky Center for Anxiety and Related Disorders. And I've always been fascinated, honestly, with anxiety-related disorders and CBT in particular, because I was also a college athlete, and when I took my first psychology course, it kind of spilled into the abnormal psychology. And once I took that, I learned something in the literature that was pretty perplexing to me; it was “Wait a minute, more people have anxiety than anything else.” It's widespread, yet it's treatable.

So immediately I was like, “Oh, sign me up!” That's something that's not only challenging, but something where we can plug some holes. So as I matriculated throughout that process, I learned about the different modalities and types of therapy, and cognitive behavioral therapy not only was rational and logical, it just made a great deal of sense. And I think that the practical application of CBT that we know today is really attractive to me because it gives you the ability to not only be flexible, but also creative. So it was just a really fun approach, but also something where you actually saw what I call the “before- and after-shot” when you're working with clients who struggle with anxiety. So it just made a lot of sense.

Jennifer Ghahari: Great. We've had several clients reach out to us for help specifically for panic attacks. And can you explain what a panic attack actually is and what someone with this disorder might experience when they're having one?

Kevin Chapman:  Yeah, sure. So I mean, I guess we define panic as a discrete experience, like a concrete experience of the fear response, essentially, where you have intense fear and discomfort. Ultimately what we've learned about panic over the years is that panic is what we call a false alarm. It's essentially a fear response out of context. And I think for many people, when they realize that a panic attack and fear are actually the exact same process, it's just that I'm having the fear response out of context, that in and of itself can be really helpful in helping a lot of clients manage.

So in many ways, when we see the experience of panic, it's very discrete. So ultimately, we have the fight or flight response, right? Our body's flooded with adrenaline and noradrenaline. And ultimately, it's preparing us for perceived danger. So we have heart palpitations, shortness of breath, lightheadedness, smothering sensations, sweating, tingling sensations in our body, and essentially it's fight or flight. And the good thing, as you know, is that if I'm in actual danger, that's super adaptive and helpful. It's that when people have those recurrent panic attacks when there is no threat, that's a problem.

I always tell people that it's like saying, “I'm pulling a fire alarm in a movie theater when there's no fire.” And ultimately, that's very scary for people who experience it. And then they start pairing that with situations. And all of a sudden we develop agoraphobia, so I start fearing places and situations in which those panic attacks occur. And now I have two problems. I have that panic cycle, but then I have situations in which the cycle occurs, and therefore I'm really distressed when I go out and about.

Jennifer Ghahari: Wow. And what will be the best and most effective treatment for something like that?

Kevin Chapman: Yeah, that's a great question. And we often talk about the most effective treatments in that regard, and the first line treatment, of course, is medication, and medication certainly seems very helpful in that regard. And it certainly helps a client dampen some of the depression symptoms that come about, also the anxiety that's associated with it. So it decreases that negative affect, if you will.

But the gold standard treatment is cognitive behavioral therapy. And that's something that I certainly implement with my clients. So CBT, and of course CBT is the gold standard where we're teaching clients to not only recognize that, psycho-educate them about what's the difference between anxiety and fear and panic, but also teaching them the importance of the role that their cognitions or thoughts about having panic attacks and the sensations themselves, and in some people, the situations in which they occur, teaching them that their thoughts influence the physiological arousal, the feelings in their body, and that leads to subsequent action, which in many cases, of course, is avoidance of things that trigger panic. So teaching them how to engage in cognitive restructuring and engage in exposure-based therapy is really the best way to treat panic.

Jennifer Ghahari: And anxiety, particularly social anxiety, is another disorder that clients often reach out to us about. What is social anxiety, and can you describe what someone feels when they're experiencing that?

Kevin Chapman: Yeah, doc, I think that when we think about social anxiety, I think that the seductive part about social anxiety is that social anxiety is a normal part of life, right? And when we talk to clients about social anxiety, we normalize it, because it's saying, when we think about being in a situation that's unfamiliar to us or that's uncomfortable, that involves people, certainly anxiety to a degree is super helpful. So on the one hand, we all experience anxiety, but social anxiety when it becomes a disorder, is essentially me having this persistent fear, not just occasional, but a persistent fear of social or performance situations where negative evaluation may occur.

You'll appreciate this, but I'll often tell the clients, so think about that. Any social situation you find yourself in, like for example, Chick-fil-A, the nicest people on earth, you technically could be made fun of in the drive-through. Now granted, that's unlikely, but ultimately, any situation that involves a person has the potential of negative evaluation. So therefore, I have this persistent fear of making a fool of myself, being negatively evaluated, humiliating myself.

And that tends to include things like initiating or maintaining conversations, group discussions, the number one fear in the United States: public speaking, meeting new people, speaking to a figure of authority. And that creates significant distress, I'm bothered by it, and also impairment in my day-to-day functioning. So that's what we talk about when we say the disorder or the diagnosis of social anxiety.

Jennifer Ghahari: Wow. You had an article on the KY-CARDS site, on your site, which discusses how wearing a face mask ironically may impact someone's social anxiety. And can you explain the correlation that some people are experiencing with that?

