trauma

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.

Psychotherapist Jerome Veith on Existential Therapy

* Note: Video is unavailable for this interview.

An Interview with Psychotherapist Jerome Veith

Jerome Veith, Ph.D. is a Senior Adjunct Professor of Philosophy and Psychology at Seattle University. He specializes in the process and healing from traumatic experiences and helping those struggling with issues of purpose, meaning, and personal identity.

Jennifer Smith:  Thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series! I'm Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today, psychotherapist Jerome Veith. In addition to his work as a therapist at our practice, Jerome also teaches at Seattle University. He designs interdisciplinary courses for students in Psychology, exploring the significance of trauma and what it means for us to process and heal from traumatic experiences. Jerome has also published numerous articles, a number of literary and philosophical translations, and a recent book focused on understanding our relationship to our past. Prior to his graduate studies in Psychology, Jerome earned a Ph.D. in Philosophy, making him an exceptionally good fit for clients struggling with issues of purpose, meaning, and personal identity.

To get started, can you tell us a little more about yourself?

Jerome Veith: I divide my work fairly evenly between teaching philosophy and psychology at Seattle University (where I’ve been working since 2012), and practicing therapy at Seattle Anxiety Specialists (where I’ve been since SAS’s inception in 2018). I really enjoy both of these lines of work - they complement each other superbly! Beyond work I read, cook, spend time with friends, listen to music, and occasionally try my hand at playing it. Since moving here over 20 years ago and falling in love with the Northwest, I’ve made a point to get to know the area more and more.

Jennifer Smith: What are your favorite parts of the Seattle area, or Washington as a whole?

Jerome Veith: In Seattle it depends on the weather, and if I’m wanting bustle or seclusion (or a mix of both). I gravitate toward places with character, atmosphere, trees, or a view: parks, pubs, lookouts, and bookstores. Further afield, the Peninsula exerts a particular pull on me (I look for the mountains every morning), and I try to make it to a little island in the San Juans at least once a year.

Jennifer Smith: What is it that got you interested in becoming a therapist?

Jerome Veith: A half-joking answer would be: drugs! Perhaps like many a teenager who dabbled in psychedelics, I fancied myself an oh-so-wise shaman-apprentice, ready to guide others through their ego-death. Luckily that hubris wore off fast. Psychedelics did spark an abiding interest in the depth and breadth of the mind, though, and that’s been a thread of my studies ever since.

A more serious response is that, while majoring in philosophy and psychology at Seattle University, I learned not only that entire therapeutic movements had been influenced by existentialism, phenomenology, and hermeneutics - which by then I considered my intellectual homes - but also that SU has a graduate program dedicated entirely to training those kinds of therapists. The folks in and around that program seemed to have a distinct way of listening to experience: a way of being inquisitive together, of allowing more to be questionable and meaningful than we commonly permit ourselves, and of noticing the interpretive moves we’re always making. That attitude (or mode, practice - whatever you wish to call it) resonated powerfully with me, and pointed toward my eventual therapeutic path. First, I went off to get a PhD in philosophy, though.

When that (seven-year!) process atrophied something in me and I desperately needed therapy myself, I experienced firsthand how illuminating and revitalizing it is to be heard in therapeutic relation. That’s when I knew this was work I wanted to do, and I enrolled in SU’s therapy program.

Jennifer Smith: You were born in the US but raised in Germany, and you lived there until you came to the US for undergrad. Your schooling before the US was entirely German, while your home life was American. Has this informed your thinking or your practice at all?

Jerome Veith: It has influenced so much! My upbringing shaped my identity profoundly - along with my eventual interest in identity itself, and certainly my way of holding identity in therapy.

Growing up in Germany at the end of the Cold War, adjacent to a US military supercomplex and near the French border, surrounded by facets of history both buried and bare, greatly shaped my attunement to all sorts of cultural edges. I became aware very early on how much is at stake in having and expressing an identity, yet for all sorts of reasons I couldn’t easily inhabit just one - but laying claim to many was also challenging. That suspension between cultures eventually became a quite generative space: one where identity is resonant but never fixed, and one that invites free exploration.

That isn’t to say that finding this space was easy or comfortable. It takes an ongoing effort to maintain. For this reason, I resonate in my work with folks who experience cultural othering or inhabit several cultural positions. They might struggle with all sorts of outsider-ness, as this can be a blessing and a curse. One sees differently from the margins, but this isn’t always a welcome or comfortable perspective. One might not be seen at all or as one intends. There is also an immense pain in exclusion that can open onto deep uncertainty about one’s permission to be, and about one’s and aspirations and possibilities of experiencing home, community, or belonging.

Jennifer Smith: What areas or disorders do you specialize in?

Jerome Veith: This is difficult to label on a diagnostic level, because the DSM’s taxonomy is so problematic and fails to capture so many of the nuances of human experience. I tend to be a good fit for clients whose anxiety, trauma, stuckness, or lostness resonates with questions of identity, self-worth, or wider meaning. Another way to put this is that I work with clients who struggle to integrate with some aspect of themselves, of the world, or even with the world as such.

Jennifer Smith: Can you talk a little about your treatment approach?

Jerome Veith: I mentioned before that I tend to work well with clients who experience deep questions underneath their presenting symptoms. However, it’s not always clear from the outset whether or how these questions are present. Discovering that, and allowing one’s questions to find articulation, is part of the work of therapy. Without talking through what’s happening, it might seem like one simply can’t manage the stresses of daily life; one might simply feel lost, stuck, or out of balance. Sometimes it only becomes clear belatedly that one needs new language or a different framing of the issue. Sometimes that reframing is the entire work of therapy; sometimes that’s just where the exciting work begins.

That said, much of my approach is a shared noticing of what’s going on - on affective, embodied, cognitive, and relational levels - both from within the client’s experience, but also from the stance of someone alongside that. Being accompanied in this noticing can be immensely helpful. It’s not that I necessarily have a better perspective, but I do sometimes have a different one; and often that’s sufficient space for new interpretation.

Jennifer Smith: As a professor of philosophy, do you find that being a therapist helps you in the classroom - and conversely, does being a professor help you in any way as a therapist?  

Jerome Veith: Yes and yes! I have a sense that years of university teaching - and doing so in a spontaneously responsive sort of way - prepared me both for the unpredictable conversations one has in therapy, and for the mode of listening that these require. Sitting with confusing texts and ideas, often for immense spans of time, turned out to be great preparation for the attentive mode in which I accompany my clients.

My therapy work has, in turn, deeply informed my teaching. In working through real and deep issues with people, I’ve come to recognize layers of human experience that are rarely captured in academic writing. I try to point my pedagogy toward these lived textures, either by way of more experiential media (film, literature, poetry, music) or by bringing in direct case material.

Jennifer Smith: Do you have any words of advice or anything else that you would like to share? 

Jerome Veith: Nothing has been more impactful for my sanity than receiving, internalizing, and continuing to give myself “permission” - whatever this might mean in a given context. For me, it’s often permission to pause, play, or ponder without needing an outcome. In a culture that seems to demand perfection from us at all turns, this can be a liberating practice.

* For those interested in working with Jerome, click on our appointment page to see his current availability.

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


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

Psychologist George Bonanno on Trauma, PTSD & Resilience

* Note: Video is unavailable for this interview.

An Interview with Psychologist George Bonanno

George Bonanno, Ph.D. is a professor of clinical psychology at Columbia University's Teacher College. His research specializes in human resilience in the face of loss and potential trauma.

Tori Steffen:  Hi, everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Tori Steffan, 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 George Bonanno. Dr. Bonanno is a professor of clinical psychology at Columbia University's Teacher College. Dr. Bonanno is recognized for his pioneering research on human resilience in the face of loss and potential trauma. In addition to the books, The End of Trauma and The Other Side of Sadness, he's published hundreds of peer reviewed scientific articles, many appearing in leading journals. 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 trauma and resilience?

George Bonanno:  Oh, that's a good question. I have a long and a short answer to that question. The shorter answer I guess is I had the opportunity when I finished my doctoral program. I was trained, I think, pretty well in experimental research and in this general research methodology part of my clinical psychology degree. And the first position I took was in San Francisco, the bereavement project when I was given basically free range to design this massive study with the resources there. And so we just basically used methods that hadn't been used before with this kind of phenomenon. A lot of the work is mostly clinical and with people who were suffering. So the assumption at the time was that most people were suffering greatly with disease of the brain. Same thing with the trauma one. And when we used a different approach, more of a I think... we would get a broader... Okay, I was going to say epidemiological.

We did a broad swatch of people, anyone who had gone through a loss and then eventually did that in the trauma too. Anyone who'd gone through a particular event, we were interested in, and we would interview them and do experimental work with them and questionnaires as soon as we could after the event, and then following them. Right away, we began to see that so many, many people were showing, they had a difficult time talking about it when they had to, but they were basically functioning really well in their lives. And we found that right away and so we began to document that. And then I thought, "Well, this is kind of remarkable." So I was interested in this and we just kept pursuing it. And before I even realized it, I've now been studying that for 30 years. I didn't really intend that, but that's what we've been doing.

Tori Steffen:  Right. Yeah, it's funny how one study can kind of lead you down a road that way.

George Bonanno:  Exactly, yeah.

Tori Steffen:  Yeah. Well, I ended up reading your book, The End of Trauma, which was very interesting and investigates why some people might develop PTSD after traumatic events and then some might not. So could you kind of explain that for the audience a little bit?

George Bonanno:  Well, as I mentioned, we were finding these patterns for years. We called one the resilience pattern or the resilience trajectory, and those are people who they go through an event, everybody is distressed and disturbed by a major stressor or a major, I use the word 'potential trauma', but everybody has those reactions. And I'd say just about everybody and maybe 85% of the people exposed by a major life-threatening event or a major loss, or something like that. But for most people, it seems to abate within a few weeks, sometimes a little bit longer, sometimes a little bit less. And so we've replicated this now so many times and other people have now as well, dozens maybe. I think the last count it was something like 80 or 90 studies showing this. So of course over time, I was busy just simply verifying this and looking at it from this way and that way to make sure we were correct in this assumption, that these people were really resilient, they're not just telling us. So we had alternative methods. We usually talk to multiple people.

So then of course, naturally we began to ask, “What causes this? Why is it that these people are so resilient and other people not?” And that's a question I'm still trying to understand today. There's a longer answer to that one and also a shorter answer. The shorter answer if I can give you it quickly is that, so there are many factors that can be identified that correlate with resilience, and we've identified these factors and other people have too. And there's a widespread assumption that there's sort of several key factors that make people resilient and resilient people have these. And after really thinking about this and studying this for years, I think they've come to the realization that there aren't key factors. There's so many correlatives, so many predictors that they're just a multitude, well over 50 and counting.

And so how do we make sense of that? But it turns out all these things also are pretty small effects. In other words, they only really explain a little bit. There isn't any one factor that really makes you resilient or not. In fact, people aren't resilient. And that led that people have to become resilient. Resilience I think of as an outcome. So all those, I'm flying a lot of this past everybody. But the answer becomes what I call regulatory flexibility. Every time we're confronted with an event, we'd have to work it out. We'd have to embrace the event and find out for ourselves what works in this situation. And we do that through a process of trial and error. And that's very much the way humans cope, very much the way humans do the world. We are equipped for that. We try things, if it doesn't work, we try something else. So that's really the answer. We've studied flexibility now in detail, we have many different components of flexibility. We identified the pieces of us and we try to keep it simple, but life is not always simple.

Tori Steffen:  There's so many aspects and variables that kind of go into resilience. And I remember reading about the resilience paradox, and I think you listed, like you were saying, about 50 variables that could go into why somebody might be resilient after experiencing trauma. One variable that I remember being pretty significant is having a support group or people around you to support you after experiencing trauma. How significant would you say that particular variable is?

George Bonanno:  Well, I think there are some factors, social support, emotional support, instrumental support. If you break down social support or what we call interpersonal support, it's actually not one thing, it's many things. And people need different things at different times. So sometimes they need help with the daily aspects of living, instrumental support. Sometimes they need the emotional support. Sometimes they just simply need the group to belong to, it's about identity. So there are lots of different pieces of that. And we tend to assume that social support, anyone of this broader umbrella of support is really the "that's always good". But the research shows pretty clearly, it's not always good. It comes with a cost. Everything comes with a cost. Benefits and cost. And the cost of support have been studied research wise, and people have told me different costs that sometimes people just aren't able to engage in the kind of reciprocity that's required for support.

Sometimes the support is well intended, but not very helpful. Sometimes the support might undermine a person's sense of efficacy and sometimes it's just not what people need. Sometimes people need to be isolated, they need to be alone and work something out for themselves. Sometimes people don't want to be around other people because of whatever the event was that they experienced. And so in particular moments, it's not always the answer. And another piece of that is that when we cope with something major, it doesn't go away, as every good therapist... No, it doesn't go away and when you say, "Here's what I need you to do," bing - now it's gone. It takes time. And so what we do at any one time is different to what we do at another time. And so being around other people and just hanging out with other people, just enjoying their company and not thinking about the event is what we need maybe a little bit later down the road.

Maybe what we need immediately is just to be comforted by someone. Maybe we need help, as I mentioned, instrumental support and that comes somewhere in the middle. It all depends. And sometimes, as I said, we just want to be alone for some point of it. So it's really a matter of, we're not talking about, if your social supports always good, this is what we've been... What's good at this moment? And that's really what we see as being helpful.

Tori Steffen:  Right. Yeah, I can see that it would definitely vary between participants that you've interviewed. One situation might work out a little bit better. So it definitely just varies across the population. And the flexibility sequence that you had mentioned earlier, I remember in your book it stated somebody asking themselves after a traumatic event, what am I able to do versus what do I need to do. How might that distinction help one be more flexible?

George Bonanno:  Well, that distinction that's when we break it down and move to different components. So part of being flexibly adapting, which you'd say, is reading the situation first. A lot of people... We assess what's happening and ask, "Well, what do I need to do here?" We've grown up doing that, but we do this normally without thinking. Part of what I think is important clinically is bringing that to people's awareness, that we do that and that that's how they get through an event. They have to think about it, kind of embrace it even for a short time and ask those questions. The question about what am I able to do comes next. And we sense that what I need to do here is I'm ruminating, I need to stop myself from ruminating, or I'm thinking about this all the time, or I'm afraid to go back to this place. I'm even afraid to go out. Or I can't sleep, what do I need to do?

I need to find a way to sleep tonight or sleep for the next few days. I need to consult people. I need to ask people, I need to figure out what do I have... But then we get to the question of what am I able to do? And that comes to our repertoire. What do we have at our disposal? What do we already know how to do? And I'm a big fan of having people think about this when they're not in a terrible bad shape. Because once we're really upset about something and we amidst of a crisis, it's really hard to think clearly. It's really hard to even think, what am I able to do? I'm not able to do anything right now. And that's a real fact of life.

When people are really upset, we don't think very clearly. So it's a good idea to think about these things in advance. And so we ask ourselves, what do I need to do here? What can I do? What are the tools I have? And then we try something. And we get to the last step, which is, did this work? Do I feel better? Did the situation change? If not, then we try something else. And I find this last step is where a lot of people stumble also. They stumble and they can stumble at any one of these steps, but the last step is when we ask ourselves, is this working? Because people often find out, "Well, no, I still feel terrible. It didn't work."

And they give up because their assumption is, "Well, I'm not good at this. I can't cope. I'm not a resilient person." But nobody can do everything every time exactly the right way. It's how we learn, it's how we become healthy people. Even the healthiest people don't always have an answer. They try things. It doesn't work, you try something else, especially if it's a major event, especially if you're in bad shape, you try something else. And that's just really how we do get through things. So I think that's also another important thing, clinical teaching moment for people to realize that.

Tori Steffen:  Right.

George Bonanno:  It's how it works.

Tori Steffen:  Yeah, absolutely. I remember a case in your book about a girl named Maren who suffered a spinal cord injury from a horse incident.

George Bonanno:  Yes, yes.

Tori Steffen:  And I remember the key part of her recovery was her own optimism and motivation.

George Bonanno:  Yes.

Tori Steffen:  Do you think that those two things, motivation and optimism led her towards recovering so well?

George Bonanno:  Sure. I think Maren's optimism, if I can speak colloquially, was off the charts. It was really extreme. And they told her she was paralyzed for the rest of her life and not only did she say I'm going to walk again, she believed she would walk again. But optimism, few other pieces like that, maybe confidence, our ability to cope, a sense of I'll get through things, I'll get through this, I'll work it out. And even if the goal is just to accept what's happened, I will work this out somehow. I'll find a way to live with this and be happy again.

And that motivation is really important for all the things that I've just said up until now. Because it's not easy when you're hurting, last thing you want to do is think about it and embrace it. What we really want to do is just push it away, cover our face in a pillow, feel lousy and just hate the world. Those are much easier, but we have to actually face what's happened and think about it enough to work out what do I need to do then and what's going to get me through this? And you need to be motivated to do that. So Maren was super motivated, but a lot of people are. I think none of these are that extreme. Maren is a great person, but she's not a superhero. She just had the will to do this.

Tori Steffen:  Right. Yeah, I think that's a large part of it, your own personal mindset and believing that you can recover. But I mean, in a situation like that, it's just really interesting that that would have such a significant impact on her healing journey. So that's a great case to study. Well, Dr. Bonanno, I really appreciate your time. Are there any final words of advice that you'd like to share with the listeners today?

George Bonanno:  Yeah, I would. Another thing that I mentioned in the book is what I call coping arguments, that we sometimes need to do something that doesn't quite seem like it's healthy. It's something we maybe never thought about doing. It's something that we're told is not a healthy thing to do. But in this moment, it may be, and I'm not going to mention too many examples, but I think things like, sometimes people, I hope the listeners don't mind me saying this, sometimes people get drunk and just for the evening. And we wouldn't think of it as a healthy coping behavior. But for one night, and it doesn't... The next day you feel lousy. It's not gone. But people feel like, okay, but I decided to do that and I'm in control. Now what do I need to do here? And they get through the morning to make themselves feel a little bit better.

Then they still have the question. I did something last night, it didn't work, but I did something. What do I need to do now? And it does seem to sometimes give people just a little break. So the other thing, I won't name any other examples, but I'm sure people can think of them, they just get us through that moment and then we take the next step. So John Lennon has a song called Whatever Gets You Thru The Night. And I think I mentioned that in the book, but it's like the song because it's really kind of what it's about. When we're coping with really difficult things, we just want to get through it. It doesn't need to be pretty, it doesn't need to make us super healthy people. We just need to get through it. So I think that's an important thing also to keep in mind.

Tori Steffen:  Awesome. Yeah, that's great advice. And yeah, there's plenty of great information in the book too. I definitely recommend everybody checks out The End of Trauma by Dr. Bonanno. So yeah, thank you so much for sharing your knowledge with us today. And thank you everybody for tuning in and we'll see everybody next time. Thank you.

George Bonanno:  Okay, thank you. Thank you, Tori, nice to meet you.

Tori Steffen:  Thank you, you as well.

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.

Psychotherapy Intern Debora de Souza on Grief Support

An Interview with Psychotherapy Intern Debora de Souza

Debora de Souza is a clinical intern at Seattle Anxiety Specialists for 2022-2023, providing care to those in need within our low-cost therapy program. She is finalizing her Master's degree in Clinical Mental Health Counseling at Seattle University and specializes in helping clients work through grief, loss and trauma.

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're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders.

I like to welcome with us today, Clinical Mental Health Counselor, Deb de Souza. Deb is a clinical psychotherapy intern at Seattle Anxiety Specialists and she is currently earning her master's degree in clinical mental health counseling at Seattle University. She works with parents experiencing perinatal mood and anxiety disorder, known as PMAD. And she also worked as a grief hike guide, helping those grieving the death of a loved one to process their loss. So before we get started today, Deb, could you let us know a little bit more about yourself and what made you interested in studying mental health counseling and grief?

Debora de Souza:  Hi Tori. Thank you so much for having me.

Sure, absolutely. This is a second career for me. I have been in the business world for quite some time locally here in Seattle in corporate settings. I always had an interest in the psychology when I first started college, that was definitely one of the careers I was... one of the schools that I was hoping to go into. Just life happens, it didn't happen. I ended up being program management and business operations for most part of my adult life. But when the opportunity came with COVID and things happened, I got laid off and I decided that it was the right time to go into counseling given that was something that I really wanted to do. And I had a lot of interest and passions, like you said, in the area of grief and PMAD and anxiety disorders, as well.

