An Interview with Psychologist David Rosmarin
David Rosmarin, Ph.D., ABPP is the founder of the Center for Anxiety (New York & Boston) a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin specializes in the relevance of spirituality in one’s mental health.
Tori Steffen: Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Tori Steffen, a research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.
I'd like to welcome with us today psychologist, David Rosmarin. Dr. Rosmarin is the founder of Center for Anxiety, which has offices in both New York and Boston. He's also a psychologist at McLean Hospital and an associate professor in the Department of Psychiatry at Harvard Medical School. Dr. Rosmarin's research at Harvard focuses on the relevance of spirituality to mental health. At Center for Anxiety, his team uses a combination of cognitive behavioral therapy (CBT) and dialectical behavior therapy, also known as DBT. These approaches are used to help patients struggling with moderate to severe symptoms of anxiety, depression, and other concerns.
Before we get started, could you please let us know a little bit more about yourself, Dr. Rosmarin, and it sounds like you have two different aspects of your career, the spirituality and then the anxiety piece. Are these related?
David Rosmarin: Well, first, thanks very much for having me on your program and I'm really happy to be here. They can be related for some individuals. Spirituality is an interesting variable. It's the kind of thing that most people in mental health don't get a lot of training in, and my program of research seeks to remedy that, to give clinicians tools to be able to assess for and address aspects of spiritual and religious life when it's relevant, which is more often than you would think, but it's not for all individuals.
In terms of anxiety, sometimes it's relevant and sometimes it's not. Center for Anxiety doesn't practice spiritual psychotherapy per se, unless individuals need specific spiritual and religious supports. I would say it is somewhat unique about our practice that it's a domain that we're not uncomfortable to address, unlike a lot of others. But it's not the only unique thing about Center for Anxiety.
Tori Steffen: Okay. Very interesting. Well, getting down to basics, could you explain for our audience what spirituality is?
David Rosmarin: Sure. Spirituality is any way of relating to that which is perceived to be sacred or set apart from the physical world. These kinds of beliefs are pretty common. In the United States, 80 to 90% of the general population has some sort of spiritual beliefs, and more importantly, in mental health settings, there's data to suggest that more than 80% of patients, even in some of the least religious areas of the United States, utilize spiritual ways of coping when they are distressed by mental health concerns.
Tori Steffen: Okay, perfect. Thank you for explaining that for us. What are some connections that you have found between spirituality and mental health?
David Rosmarin: Sure. Like any domain of life, it can be positive or negative, and spirituality is no different. In many cases, people have spiritual resources, and they might think that their faith gives them a lift. It might help them to deal with depression. It might protect them against certain things like substance abuse or alcohol abuse or suicidality. There's some very strong research to suggest that completed suicide is substantially less among people who have certain types of faith. It might give them a sense that they can get through difficult periods of life. We've seen some evidence here at McLean and elsewhere that when individuals have spiritual and religious resources at the beginning of treatment, that can help them to reduce quicker through their treatments even if the treatment has nothing to do with spirituality, interestingly.
On the other hand, though, it can be a source of strain, I mentioned. It can definitely be negative, and a lot of individuals struggle with their faith. They might think, why am I dealing with depression again? What's God doing to punish me? What did I do wrong? They might feel guilty or estranged from a faith community. They might feel bad about certain feelings they have; they might have certain conflicts which are sometimes very serious. To be able to discuss all of these, the positive and the negative and all points in between is just part of being a good psychotherapist, frankly.
Tori Steffen: Okay. Yeah, it seems important to know about the spirituality piece, especially when you're treating patients with suicidality and it's great to know that that can help too. Well, could you describe for us how the methods of both CBT and DBT work as those naturalistic treatments for anxiety?
David Rosmarin: Sure. You mentioned my career has two parts to it, and I would say there is some connection and overlap, but a lot of it is really disparate. At Center for Anxiety, we use a combination of cognitive and dialectical behavior therapy, which is somewhat innovative in the treatment of anxiety disorders. Most individuals treating anxiety concerns would really stick more to cognitive behavior therapy. But these days, anxiety, as I'm sure you're seeing out in Seattle, a lot of individuals come in with some pretty severe symptoms. They might have self-injury, they might be debilitated by their anxiety or other symptoms that they have. There's also high levels of what we call comorbidity where people have co-occurring anxiety with other concerns, whether it's substance abuse or depression, as I mentioned before, or any number of issues, obsessive compulsive and related disorders and these concerns and the complexity and the severity that people have today, they really, we have found can benefit from a broader toolkit of strategies that we can provide in psychotherapy to them, and that's why it spans both cognitive and dialectical behavior therapy in the practice.