Kevin Chapman: Yeah. You know, it's interesting, because if we had our druthers as fellow scientists, of course, we would want to study that and see how that comes out empirically. But anecdotally what we find, I think, that one of two things can happen because of the pandemic with the COVID, of course, pandemic. And I think that what we find is number one, for people who have social anxiety, I've found quite a few clients, when they wear a mask, it's somewhat of a buffer to their social anxiety. In other words, they feel less anxious, because you can't really see my facial expressions, and therefore I have an illusion of control. So on the one hand, you can see it as a good protector.

However, from a cognitive-behavioral standpoint, we could call that a safety signal, too. And that could be problematic, because once you're able to resume normal, as we know normal life at this point, and interact with people socially, that kind of essentially prevents you from navigating those situations the way that we would want you to in treatment. In other words, that buffer is temporary. Just like having a bottle of Xanax in my pocket or having some essential oils or my safe person, or whatever it might be to make me feel better temporarily. So on the one hand, it can be a buffer. On the other hand, it can backfire and perpetuate vicious cycles of social anxiety, because after all, we communicate often non-verbally with our facial expressions, and that's what many people are very sensitive to, is “how I appear to other people.”

Jennifer Ghahari: Wow. Okay. It's a lot going on. Yeah, it's interesting that it's almost like a Band-Aid, but like you said, once that Band-Aid gets removed, the wound is essentially still there. Wow.

Speaking of COVID, the pandemic has led to an increase in anxiety for so many reasons, like health, financial, isolation, fear of the unknown, et cetera, et cetera. And you've come up with an acronym on your website to help people find ease during the crisis. Can you explain to our listeners what that is?

Kevin Chapman: Yeah. And I think, you know, doc, that I love CBT. So any time I do any sort of media, my whole purpose behind that is to disseminate the science and psychology to help people on a day-to-day basis. That's why I like media platforms. It's for dissemination. So with that being said, the acronym that I came up with is steeped in CBT, and people have really resonated with it, because it's very practical and easy to understand, and we call it FIGHT. And in this case, we talk about “Fight COVID.”

So FIGHT is an acronym. The F is focus on what I can control. So ultimately, I can't control what will happen in three hours or what happened two hours ago. But what I can control is what's happening in this present moment. So kind of borrowing from mindfulness-based literature, I can focus on this moment in time. I can regulate my emotions. I can regulate my breathing. I can see how this couch feels on my body, things like that. And focusing on what I can actually accomplish in the moment is critical to regulating emotions as it relates to things like COVID and such.

The I is identify negative thoughts, and identifying of thoughts ultimately is super important for regulation because thoughts, particularly catastrophic thoughts or negative prediction type thoughts, tend to fuel the fire, of course, to strong symptoms of anxiety. And that's something that when we identify the thoughts that are leading to the emotional experience itself, that gives us a knowledge base to be able to alter that to some degree.

G is my favorite, it really is. And that's generating alternative thoughts. That's the heart and soul of cognitive therapy, is coming up with not necessarily positive thoughts, because there's a lot of things happening right now in our society that's just simply not good. However, we can be flexible in how we think about situations. And that's what's key to emotional regulation, is that if I'm flexible in how I think about things, coming up with different alternatives, that can lead to different emotional experiences, which is so important.

Which leads to the H, which is highlighting adaptive behaviors. What can I do behaviorally to alter my emotional experience? What can I do to help my neighbor? What can I do that's something that's an action step that will alter my entire emotional experience? You know, as well as I do, like with depression, if I can engage in behavioral activation, just walk down the road, that in essence creates endorphins. And then even if I didn't feel like doing it, it makes many people feel better. So engaging in adaptive behaviors.

And then finally it's something that we really nerd-out about, and that's T, and that's teaching somebody else the same principle. So CBT is not a selfish treatment modality. It's something where it's like, if I learn how to do it, then I'm becoming my own therapist, and therefore, I can teach somebody else the same exact thing. So that's the FIGHT acronym, and it seems to be pretty practical.

Jennifer Ghahari: Awesome. Thank you. And so as a psychologist and a therapist specializing in CBT, do you have any other advice or recommendations for our listeners if they're suffering from panic attacks and/or social anxiety?

Kevin Chapman: Yeah. Well, number one, I would say for sure, “You're not alone.” And I think in many ways, many people we encounter who experience anxiety and related symptoms, because it feels so bad and they have such low distress tolerance, I think that they often feel isolated and like nobody can ever understand how I feel. And I just want to say to listeners that, number one, it's normal to experience anxiety. Many people who don't have disorders experience panic attacks. The bottom line are these are all things that we experience on a semi-regular basis, especially social anxiety. So number one, normalizing your experience.

Number two, you can be helped. And I think that is so encouraging, because CBT is the gold standard for a reason. If you're motivated, there are people, capable therapists out there, who have the expertise to be able to help you navigate these situations. And I love this. This is one of my quotes. I call it the emotional law of gravity. Always remember that what goes up must come down, and that's true for emotions, too. So in many ways, when we think about experiencing distress, know that though it's uncomfortable, it's not threatening, and this too shall pass.

Jennifer Ghahari: That's wonderful. Thank you so much. I really appreciate it. And thank you for being part of this installment of The Seattle Psychiatrist. Again, a lot of our clients reach out for help on these topics, so we appreciate your expertise in helping out.

Kevin Chapman: Well, thank you. It's a pleasure. Thank you.

Jennifer Ghahari: Thank you.

For more information, click here to access our article in “The Seattle Psychiatrist” Magazine: The Impact of Nervous System Attunement on Social Anxiety.

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.


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