So I said, no time like the present. I had already applied to Seattle University and got accepted prior to COVID and I decided let's just make this a new career path for me. And it's been really enjoyable. I really am glad that I took the leap. It's a little bit threatening, but it was fun.

Tori Steffen:  Yeah, that's amazing. It sounds like it just worked out time wise and you got to love that smooth transition.

Debora de Souza:  Yeah, it was great. Meant to be.

Tori Steffen:  Yeah, exactly. Well, can you describe for us how your time at SAS as a clinical intern has been so far for you?

Debora de Souza:  I started in September and I have to say it's been really, really good for me. I feel very supported at SAS, that's one thing I really wanted. I applied to several sites and I actually had already accepted another site. And when I got an email from SAS to interview. And it just clicked, it really clicked with the folks that I talked to on my interview, the approach that they had to internship and also I like the low-fee model that was offered, that interns participate, where we provide service to folks that may be in that gap where they can't qualify for insurance, and they don't have private insurance or state insurance, and we can provide a service to that population. That otherwise may not even have access to care. So it's been really, really nice. It's a small group of interns, a lot of support from great supervisors and also from the staff. So I feel ... again, I think as a new person, as an intern, new person on the field learning how to become a counselor, the support is critical.

Tori Steffen:  Absolutely. I would definitely agree with that. It's a lot of stuff to learn and I feel like you really learn it from experience. So having supervisors help you through a little bit is crucial.

Debora de Souza:  It's vulnerable work.

Tori Steffen:  Absolutely. What would you say has been the most challenging about being a clinical intern?

Debora de Souza:  Well, I think the truth that come to mind right away is that I kind of expected, but experiencing it is a little bit different, is how vulnerable it is for me as a person sometimes, and how I can get flooded and overwhelmed, emotions when people share things that might be triggering for me and trying to differentiate what is mine, what is the client? So that's been a learning. And I knew from a scholastic standpoint, but it's different when you feel it, when you're in the room with someone. So that has been something.

Also how imposter syndrome is real. Sometimes you sit with somebody explaining their circumstances and you're like, "I deal with that too and I'm still finding my way. How can I support you?" So that is real. I think just learning how to be a counselor or a therapist and sit with someone. One thing that I did not expect, I've always worked long hours and being tired. And I remember telling Case (Lovell), who is my supervisor, in the first week how completely exhausted I was after a full day. I think it was my first day with four or five people.

Tori Steffen:  Wow.

Debora de Souza:  And I was very emotionally and physically tired. I just wanted to come home and go to bed. That was surprising for me because it takes a lot of effort to really focus and listen. It's a different way of engaging with people that I wasn't used to. Because that's not how we do it in our lives.

Tori Steffen:  Right. Yeah, that's something I wouldn't have expected either. But knowing that, it does make sense that it'd probably be drained, especially emotionally and need a good day of rest after your first week probably.

Debora de Souza:  It's a learned skill I hope, it gets better over time as you-

Tori Steffen:  Yeah. Yeah. I think it's one of those things that the more you practice, the more that you learn how to do it better. And-

Debora de Souza:  Absolutely.

Tori Steffen:  Deal with the feelings that come with it. Well, what would you say has been the most rewarding about being a clinical intern? Any specific moments come to mind for you?

Debora de Souza:  Yeah, I keep going back to the... I guess, I'm surprised and touched a lot how vulnerable people get with you. And it sounds like cliche, but really genuinely honored that sometimes without not knowing much, two or three sessions maybe, people really share deep things that they may not have other spaces in their life outside of session to talk about. And I'm very honored by that. And I think that is one thing that I keep it in mind a lot, is that I get to do this job. I get to sit with folks and support them and how intimate it can be, the relationship in one way. When you are really vulnerable, and also how much trust they have on us to be themselves and not being judged.

And as for an example, one that I have a client that we have sessions where the camera's off. My camera's on, but the client's camera is off. I got used to it, that's how this client prefers to engage. And I remember the first time he turned the camera on and in the middle of a conversation and it was to show his dog, he was talking about his dog. And he kind of came into frame very briefly, but he turned the camera to himself and said “hi.” It was the first time I actually saw his face and I was almost a little bit emotional. It was so meaningful to me that he... because he trust me enough to be a little bit more vulnerable and just say hello. So we've been seeing each other for some time and he still keeps the camera off most of the time. But every once in a while he'll turn it on and say hi or bye.

Tori Steffen:  Ah, that's amazing. Yeah, that's, I'd say, such a wonderful moment to have with the client and kind of just know that you've built that trust with them. So that's amazing.

Debora de Souza:  It felt really good.

Tori Steffen:  And it must have been amazing to see his dog, too.

Debora de Souza:  Yes. He has a very close connection with his pet. We always talk about the dog. He always comes to the session with us.

Tori Steffen:  Really? Ah. That's amazing. Well, kind of moving over to the outdoor grief groups that you work with. Can you explain how those work for the audience and maybe what activities you guys usually do?

Debora de Souza:  Yes, I do, I do. I love ... it's a volunteer position with the local... not company, but with the local group called Wild Griefs in Olympia, Washington, it's a small group, they're expanding now. We are volunteer hike guides. And basically it's to partner the power of nature to process grief. It started off as initiative to support teens that were grieving. A lot of times the loss of a parent or a caretaker or maybe a sibling, and provide them opportunity in nature to bond with each other, to share their experiences. And that was how it first started.

Wild Grief has several programs, all nature related, all outdoors throughout the entire year. So it's not a summer/spring only. We go out in December, the day before Christmas sometimes.

Tori Steffen:  Wow.

Debora de Souza:  And they offer programs that are day programs, like hikes. Some are more nature walks, some are more hikes, like five hours or so. Also overnight programs, which is a four day backpack with teenagers and a group of us take teenagers out backpacking in mountains around Washington. And each day is framed, there is some process. Each day is framed to go... they use the four tasks of grief as a baseline, basically accepting grief, feeling your feels, adjusting to a life without the person that you lost, and then making a new relationship with that person. So we try to frame all... even if it's a short hike or if it's a four day camp, we try to do that.

We also have a camping program that I usually participate on, that I really like. It's with the family. So it's a family camp, everything's provided, literally from shoes to food to pants. The family just comes. So a parent or a caretaker and children that experience a loss within that family unit. And we spent three days together camping somewhere around Washington. And it's beautiful to see not only the parents relating and connecting, but how the kids really find support on finding another child that has lost their dad, for instance. And be able to just talk about it, which they don't have a lot of space, maybe, in their life outside, in school and other friends.

So both the family camp and the hikes are the longer programs. The other programs are day hikes. And they say something else like nature does the heavy lifting and we just really provide the safe space to share, it's optional. And it has been really beautiful to see. We don't know who's coming, they sign up and we meet up in the trailhead. And usually there's two, maybe three guides, depending on the number of people. And we start hikes and then we stop in some places we usually kind of case out hikes and spaces before. Because we have two or three stops where we do little small processing groups.

And we talk about our person and we share memories of that person, the impact of that person in their life. And we compare with nature sometimes the changes of seasons. How does that reflect on the changes that grief does throughout time. And the rebirth when we see a log and there's a whole bunch of new growth in that dead tree. And the same thing with our grief, after the loss, we adjust and we move forward, and we bring that person with us in a different capacity. And just being with other people. So you can talk about your feelings with no judgment.

Tori Steffen:  Right. Yeah, it sounds like kind of the perfect safe space to provide people who are grieving. And you're right, you just have to get away from everyday life sometimes. Because work and school and all these responsibilities get in the way of processing the heavy emotions. So that's amazing. Yeah, it sounds good.

Debora de Souza:  Being outdoors really helped.

Tori Steffen:  Great program.

Debora de Souza:  Yeah, it's very nice because being outdoors, I even feel myself just with the trees and the sounds of nature. You are walking, you're also moving. We do have strategic stop times, but they're brief. I think it's a great idea, I'm glad that the board, the founders, the couple people that found that decided to expand and move forward and be more inclusive.

Tori Steffen:  Yeah, it sounds like they're doing a great job with being inclusive for all types of experiences, so that's amazing.

Debora de Souza:  Absolutely.

Tori Steffen:  What are the main benefits that you see the participants gaining from their experience in the hiking program?

Debora de Souza:  I think it's community. We talk a lot about acceptance, just have a space. Grief can still be a taboo topic in a lot of places at work or people, maybe people rush you like, "Oh, it's been already six months or a year." You hear a lot of those terms so people feel like, oh, I should ... it's not okay for me to talk about it or to bring it up. So people push it down their emotions, so that's a space that they can do. And it's amazing that we were all strangers in the beginning of the hike, it's oftentimes by the end, people exchange numbers or want to keep in touch. Or people come to several, we have hikes once a month, at least. So we'll see people coming again and again and them bringing children or bringing a friend. So definitely community and acceptance. And being outdoors. Yeah, being outdoors is always good.

Tori Steffen:  Right. Yeah, it sounds like just the perfect mixture of things to help you along that healing journey. Yeah. And that's amazing.

Well, if we could discuss the topic of grieving parents, specifically. There's a specific topic around it. So how it's become more acceptable for men to grieve where it was previously not really as accepted. Would you mind going into that a little bit?

Debora de Souza:  Yeah, absolutely. I think it's even harder for men. I think sometimes men get forgotten. And especially around parenting, I think we're talking about specifically about... there's another volunteer position that I have with the Perinatal Support Washington. I'm a warm line for answering the phone on certain shifts during the day. And most of the callers are women who are experiencing PMAD, Perinatal Mental Anxiety Disorders. So postpartum depression, postpartum anxiety, some miscarriages, sometimes stillbirth or birth trauma is very common. So we do a lot of talking to them, just trying to assess their situation, how we can provide support.

Sometimes every once in a while we get a dad or a grandfather calling to support someone that they love in their lives, who they're concerned about. So there's a lot of psycho-education, a little bit, like “Where do I go with this? How can I help my daughter or my wife?” And eventually, as you get to work with them, we have extended peer support. So if the person... until they get connected with some sort of therapist or service, they have the option to keep working with us and we can call them once a week. We can set up a cadence and we have brief calls with them. And I found that with fathers or with males, eventually it comes to their grief and their experience with, in the case of a miscarriage or stillbirth. And being able to express that because they think it's all around the woman, the mother, the expecting person.

Which makes sense and they feel a little bit lost or they say, "Oh, my wife just had a baby. And all the attention goes to her and I'm not feeling safe to say that because that's not cool. What kind of dad are you? What about me?" Or, "I'm grieving my wife because it used to be just me and her, and now there's this baby who's a newborn is very demanding." So we end up supporting and doing a lot of psycho-ed and just help and listening to both parents, to both caretakers. And grandparents do it the same and call and say, "I don't know how to help more or how to be present to my daughter, to my family member."

As far as personal experience with a male, a coworker, I did suffer a pregnancy loss and I was far along enough that people in my work knew. So I was away for recovery. And when I come back to the office a few weeks later, one of my coworkers, another gentleman that was in my team and asked me out to lunch, he wanted us to talk. And I think in the beginning, just to support me, “Welcome back, how can we be there for you?” But more in a private setting. And he got really emotional during that meeting with me and start crying and openly grieving a son that he lost, I believe it was like 30 years earlier. Because we talked about how weird was talking about pregnancy. But because I was so evidently pregnant, there was no way around it. And he just shared his own story that back when his wife lost their first child, he had nobody... men do not participate. They never talked about it. It was like they did the medical procedures, she came home. That wasn't even their first child, the second child was.

So it was just culturally different. I'm sure at the time, things were difficult. We have come a long way of normalizing not only perinatal mental health, but miscarriages and birth losses and challenges with IVF, challenges with fail adoption, the journey to become a parent can be riddled with challenges. And fathers feel it, too. And that gentleman really touched my heart, I will never forget because it end up kind of me making space for him and listening about his boy and how much that hurt him. That pregnancy wasn't viable and he didn't get to hold him. So it was a very powerful, and beautiful moment. And I'm very thankful that he felt safe to share with me.

Tori Steffen:  Yeah. And it really brings to light that men experience the same grief. And it is more evidently the mother is physically going through it and that's definitely significant. But the father is in there just as much. It's their child, as well.

Debora de Souza:  Absolutely. A lot of anxiety for dads when the first baby comes.

Tori Steffen:  Oh yeah, I bet.

Debora de Souza:  They're adjusting too. So it's nice to have a service like Perinatal Support Washington. So we have fathers volunteers, as well. So if you want to, you don't have to talk to a mom, you can also talk to a dad who has been through postpartum depression with their wives and whatnot. And it's really nice. It's a really great service.

Tori Steffen:  It sounds like just such a great resource for new parents, anybody who's gone through it.

Debora de Souza:  Oh, the landscape has changed. Even from my time of my losses, I really struggled to find someone, a therapist that was familiar with perinatal mental health, how that could support me. And I'm glad there's a lot more resources, I think, right now, nowadays.

Tori Steffen:  Yeah, that's amazing. It's not something that I have seen be super common out there. But it's absolutely needed, I would think. So, that's amazing. So what are some good resources that you know of that grieving parents can look into maybe after losing a child or losing a loved one? Are there any good go-to resources that you know of?

Debora de Souza:  There's several, like I said, the landscape did change. I will share the Wild Grief link and page, as well as the Perinatal Support Washington for Washington only. But there's also Perinatal Support International. A lot of resources, a lot of support groups are ran by those organizations and they're usually free of cost. And now since COVID, especially, they're online. They also list other ones, sometimes with churches or with community centers that people can find locally and connect. And they're a lot of support groups, which is wonderful. Because the safe spaces and the peer-to-peer support can be vital.

One that I like a lot myself and they offer trainings and they're very laid out website, it's called the Return to Zero. And they made a movie, they have a book. It's a couple talking about the experience when they lost their son, their first child. And from there, it kind of sprout into this beautiful website, where you can go in there as a parent grieving. And they really go the gamut, like I said, in fertility, IVF, anything in the Journey to Parenthood. Beautiful site, a lovely work, very well done and well set up. So you can get from referral to therapists, training classes. They have a lot of training classes for volunteers and people that work with parents and people in experiencing PMADs.

And it's just something that I wish I had access to back in the day because you just feel it can be very lonely. You go through very... and nobody wants to talk to you because people think that it's a baby and it's going to make you sad. Or they don't know what to say. I get it. It get all that. And when all you want to do is talk about it. And that's the funny part, all you want to do is ... especially when a baby. A baby is a baby and has a whole life already, the minute that you realize you're expecting.

Tori Steffen:  Yeah.

Debora de Souza:  It's amazing how you're already think the weddings, it's sounds silly. But a whole life become concrete. So that's another thing, as well. We used to have a miscarriage early on, sometimes people say, oh, at least try to do those kind of modifiers. “Well at least it was early enough. Or at least you can get pregnant again.” And for a parent, I think that life has already happened from conception on. So those are great support that folks can go to and get all kinds. And very cultural responsive too, and inclusive because different cultures... and I think I can speak from my culture, as well. It's very unique sometimes how you deal with the topic, how you deal with grief itself. So they do a very good job of having a multicultural approach and training and language that is inclusive to all parents. So Return to Zero, I will share the link, as well. They're excellent.

Tori Steffen:  Perfect. Yeah, we'll make sure to link those in the notes later, but that's so helpful. Thank you for sharing the resources. I'm sure it'll be really helpful to hopefully some of our audience.

Debora de Souza:  I hope so. Yeah.

Tori Steffen:  Awesome. Well, are there any final words of advice or anything else you'd like to share with the listeners today?

Debora de Souza:  No, it's been really a pleasure. I think I said my thing is about normalizing grief, normalizing sharing feelings. And even if we don't know what to say, sometimes not saying anything, just being there. Just letting the person know that you are there to say... and it sounds cliche again, but it's so important so you don't feel so lonely. You feel like it's okay, people understand. Because that's one common experience that we’re all going to have. At some point, we're going to lose someone.

But also other griefs, as well. It doesn't have to be a death of a person, ending of relationships. I mean, through COVID there were so many changes. And I always like to think about positive changes. Some people say positive changes, happy changes bring grief. And I'm like, oh, it's true. In order for something new to happen, something had to die or change. And I didn't think of that. I said, well, think about a wedding, there's a different life that you're entering now. But things are changing... sometimes and a lot of times bring grief with it. And I think it's uncomfortable, we don't like to talk about it.

Tori Steffen:  Right and it's like-

Debora de Souza:  We all feel it.

Tori Steffen:  Exactly. And those big positive changes are great. You're having-

Debora de Souza:  New jobs, moving to another country. I mean, there's so much that you can think, "Oh, this is so fun and exciting." But there's always some... the other side, that you're leaving something, there's a cycle ending in some way. And just honoring that and taking time to feel the feels just like the best... it's beautiful. Doesn't apply only to death, physical death.

Tori Steffen:  Right. Yeah, just taking the time to process the change, I think will help you, lead you into the future and make it easier on you emotionally.

Debora de Souza:  And be a kinder human being. Understand when other people go through their change, it promotes kindness. It's definitely a positive in my book.

Tori Steffen:  Yeah, absolutely. Well, thank you so much for sharing your knowledge with us today, Deb. It was great talking to you.

Debora de Souza:  Thank you so much. It's my pleasure.

Tori Steffen:  All right. And thank you everybody for tuning in and we'll see you 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.

Post-Doctoral Fellow Kristy Cuthbert on Panic Disorder & Agoraphobia

An Interview with Post-Doctoral Fellow Kristy Cuthbert

Kristy Cuthbert, Ph.D. is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. She specializes in CBT and DBT for anxiety and related disorders, such as phobias.

Tori Steffen:  Hi everybody. Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Tori Steffen, 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 post-doctoral fellow Kristy Cuthbert. Dr. Cuthbert is an Administrative and Clinical Fellow at the Center for Anxiety and Related Disorders in Boston. Dr. Cuthbert specializes in CBT and DBT for anxiety and related disorders. She's also worked with individuals with post-traumatic stress disorder and borderline personality disorder. Her research focuses on alternative spectrum models of psychopathology and on treatment implementation in clinical settings. She has specialized training in working with veterans and has focused much of her clinical work on women's mental health and providing access to care for low-income populations. So before we get started today, Dr. Cuthbert, could you let us know a little bit more about yourself and what made you interested in studying, treating panic disorder and agoraphobia?

Kristy Cuthbert:  Sure. So thanks for the introduction. So I think my interest came about simply because I did my graduate training at Boston University, that's the home of the Center for Anxiety and Related Disorders. And they offer cognitive behavioral therapies for anxiety and related disorders of a fairly wide range as well as mood disorders. However, I found it to be both challenging and rewarding to work with individuals who have diagnoses of panic disorder and, or a agoraphobia. Because entering into that first exposure I think, and I can talk more about what that is and what that entails in a moment, but entering into that first exposure, I think people have a lot of fear. And then once they face that fear, it just kind of unlocks this ability to do more and more. And it's really great to see people succeed and to feel empowered at the end of the process.

Tori Steffen:  Yeah. And that must be really fulfilling work to do, to be able to help people and see the success rate.

Kristy Cuthbert:  Yeah.

Tori Steffen:  That's awesome. Well, getting down to the basics around our topic, can you explain for the audience what panic disorder and or agoraphobia are and how common they tend to be?

Kristy Cuthbert:  Sure. So I think this can be kind of complicated if you're not super familiar with all of this terminology, because there are panic attacks and then there's panic disorder and then there's a agoraphobia. And so the answer can be complicated. I'll say that panic disorder is specifically related to two or more panic attacks that meet a certain set of symptoms that we ask people about and that these attacks occur out of the blue. And that's a critical distinction. So some people will report having a panic attack in the middle of the night, and it just feels really surprising and sudden.