Tori Steffen: Okay, great. That definitely helps introduce our topic today with CBT and DBT. How effective would you say are both approaches, CBT and DBT in treating those symptoms of anxiety, depression, suicidality?
David Rosmarin: Yeah, that's a scientific question and fortunately we have research to study it. Center for Anxiety has a research protocol and all patients at all sessions are administered measures, and we track over time their progress. We a couple years ago did an evaluation of our IOP, our Intensive Outpatient Program, which are individuals who needed three or more sessions per week.
One of the things that's unique about Center for Anxiety as I mentioned before, is that we provide really a higher level of care than just standard once a week outpatient. Individuals coming in with a lot more severe concerns and symptoms, I'd say about 50% of our patients at this point, require IOP, Intensive Outpatient Program or treatment, IOP we call it, and our data was very positive. We saw substantial reductions and clinically significant reductions in anxiety and depression for substantial decreases in those symptoms over the course of treatment. In fact, none of the patients in that study had an increase in their anxiety or depression over the course of treatment, which I think was particularly encouraging given the severity that they had when they came in.
Tori Steffen: Wow. Yeah, that's definitely good to hear that there's those treatments out there to be able to help with those symptoms. Have you seen any limitations that might prevent the treatment of anxiety, depression using those?
David Rosmarin: Being in an outpatient setting, one limitation is the cost of treatment. Unfortunately, with the era of managed care, and I'm sure you have a similar situation out in Seattle, these are out-of-pocket services, and it does limit the people who can come, which is really truly unfortunate. One advantage though that I think we have, and one way of addressing this is we do have a training program and many of our trainees are learning these techniques and they are able to be accessible at lower fees. Also, some of them move on to different sites which can provide services to individuals using insurance or having no insurance at all. I do feel like we're having an impact on the field more broadly, but in terms of our actual caseloads, that's a very significant limitation.
Tori Steffen: Okay. Definitely makes sense. Well, your research discusses the ways that CBT and DBT involve behavior activation and mindfulness. Could you describe how those might work for audience?
David Rosmarin: Yeah, so DBT is a broad set of tools, principles, really, and tools to help individuals struggling with severe levels of distress, moderate to severe levels of distress. One of the core tools is called mindfulness, that was the word that you mentioned. Mindfulness means being attentive to the present moment and not being judgmental of oneself. One of the things that happens is not only do people feel depressed or anxious or have other symptoms, but they judge themselves for feeling anxious, depressed, and that judgment instead of simply being anxious or being depressed and allowing oneself to feel that way, that judgment of oneself and negative perception of that feeds in and actually creates more of a surge of adrenaline. It suppresses dopamine, serotonin, other neurotransmitters and individuals are more likely to struggle substantially when they judge themselves. Mindfulness is a training of simply allowing oneself to be in the moment and to experience whatever they're going through without that critical eye.
Tori Steffen: Okay, great. Thank you for explaining that for us. Your research was also discussing how psychoeducation plays a role in the treatment. How might that work to address those symptoms for anxiety and depression?
David Rosmarin: There are a lot of basic facts around anxiety and depression and other symptoms that people don't know. For example, if you're feeling depressed, you probably will not want to engage in this much activity because hey, you're feeling sad, you're not enjoying things as much. You're struggling to have the energy and your sleep might be dysregulated. However, to the extent that people simply keep a schedule, even if they're feeling depressed, their depression can and often does remit.
Scheduling an activity which is supposed to be so to speak, pleasurable, even if it isn't, can actually be a part of that. Going to an exercise class, simply going for a walk, lacing up one's shoes, getting out of bed, not sleeping during the day. This is what we call behavioral activation, which is actually in some ways invented in Seattle in your backyard over there and certainly came to be a tour de force in the world of behavioral psychology in Seattle. But in any event, this is a concept that we can just educate patients.