And then for agoraphobia, people taking this a step further feel fearful about going out in public because of those panic symptoms or fear that those panic symptoms will come up. Or this can also be related to other fears about embarrassing symptoms like having an upset stomach or having to urgently go to the restroom or having trouble escaping for whatever reason from very busy and crowded places. So in addition to the two disorders, panic disorder and agoraphobia, you can also have panic attacks, which can be related to any number of other anxiety disorders. So if you have a specific phobia and you're afraid of bees, you can have a panic attack if you see a bee. And so that would be specified as a part of the phobia. The key there being, that panic attack is triggered by the bee. Whereas in panic disorder, those attacks come on very suddenly and are not related to, "Oh, well I saw a bee." Right?

Tori Steffen:  Okay. That makes great sense. Thanks for making that distinction for us.

Kristy Cuthbert:  Yeah. And in terms of how common they tend to be, I'll say that the 12 month prevalence rate in the DSM-5-TR for that is 2 to 3%. And for agoraphobia, it's 1 to 1.7% as the 12 month prevalence. So panic disorder is not entirely uncommon, neither is agoraphobia. So it's not uncommon to see those. And that doesn't even include panic attacks, the ones that can occur with other anxiety disorders.

Tori Steffen:  Right. Have you seen any, or in the literature, are there any known causes for agoraphobia or panic disorder?

Kristy Cuthbert:  So I think in terms of causes, this can be wide-ranging. For both disorders, they tend to co-occur at very high rates. So one theory is, so for example, to think about panic disorder, panic disorder and agoraphobia can be preceded by anxiety disorders. So perhaps you start with social anxiety. And when you have social anxiety, you might have a panic attack or panic symptoms. And then you start to really focus on those symptoms and develop fear and anxiety about having those symptoms. So then you're more likely to have those symptoms come on unexpectedly or to have more fears about going out in public or in crowded spaces where you then might have those symptoms.

So sometimes it's just a matter of experiencing some of those discomforts and really keying into those physical cues. Because it's kind of like when you get an itch on your head. This always happens when I'm getting a haircut. So I want to scratch it, but I'm getting a haircut. And so because I can't, I focus on it and it feels more and more intense. So for whatever reason, a person might start to notice those physical sensations and then that feeling like, "How do I control this?" And not being able to fully control it can kind of start that cycle of panic and then lead to agoraphobia as well.

Tori Steffen:  Okay. Yeah, that makes good sense as in how it could potentially lead to agoraphobia. So thank you for breaking that down.

Kristy Cuthbert:  Sure.

Tori Steffen:  And as far as treating agoraphobia and panic disorder, what are some of the common treatments for the two?

Kristy Cuthbert:  Yeah, so I'll say the gold standard treatments for panic disorder and agoraphobia are exposure based therapies. And cognitive behavioral therapy more generally. So you can talk about what it means to have a racing heart, and from a cognitive perspective, you might think of other situations where you had a racing heart like when you were working out, and then it was okay. You might think about what it means to feel panic. It means, “I'm out of control.” And you might look for evidence that doesn't support that you're out of control.

For the most part though, we do focus on exposures. And for panic disorder, one of the key types of exposures that we do is called an interoceptive exposure. So these are exposures where we kind of mimic the symptoms of a panic attack. So if one of your main symptoms is hyperventilating, we have you breathe through a coffee stirrer to actually simulate that and to sit with that. I've had patients wear heavy coats and heaters to simulate warmth and sweating, and maybe we will run in place for a couple of minutes to get the heart racing to really try to bring on the simulated symptoms of a panic attack and then to sit with that discomfort until it passes.

Because another thing we know about panic disorder and agoraphobia is that people often have safeties or safety behaviors. So they might carry medications around in their pocket. They might do certain things like bringing friends along with them when they travel so that they don't feel discomfort. So we also ask that, say we're sitting with those panic symptoms, we ask people not to engage in those behaviors. So we're not going to keep an empty bottle of benzodiazepines. We're not going to... We're going to leave that at home, we're not going to take off the coat and crank up the fan to try to combat the symptoms. We're just going to say, what if we leave them alone? And we try not to react to them. And to learn that by not reacting to them, it kind dismantles that false alarm telling you that there's danger.

So for agoraphobia, taking that a step further, we also do what we call situational exposures. So if you're afraid of public transportation, because it gets really crowded here in Boston and because you want to make sure you can escape, whether because you have panic symptoms or for some other reason, we get on the train. We get on the train when it's busy, we ride the train, we resist that urge to escape, we watch for other safety behaviors. Like again, carrying a medication. We may start by doing an exposure together. And then the person I'm working with might start to ride the train or take the bus on their own.

And of course, in more severe cases, this is trying to get them out of the house. So we might start by having them go to a grocery store that's a mile away. And then when they get into the grocery store, making sure they're not using any safeties to try to distract from the discomfort. The idea is that if we face the discomfort, then we'll see that it passes on its own without us having to react and that breaks up that cycle of behavior, and eventually that fear starts to become extinct.

Tori Steffen:  Okay. So the goal is to reduce the fear that one would get?

Kristy Cuthbert:  Right. And another goal is to learn safety. To be able to say, "I'm in a grocery store and I noticed that I'm having these panic sensations. I noticed the urge to want to escape, and I know that this is a safe place. As far as the world is safe, this is a safe place. And I know that what I'm experiencing is not necessarily a medical emergency. I've had these symptoms before. I recognize them as panic. I'm going to trust what I have learned about these symptoms, which is that I am safe if I just let them pass." So that learning safety is also an important part of it.

Tori Steffen:  Okay. Okay. Well, great. And I know we spoke a little bit about how panic disorder and agoraphobia can co-occur pretty frequently. Is it likely for agoraphobia to be comorbid with any other mental health issues as well?

Kristy Cuthbert:  Sure. So I talked a little bit about potential precursors. We also see a lot of comorbidity and different disorders that might occur in addition to, or once someone has started to have panic symptoms or agoraphobia. Depending on the severity of agoraphobia, it can be incredibly isolating if people don't go out often, if they have a lot of restrictions about where they can go that they feel safe. So a lot of people with agoraphobia will often have a diagnosis of major depressive disorder and substance use disorders. Because benzodiazepines are often prescribed. And depending on the severity of panic, benzodiazepines can be misused and can be addicted. People also drink or use other substances to try to take the edge off of that anxiety, either when they're feeling panic or if they have to leave the house or go into an uncomfortable situation if they have agoraphobia. So those are two of the particularly important comorbidities that we know of.

Tori Steffen:  Okay, that's good to know. And have you worked with any other phobias out there, any that you can name for us?

Kristy Cuthbert:  Yes. So we also treat specific phobias at the clinic. So I've worked with phobias of vomiting and specific phobias of animals like dogs, blood, injury, and injection phobias, insect phobias, snake phobias. I don't particularly work with snake phobias, but we do treat those at the clinic. And spider phobias. So yeah, a pretty wide range of specific phobias.

Tori Steffen:  Yeah, there's definitely a lot out there.

Kristy Cuthbert:  Yeah.

Tori Steffen:  So yeah, that's very interesting. And how might somebody with a specific phobia typically present? Kind of what's their common experience, I guess?

Kristy Cuthbert:  So I would say that from the cognitive behavioral model, we look at everything from this model of our thoughts and our feelings influence our behaviors. So most of the time what we see is a pattern of, and I'll use a dog phobia as an example. Sometimes it comes from having had a negative experience when they were younger. Sometimes it doesn't. It might be that their parents didn't have dogs, didn't like dogs. It might just be that they never had them around so they're just an unknown entity. They can develop for a wide range of reasons.

What tends to happen to maintain it though is... Say I'm going to work, it's important for me to get to work on time, and at around eight o'clock when I'm supposed to be walking through the door every morning, there is a medium-sized dog across the street from me right there next to the door of my office. That thought, feeling and behavior pattern might go something like this. I feel physical sensations, I feel a little bit sweaty, my hands are shaking a little bit. I feel maybe some flip-flops in my stomach, like I'm nervous. And I know that's because I see this dog. So then I think, "That dog might bite me, I'm in danger. I need to get away." And then that leads to the behavior. I don't cross the street. If the dog crosses the street towards me, I walk the other way. I avoid or try to escape the situation.

So what that does though is that says, "Yes, it really is a dangerous situation because you had to get out of it." So it reinforces the fear. So that pattern is something that we see that sort of seeing the object, feeling uncomfortable, labeling it as dangerous and trying to avoid or escape, that's a pretty common pattern.

Tori Steffen:  Okay. And that fits so well with the cognitive behavioral therapy outlook. So that's really cool.

Kristy Cuthbert:  Exactly. Yep.

Tori Steffen:  And have you seen that any phobias are more common than others, in general?

Kristy Cuthbert:  You know, it's really tough to say. I know that we do treat a lot of blood, injury, and injection phobias. Having blood drawn, getting medical procedures. I don't know at our particular clinic if those are any more common. And I don't know the prevalence literature off the top of my head. I would say that we do see that a lot, probably because if I am scared of a snake, for example, that's really not impairing my day-to-day life because I don't have to regularly interact with them. Now, if I were a keeper at the zoo and it was my job to take care of the reptiles, then I might come in and say, "I have a snake phobia." Or if I was an avid hiker and I stopped going hiking and kind of lost this thing that I loved, that might warrant treatment for a phobia. Blood, injury, and injection phobias or phobias around medical procedures, these are things that most people need to have done at some point. So we will see those people come in to have those treated.

Tori Steffen:  Okay. Yeah, that's an interesting one. For the blood phobia, is it mainly seeing blood and having a fearful reaction to an open wound, is the common experience?

Kristy Cuthbert:  So this can be wide-ranging. For some people it is. For others, there's very specifically a fear of having blood drawn, that fear of passing out if they have blood drawn. Some people do have that experience. So that I would say is a little bit of a unique treatment because we often will teach them a technique of tensing and relaxing muscles to make sure the blood is flowing. It increases the blood pressure and can prevent passing out while having blood drawn. So that's something that people can learn and do.

And the rest of it is very, very similar to exposure for panic or agoraphobia. And that we say, "What is it that you're afraid of?" "Well, I'm afraid of having my blood drawn."` So we start wherever a person is ready to start. So it might be, "Watch this video of someone having their blood drawn. Let's go into our medical lab and I'll have you put on the tourniquet and we'll prepare and you can sit with that anxiety." Which is often anticipatory. We also have specific phobias of driving. So for those, we'll start with one stretch of road. And then we talk about trying to see how is that similar to other stretches of road that I might be afraid of? "If I can do this, can I do this highway as well?"

So it's sort of a buildup to eventually having your blood drawn, eventually taking the highway you're most afraid of.

Tori Steffen:  Right. Okay. Yeah, that definitely makes sense with gauging where they might be ready to start and starting there. So can all phobias be treated with exposure therapy?

Kristy Cuthbert:  So I would say for the most part, there's always something we can do in terms of an exposure. You can be pretty creative, like I said. You can find anything in this day and age on YouTube. There are YouTube videos of just dash cams of people driving on highways. That's an exposure for driving phobia, right? If it's a scenario that you don't often find yourself in, like interviewing for a job with a person in authority. We have what we call confederates come in. It might be our clinic director, it might be one of our professors who's cleared to work in the clinic. But we have them come in, they're doing the interview so that someone starts to get that experience.

And if the situation is one that you can't really recreate, like, "I'm scared of getting the flu and being sick," then we'll do an imaginable exposure. So that's where people write out a script of what is that scenario that you're afraid of? Write it out in as much detail as you can, engage all five senses about what you notice about the situation, and then sit with the discomfort and challenge any sorts of judgments that might be in your write up. So I think it is very versatile. Exposure therapy, I think, is the standard treatment for most phobias. Yes.

Tori Steffen:  Right. And how effective would you say that exposure therapy is in treating a wide range of phobias?

Kristy Cuthbert:  Yeah, so you can really generalize this concept. And there are trans diagnostic approaches like the unified protocol that treat a wide range of anxiety and mood disorders based on these same concepts. So much like we avoid driving or avoid dogs, we can sometimes avoid uncomfortable emotions. So sometimes exposure is exposure to an uncomfortable emotion and being able to tolerate that emotion. Sometimes if we're feeling depressed and we don't want to be up and active, the exposure is being active. Depression tends to make us feel like we don't get a lot of pleasure out of activities. The problem then is that we stop doing the activities that might make us happy.

So taking that same approach, it's entering into those situations and saying, "I might not cure my depression today by going for a walk, but if I do this every day it's going to be really hard to hang on to that inertia and that heaviness that can come with depression." Likewise, interoceptive exposures, the ones where you simulate the physical symptoms of panic, you can do that with depression. The heaviness of depression, for example. There are ankle weights and arm weights that you can put on to kind of simulate heaviness. So it really does touch on a wide range of anxiety and mood disorders.

Tori Steffen:  Wow, that's really interesting. Yeah, I'd never heard the examples for depression as well, so that's great to know that it can also help with that. Well, awesome. Well, while treatment options are best and ideally done under the guidance of the licensed mental health professional, are there any things that individuals can do on their own to potentially reduce the symptoms of panic or agoraphobia?

Kristy Cuthbert:  So I would say a starting point is to be willing to say, "What is my panic look like?" I think one of the scary things about panic is your body is physically reacting. And so it's really hard to know is this a medical emergency? Because it feels so uncomfortable. Obviously you're having a physical reaction. It's hard to know. I would say that over time, panic attacks though, you can get to know them. And you can say, “I know what this is,” and to approach it with a familiarity, which I think can prevent the urge to, for example, Google your symptoms or to say, "Should I go to the ER to get this checked out?" If you start to understand what your panic is, that's a first step. Of course. I always give the caveat, make sure you're aware of what your physical conditions really are so you do know what to look out for. And also really balance that with saying, "I also know what my panic feels like and it feels like this."

And I would say the other thing is to think about the story you tell yourself. So I say this a lot with patients, and this really gets at the cognitive piece. So two things about the story you tell yourself. First of all, if you're telling yourself that, "Yes, I'm scared of having my blood drawn and I did it today, but I was scared the whole time." Well that kind of discounts this big achievement, you did something that was important to do. And it also can create a bunch of fear around it. It's almost like the expectation is that I should be able to have my blood drawn with no fear or you know what, I should be able to drive over a really high bridge with no anxiety. That is a really high expectation. And I would say that sometimes I drive over bridges and I'm like, "Wow, this is a really high bridge."Or I have a pretty healthy level of anxiety in busy traffic, because you're watching a lot and you're vigilant.

So don't see anxiety as a thing you want to eradicate. Just kind of learn to get more comfortable with it and learn when it's kind of out of proportion to what you think you're experiencing and give yourself credit for victories that you do achieve. If you get across a bridge because you have somewhere to go, pat yourself on the back for that if you're afraid of driving across a bridge. And the other thing is to picture going into it. What do you tell yourself about that bridge? “I'm going to drive over this bridge, I'm going to lose control and drive the car off the bridge.” And then ask yourself, “What is making me think this? What evidence do I have for it?” Sometimes the one thing that gets in the way is the story that we tell ourselves. Even before an exposure, if you're telling yourself that story, it's going to amp up the fear. And part of the fear is going to come anyway. And the story we tell ourselves can make that fear feel stronger.

Tori Steffen:  Right. That makes a lot of sense, and that's great advice for just kind of starting off and getting introspective about what's really going on. Well, Dr. Cuthbert, do you have any final words of advice or anything else that you'd like to share with the listeners today?

Kristy Cuthbert:  Not that I can think of. I think other than to say above and beyond the things that people can do on their own, it's okay to ask for help, to see someone who specializes in different types of therapy. If you feel like you're afraid of something and you're not quite ready to do exposures, there are other types of therapy where you kind of explore the root causes or where you focus on approaches that have you live your life in spite of your fears. And eventually it might mean facing your fears. And it's all about looking at your values and living according to those values. If you feel like anything, any specific fear, panic symptoms or fear of certain situations, if you feel like that's getting in the way of living a life according to your values, it's okay to seek help from someone to help get you through it. Some of these treatments can be completed in as few as 12 to 16 sessions. So it is worth the investment and the time that it takes.

Tori Steffen:  Yeah, I would have to agree. That's great advice. So thanks so much for sharing that, and thanks for chatting today. It was really great speaking with you about this. And I hope you have a great rest of your day.

Kristy Cuthbert:  Thanks, you too.

Tori Steffen:  Thank you. And thank you everybody for joining.

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.

Consultant Leon Seltzer on the Effects of Childhood Self-Shame

An Interview with Consultant Leon Seltzer

Leon Seltzer, Ph.D., holds doctorates in both English and Psychology. He recently retired from general private practice with clinical specialties in anger, trauma resolution (using EMDR and IFS), couples conflict, compulsive/addictive behaviors, stress control, and depression.

Jordan Rich:  Hello, everyone. Thank you for joining us today for this installment of the The Seattle Psychiatrist interview series. My name is Jordan Rich and I'm a research intern at the Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice with a specialty in anxiety disorders.

For today's interview, I would like to welcome Dr. Leon Seltzer, possessing doctorates in both English and psychology. Dr. Seltzer has previously functioned as an English professor at Queens College and Cleveland State University, and then later, as a psychologist, maintained a private practice for 35 years.

Upon retiring from his private practice, he's continued to offer private professional and personal consultations. In addition to publishing two books titled The Vision of Melville and Conrad and Paradoxical Strategies in Psychotherapy.

Dr. Seltzer has also been an extremely prolific writer on Psychology Today's website, authoring over 550 articles relating to psychology and psychotherapy, particularly on topics such as problematic relationships, compulsive and addictive behaviors, controlling one's anger, suffering from deficits in self-esteem and one's general self-image, and issues inherent in narcissistic personalities. Dr. Seltzer’s blog is titled Evolution of the Self with the subtitle On the Paradoxes of Personality, and his varied articles for Psychology Today have received over 50 million views. Thank you for joining us today, Dr. Seltzer.

Leon Seltzer:  And thank you for having me. I'm very happy to be part of your series.

Jordan Rich:  So to start, Dr. Seltzer, would you mind telling us a little more about yourself and what drew you to the study of psychology?

Leon Seltzer:  Well, I guess one of the things that's most interesting about that is my starting out majoring in English and becoming an English professor for over a decade. And the reason for that was that I had gotten the message, this is many decades ago, that what psychologists did was diagnostic testing, which wasn't a particular interest of mine, whereas psychiatrists were the ones who did the therapy.

And because of that, well, I had basically tried to decide whether I wanted to major in psychology or music because I love music, that I got so much encouragement from English professors that by default almost I majored in English. Which I don't really regret that much now because even though I left the field, it enabled me to really see myself as much as a writer as a psychologist and gave me the opportunity to do a lot of writing as I have on psychology, on psychotherapy once I entered the field. So no regrets there. The only thing I might mention is that I did a human growth training.

And it was interesting because it was during the training that I realized that if I had it to do over again, because my first love even after getting tenure was psychology, that that would be my preference. It was that training that made me realize if I were willing to go through what frankly is the torture, another doctoral program, that it was a possibility. And that's what I did. So I don't know if there's anything more you'd want to know about my past, but that is probably the most curious thing.

Jordan Rich:  Yeah, it's a fun little journey back around to your calling. It's very fun to see the kind of cyclical nature of it. So on your blog you describe a lot of your articles as surrounding the paradoxes of personality, which is a very specific phrase. Would you mind explaining to us what that phrase means to you?

Leon Seltzer:  It's interesting that Niels Bohr, the physicist, and I think it was back in the 1920s, said something like, "The opposite of any profound truth is equally true." Which would surprise a lot of people, but what I discovered is that there are many different perspectives toward one and the same thing, each of which has a certain validity.

And I think one of the things that most therapists do, regardless of what school they believe in or practice, is basically to have people understand some of their, what? Maladjusted behaviors as behaviors that were once necessary for them, that they weren't mistaken at all. And that the problem is simply that those behaviors based on self-protective mechanisms have basically become less and less adaptive as they've gotten older.

So, just to be able to see how things can be understood in different ways. One of the things I did actually before today was to kind of look at some of my more recent posts, or—and articles for Psychology Today. And I might just want to read some of the titles if I can find this here, simply because almost all of them are imbued with paradox.

So, looking at the most recent one, I did an article called Determinism vs. Free Will: A Contemporary Update. And my point was that to think that we have absolutely free will is probably not very accurate for the simple reason that if you believe at all in cause and effect, then it is also true that one cause can have many effects and many causes can have one effect.

Then anything like absolute free will doesn't square with the research that's been done, particularly in the last decade or so. The same thing with determinism. To say that our lives are predetermined is also reductive. It really doesn't get at the fact that there are certain choices that we do have. So it's like it's a paradox, that even people who don't technically, theoretically believe in free will live their lives as though they have free will.

So again, whatever it is, I'm always looking for the paradoxical element because it's a way of going deeper. And when I go deeper, I generally find I have a more profound understanding of whoever it is I might be working with. Let me look at a few other titles. The one before that was Why Discord, Paradoxically, Is Vital in Close Relationships.

And I think the very title is paradoxical because why would you want discord in a close relationship? And basically, what it is about is that, if in fact when we grew up our family, our immediate family disapproved of certain of our behaviors, then if our spouse enacts any of those behaviors, the child part of us will feel threatened. Because if this is our intimate other, our other half as it were, then it's going to feel threatening to us.

So we're going to have to dissociate from our partner. And a lot of times people don't even really understand the basis, the crux of why they've suddenly moved from harmony to disharmony. So it's very useful when they're in a suggestion of discord to realize they're not just talking about money, they're not just talking about how introverted or extroverted the other person ought to be, maybe depending on how introverted or extroverted their parents were, that they're talking about something that is most likely unresolved in their past.

So to give an example of this, let's say that a child by nature is kind of boisterous, asks a lot of questions, always wants to share everything that's going on with him or her. And the parents are both quite introverted, they're quiet individuals and they're made uncomfortable by their child's extroversion.

In a sense, they feel invalidated by that extroversion. It's going to be very hard for them not to be critical of their child, although the child isn't doing anything wrong. But if the child is young and, of course, very susceptible to his parents' ideas about him, he is going to think, “I need to be less loud because they keep saying, shh.”

And that makes me feel ashamed. It makes me feel that my bond with my own parents is tenuous. And I can't think of anything that would be scarier for a child not to feel secure, not to feel safe in their attachment bond with their parents. Now to the degree that the child tries to conform to what the parents need or want of him, then he will be, in a sense, suppressing his essential nature. And I've seen so many adults in the past that felt empty, almost as though some part of them was missing.

And it was a part that they had repressed because it was associated with parental disapproval, maybe even parental rejection. And I won't go into it, but it's the same thing if the child is very introverted and had two extroverted parents who felt that he was too insular, that he was isolating himself from his peers, that basically he needed to be in more group activities even though he enjoyed collecting stamps, whatever it was, or maybe just watching baseball games by himself on tv.

And it's a shame because most parents just want to socialize their kids because they realize that's their responsibility, but they have blinders based on how they were parented. So a lot of the problems that I had dealt with with clients basically had to do with the fact that their parents had blind spots.

And I think one of the things that is so useful about all forms of therapy is to the extent that the client gives the therapist a certain authority comparable or hopefully greater than the authority he gave to his parents and gets the message that who he is is acceptable. It may deviate from the norm, but that doesn't make it unacceptable.

And even if he's engaged in antisocial behaviors, although the therapist would like not to see that kind of behavior, the therapist would help him understand compassionately why he developed those behaviors. And it could be that he had to suppress his anger toward his parents because that would further alienate his parents from him. So that was too scary. But the main thing is if you experience anger and you don't express it, it doesn't disappear.

It just goes in deeper and deeper and then it gets displaced onto other people who don't deserve your anger, your aggression, whatever it might be. And it's the same thing with passive aggression. And on the other side, and this is more true of girls than of boys, what girls may do is try to please their parents because their parents react to them favorably or more favorably or only favorably when they're putting their parents' needs in front of their own.

And then the problem is I have seen adults who when asked, “Well, what do you need?” They didn't know. They had never thought about it. They had never had the luxury of asserting their needs to their parents without being told that they were being selfish. So and again, this goes back to the paradox of it all, that what happens is you end up blending with your defense mechanisms, and people pleasing can be seen as a defense mechanism.

And when you do that, you basically become alienated from yourself. And when you think about it, being alienated from yourself is probably even worse than being alienated from your parents. And the main thing about giving authority to a therapist who can have a deeper understanding of what's unconscious in you and bring it into consciousness is you can't change outdated defense mechanisms without making them conscious first.

And a therapist has to find a way of helping you do that without, in a sense, revitalizing or reawakening defenses that the child part of you still thinks are essential. I'll do one more title and then we can move on to whatever your next question is. Yeah. This is one of my favorite titles.

It's called, The Monster Once Beneath Your Bed May Now Be in Your Head. And this too is about internalizing those things that threaten you from outside. I once had a client who had this dream of being followed by a monster, being chased after by a monster. Maybe she was five, six years old. And she ran into her parents' bedroom and basically wanted to cuddle with her mother, and her mother was really the monster in the dream.

So what do you do with that? And this is how people end up kind of suppressing things and then later repressing them. The difference between suppression and repression is suppression is feeling something but not allowing yourself to express it because it feels way too dangerous for you. Over time what happens is just having that feeling is scary and you can try, and it's amazing that human beings can do this, not to experience the feeling.

This is why a lot of people have anger problems, don't realize that the anger isn't the source so much as anxiety is the source. Boys more than girls may suppress, well, I should say, yeah, girls more than boys, but both genders do this. What they will do is basically, in order not to feel an anxiety, which is disabling. Anxiety is obviously one of the most uncomfortable emotions that anybody could experience because it feels as though you're about to go over a cliff.

What anger does, anger by definition is always self-righteous. So it makes you feel that at least you have reason on your side, that basically the way you're being treated is unfair. You don't deserve to be treated that way. So anger feels a lot better than anxiety. The problem is if anxiety is what's underneath the anger, you never get a chance to work through the anxiety, and that is what would be ideal.

Then you wouldn't need the anger, to the degree that anger is a defense against anxiety. And in my earliest writings for Psychology Today, and I don't know what I mentioned, at this point, I think there's something like 554 articles. And you did mention very prolific, I think in your introduction.

And I'm surprised myself that I wrote that many, but I'm just dedicated to try to share whatever I've learned in all the 35, 40 years I've been doing therapy to kind of disseminate whatever clinical wisdom I have earned so that people don't have to necessarily read a 300-page book, but can maybe just read an article and get a sense of what they might not have realized beforehand. I probably have been talking too much. What's your next question?

Jordan Rich:  Never talking too much. So thank you for breaking that down. I had never heard that phrase before. So hearing your explanation and your examples was very helpful. Speaking of your writing on Psychology Today, one of your recent articles is titled, Does Self-Shaming Help You Avoid Being Shamed by Others? Could you elaborate on what you mean by this and what you think kind of gives rise to these defense mechanisms and how while we're still kids, they might serve us in positive ways but might not ultimately be good for us? Could you break that down for us a little?

Leon Seltzer:  Yeah. And that itself is paradoxical because the question would be how in the world could self-shaming be beneficial to us? But what we internalize defensively if our parents are shaming us, is to say, "Okay, I must be bad." And I think I also wrote a post saying, Do You Need To Be Bad To Feel Good? If feeling bad in some strange, not to be paradoxical, but perverse way helps you to feel more connected with your parents, then it's going to feel safer.

It's going to feel a lot less dangerous to agree with them on how you think they are assessing your behavior. So it's almost as though in shaming yourself, if they give you the message explicitly or implicitly—and it's actually more dangerous if the message is implicit because then you really can't work with it, because they never actually said it.

It was maybe just the look in their eyes. Because I remember one client I saw a long, long time ago who talked about one of her worst memories being when she went into the kitchen, her mother was preparing a meal and needed to talk to her about something. And her mother looked at her in such a way that she basically ran out of the kitchen because she felt so denigrated, so put down. And I think she ran into her bedroom and cried.

Her mother didn't say a word. But basically if a child says, “Okay, they think there's something wrong with me, I think there's something wrong with me.” So it's almost like they're asking their caretakers the question, “Can you accept me now? I think about myself the same way you think about me, doesn't that join us?” And that to me is the saddest thing in the world. And I don't know that anybody has ever written about self shaming being a defense mechanism, but I think that illuminates why it would be.

Jordan Rich:  Yeah, that's definitely a very heartbreaking scenario. So looking at the long term, what do you see as some problems that could arise as a result of a person having this harsh sort of judgment of themselves?

Leon Seltzer:  I'll give you another example. I worked with a client whose parents basically believed in corporal punishment and the father probably found something to beat him for on, pretty much on a daily basis. And one of his worst memories was he had made a mistake and his father said to him, “Here's $5. I will give you this $5 after you pack your suitcase because you're not welcome to live with us anymore. You keep making mistakes.”

This father also expected him to follow rules that were never described to him. And kids can make mistakes because they don't automatically know what the rules are, and different families have different rules anyhow. And when his father would beat him, and tears came to my eyes when he told me this. His father said, “Take off your belt. I'm going to beat you with your own belt.”

And as he was beating him, this is almost unbelievable, the father said to him, “See, your belt hates you, too.” How can anybody say anything like that to his son? Of course, one of the things I learned that his father was comparably abusive to him. And remember what I said before that basically a lot of these behaviors aren't thought out, they're automatic, they're programmed in.

And the problem is, unless you reevaluate how your parents treated you and recognized that it was abusive, you didn't deserve it. Because you may have thought you deserved it. That's what self shaming is about. “If they're treating me this way, I must be bad and all I can do is agree with them that I'm really a bad kid. So at least that is some way that we will be on the same page.” But in any case, there was one time when he did pack his bag.

He did take the $5 and he went out into the fields. He didn't know where to go, so he just walked as far as he could. It was also cold. And at three o'clock he heard coyotes and that scared him to death. So he ran back to his house, begged to be let in, but feeling an incredible amount of shame because he knew he had to adapt to however his parents saw him.

Now the final irony in this story, which speaks volumes, is he became a renowned surgeon and never stopped seeing himself as a fraud and was just waiting for the other shoe to fall. Because even though everybody told him what a fantastic surgeon he was, he was called in to deal with the most difficult cases the other surgeons frankly didn't know how to handle and routinely he would know what to do.

It's like his hands were an unbelievable gift. But he still had this sense of inferiority. And in close relationships, he had been married more than once, he had difficulty making them work because the passive-aggressiveness that he felt as a child would come out in various ways, he could easily be triggered. The other thing is if you haven't worked through your childhood issues, you are going to be reactive.

And what that means in psychology for a person who's reactive is you are dealing with something that doesn't really exist in the present, but because it's a reminder of what typified your past, it feels like your past is in your present. So you react accordingly. And the main thing is for any therapist is to get people to respond. That puts you a choice.

When you react, it's basically the dominant programs that you internalize that have the final say. So again, working with somebody like that, you give him a message opposite from that person's parents, and you do it with an authority that ideally the person would respect and you go slowly. It has to be incremental. Because there's no way that a person could assimilate a message about himself that's directly contrary to the message that he got earlier.

So in terms of defense mechanisms, I would say all of them are maladaptive once you become an adult. So dissociation is the biggest one. Because dissociation takes you out of the present. And if there's some conflict, if there's something that feels threatening and you can't get hold of that and talk to yourself in a way that in the moment it dissolves, then basically you can't think clearly.

Because anybody whose emotions get hold of them is going to be, in a sense reduced to a childlike reactive state. So denial is similar to dissociation. It also takes you away from the present, which is what all defense mechanisms do. And the only defense mechanism that it occurs to me is always adaptive is sublimation.

Because what sublimation is about is defined in earlier, the earliest psychoanalysis vision with Freud is that basically the impulses that you have that are destructive, that are anti-social, that are overly libidinous, whatever you want to call them, you know at some level would be inhumane to express, dangerous to express, probably illegal.

So Confucius said something like 2000 years ago that if you embark on a journey of revenge, first build two pits. Is it pits, what would it be? Or burial sites. And the whole idea is you end up killing yourself even as presumably you're killing someone else. So it is normal, I think it's really in our DNA to have nasty vengeful thoughts about somebody who's exploited us, taken advantage of us, deceived us.

But to seek revenge on them, it's like giving them a taste of their own medicine, doesn't really resolve the problem. We somehow have to say, “Okay, what is it that I can learn from this? Revenge is not the answer.” And then move forward. The problem with somebody who is really immersed in getting revenge on others, retribution, if you will, is that they're really not focusing on what their personal welfare is.

I don't think that anybody can really be fulfilled by getting revenge because they're still back in the past. So sublimation is basically saying, “Okay, let me take up a musical instrument. Let me color a mandolin or something like that.” That basically you're trying to use that energy, and this is what sublimation is, transform it into something positive and something fulfilling.

So any form of play might be seen as a healthy return to childhood because I think that the healthiest adults are childlike. Not childish, but childlike. And that's one thing about having children, when parents play with their children, they are childlike and they can play a game with the children. And as much as the children love having their parents play with them, they are in a sense restoring something that may have been lost with all the adult obligations that on a daily basis they need to fill.

Jordan Rich:  Yeah. So thank you for diving into some healthier means of self-defense. I think that's going to be very helpful for our audience. So you've touched on reprogramming the self-defense mechanisms you've developed, specifically self-deprecation. Is there any specific advice you would give as to how to reprogram those behaviors or any therapies you would recommend to help someone through that process, any specific therapies?

Leon Seltzer:  The main thing is ultimately all healing comes from within, that therapists need to facilitate the process, they need to kind of guide it. Because basically, people who go into therapy go into therapy because they're stuck. It's not as though they need to have schizophrenia to go into therapy. And schizophrenia is handled as much by medications as anything else because it's considered a brain disease mostly.

And in terms of getting unstuck, some people can do it through what's called bibliotherapy. If you look at my background, you can see that I am pretty much enamored of books, and I stopped buying them when I realized that there was absolutely no more room on my bookshelves to put them. You can see how crowded they are.

I have to really work hard to extricate one book from the book on the left side and the right side. And I probably would not have anywhere as many books if I didn't start buying them before I knew how to use computers or there was all this information available on the computers. I know one thing I do in terms of consulting is I basically recommend books and articles and even videos they can read or they can see, because there's so much psychotherapy material now just on YouTube.

Basically, I'll want them to get a sense of what outdated defense mechanisms may be getting in their way. So sometimes I would explain core concepts to them. Given the fact that I function as a psychotherapist for so many years, I don't want my accumulated clinical wisdom if we can call it that, to go to waste. So I make myself available.

And generally I consult with people who've read one or more of my articles for Psychology Today and have questions. And if the questions are simple, I'm happy, gratis, to answer them, whether it's email or on the phone, maybe 5, 10 minutes. What I find sometimes is that they're complicated and without knowing more about their past, I wouldn't want to be glib and suggest something that would be untenable for them.

So then I make myself available, say for a more formal 60 minute consultation or more than one if that's necessary. But basically the model that I suggest to them is called Internal Family Systems Therapy. And what that means as opposed to Family Systems Therapy, is we have a family inside ourselves, and that internal family can easily give us different messages. So the essence of ambivalence.

And most people who go into therapy are ambivalent. I remember a cartoon I saw many years ago, I think it was called Cathy, it hasn't been in there for a while. But Cathy said something about the fact that she wants to be totally different, but please don't ask her to change.

Because change is very scary. What happens with change is you immediately find your level of anxiety elevating. Of course, because you're asked to change in different ways that your parents that are also inside you have been telling you, or you think they've been telling you not to change because it would endanger this core relationship that you have.

But in any case, with Internal Family Systems Therapy, it's interesting because Schwartz has written at least three or four books for lay people. Richard Schwartz is basically the originator of that particular model. And more and more people are seeing it as state of the art, although it's a very eloquent, elegant theory at the same time that it's not that easy to implement.

But basically, his second book for lay people. I love the title, is called You Are the One You've Been Waiting For. And what he talks about is a person's essential, authentic self, liberated from all these protective mechanisms that he refers to as protective parts. And those are parts of you, spontaneous, playful, wise even, that we all have.

And when we're feeling emotionally overwhelmed, because maybe we're in an incident that's shaming. And anything that's shaming to a child really is traumatic for that child because what defines it as trauma is they feel that their bond with their parents in the moment is being endangered, and they know that they're not self-sufficient, they're not mature enough to live on their own.

They can't run down to the Jones' house at the end of the street and say, "Would you please adopt me? I'm having problems with my parents." So they have to make all these adaptations that I've already talked about. So the main thing about IFS, Internal Family Systems is basically to get more and more in touch with the behaviors that really inhibit you from realizing who you truly are.

And basically, when I advise people, what I advise them to do is to think about how they needed to adapt to their parents' orders. It'd be one thing if the parent made a request, but it was okay if the child refused the request. But frequently, if the child feels that they have to have certain unalterable rules for the child, then the child doesn't have any sense of choice.

So even in self shaming, the protective part inside the child says basically, "You have to do this, otherwise you'll just constantly feel anxious." And I think the saddest thing is I've worked with people in the past that basically would engage in all sorts of extracurricular activities when the school day was over or would go to their best friend's house and come back only when they knew they had to come back for dinner, because as soon as they walked through the front door, their anxiety level would escalate.

And I can't think of anything more disturbing, more horrible than to never feel safe in your own house. And that hardly reflects the majority of people who are in therapy, but to some degree, they had to change who they authentically were in order to adapt. It's not always to the parents. It can be to an older sibling. It could be to kids in the neighborhood.

It could even be to their teachers, because teachers unwittingly can shame students very easily without even knowing that they're doing it. And it's not as though the child can go up to them after class and said, “You just shamed me.” No, they bear that burden inside. And basically what therapy is about, particularly in IFS, Internal Family Systems Therapy is basically to release those burdens, to integrate that wounded child part of you with your adult, and basically bring that child into your present life.

Have the child remind you when it's time to play, maybe even when it's time to get silly. Because being an adult really isn't that much fun. If you think about it, when we think of our adult selves, we think of being conscientious and responsible and productive, and that definitely has its place. But if that's all our life is, then our adult life becomes as burdensome as maybe our childhood was.

Jordan Rich:  Well, thank you for that advice, Dr. Seltzer. That actually concludes my questions for today. So to close, are there any final words of advice or anything else you would like to share with our listeners?

Leon Seltzer:  Well, I don't know that I can say anything that I haven't already said, or I could speak for another 10 hours, one or the other. So we should probably leave it as it is right now.

Jordan Rich:  Right. Perfect. Well, thank you again for meeting with me today, Dr. Seltzer. And thank you to everyone else 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 Pam Jarvis on Attachment & Trauma Awareness in Schools

An Interview with Psychologist Pam Jarvis

Pam Jarvis, Ph.D. recently retired as an Honorary Visiting Research Fellow at Leeds Trinity University in Leeds, England. Dr. Jarvis specializes in psychological wellbeing in childhood, adolescence, families and education.

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're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today chartered psychologist Pam Jarvis. Dr. Jarvis is a professor at Leeds Trinity University in Leeds, England. Dr. Jarvis specializes in a multi-disciplinary research perspective, including psychological, biological, social, and historical perspectives. She's written several publications including the book Perspectives on Play, which looks at play-based learning in four to six year olds, and the article Attachment theory, cortisol and care for the under-threes in the twenty-first century: constructing evidence-informed policy. Before we get started today, could you let us know a little bit more about yourself, Dr. Jarvis, and what made you interested in studying attachment and trauma awareness in education?

Pam Jarvis:  Okay, so I should correct that. First of all, I'm retired from Leeds Trinity University now.

Tori Steffen:  Okay.

Pam Jarvis:  And I was a Reader, which is a particularly British term for academics in various, so just to put that on record.

Tori Steffen:  Okay.

Pam Jarvis:  And you asked how I got started, well that's an awful long time ago because I studied as a young mature student when my own children were very small and they're all in their late thirties now. And I had an idea that I wanted to sign on for a degree because I hadn't done that at the so-called right time. And I was interested in psychology and I ended up working as sort of playgroup volunteer and doing my psychology degree at the same time, so it was just a perfect kind of environment to get interested into that kind of arena. And I followed that through really throughout my career with all the other things I've done.

I've also got quite a strong interest in history, but my major thesis in that was written on a pioneer, a nursery pioneer here in Great Britain, although she was actually born in New York State, I think in America, but she grew up and practiced in London. Margaret McMillan actually grew up in Scotland and practiced in London, so it's been a thread, if you like, all the way through my career that, that is the part of psychology that I was always interested in. I would do other things because I'd be encouraged to do that, but then I'd always come back to it. My PhD was on children in early years education, but it was more focused towards their learning on play-based learning. But emotion played a big part in that too, so really it's been a sort of thread that's gone all the way through whatever I've done.