Another one is with anxiety, the more you avoid, the more anxious you will be. If you're afraid of something and you avoid it, you're going to become more anxious of it, not less, even though it feels better in the moment. These are basic concepts that have been clarified through the literature, through experimental science, through clinical science, and they're grounded in theory that patients and anybody just needs to know. So, sometimes just some basic info can go a long way.
Tori Steffen: Okay. Yeah, that definitely makes sense how important psychoeducation can be. Are there any other approaches than CBT or DBT that individuals can utilize to combat those symptoms?
David Rosmarin: Yeah, one of the DBT approaches that we really love is called distress tolerance. People often think that one of the goals of treatment is to reduce the amount of distress they're experiencing, and to some extent that's true, but to a larger extent, one of the goals, a better goal, I would say, is to increase the amount of distress that we can tolerate. There's a big difference between trying to reduce my distress versus trying to increase my capacity to withstand distress, and when we think about it the other way, the increasing our distress tolerance in of itself, we're not expected to never be distressed. It's not a surprise when we're having a really rough day and the goal then becomes to weather the storm as opposed to getting the weather to change. As we all know today, climate's very hard to predict and to control, not that we shouldn't try, but we can and certainly should learn to tolerate more with the situation that we have, especially when it comes to our emotions.
Tori Steffen: Okay, awesome. Thank you for sharing that. While CBT and DBT are best and ideally done under the treatment and guidance of a licensed mental health professional, what are some things one can do on their own to potentially reduce or lessen some of those symptoms of anxiety or depression?
David Rosmarin: I'm thinking about another DBT module called emotion regulation and simply the idea of being aware, for example, on a scale of 0 to 10, how stressed are you right now?
Tori Steffen: Myself, I would say maybe a four. Not too bad.
David Rosmarin: Four, not too bad for a mid-morning west coast kind of vibe. I get that, even though it's a Monday. That's great and you're aware of it right away, and maybe that's because you're involved in the field. Other people will fumble, I don't know, is it high? Is it low? I don't have a baseline. Simply being aware of how sad you are, how anxious you are, and throwing a number to it. If you don't want to throw a number to it, at least is it high, is it medium, is it low?
Being able to share that with someone, that's another factor in emotion regulation. Being able to just communicate how you feel to other individuals, whether it's a professional, as you mentioned, or a friend. Whether it's a post on Twitter, hey, feeling a little bit sad today, whatever it is. Then these kinds of things, it's important to maintain awareness and then to recognize also that we can shift our emotional states. Sometimes you might all of a sudden feel really dysphoric and sad and part of that we can't necessarily control, but we might be able to indirectly influence that. Listening to reggae music, right? Hard not to bop. Going for a walk, calling up an old friend, eating ice cream. But sometimes those can have negative effects, as well. Being aware of our emotional states and how what we do affects those, that's really the core of emotional regulation and that's something everybody can benefit from today.
Tori Steffen: Okay, great. Awesome advice. Well, do you have any final words of advice or anything else that you'd like to share with our listeners today?
David Rosmarin: I guess I'll share this, that we're living in very challenging times. People have higher levels of anxiety and depression than ever before in history for a variety of reasons. It's very real, these concerns, and they have very significant and real effects on people's lives. Our phones are ringing off the hook. The other day, I think they're 22 intakes that came in and that's very significant for a modest practice of our size.
I think it's important for people to know that they're not alone today, that if they're struggling, there's plenty of other people that are there. More importantly, that there are treatments that really are helpful, and in not a lot of time. I mean, our treatments will often see people 5, 6, 7 sessions and see a decrease. They might stay on longer to target other aspects of their mental health, but A) people are not alone and B) there is hope to be had and a lot of hope, so I think those are probably some important messages to get out there.
Tori Steffen: Definitely important to keep a positive perspective on things, so that's very helpful. Thank you so much. Well, it's been really great talking to you today, Dr. Rosmarin, and thank you again for joining us and contributing to our interview series.
David Rosmarin: Thanks for having me on your series.
Tori Steffen: Thank you very much. Hope you have a great day.
David Rosmarin: You too.
Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.
Editor: Jennifer (Ghahari) Smith, Ph.D.