Tori Steffen:  Right. That's great. Yeah, it's nice to have so many different perspectives in your practice. And then I'm sure studying child development with kids of your own might have helped a little bit or given you some knowledge.

Pam Jarvis:  Well, yes. Because you had the theoretical and the practical going on at the same time, so yeah.

Tori Steffen:  Right.

Pam Jarvis:  In action.

Tori Steffen:  All righty. Well, getting down to basics, could you explain for the audience what currently exists in the educational environment for student wellbeing?

Pam Jarvis:  Oh, that's a big question. I think it depends on the nation. The Scandinavian nations are much better at this then we are in Britain, and unfortunately you are in the United States. A lot of it revolves around the importance really that the society accords to that period of life and the interest that lawmakers have in early years development. And in my own country it's not much and hardly any, so I think I worked with a lady for quite some time who was a professor of early years child development education at Salem State University in Massachusetts. And the way she described your childcare provision was a patchwork quilt in terms of what was available in various states. Massachusetts did quite well, I think California does reasonably well, but not quite so well.

I'm not an expert on that, but I think where you can make the judgment on Britain in terms of, well, in England, what we do in England, Scotland is slightly better and the politicians are more interested in early years education and in what I'm going to talk about later, adverse childhood experiences, particularly. The politicians at Westminster in England are not interested at all. They have a very much a kind of attitude to, well, how cheaply can you do it?

Tori Steffen:  Yeah.

Pam Jarvis:  And I think some American states have that kind of attitude when you get a, I don't want to be political here, but when you get a Democratic president, I think you get a bit more interest and when you get a Republican president, you get a bit less interest. And the same thing goes for us that when you get a Labor government, you get more interest. When you get Conservative government, you get less interest. And at the moment, we're under one of the worst Conservative governments we've ever had.

Tori Steffen:  Yeah.

Pam Jarvis:  It's a difficult situation really, but we have hoped that it might get better. Things have turned around before, so I think that we are very dependent in England on the Westminster government, where in America it's the education and it's evolved status now. And it's much more about what state you are living in, but where money's coming from the top, there is a hit on that. Sorry, the trouble with this subject is it so quickly gets into politics.

Tori Steffen:  Yeah.

Pam Jarvis:  We know what good practice is, but it's whether we can provide the lawmakers to actually do it.

Tori Steffen:  Right. Yeah. I think what's important is kind of bringing awareness to just how significant it is to provide the resources for students, so that's what we're going to get into today.

Pam Jarvis:  The Scottish government have done particularly well over the last, I suppose five years. And they've moved in a really big way to a very informed practice. But I wrote a chapter for a document that went forward to Scottish Parliament and it was very receptive.

Tori Steffen:  Wow.

Pam Jarvis:  But not in England, unfortunately.

Tori Steffen:  Yeah. Well, hopefully America and England can learn from others that have a good system in place.

Pam Jarvis:  The Scandinavians. And I think Scotland did draw a lot of its ideas from Scandinavia, although they have their faults as well, nobody's perfect.

Tori Steffen:  Right. All right. Well getting to the topic of attachment theory, could you explain the relevance of attachment theory in education for our listeners?

Pam Jarvis:  I mean the relevance for attachment theory for human beings in every walk of life is enormous. Attachment theory has gone through several stages. And the original one with John Bowlby, who was the creator of the term, had lots of faults, but there's a central core in it, which is the internal working model. And what that means is that when the child is born, it will learn from the adults who look after it how human beings act in their relationships. And where a child gets an upbringing or an environment where they feel that their cared for, that they can call for help when they want, when they feel that their needs will be addressed, they become secure and that then will develop an adult who will feel secure in society. I mean, none of us feel secure all the time. I know I've taught this for years and years to many students and a lot of them actually were parents at the time, and they would sort of come up with this idea, “Oh I'm a bad parent because I'm not perfect. I don't make my child secure all the time.”

I might have actually told them off when I shouldn't have done this type of thing. And I think the first thing to say is, none of us are perfect but we can be good enough, effectively. And it's how the child perceives really whether they're loved and whether they will get support. And then as they grow older, they will apply that model to the rest of society. They will apply it to teachers, to peers, they will apply it to romantic relationships. There are things along the way that can happen that will make things better or worse. It's not just all with, this was one of the thoughts of the original Bowlbyian theory because it was everything with the parents and after the three years, well then that's it. And that's not true, but it is important. What can happen if a child gets the message that other people are not kind and I am not lovable. This is the model of both society and themselves that they will go out with that the self is not worthy of love.

And the society is not going to help you if you ask for help, they're not going to be kind to you. And then all else transpires from that. Most of us go out with it's not an either/or. Most of us go out with something that's somewhere on a scale. This is another thing with Bowlby because it was a 1950s theory. It was very either/or, it's not really like that. But if we're just too far away from the not good enough, what we are doing with those children, you are not only creating that model but also creating an internal stress, it's much easier to stress someone who is not secure because they haven't got any help coming, so we are going to get very stressed very quickly. This is the model of the world in your mind, nobody's going to help me and this is all going wrong. Whereas somebody who is more secure is much happier to go to a colleague and say, “I'm running into trouble here, can you help?” And think that, “Yes, they're going to help me.”

Tori Steffen:  Right. Yeah, that definitely makes sense. How it would have an impact on a child's perspective on if they can reach out for help. And you brought up the stress piece.

Pam Jarvis:  Yes.

Tori Steffen:  So definitely important and very interesting topic to study, and moving kind of over to trauma. How is the topic of trauma connected to wellbeing in education?

Pam Jarvis:  Basically we'll start off with this model of the child of, basically what happened in the 21st century was that there was a lot of work done actually on stress, how stress works within the body. And then this was taken to early years in terms of some children tend to get more stressed more quickly. And what then, because the setting up of the cortisol system is done in the very early years, if that makes sense, so therefore I always cite it to my students like a central heating system that if you've got the thermostat turned up too high, you're going to make the boiler work too hard, so effectively what's going to happen if you continually work the boiler too hard is either it's just going to go poof and die or it's going to blow up. And this is the type of emotion that you've got in these children.

And in education, this does obviously impact on behavior because those children are going to be on a much sort of tighter spring in terms of behavior, they'll do things that seem unreasonable and expect things from adults that seem unreasonable. But the other issue in education is that if you've got these stress patterns running in your head all the time, you are not going to learn as well or as quickly. Because again, the way I describe this to my students is rather like you've got a computer with a finite ability to pay attention to something. And if you are always looking on the horizon for the next bad thing that's going to happen to you, then you don't have that attention or concentration to apply to learning.

Tori Steffen:  Wow.

Pam Jarvis:  So for children who are at the really far end of this scale, it's a really difficult situation. Now here in the UK, one of the issues that is a problem is poverty because this stresses a family, which stresses the child, which creates arguments, which creates insecure attachment, which creates sort of too high reactivity stress reactions. And then this is how disadvantaged children are then disadvantaged as they go along and along and along because when they start education, they're not really set up to learn. And because of the stress that they're carrying, the adverse childhood experiences, which originates in America around about the two thousands also adds some information to this.

I don't know if you're familiar with that, you could probably do a whole piece on adverse childhood experiences, ACEs. Felitti et al, that actually I think was principally studied in California and it's rather simplistic, but it sets up a series of life events that are likely to give a child high adverse childhood experiences, which creates this excess stress. And yeah, it's all related. That's what my article is about. The one that read from early years international is how we put all this together. The work that Bowlby did in the 1950s, the work that's been done in this century on the cortisol reactions and the adverse childhood experiences idea that has come from Felitti. Which is somewhat problematic because again, it rather oversimplifies, you can't just give someone an ACEs score and kind of walk away and say, “Oh, well, that's it.”

This is always the problem with this. And in school in particular, there was a school or an area I think in Scotland that started actually assessing children for ACEs and putting that on a permanent record, but where it can be used to help children and provide help for the family, it can also be used to stereotype, so teachers could go back to it and say, well, this child hasn't achieved because look at their ACEs score, so basically they stopped doing it because it was causing argument. It's something very, very difficult in education because I think in education often there is this problem, which is if we're going to diagnose something, we need to know how to treat it. And if we're going to diagnose it and not treat it, we maybe are going to cause more harm than good because child will be stereotyped, so this is where we are at the moment.

Tori Steffen:  That's a great point. Yeah, there's so many different areas that kind of go into the attachment, and education, and trauma, and the biological perspective that you mentioned, so that's great that you know, were able to take it a step further and kind of fill in some of those gaps by putting all of this information and knowledge together, so it's definitely important to know.

Pam Jarvis:  That was the purpose of the article. Yeah, it was effectively a literature review that said, there's this area of theory, there's this area of theory, there's this area of theory, but they all go together to make this picture.

Tori Steffen:  Right.

Pam Jarvis:  And then of course you are setting the scene for a lot more research.

Tori Steffen:  Yeah, and it just gives us so much more information that's really crucial to providing for those students that have insecure attachments, or trauma, or low stress management, which we're going to get into here soon as well.

Pam Jarvis:  I mean, this is something that, what I worked when I was a teacher, principally with children in the secondary phase, junior high and high school, and I ended up basically going to work to train early years professionals here. And the reason I decided to do that, well, there were so many teenagers that I would deal with who I in the end would think, well, most of the problem with you is something that probably happened before you arrive, but now I'm looking at you at 15 and our options are limited, there are options, but they're limited. Whereas if I go and work with people who work with children in early years, that will be training people to understand this so we can do better at the period where we should be doing better and have more impact, if that makes sense.

Tori Steffen:  Right. Oh, absolutely. Yeah, it's important to kind of reach these children early because a lot of the development is happening at those very young ages, so that's a great point as well.

Pam Jarvis:  There's not nothing we can do at 15, but it's so much better if we did it at three or four.

Tori Steffen:  Right.

Pam Jarvis:  Or even before birth if we work with the parents.

Tori Steffen:  Yeah, exactly, exactly. Well, why do you think is it beneficial for schools to be more aware around the topics of trauma and attachment?

Pam Jarvis:  Well, here in Britain or in England I should say, and in America there's been a sort of fad over the last 10 years for this zero tolerance idea with teenagers that if they do something very small wrong, then you come down on them really hard and sort of make them mind if you like put them in isolation. But the trouble is, if you've got children who are basically on edge all the time, if you apply a zero tolerance regime to that child, you're going to make them much, much worse because the model of themselves they're carrying in their head is, I'm not worthy. And the model of other people they're carrying in their head is they are not going to help me.

All you're doing is justifying both of those beliefs if you're going to apply a zero tolerance technique to them, so where we have trauma-informed practice instead of immediately saying, well, a punishment is going to work here. I think the lady who works in California, sorry, whose name I've forgotten, I always do this in interviews, I should have looked this up, but I've got on her says, do not say what is wrong with you to a child, say what happened to you. They may not know in fact, but that's the question the adult should ask first. If you've got a child who's always creating problems, it's not what's wrong with them, it's what happened to them to make them do that. Obviously all teenagers misbehave at some points and sometimes the reasons aren't very deep, it's just trying their luck because that's the way they are.

But if you are a reasonable teacher or if you are a reasonable school counselor or whatever, you ought to be able to tell the difference. And this is to me where the importance of training comes in. I don't think we need to train teachers to be social workers, but we do need to train them to spot the problems. And I'm honestly not sure about teacher training in the US. I think, again, it is different in different states, but in England, I can tell you for a fact, we don't train teachers like this and it's just not appropriate. They need to be trained in this, in child development effectively.

Tori Steffen:  Right. Yeah, that is a really good point. As you mentioned, maybe teachers aren't exactly social workers, but they do have a large impact on children, on their wellbeing, and it is important for them to have those tools to address issues that come up, so that's a really good one.

Pam Jarvis:  Well, they're a first line practitioner, aren't they?

Tori Steffen:  Correct.

Pam Jarvis:  They're the ones who will flag this up. No one's saying that they have to deal with really difficult cases on their own, but they know enough to flag this up. I mean, all the time I was teaching teenagers because I was a psychologist, obviously I did, but I would go to higher up to various people who would clearly have no idea, and it was so frustrating.

Tori Steffen:  Yeah, yeah, that's definitely important to have. I think that just that alone could make a really big difference.

Pam Jarvis:  It really could.

Tori Steffen:  Yeah. Well, something in your article noted that children who experience ongoing stress from an insecure relationship with adults, they can develop issues with stress management.

Pam Jarvis:  Yeah.

Tori Steffen:  How might that say a low stress management, how might that show up in an education environment?

Pam Jarvis:  It's children who are not focused on learning, sometimes they can act out, but often it's just a kind of just not focused that a teacher can tell this, that the mind is somewhere else. And also a child who's very on the edge, if they get some kind of mild admonishment from a teacher, will just flip out and create a huge amount of difficulty. And then obviously in some regimes, the punishment for that is very harsh. One of the things English schools do is often exclude children for either for a short time or if they really badly offended them permanently. But that doesn't answer our question, it just passes it on. And there's a term here in the UK, I'm not sure if it's familiar to you, which is the exclusion prison pipeline.

Tori Steffen:  I haven't heard of that.

Pam Jarvis:  Yeah, so the child is effectively back out of education and then they'll turn up in prison sometimes later.

Tori Steffen:  Right.

Pam Jarvis:  And still carrying whatever it was that happened when they were three, and nobody's tried to address it or two or whatever.

Tori Steffen:  Right, which could create issues down the road that could have been avoided from the start.

Pam Jarvis:  Well, the biggest sort of irritation to me is that is so expensive.

Tori Steffen:  Yeah.

Pam Jarvis:  It costs more to keep a child here in secure accommodation, child offenders, than it does to send a child to Eaton where Prince William and Prince Harry went, so what is the sensible thing to do? It's not just about being a woke liberal, it's about common sense.

Tori Steffen:  Right. Yeah, that's a really good point. Well, what can schools do to help students with higher stress and insecure attachment styles?

Pam Jarvis:  Well, we need trauma informed environments, so this is staff training so that all teachers are aware when to spot the signs of a child who is highly stressed. And we also need, there's endless arguments in England about exclusions that if a child is dangerous to other children, you can't keep them in the classroom. I mean obviously that's true, but the question is, is where are you then sending them? Are you sending them to an isolation booth and punishing them or are you sending them to an adult who is trained to work with them. And actually get to the bottom of what it is that's bothering them? Often, as I say, they can't say, but it's taking, if you like, I think what the adult has to keep in their mind is this child most likely has a model of themselves that is they're not lovable and they have a model of me that I'm not willing to help them, so it's starting to work on that.

Tori Steffen:  Yeah.

Pam Jarvis:  Wherever it is you are sending them. Teachers can do this too for children exhibiting sort of lower levels of stress, but that needs to run all the way through the school process. And we're really not very good at that in this country.

Tori Steffen:  Yeah.

Pam Jarvis:  With the fact Scotland has made a start on this.

Tori Steffen:  Okay, well it's good to hear that somebody out there is confronting the situation and hopefully we can learn from what works, what doesn't, so that we can kind of reap those benefits as well.

Pam Jarvis:  What we hear, the problem, I'm sorry, this is becoming a very policy oriented discussion, isn't it? But the thing is, you can't, what we hear is actually putting this kind of policy in place is very expensive, but the argument is that more children are going to come out the other end who are not going to go into prison, who are going to create family lives that are less fraught themselves for their own children. And it's that invisible saving. There was a project actually in the US called Headstart, I don't know if you've heard of this? Where children from projects and their parents were given a lot of help and care, they'd be about my age now in their sixties. And there was disappointment because it hadn't made them sort of hugely academically more able when they got to school than children that hadn't had been in the project.

But as they grew older, they were more likely to form secure partnerships, adult partnerships. Their own children were more likely to be secure, they were more likely to be employed, they were more likely to graduate high school. So all of that, even though it hadn't made them super clever or raised their IQ by a huge amount, that security in their lives had made them, if you like, better citizens, be because they had a good, we keep going back to the internal working model, don't we? Because they had a self-confidence in their own abilities, and they also had the belief that the society was a good place.

Tori Steffen:  Right.

Pam Jarvis:  Why would I contribute to a society where I think nobody much likes me, or is going to help me.

Tori Steffen:  Yeah, that's definitely important to understand how, it just sounds like it's very significant, the attachment style and the way that the child perceives themselves and others, which makes sense that, that alone can have such a big impact on educational success. And then later in life relationships, so many other areas in life.

Pam Jarvis:  And educational success doesn't just mean high grades and going to an Ivy League university.

Tori Steffen:  Right.

Pam Jarvis:  It means getting to the end of education, graduating, and maybe doing a very ordinary job, but that security to do that, to stick at it. And attachment is really, if you like, the melting pot for all this.

Tori Steffen:  Right.

Pam Jarvis:  That early part of life where we learn who we are and how other people will react to us, our expectation of ourselves and others.

Tori Steffen:  Absolutely. Well, if students are experiencing anxiety or other mental health issues, are schools able to provide any type of therapy or even just recommend that the caregivers seek out therapy?

Pam Jarvis:  Well, again, in England, and in America, I presume it again, depends on the states. In England, no, we are in terrible trouble with this. We've got huge amounts of teenage mental breakdown, which isn't only to do with the home, it's to do with social media, and to do with the experiences they went through in lockdown and COVID. Our mental health service is massively, massively overloaded. But really we could, as I say, train other professionals in the children's workforce to be able to do some of the work, but we don't.

Tori Steffen:  Right.

Pam Jarvis:  Every so often the prime minister, whoever it is this week, says, “Oh, well we are going to put more money into the mental health service.” But my kind of reaction to that is, well, that's like pushing somebody off a cliff because we've got so many families living in poverty here and sending an ambulance in the bottom. Why don't we help families at the beginning, so we don't have so many kids with mental health problems in the end?

Tori Steffen:  Right.

Pam Jarvis:  We can't really do much about social media or there are things we could do, and I have written about that. And again, we could do a lot more about family poverty, a lot more.

Tori Steffen:  Yeah, yeah.

Pam Jarvis:  We can't make all families secure.

Tori Steffen:  Right.

Pam Jarvis:  But we can raise the chances, and we just don't bother.

Tori Steffen:  Right. Yeah, why not start from the beginning versus trying to fix issues later down the road when it's going to be, you have limited options as how to help these individuals.

Pam Jarvis:  And their bigger issues.

Tori Steffen:  Yeah, and they already have that ingrained insecure attachment. Yeah, I think it would be more beneficial from the beginning, see what you can do to intervene there versus later on.

Pam Jarvis:  I mean, I haven't actually specifically written about this, but I mean logically, if you are insecurely attached, the type of trolling and bullying you get on social media is going to have a much bigger effect on you and so on.

Tori Steffen:  Yeah, yeah, because you just have less tools maybe to deal with that kind of stress.

Pam Jarvis:  Yeah.

Tori Steffen:  Yeah.

Pam Jarvis:  Well that's the thing with stress, isn't it? The actual term stress was taken from engineering, I believe originally and if you've got a bridge that's built with stress metal, you put a train on it that's too heavy and it goes pow, same thing for human beings.

Tori Steffen:  Yeah, I like the analogy.

Pam Jarvis:  If this is already cracked and you put a heavy load on it will give way.

Tori Steffen:  Yep. Yeah, that's a perfect analogy for kind of what you can expect from students. Well, what can families do on their own to help children develop a secure attachment? And if they are able to develop that secure attachment, do you think that, that would lead to a higher wellbeing in a school environment?

Pam Jarvis:  We have to recognize how hard it is for families to start with, I think, because I would hate to input family blaming because there are so many stresses on families now. But all things being equal, what the child needs in the first three years is a group of bonded adults. Bowlby said it just had to be the mother, this is not true. That's been shown again and again and again.

Tori Steffen:  Yeah.

Pam Jarvis:  What children need is a circle of adults, it could be three, five, but who take care of them and are bonded to them and what they will, who are emotionally available to them who have a focus on them. And what tends to happen is they create a main attachment and then these subsidiary attachments, so therefore it doesn't really matter. Your daily round could be to be with mom on one day, with dad on another day, with granny one on one day, granny two on the other day. That's fine, as long as that's familiar and you are bonded to those people. And out of that a main attachment will come, but the other people are acceptable substitutes. The big problem that you have with children is if they're sent particularly to daycare where the staff keep changing and then they don't have an adult in that environment who they have that bond with.

And there are ways, personally, and this is just my personal preference, I would prefer that families were at least given the option for parental and kin care within the first three years. But if there's a lady down the road who's a really experienced child minder and you're paying her to take care of the child and she's wonderful with the child, what's the problem with that? She just becomes another one of that bonded circle. Barbara Tizard who worked with Bowlby, I think she's still alive, but she'd be quite old by now. She said, well look, the way that children were cared for in the early industrial period in Britain, because women did have to go out to work when they worked in the field, obviously the children could often tail along behind them, but there was a tradition in England of paying one woman in an extended family to care for all the children, so it could be a sister, a cousin, it could even be a grandmother.

But this created, although they might have been poor or sometimes the kids didn't get enough attention, there would be a group, a kin group of children, and a bonded adult, so really, in many ways that's better than sending a child to faceless daycare. It's a really low, here across the UK and in America childcare is, the parents pay for it. If you're lucky, I think in America you are going to get a creche attached to your job, that doesn't happen in the UK, so parents pay for the daycare that they can afford, so if you've got parents in poverty, often they're paying the lowest price for daycare and that daycare is paying the practitioners the lowest possible money. And those practitioners are, they're moving in and out of those roles all the time because they're so badly paid and they'll get a better job. It really is setting up a child that, if you like, disadvantage leads to disadvantage, leads to disadvantage.

Our prime minister for 60, 30, I can't remember, about 45 days, wasn't it Liz Truss, she was children's minister of 10 years previously, and she was asked, would you send your child to this type of daycare? And she said, “Well, children do get care, obviously I'm not looking after them all the time.” And it came down to the fact she had a nanny. Well fine, they can bond with the nanny. With attachment, what I think this is something that's often missed, the disadvantage often breeds disadvantage all the way along the line because it's about how you fund your family.

Tori Steffen:  Yeah.

Pam Jarvis:  And that is often in direct sort of opposition to good attachment in that first three years.

Tori Steffen:  Right. Yeah, you can see how it could be a domino effect of sorts and it's going to have an impact on the development of the child, and especially around trauma and attachment, so yeah those are important things to think about when you're choosing care for your children. And a really great point about the bonding with a number of adults, I envision just the parents, but it really makes sense to have a larger group of adults that children can bond with.

Pam Jarvis:  Well, granny's are often very helpful in this respect, but as you know, society's getting poorer, then often the grandparents are having to go to work.

Tori Steffen:  Right.

Pam Jarvis:  It's quite worrying, I think what is happening in the current situation where we have rising fuel prices, rising inflation, and it's making families poorer and poorer. And at the bottom of all this, children are suffering.

Tori Steffen:  Yeah, yeah, absolutely. I can definitely see how that would have an impact. And let's say everything goes right and a child does develop that secure attachment. Do you think that a secure attachment leads to wellbeing in school for that child? They can accomplish it a little easier.

Pam Jarvis:  I think they have the best chance of being the best that they can be. If you send them to a really bad school, well then nobody is emotionally indestructible. You can't bank on it, but you've given them the best chance, I think.

Tori Steffen:  Yeah. Yeah, I would agree. I think you're setting them up for success in a way. Yeah, just providing a good development, so I definitely agree with that.

Pam Jarvis:  It's kind of how we see success and success in a life, well it doesn't necessarily mean you went to the best university or you had the highest paying job.

Tori Steffen:  Yeah, very true.

Pam Jarvis:  It's being comfortable to be yourself and you've got your best chance of that if you feel that people like you and that they will help you.

Tori Steffen:  Right. Yeah, just having a healthy perspective on the world, on yourself will have a big impact on what you choose to do in your life, no matter what it may be. All right. Well, Dr. Jarvis, do you have any final words of advice for our listeners or anything else you'd like to share with us today?

Pam Jarvis:  Yeah, I think we have to see children as much more important in neoliberal societies like the UK and the US than we do. They are almost pushed under the wheels of the economy and profit. And we exist in order to make money and to make profit. And in that culture, the children are the ones who suffer the most. I think particularly, we... Actually, today we've had a news article about a private company that we're responsible actually for looking after children in residential care who gave them the most appalling service because their motive was profit. Rather than the quality of the care for children. And I think we are in danger of pushing children under these wheels and just not worrying about the emotional setup we are building for their future, but the only future that any of us have is our children. And I think this is something that we just don't think about enough.

Tori Steffen:  Yep. Very good points there. Yeah, like you mentioned, it's important to just start early so that you're not spending, you have to create all these policies and put things in place for later down the line as far as social workers and wellbeing. It just makes more sense to put the emphasis on child wellbeing during development. It's going to do your children a favor and just kind of well roundly help everything else along the way.

Pam Jarvis:  The economy is for people, people are not for the economy. And I think that's especially relevant to childhood because of the development that they need and the human things that we have to give them to allow them to develop healthily. We pay a lot of attention to physical health, because we can see it. But we don't pay enough attention to emotional health.

Tori Steffen:  Yes.

Pam Jarvis:  And then very quickly, it's coming up to too late. You're going to have to do an awful lot of work to reclaim that child where if you've done it properly first off, then it wouldn't have been so difficult.

Tori Steffen:  Right. Yeah. Well, hopefully parents and teachers out there can kind of develop those tools and skills to help these young kids develop in a healthy way, so thank you so much for sharing all your knowledge today with us, Dr. Jarvis. I've definitely learned a lot and I'm guessing our listeners did as well, so thank you so much.

Pam Jarvis:  Thank you.

Tori Steffen:  Thank you so much, and thanks everybody for tuning in and we'll see you 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.

Social Worker Erin Maloney on the Innocent Lives Foundation

An Interview with Social Worker Erin Maloney

Erin Maloney, LCSW is the Director of Wellness for the Innocent Lives Foundation. She is a licensed clinical social worker specializing in trauma, addiction, ADHD, anxiety, depression, and other mood disorders.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview series. I'm Theresa Nair, 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 clinical social worker, Erin Maloney, who is the Director of Wellness for the Innocent Lives Foundation. Erin earned her Bachelor Degree of Science and Psychology from St. Joseph's University in Philadelphia, and a Master's Degree in Social Work from Widener University in Chester.

She is currently a licensed clinical social worker specializing in trauma, addiction, secondary trauma, ADHD, anxiety, depression, and other mood disorders. Thank you for joining us today, Erin.

Erin Maloney:  Thank you for having me.

Theresa Nair:  Before we get started, can you please tell us a little bit more about yourself and what made you interested in studying clinical social work?

Erin Maloney:  Absolutely. I am a little bit about me. I am a mother of three. I also have a husband and a dog. I live in Scranton, Pennsylvania, like “The Office”. I have always been interested in mental health, actually since a very young age. I told my mom probably about five, six years old that I wanted to become a therapist and she just pushed me along to do whatever I wanted and follow my dreams.

I did, I entered into psychology and I loved it and I worked for quite a bit with my Bachelor's doing case management type work, but I realized I needed to further my education. While I was finished with my Bachelor's, I saw a plethora of therapists in the company that I worked for. It was a nonprofit behavioral health clinic and I saw everybody from LPCs to LSWs, LMFTs, every acronym in the book.

But my immediate supervisor was an LCSW and I found that she had the most, at the time for me, the most variety of opportunities. She could be a director of a program we might have had for behavioral health for children. Or, she could have actually done private practice type work, and I liked that because I could see a lot of settings.

That's when I decided to embark into Widener. I worked full time but got my Master's at night, and I really enjoyed finding that I wanted to keep pursuing from my Masters to license into the clinical license. That's how I got started in it. Always had an interest, always had an interest in people's minds and how it worked.

Theresa Nair:  That's great. It's wonderful when you feel like you're pursuing your purpose and even your calling.

Erin Maloney:  Yes, yes.

Theresa Nair:  For those who are not familiar with your organization, I'm wondering if you can tell us a little bit about the mission of the Innocent Lives Foundation and how it works to bring anonymous child predators to justice?

Erin Maloney:  Absolutely. I just want to say at this point, just a quick little trigger warning. My foundation does deal with trauma related to children and exploitation in any sort of assault. So just a little trigger if anybody is listening in to take care of yourself before or after. I don't think much will come up, but I always like to give that in advance.

Innocent Lives Foundation, what we do is our mission is to do that. We try to get the predators who are hiding online behind the scenes who are trying to exploit children or publish and/or share materials of, we call CSAM, Child Sexual Assault Material. That's our biggest mission is to bring to light the people hiding, to get them out of the dark and get them prosecuted properly.

Now, one of the things I always like to mention is we are non-vigilante. That is a very important part of our mission. We do not set ourselves up as young children. We do not try to entrap perpetrators. This is actually information we find on the open web. It's unbelievable what you would find on the open web, but we use what they call OSINT, which is open-source intelligence. It's basically anything any of us could find on the web, but they know where and how to look specifically for predators laying right within our children.

What we do at the ILF is we get leads and it could be come from, we have a form right on our website that people can enter. It could be a parent concerned about maybe who their children are chatting with. We might get law enforcement to say, "Hey, we could really use some good computer diving hacking skills to find out this case."

Or, it could actually come directly from somebody who might give it to us. Or, our researchers actually are doing the research and they can find a lead. Just be so maybe a username or somebody having an inappropriate photo up. We have, at ILF, different aspects that I wanted to go into because it sounds very confusing. What are you guys doing?

We have three distinct teams. We have what we call The PIT, which is Predator Identification Team, and they're our researchers and they are phenomenal hackers. We call them good guy hackers. They use their skills for good and they're all volunteers. But what they do is they are literally the ones behind the computer doing all the research for us finding this.

We have Education and Outreach Team, which those are our people who are more about putting out blogs, putting out educational materials, fundraising for us. They're really good for caregivers who might be struggling with anything like this.

Then lastly, we have a Development Team and what they do is they actually protect our PIT by developing tools that they can use to protect our PIT people from what they see. One of the big things we have is a blur tool so that our researchers are not seeing actual skin, they just see a blurred image and they can unblur it enough to maybe see a face if they need it, but it's to help them not be exposed to so much content in terms of that.

Those are our three distinct teams, and so what we do at ILF is we all work together in tandem to basically have that one common mission to help bring predators out of the light.

Theresa Nair:  That's great. I mean it's really interesting that you have the blur tool.

Erin Maloney:  Yes.

Theresa Nair:  Because I was wondering, how do you search for this without seeing all of it? So, that would be helpful.

Erin Maloney:  Yes, yes. We very much try to protect. Unfortunately, sometimes the text cases are some of the hardest because you're reading it and your mind goes there, but we still try to protect as much as can.

Theresa Nair:  Is that on the general internet or what's referred to as the dark web?

Erin Maloney:  Yes. Yeah. There is a whole dark web that we are aware of, but we actually try to leave that to law enforcement to do themselves because it is such a gray area. We keep everything above board. Like I said, we're trying to not be vigilantes, not get ourselves in trouble.

Everything people do, even our researchers do things on a device of ours so they're never caught with any sort of material or viewing. We would never want anybody be in trouble of any sort, so everything is done through a computer they have from us with tools and things like that to protect them.

Theresa Nair:  Okay, that's good. That helps to clarify how you even do something like this?

Erin Maloney:  Yes, yes, exactly.

Theresa Nair:  You spend a lot of your time working with volunteers within the organization, the people who are using their skills in order to help identify child predators. You're providing counseling services, I believe. Can you explain why it's important to provide this type of service to the volunteers, and what types of mental health impacts can result from this line of work?

Erin Maloney:  Absolutely. As this started, my CEO he realized quickly, he actually started Innocent Lives Foundation by accident. He is what they call a pen tester. His company does do security breaches for companies to help them learn how to improve the security of their companies.

In doing so, he accidentally stumbled upon child sexual assault material on somebody's device and was able to turn that into law enforcement. It was very validating and reassuring for him and he thought, "I did this so easily, why couldn't we do this as something like a nonprofit or a mission?" He started it from there, which really led to, but he knew the importance of the mental health piece. He said, "If we do this, we have to make sure we're not harming anybody in doing so."

That's how it's always been a proponent since day one. I'm part of every aspect from when they get onboarded. We have a very extensive onboarding. People go through various interviews, and one is a wellness assessment with me because again, we are trying not to damage anybody. If there's significant trauma that's maybe unprocessed or raw still, we're not going to want to have somebody in that capacity working right now with us.

By doing that now you had said, so there's the component of me meeting them early on and then I actually meet with them once a month if they are what we call The PIT, so at minimum they have to meet with me once a month. If you are in another aspect of our team like Education Outreach or Development, you only have to reach out with me once every three months because obviously they're not dealing with the content as much. Like I said, it's different timeframes for different people.

So, that's how I work with them. Now, if somebody has a already current mental health... Now remember, these people are coming voluntarily and not all of them have a psychological disorder. Not all of them have an Axis 1 diagnosis. However, some do and when they do, I make it very clear that I'm more of a wellness piece. If they need extensive work, if there's somebody that I sense needs almost weekly sessions or if they have an addiction they're struggling with or anything even more significant, then I definitely refer them out to a private therapist in their area and/or medication management or other resources.

Then I actually collaborate with any of the people they need me to collaborate with because it is such a unique setting situation. If a therapist needs a little bit of advice or what we do where we do, I'll consult with them as well. I'm involved with them quite a bit, at least once a month and I have a very good rapport with all the volunteers.

Theresa Nair:  Do you find that people may need more services the longer that they do this? Or maybe after particular incidents? Are there maybe something in particular that they find or is it steady?

Erin Maloney:  No, you know what it is? Actually, it's not the work that I notice, it's life changes that impact their volunteering with me. When I say that, we have new parents, for example. Let's say a volunteer has never been a parent, but suddenly they're a parent and they might be one of our researchers. They may not suddenly be able to stomach what they once stomached, and so they may very well say, "I cannot."

We actually have a pause program which is completely non punitive. It's something the volunteer can initiate, or myself if I really sense somebody's just not doing well, I'd encourage that. Really, up to 90 days they can just quietly stay with us. They can join meetings if they want, they can meet with me if they want, but they're not required to do any sort of minimal work for us to keep them active as a volunteer, which is nice.

Then the other option is we also have moving around. We had one PIT member who had a hard time, again with children, and almost sometimes people could actually put their child's face on a victim, which you'd never want to see happen. That is, we never want to damage anybody. So, that person actually still wanted to be with our mission so they stepped aside to Education Outreach and they write educational blogs, or they might speak publicly at a local community event for themselves.

It's really neat. You can still move around and help with that very same mission, but not damage yourself psychologically if you are struggling. I don't find the work... I feel like if people are already here in the mindset to do this type of work, then they've either been exposed to things or they're pretty prepared to compartmentalize their brain to step into this work and step out of this work.

Theresa Nair:  That's interesting because you would assume that maybe it was something that they saw. But it's interesting that it's more life changes that they might be going through.

Erin Maloney:  It truly is. Yep.

Theresa Nair:  And what they're able to view at different points in their life.

Erin Maloney:  We have a very strong level system, that when they start, they start at a very bare... it's more just finding leads. Maybe finding usernames that might be connected to something, and then there's levels. We're not going to have somebody brand new coming in exposed to something that might be very horrific.

I don't even, age is a big factor. Maybe younger children might be too difficult for them, so we're not going to do that. We're going to have them work up in levels and so that they're not really exposed to anything too much too fast because they could process with me the whole time they're doing it whether they're okay or not with that.

I'll check in on them with their case and how it's affecting them and generally fits good and they seem like they're confident with it, then they can move up in the level system, if you will.

Theresa Nair:  Sounds like there's a lot of options for volunteering.

Erin Maloney:  Yes, yes. We do not let it damage or harm anybody because they're helping us. They're volunteering for us, so we would never want to do anything that could hurt somebody.

Theresa Nair:  Okay. I know you've mentioned, and it says on the webpage as well, that you use cognitive behavioral therapy to assist your work with Innocent Lives Foundation.

Erin Maloney:  Yeah.

Theresa Nair:  Could you talk a little bit about how you use that, and then also if there's any other techniques that you find to be productive?

Erin Maloney:  Absolutely. Like I said before, my wellness sessions are typical check-ins. How are you doing, tell me what's going on in your life? But what I listen for and people know, all the volunteers know I use cognitive behavioral therapy because I'm listening for any sort of negative or illogical thoughts and they know that and they know when I can pinpoint that, what I might hear.

If I sense that somebody's really struggling with something, then we will start using cognitive behavioral techniques to see if we can figure out whether this is something more pressing, either a budding anxiety disorder. Or, if this is just something in their lives, maybe an adjustment to something that they're dealing with.

I do a lot of reframing. If I initially hear them say something negative, I might put it in a different reframe. If they're like, "Oh yeah, yeah, yeah" and they get that and I don't hear it again, then I realize they might have just been dealing with something. What I do a lot of with the volunteers is activity scheduling in terms of cognitive behavioral therapy. Because what we do is you would not be able to necessarily do this work in front of your family in the middle maybe of a work day. There's a lot of this content that cannot be exposed. We have to activity schedule, is it best to do this maybe an hour? But you don't want to do it right before bed either. Maybe there's an evening hour that this is best for. Or, perhaps you have a quiet hour in the day with nobody around you. We do that to find the best for a person to pick the time that they can do this type of work.

Role playing. If somebody's struggling with anything really in their lives, but in particular maybe wanting to switch gears in ILF, I might help role play with them. Maybe if they want to approach that with our COO and how they might be able to switch over into a different capacity.

So, I do a lot, now again, if I sense it's something more, then I will encourage them to seek out therapy on an ongoing basis so they can do real true weekly or even twice a week sessions if needed. But generally with some cognitive behavioral therapy, I could figure out if it's something more or not, and that's what I tend to do.

Theresa Nair:  Okay, and do you tend to see any increases in anxiety or depression from the volunteers when they work for maybe an extended period of time on this?

Erin Maloney:  Well, it's funny you said that. If I do sense that, then that's again where I will go into that pause option. "Hey, do you need to pause? Are things getting too much for you?" But it's funny you say that, I've actually seen it go both ways. Where I've seen it in the negative might be, again, if they have a, let's say they're starting a new job position and this is their volunteer position, they might have too much on their plate and so their anxiety's increasing and then they have guilt about not doing their volunteer work, then there's all that.

If I sense that, then we definitely encourage a pause and again, a pause could be 30 days. It doesn't have to be 90 days, but we just encourage that you take a little mental break, take a break from us and come back when you're refreshed and ready.

However, it goes on the other side where this work is very validating sometimes. Because a lot of our volunteers may either have been a survivor of assault in their past. They could have been groomed as a child themselves, or they have a family member who this maybe impacts. When they have a case that's a win, that is completely validating. It's a way to take power back from maybe where they've felt powerless in their past. It can actually be very, very good mentally as well.

The only struggle with that is the reality is we don't always get feedback from law enforcement of how our case is? We hand in a report to law enforcement, but it might not always be clear whether that case went to trial, whether that person was convicted.

We don't always get the information, and so I have to make sure the volunteer's okay with that, that we're not always going to know every win. Are you going to be able to stay motivated on cases you don't know the answer to? There's a lot of areas to poke around in there.

Theresa Nair:  That is interesting. There's that sense of empowerment, right?

Erin Maloney:  Yes, yes.

Theresa Nair:  When they're able to do something, but I'm sure it's a little frustrating when you just never know what happens?

Erin Maloney:  Yes. Exactly, exactly. But that's not our role. We don't want fame, we don't want to be associated with putting somebody away. We are really truly just totally behind the scenes trying to help. We have the computer skills to find a lot of people and we try to hand that over to law enforcement, and so we don't always get the answers.

Theresa Nair:  Do you think there's other areas of volunteer work, or perhaps other professions in general that would benefit from providing these types of mental health services to volunteers or to employees?

Erin Maloney:  Yes. It's funny you say that. We have some volunteers who are either currently or ex-military, or current or ex law enforcement. They have said many times that if they had somebody at their office to talk to, it could have made a major difference for them with some of the things that they endured or witnessed.

I know there's a lot of EAP programs for companies, but I think there is something at me being here every day for them that makes a very big difference. They just know. I get to know them very well. It's a stable, long-lasting relationship, and so they don't have to re-explain themselves to somebody new. I'm part of the team itself and employed there, so it makes a big difference I think in that consistency that they know I'm here and they could come to me at any time.

Theresa Nair:  It seems it might also be beneficial that you have a regular scheduled monthly meeting at least with everybody.

Erin Maloney:  Yes.

Theresa Nair:  Because I think sometimes in workplace mental health services, people are afraid to use them because they're afraid of being stigmatized even if somebody sees them going to talk to the person, or if the boss finds out that they're talking to the person. Do you think it's helpful just going ahead and scheduling appointments with everybody?

Erin Maloney:  Yeah, I really do. It's so funny you say that. Yeah, because I could definitely tell there's a resistance. Our team, for the most part, it is a lot of people who happen to be in cyber security type industry. When you're in that industry, you actually tend to be, not to stereotype an entire group, but sometimes you tend to be introverted and private.

Therefore, I do think this forces people a little bit out of their comfort zone and then they do realize, "Oh, this isn't so bad." Because I'm not deep diving way into their past, Freudian style. It is non-confrontational. I go at their pace and whatever they choose to talk about. Obviously, we talk about case work, but anything else they might need to address.

It gives them a huge shift if they already had a fear or resistance to therapy where it's not so bad for them after a while, once they get to know me better. Yeah, I agree. I think it's very good that it's almost forced upon them and I send out reminders and I reach out.

If they avoid me after a certain amount of time, then we have to do the whole, "Are you trying to pause? Is there something you need?" So, it's nice, but that's rare that I don't hear from somebody

Theresa Nair:  Then it's, "Well, I'm talking to her anyway. I may as well have a real conversation, right?"

Erin Maloney:  Exactly. The other thing to this is that again you mentioned, you asked about different fields. Well, law enforcement or some other heavy content type professions, they can't turn to their family or their loved ones and just spill what happened in their day, similar to this type of work. They're not going to turn and say, "Guess what this case is about?" You can't. You want to protect your own loved ones and family and friends.

A lot of our volunteers are anonymous, so this gives them a direct place to process what they need to process without feeling they're burdening anybody. Without feeling like they're going to hurt or harm anybody. It's just a safe space for them dedicated to them, and I feel like it gives them that open door.

Theresa Nair:  Then they can talk about that case work that they maybe couldn't discuss with other people.

Erin Maloney:  Exactly, exactly.

Theresa Nair:  I think that's a great model. I wish more places would do that.

Erin Maloney:  I do too. I do too. It's very nice, and I do feel like with law enforcement in particular, I think of that field and just the things that come home from, or anybody on the front lines really. After a really rough day of what you might witness or see or hear, and then you have to go home with that.

That's where I feel for people when they don't have any place to just unload that on, and making the time. That's the other thing you had mentioned. We all have a hard time making the time, and at least with this, it's mandatory so it's part of your volunteer. We ask people to volunteer if they're volunteering with us for about 10 hours a month if possible, but that includes a lot.

We have a team meeting, which is once a month. We have myself, would be an hour so that's already detracting right off their volunteer hours for us, so it helps that it's just built right in for them.

Theresa Nair:  Right, and then they don't have to take the initiative to seek out speaking to somebody. It's just a part of it.

Erin Maloney:  Exactly, exactly.

Theresa Nair:  Well, as someone who specializes in cognitive behavior techniques to support the mental health of those engaged in volunteer work, do you have any parting words of advice or anything else you'd like to share with our listeners?

Erin Maloney:  Sure. I mention this to volunteers all the time, and I would like for your listeners to know. I think balancing life is the key. You really have to balance your life, and volunteering is actually a very worthy and beneficial cause to you. This really helps fuel your soul. But if the plate's full and you just need to get rid of something, then that's generally, unfortunately some self-care things or things we do for ourselves might be some of the first things to go.

So, I just always say, "Stay balanced." But if you are realizing you can't manage everything, you can't problem solve, you're losing your focus, you don't want to burn out. Really, I always say we cannot, you do not want to burn out. Before you start, that's where, going back to the cognitive behavioral I therapy, I listen for the negative.

If I start hearing negative comments and negative thoughts that are just kind of untrue, I really try to help reframe. But if it's not possible, then we have to look at what they might have to cut out of their lives? What they might have to do to manage things? Balancing life, self-care is very important, but you need to know when you need to step back and maybe make some changes.

Theresa Nair:  That's great advice. Well, thank you so much for making the time to speak with us and participating in our interview series.

Erin Maloney:  Thank you. Thank you for having me. I just want to make sure I tell you guys that you can always go to our website, innocentlivesfoundation.com. There are great resources and tools on there. If anybody ever had to make a report of anything they were concerned with, again, it could be a parent, a caregiver, a teacher.

If somebody's concerned about maybe what a child's posting or who a child's speaking with or they're unsure of things that are online, you can always submit a report right there and we'll reach out and see what we can help investigate for you. Please use us as a resource as needed. Again, we have great blogs and articles on there and things that you might find very helpful.

Theresa Nair:  That's great, and we will also link to that website underneath our interview so that people can find it easily.

Erin Maloney:  Wonderful. That sounds great.

Theresa Nair:  Okay. Thank you so much for joining us today.

Erin Maloney:  Of course. Thanks for having me.

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 Jonice Webb on Childhood Emotional Neglect

An Interview with Psychologist Jonice Webb

Jonice Webb, Ph.D. is licensed clinical psychologist located in Boston. She specializes in identifying and treating childhood emotional neglect.

Preeti Kota:  Hi, I'm Preeti Kota, and I'm a research intern here at Seattle Anxiety Specialists. And today I'm joined by Dr. Jonice Webb. Dr. Webb is a licensed psychologist whose interests concentrate on childhood emotional neglect. She's a speaker and bestselling author of two self-help books, Running on Empty: Overcome Your Childhood, Emotional Neglect, and Running on Empty No More: Transform Your Relationships. She has increased awareness of the effects of childhood emotional neglect, and trained hundreds of licensed therapists in identifying and treating childhood emotional neglect in their clients. Dr. Webb, would you like to introduce yourself and share a little bit about your research?

Jonice Webb:  Yes, absolutely. Thanks for having me on. So, I am a licensed clinical psychologist located in Boston, and I've been practicing psychology for, I hate to admit it, but probably like 25 years now. And during that time, having worked in a lot of different settings, I noticed that I started seeing this pattern among my clients, and I got very curious. What is causing this particular group of symptoms to appear in people that seemed to have nothing in common? Otherwise they were from different socioeconomic backgrounds, different cultures, different diagnoses, different types of families, and backgrounds, and yet I kept seeing it over and over. And I just got very curious and started trying to figure it out and eventually realized that what I was seeing was a very pure form of emotional neglect that all these people had in common in their childhood homes. And when I saw that and realized what it was, I started doing research among the databases of the American Psychological Association, trying to find research on emotional neglect, specifically childhood emotional neglect in its pure form.

Meaning not necessarily accompanied by abuse, but just, and not physical neglect, but just pure emotional neglect. And I realized that there really wasn't... It wasn't being talked about it. Wasn't being written about it, wasn't being studied. And that's when I realized I needed to write my first book Running on Empty and it's just taken off from there. And so at this point, then I wrote another book and that was in 2012. In 2018, I wrote Running on Empty No More: Transform Your Relationships, which took the concept and applied it further. And I have a blog on Psychology Today and emotional neglect recovery programs on my website. So it's pretty much everything I do now. I'm very passionate about it.

Preeti Kota:  Wow. That's great. So to dive into the questions, can you talk about the process of early childhood emotional neglect, leading to a lack of self-trust?

Jonice Webb:  Sure. So, childhood emotional neglect happens when a parent fails to respond enough to the feelings of their child. And it doesn't have to be zero amount that they respond, but parents who tend to minimize the importance of feelings, or are even blind to feelings. And there are many, many people in this world who are good people who want to be good parents, but who just don't understand that emotions matter so much. So, when they're raising their child, things like just ignoring the child when they're really upset about something, pretending not to see it, or just not seeing it, not asking questions, not being interested in the child's inner life, or what they're experiencing and not responding to that. When a child grows up this way, they tend to get the message that is not necessarily ever said out loud, but is communicated by a lack of asking the right questions, and saying the right things.

So, sort of like if your parents just pretended that your right arm didn't exist, and just acted as if it wasn't there, you would grow kind of ashamed of your right arm. And you would be like, "Why do I see this, but no one else does?" And you'll try to hide it from other people and from yourself. And that's what children do when their feelings are ignored is they get the message their feelings are irrelevant at best, or bad at worst. And then they block them off so that they won't get in their parents' way. They won't have to deal with them themselves. They just sort of build this wall inside their brains, not consciously, it's just sort of an adaptive mechanism so that their feelings are cut off, and this might get the child through their childhood, but it doesn't really work as an adult because we really need our feelings.

Our feelings are the deepest expression of who we are, and they provide us guidance, and motivation, and all sorts of connection and great things that are really important as we go through our adult lives. So people who grow up with their feelings cut off, don't even realize it don't remember anything happening to them that could make them have problems in their adult life necessarily, and end up just sort of secretly struggling with it, and not understanding what's wrong. And that is the essence of childhood emotional neglect. It plagues a lot of people who aren't aware of it.

Preeti Kota:  And is it the parents that have the most impact on childhood emotional neglect, or can older siblings, or friends have the same effect?

Jonice Webb:  That's a great question. It's primarily the parents, because the human infant is wired to need affection, and emotional connection from their primary caretakers, which in most situations are the parents. Sometimes there can be like, I've heard stories of a nanny providing it when the parents couldn't so there could be a substitute stepping in to provide it, but to be deprived of it, it really is to be deprived of it from your parents.

Preeti Kota:  And then do those with childhood emotional neglect tend to be more prone towards any comorbid mental health disorders, such as anxiety or depression?

Jonice Webb:  Yes. First I want to say all people with childhood emotional neglect, which I call CEN, do not... It's not like everyone develops a comorbid disorder. I've seen lots of CEN people who don't have any history of diagnosis and don't qualify for one when I see them. But nevertheless, they're struggling in various ways, but it does make you more prone to both depression, and anxiety. And I think that it's because when you have your feelings walled off, you're not processing them as you go through life, which most people just do naturally, you get upset, you deal with it, and then you've dealt with it. So you move on. But when your feelings aren't, when you don't have that natural connection with your feelings, they just all sort of pool together on the other side of the wall.

And because you're not aware of them and you're not connected to them, they just kind of mix together and they can turn into basically three things that I've seen, depression, anxiety, or irritability. Some people just become very irritable people, and it's because they haven't dealt with their feelings, or they'll end up depressed or they'll end up having anxiety, free-floating anxiety, or anxiety about certain things. And it's because they haven't dealt with their emotions.

Preeti Kota:  Is there a certain factor that makes a person more prone to having irritability, or anxiety, or depression in reaction to the same thing?

Jonice Webb:  I wonder that myself, I wish I knew the exact answer, but I don't, but I can tell you what my hunch is, which is that it depends on the nature of the walled off feelings. If most of your walled off feelings have to do with sadness or loss, I think you're more prone to depression. If most of your walled off feelings have to do with fear, or trepidation, or any of the sorts of fear based types of feelings, you're more prone to anxiety. And if it's more anger, you're more prone to irritability. That's my guess.

Preeti Kota:  Interesting. So, how do you not confuse following, or listening to your emotions as a source of guidance with giving into your impulses?

Jonice Webb:  First, I'll just explain that one of the things I talk about a lot and try to teach people to do is to pay attention to their feelings, and to listen to them. So I think that's what you're referring to here in this question, and to follow them. But that doesn't mean just like knee jerk following, because emotions can be excessively strong. They can be misplaced at times. And sometimes we feel things really intensely that actually are, we're feeling it so intensely because it's touched off something from the past that we haven't dealt with that feeling enough yet. And so that feeling attaches itself to the current situation, and makes you feel you can have big feelings over something that seems kind of ridiculous, or small. And it's because it's just blown out of proportion by the past. So, there are many reasons why we can't just knee jerk trust our emotions.

So, the way it works well is to take note of what you're feeling, process it with your head, meaning, think it through what is this feeling? Because every feeling is a message from your body. So what is my body trying to tell me here, by making me feel angry right now, could it be this, could it be that? And you sort it out with your head, and then you say, should I be angry right now? Actually, yes, I should. Someone just insulted me. What should I do? And then you think it through, and that way your body informs your head, and your head informs your body, and the two work together to make a good decision, and choose a correct action or the most correct that you can.

Preeti Kota:  How do you find the balance of if you are using your head too much, it's like overthinking, but if you're using your emotions too much, it's kind of impulsive?

Jonice Webb:  Yeah. Well I think we all struggle with that, and it really is a matter of just trying to really consciously do this process enough that you get better, and better at it. And we all are going to mess it up. We all do. There's no way to be perfect at this, nor should anyone expect themselves to be. Really for every human being who's alive, it's a work in progress. Getting our brain to work with our body, to get good results is the essence of being healthy, and living well.

Preeti Kota:  And then how does indecisiveness relate to people's inability to trust themselves?

Jonice Webb:  So when your feelings, so our feelings, as I said a minute ago, really inform us, and they're our guide to what we really want, what we need, what we like, and dislike what we care about. It all is communicated to us through our feelings. And so when you're cut off, I think cut off is a strong word. When you don't have a good connection to your feelings, then you don't really have the sort of weather vane that your feelings should be providing you. Your feelings, or the rudder is what I meant. Not a weather vane. Your feelings are your rudder. And so to use a boat metaphor. So it's very important to be able to consult your body, and get answers that come from your deepest self, which is your feelings. And if you don't have a good ability to do that, it's kind of consulting your gut, right?

A lot of feelings occur in our gut. We now know there are neurons in our guts, in our GI system. And there's a reason why you feel things in your gut, but if you're disconnected from your feelings, then you're disconnected from your gut, and you don't end up trusting yourself nearly enough when it comes to making decisions. And you're much more vulnerable, and prone to asking other people, "What do you think I should do? What do you think? What do you think of this? What do you think of that?" And that's a kind of dangerous way to live because people can have all sorts of opinions and it doesn't mean it's right for you.

Preeti Kota:  So then how do you start to trust yourself if you think you're going to make the wrong decision?

Jonice Webb:  Get in tune, get in tune with your gut. And start the process of healing childhood emotional neglect. It really involves getting in touch with your feelings, starting to value your feelings more, and paying attention. I've probably told hundreds of people with childhood emotional neglect, what does your gut say? Let's ask your gut about that question. And it's a foreign, it can feel weird at first, but if you do it, if you keep doing it, and keep paying attention to your feelings and processing it with your brain, it's a matter of practice, and changing old habits and filling them with new ones.

Preeti Kota:  And then how are self-trust, self-esteem, and confidence related?

Jonice Webb:  When you have a good gut sense, and you trust your gut. No one's gut is right all the time. When you trust your gut, you're trusting your feelings, and you're trusting yourself, and you're valuing your own internal world, and your own internal process and sense of self. So when you have that, you trust yourself, and you can feel more confident. And that leads to all sorts of good things, feeling comfortable in your own skin, feeling comfortable around other people. It's the process of overcoming social anxiety, just becoming comfortable with who you are and trusting yourself so that it all goes together.

Preeti Kota:  So, you would say the first, are they kind of linear or..? Like increasing your self-trust, leads to an increase in self-esteem?

Jonice Webb:  Yes, I would say so.

Preeti Kota:  Okay.

Jonice Webb:  Vice versa though. It goes the other way too.

Preeti Kota:  Okay. How do you break the habit of dismissing your feelings to start accepting them?

Jonice Webb:  Yes, that is a whole process. I developed this technique for people to use, it's called the identifying and naming technique. It's in, I think I have it in both of my books, but it's definitely in Running on Empty. And basically it just involves turning your attention inward, and checking in with yourself and asking yourself, "What am I feeling right now?" And then following that up with some other questions that help you identify why you might be feeling it and what it's coming from. And just doing that check in with yourself if you can make yourself do it several times a day, even starting with once a day or at whatever level you can handle.

And it's okay if you come up empty and it doesn't feel like you have a feeling, because a lot of people with emotional neglect have that experience that they ask themselves, "What am I feeling?" And that they come up with nothing. But if you keep doing it, and keep trying to tune in, it's sort of like that process, it's so simple. But what you're doing is you're connecting your brain and your body. And every time that you try to forge that connection, you're chipping away at that wall that's blocking the two off. And even if you don't come up with a feeling, you're making progress and you just have to keep at it, keep at it.

Preeti Kota:  Is that kind of related to mindfulness?

Jonice Webb:  Yeah. It's a mindfulness technique, because basically you're turning your attention inward, and you're putting your full focus on your inner world. And that's something with people with emotional neglect are usually not very good at because they're used to focusing outward. Everybody else is what's important. Everybody else, everything else, the outside world, and this kind of makes you look inside at yourself.

Preeti Kota:  So, how does the need to belong relate to the need to trust yourself? Are they conflicting?

Jonice Webb:  The more you trust yourself... So, interestingly, I'm going to start somewhere else for a second. Interestingly, people with childhood emotional neglect have a proclivity to feel out of place. And they tend to have an almost verging on social anxiety, if not social anxiety. And it's because they feel disconnected from... They feel like when you have your feelings blocked off, some part of you feels something's not right. It's like you're missing something that everyone else has. And I've heard many emotionally neglected people put this into words and say, "I feel like I'm on the outside looking in on everyone else who's really living life." Or "I feel like I'm living in black and white and everyone else is living in color." Or "I walk down the street and I see other people smiling, and laughing, and walking together. And I feel like, why can they do that so easily? It doesn't come easily to me."

And when you're cut off from your feelings or disconnected from your feelings, it can feel like you're different than everyone else, and something is secretly strangely wrong with you. And that makes it hard to feel like you belong anywhere. And it makes it hard to feel like you can be yourself in any social situation. So, you can end up feeling like you need to be a certain way, or do a certain thing, or act a certain way in order to get accepted and fit in, because you just haven't figured out yet that what you need is just to be your true self, which includes your feelings, and your thoughts about those feelings, and that whole process that you're skipping over in your life it's needed in order to be able to be your true self and feel like you really belong and are worthy.

Preeti Kota:  But what about when during childhood, when you don't really have that mindfulness technique in hand, and you feel like with friends, or something and you feel like you want to belong, but you don't really know how to trust your feelings first?

Jonice WebbThere's no simple answer to that. I mean the real answer, the real, real answer is really work on being your true self. If you are your true self and your friends reject you, it means you're with the wrong people, and that's all there is to it. It doesn't mean you're bad. It doesn't necessarily mean they're bad. It just means you're trying to squeeze yourself into the wrong space with the wrong people. And it's hard to find the right people unless you are being your true self, and showing who you are so that those people can connect to your true self.

Preeti Kota:  How do you change your existing relationships with people who have already learned that you distrust yourself, and therefore don't respect you as much?

Jonice Webb:  Well, I think the most important thing to say about that is that people read each other on all sorts of levels that are not conscious. And we tend to trust people as much as they trust themselves. So, we sense how much someone trusts themselves, and that's how much we trust them, and how much we respect them. And so the best way to help people around you trust you more is to be yourself more, and to show your own true feelings more. And that doesn't mean all the time, just impulsively. It means being in tune with yourself so that other people can be in tune with you. And when people feel truly in tune with you, like you're authentic, and you're being your real self and they're allowed to see who you are, that's when they really value and trust you.

Preeti Kota:  But how do you overcome the possibility of rejection, or invalidation when you show your true self?

Jonice Webb:  It's always possible. And so part of this has to do with believing, with accepting who you are, and how you feel about things. And if there are things about one's self that you don't like, then you can work on changing yourself. You can even change your feelings to be the way to feel about something the way you want. So, in a way we all shape ourselves, but in order to truly shape ourselves, we have to be in touch with who we actually are, what our feelings are, and who we want to be. And so the key really is to tune into yourself, believe in yourself enough that if someone does reject you, you're able to weather that and say, "Okay, I guess that person doesn't value who I really am. Is that someone I really wanted to be in my life anyway?"

Preeti Kota:  And then a lot of people have a self critical part of their self that makes it hard to believe in themselves, so how do you suggest overcoming that?

Jonice Webb:  People with childhood emotional neglect tend to be very, very hard on themselves, and it could be, they had a critical parent and they internalized that. Or it could be that they had zero, or very little feedback about themselves growing up, which is true for many, many people with CEN. And if you're a child growing up and you don't have much feedback coming in, if your parents aren't giving you observations about who they see that you are, if they don't see your deepest self, and reflect that back to you, as a child, you have to fill in all the blanks, and children can develop a very harsh internal voice that's sort of like their creation of the parent they need. And that parent, kids don't really know necessarily, especially if they haven't received it, they don't know how to accept, or they don't know how to talk themselves through a difficult situation or a mistake. So it just turns into the mean parent, "What an idiot. How could you do that?" Talking to oneself the way you would never talk to a friend.

And so that can be a hard thing to overcome, except that the more that you can value yourself, and listen to yourself the more, and actually deal with your own feelings, then you can also start challenging that voice, catching yourself when you hear it, or catch yourself when you use it. And really start talking back to it, and say things like, "It's not true I'm stupid. Everybody makes mistakes." It really is a critical voice or a critical part of yourself is a really difficult thing to beat back, but it's absolutely not impossible. I've seen many people do it just by doing that whole process I just described.

Preeti Kota:  So I think you've already touched upon this, but what strategies do you have for listening to your emotions and turning inwards specifically any daily habits?

Jonice Webb:  Yeah. Doing that, identifying and naming, I think is the number one thing to do. The technique where you tune in and ask yourself, what am I feeling? And then there are other things you can do once you are identifying some feelings which involve processing the feeling and asking, and I created this technique also called the IAAA, where you identify the feeling, you accept it for what it is. Then you attribute it to a cause, and then you decide on an action. So that whole process pulls your brain and body together to start using your feelings instead of just shoving them away. So, practicing that another thing people can do is try to start identifying what other people are feeling, and if you're too good at that, it's not something to do, it means you're over focused on other people.

But just becoming aware of emotions, watching how other people handle their emotions, watching for emotions and other people, and what they do with them can be very instructive. I call it becoming a student of emotions and feelings. And just starting to... Once you make up your mind, I'm going to learn everything I can about how emotions work, what I'm feeling, and how my emotions work. Once you declare that to yourself, and start tuning in, it's really a great start towards fixing everything that didn't happen for you as a child.

Preeti Kota:  So, would you say, I think we touched upon this earlier, but about balancing between the mind and your emotions, would you say that's like the rational and irrational split or I don't know.

Jonice Webb:  Not necessarily, because feelings are not always irrational and thoughts are not always rational, so I wouldn't put it in that camp.

Preeti Kota:  Okay. And then do you have any parting words of advice or anything else you'd like to say to our listeners?

Jonice Webb:  Sure. I just want to emphasize that emotional neglect, childhood emotional neglect is not something your parents do to you. It's something they fail to do for you. And so it's not an act, it's not something that happened to you. It's something that failed to happen for you. And because of that, your brain as a child, doesn't record it, and then as an adult, it's really hard to remember childhood emotional neglect happening to you, because it wasn't an event. It was a non-event, right? And our brains don't record things that don't happen. So, it's hard for people to know whether they have childhood emotional, neglect or not, but people can go to my website, and take the emotional neglect questionnaire. And that will give them an idea of whether they fall in this camp or not. And when they take the questionnaire, they'll also be a member of my newsletter, and they'll be kept informed of every blog I write on Psychology Today, and every interview I do, and everything I write, and talk about, so.

Preeti Kota:  Great. Thank you so much. I learned a lot about childhood emotional neglect, and I think it's very helpful for people to go back and see how that could have affected them today and definitely has a very influential impact on our daily life. So thank you so much.

Jonice Webb:  Absolutely. Thanks for having me.

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.

Physiologist Jagmeet Kanwal on Music in the ICU

An Interview with Professor Jagmeet Kanwal

Jagmeet Kanwal, Ph.D. is an associate professor in the department of neurology at Georgetown University. His research focuses on the auditory processes involved in the coding and decoding, neural integration and perception of communication sounds, specifically the effects of music on patients in the hospital ICU.

Preeti Kota:  Okay, thank you for joining us today. Hi, I'm Preeti Kota and I'm a research intern here at Seattle Anxiety Specialists. I'd like to welcome with us, Dr. Jagmeet Kanwal. Dr. Kanwal is an Associate Professor in the Department of Neurology at Georgetown University. His research focuses on the auditory processes involved in the coding and decoding, neural integration and perception of communication sounds. A deeper understanding of these processes can provide new insights on speech and music perception in humans.

Today, we are going to discuss his ongoing study on how music may help overcome pain perception and produce physiologic and metabolic changes that facilitate recovery in ICU patients. Before we begin, can you please tell us a little bit about yourself, some of the work you've done, as well as what got you interested in studying for a doctorate in physiology and zoology?

Jagmeet Kanwal:  Hi, Preeti. Good to be participating in this and have the opportunity to talk to you about some of our work. I'm originally from New Delhi, India, and I came to the United States to pursue graduate work in neuroscience. I was fascinated one day to visit a research laboratory when I was a kid. Where cats were walking around with some contraption implanted on their heads, that was the work of a well-known physiologist, Dr. Sheena at the All India Institute of Medical Sciences in India, who was studying the feeding and satiety centers in the hypothalamus. He later also did research on yoga and meditation and how some of the yogis would lower and even stop their heartbeat, simply by meditating.

So I was fascinated by all of this type of work and decided to pursue my own career in neuroscience. As a kid, growing up in the late 1960s and '70s, I was very interested in all things nature and particularly in animals and animal behavior. And so when I got the opportunity to do graduate work in the United States, neuroscience was not yet well-established. I wanted to understand how the brain controls behavior, and had the good fortune of working on my doctoral work in the Department of Zoology and Physiology at Louisiana State University in Baton Rouge, Louisiana.

This was a perfect environment because it not only kept me in touch and learning more about animals, but also getting a deep understanding of physiology and particularly of neurophysiology as a basis of guiding behavior. Some of my earlier work related to understanding how sensory systems work. I initially started studying chemosensory systems in fish, and then became interested in the auditory system, which was an excellent system to study in bats, because bats use this to echolocate, which means they can literally see their environment with their ears by producing sounds.

Fast forward to my appointment as an Assistant Professor at the Georgetown University Medical Center, where I became interested in how humans use sound. One of the most intriguing ways in which humans use sound is by producing music. So I began to wonder why do humans produce music, how the brain processes it and how does it affect our physiology? At that time functional MRI was a relatively new technique that allowed us to peer into the brain and in humans for the first time and see the processes involved in sensory processing, perception, learning and memory, and many other behavioral functions. We used both functional MRI and electroencephalographic or EEG studies to learn more about auditory processing of musical sounds. The current study on ICU patients is then a continuation of some of that early work on the perception and imagery of music in normal individuals.

Preeti Kota:  Wow. I love how that all connected and you're basically just doing what got you started or interested in your career, but it's very fascinating, all the projects you mentioned.

Jagmeet Kanwal:  Yeah. It's a gradual continuation and transformation of, as you go along and learn new things, as I'm sure you will also discover as you pursue your career.

Preeti Kota:  Yeah. So my first question is, can you describe your current study about how music may help to facilitate recovery in ICU patients and what you expect to find?

Jagmeet Kanwal:  Yeah, so the current study was partly inspired by the work of Julia Langley, who is the Director of the Lombardi Arts and Humanities Program in Georgetown University. And so we met actually a few years ago when she was leading a tour at the art museum, at the Smithsonian Gallery. And so we started talking and then one day we met and this project was born.

So for many years, actually, she and her predecessors at the Lombardi Arts and Humanities Program had been using music to enhance and improve the hospital environment for those recovering from anesthesia and other life-threatening diseases at the Georgetown University Medical Center. So together with her interest in the arts, in the medical setting, and my background on the auditory system that I just explained, we decided to examine how music might affect the physiologic and metabolic processes during periods of high stress in one's life.

We were also inspired by the work of Andrew Schulman, a professional guitarist and musician in New York City, who had a close brush with death at the age of 57. He survived the incident against all odds with the help of music. The physicians hailed this as a medical miracle. Once he had recovered, Andrew resolved to use his musical gift to help critically ill patients in the same ICU where music had helped save his own life. Later, he wrote a book titled Waking the Spirit. That's the one over here. And in this, he related his experiences and efforts to help people recover from their trauma in the ICU setting with the aid of music. In his book, Schulman posited that the relationship between the pain we feel and the songs and compositions we love has its roots in a tender transcended form of symbiosis.

So in our study, funded by the National Endowment for the Arts, we wanted to understand the physiological and neural pieces of this symbiosis and how music can trigger healing and save someone's life. We postulated that if music can indeed trigger this or play this role, it could improve the lives of many and save millions of dollars in drugs and the costs associated with patients having to stay in the ICU or hospital environment for a long period of time. From a purely scientific perspective, it was intriguing also to think of how music, something that is apparently a human creation, primarily for our entertainment, can indeed play such a vital role in our health and recovery.

By our study, we therefore expect to discover some of the brain and bodily mechanisms that play a role in our wellbeing and the processes by which music can intervene and facilitate recovery.

Preeti Kota:  Oh, wow. That's exciting. I didn't even know he wrote a book actually.

Jagmeet Kanwal:  Yeah, he did. He has created now the music for our study. He specially created that and recorded it and we now have a CD. So we are going to play his music that he created using his eight-string guitar, I believe. And so he has some kind of an idea of how the music should be, in this particular situation to help the patients, because he actually goes around and plays music to, he said he's done this to thousands of patients. And in fact he now has this organization called Medical Musicians who actually are now trained in this particular setting to use music to help patients and physicians who have experienced and seen his work and seen the effects, they obviously believe in it. So that's going on, at least in New York City, and probably even more outside other cities now with his establishing this particular group of people.

Preeti Kota:  Yeah. That's really inspiring. Would you mind just going into a little more detail about his journey and inspiration for starting this kind of...

Jagmeet Kanwal:  I don't know too much about him, but we have talked and met and he has played the music to me. And from what he explained to me, he was in a coma for many days and was not coming out of it. And so then the physicians were getting worried and his wife was getting worried. And then one day, she went to the physician and she said, "I know he loves music. And there is this piece that he used to play frequently and likes it a lot. So can I actually play this in his ear?" And so they said, "Okay." And so apparently after she did that, that started triggering his recovery. So everybody was pretty intrigued by this happening. And since he was a musician himself, he really understood how music affects him. And he felt that if music can be so beneficial to me, then why not help other people? So that's what he's been doing.

Preeti Kota:  Wow. Okay. That leads me into my next question that, are certain types of music more beneficial than others? Or is it dependent on the individual person and their personal likes?

Jagmeet Kanwal:  So we don't yet fully understand the biological mechanisms by which music plays a beneficial role, but clearly, certain types of music are more effective or different in different situations. For example, there are some common elements in religious music around the world that help to soothe and calm our nerves and reduce anxiety. Music is of course very rich and its acoustic content can be used both for our wellbeing and also to excite and energize us to act. Not only to celebrate at weddings and other situations, but also sometimes to kill others, as is the case with war music that is prevalent in all cultures.

So sounds and music are really fascinating and that's really why I continue to study that, because it has such a powerful effect on us. And it's something that we can create. We have the ability with our own body, with our own vocal organs. We cannot create light, but we can create sound. And so it creates some kind of a feedback loop that perhaps gives us the ability to modify our own feeling. So we may dance at a wedding of a close friend or relative, but also engage, as I mentioned, in war dances to attack our enemies. It's all in the sound. How the sound is used, what type of sound is used. And that's what, therefore, is very interesting to see how the brain is wired up to use these different types of sounds.

Preeti Kota:  Do you think that music, in terms of your experiment and study, is it more helping patients through relaxing their nerves or exciting their nerves?

Jagmeet Kanwal:  Actually, that's a very interesting question. In talking to Andrew, he said the way he is creating music is actually to do a little bit of both. So when a patient is in a coma, you want to do a little bit of excitation to wake up his brain and certain parts of the brain that might be involved in the healing process. The way I believe that he has created his music is to, a little bit stimulate the person, get him excited a little bit, but then also calm down. So it's a process of push and pull, perhaps. And then he also has in fact different music pieces that he created for playing in the morning versus in the evening, when you want the person to have a good rest and then be able to recover from the day's stress and going through all of the treatment that they're probably going through. That's the way it's supposed to work.

Preeti Kota:  Does the excitation part occur simultaneously or before the relaxation part?

Jagmeet Kanwal:  I think it's alternating between those two, so you want to excite the person a little bit, but you don't want to excite them too much. We know, for example, rock music, when you play that, literally your heart starts to beat faster. So one of the ideas is that the beat of the music directly affects your rate of heartbeat. That is why a lot of the dancing type of music has a faster beat, as compared to more relaxing classical music or religious music has a slower and a different beat. So beat has a lot to do with it, in addition, of course, to the harmony of the sounds.

So he does a little bit, because you want to, for example, you may want to stimulate the heart a little, but you don't want to do too much so that you don't want to increase the blood pressure too much. So it's an alternation between those two types of music, as far as I understand.

Preeti Kota:  Okay. So what are the brain regions involved in music perception and pain perception, and how are these related?

Jagmeet Kanwal:  That's a good question. So of course we are learning a lot about music over the last decade or two, there's a lot of work going on. Compared to when I first started studying music perception, it was very little. Even now there's almost nothing in the textbooks, but even thinking of music as something that should be scientifically studied was questionable.

Now we know a lot more about some of the brain regions that are involved, but still the interaction between for example, pain perception and music is still not well-established. So we do know that many brain regions are involved. And so we start with musical sounds entering through our ears, and reaching a nucleus called the cochlear nucleus within the brain stem. This nucleus receives input from a spirally, coiled structure inside our inner ear that vibrates to the slightest of sounds. Then it amplifies the mechanical energy in those vibrations and transduces that into electrical signals. That electrical energy then can be used by the brain for doing different kinds of things.

So from there, the sound signals then travel as electrical impulses throughout the auditory system that parses and integrates them into a perceptual hole that can be used by other brain centers, such as our limbic system, where emotions are thought to reside.

So now, one of the well-studied limbic brain structures is the amygdala, and where pain signals are also reached from various parts of our body. Thus, one of the structures, at least, would be the amygdala and within the amygdala, both music and pain then come together. So both of those inputs are coming in, into the same brain structure. And so we believe that perhaps here, the music can override and suppress the perception of pain signals.

So it's like a gateway. From there, if the pain signals go to our conscious memory, because the amygdala is connected to our frontal cortex, which is more involved in our perception, then perhaps the music gates can cut it off, the pain signal, from reaching more conscious parts of the brain. So you can’t do much from the signal that's coming through the body, but that's not the only place where you can do something about it. It goes eventually into the brain, and that's really where we perceive the pain. And so if there, the pain signal can be suppressed, then that would be a way to deal with pain. And so perhaps music does that.

So in fact, we put an electrode into the amygdala and we recorded and we wanted to test if sounds do really reach there. And of course, these studies you cannot do in humans. So we did that in animals and in bats that we were studying at that time. And indeed, we were among the first to show that these signals so forth, these sound signals do reach the amygdala. So the neurons in the amygdala, they respond to the sound. And about the same time people were studying also the amygdala in humans using fMRI, and they discovered that the amygdala responds to laughing and crying type of sounds.

So that's when it was established that the sounds in fact, do go into the amygdala. And so that would be a basis of the musical sounds also going into the amygdala, because we were looking at actually animal communication sounds, which also have an emotional component, and so just like music had an emotional component. So then at least we have the beginnings of a possibility of how music and where in the brain it can actually play a role in the perception of sounds.

Now intriguingly, we also not only put our electrode into the amygdala and recorded the response to sounds, but at the same location, we delivered a small electrical signal, a little electrical pulse. And when we did that, we discovered that lo and behold, the heart rate of the animal changed. So the heart rate went up, the breathing rate went up. So that was amazing because that means that the same area that is receiving the sounds, in fact has a control on our bodily functions, particularly the heart rate, in this case, and breathing rate.

And so that provides a very direct connection. In fact, that was like the first evidence that the control of our heart rate is not just from the brain stem, as it is in the textbooks, but there is another higher center in our emotional areas of the brain, in here, particularly the amygdala, that can also affect our heart rate. And of course we know from our everyday experience that if we get scared or we have some different feelings, our heart rate is affected accordingly. That's probably happening in the amygdala. That's what we are hoping to find out more about.

Preeti Kota:  And then depending on the type of music, is there a more lasting impact on the amygdala for certain types or..?

Jagmeet Kanwal:  Right. That's something that we don't know yet, and there would be new studies that would have to be done in humans where you would record their activity in the amygdala and present different types of music. Something I really always wanted to do, because we know we have so many different types of music and they have different effects on us. It'd be interesting to see which kind of music influences the amygdala more than others. But a lot of the studies on fMRI are typically focused more on the cortex, because it's a large area. And so you can easily see the activation and so on. The amygdala is a deeper structure in the brain, relatively smaller structure.

So it's a little bit more difficult to do the studies on that. And also the MRI, it creates a lot of sound by itself because every time you send a magnetic pulse, very high magnetic pulse, there's a vibration associated with that. That makes it a little bit more difficult also to do sound studies using fMRI, but there are some ways to get around that. So I think in the future, hopefully, we will know more about that.

Preeti Kota:  Do you think it'll interfere with that? The MRI pulsing?

Jagmeet Kanwal:  Yeah. It does, but we put earphones on the person's ears, and what people do is that they... So because the MRI signal takes a little time to build up, so what they do is that when they present a sound, they collect the signal to that sound a little bit later, so that it's phase-locked to the time of the presentation of the sound and not so much, there is less of a component that is affected by the sound of the magnet itself. So the timing of those two are a little different. And so that way, they can extract the signal that is more to the presentation of the sound that they want to test.

So there are ways of getting around that. But it's a pretty loud sound so there can also be some interference that's hard to take out.

Preeti Kota:  And then just touching back on what you mentioned earlier about how the music sample that you are using, it was personal to, I forget, I'm sorry. I'm forgetting his name.

Jagmeet Kanwal:  Andrew Schulman.

Preeti Kota:  Yes. Do you think that will lead to varying effects on playing it for people who it's not personal to?

Jagmeet Kanwal:  That's a very good question. And we struggled with that, because a lot of the other music studies, they actually present the music that a person likes, because everybody doesn't like the same music and obviously you don't want to present some kind of music to somebody they don't like.

So typically, in this kind of a situation, when people want to study the effect of music in a medical setting, they give the patient a choice of many different types of music and then the person chooses, "Yeah. I'd like to hear this when I'm recovering from my anesthesia," and so on. In our case, we decided to go with the music that he created because apparently he has been using this music on different patients. And so there's some, apparently, universality to the type of music that he has created.

In some ways there's a little bit of an issue, but in other ways it makes it more uniform. And so we can then see how the music is affecting and we know the different parts and therefore we can parse out the different musical pieces and perhaps see their effect on the heart rate and so on. So it'll also provide some more consistent data. So it's a trade off, but that's what we decided to do for this study.

Preeti Kota:  And I guess there's a lot more variables if you use subjective music based on the person's taste, based on the rhythm and types of-

Jagmeet Kanwal:  Exactly. And already, there's a lot of variation in humans. So it just adds to that.

Preeti Kota:  Are there certain health conditions in which music may be more helpful than others, like a stroke or coma, for example?

Jagmeet Kanwal:  Yeah. So music has been known to play an important role in many health conditions, such as in Alzheimer's, Parkinson's, catatonic conditions resulting from trauma and various other anxiety disorders. In addition, music can help pregnant women to relieve the pain during the process of childbirth, labor, and delivery, and many other conditions that humans may suffer from. So there have been a lot of studies actually on the fact that the pain threshold really changes when one is listening to music, but from a scientific point, a lot of those are observations. And so to have a scientific understanding of how it happens, that is still missing in the literature. And so we think that music may be particularly helpful in facilitating recovery based upon the data that, for example, Andrew Schulman's work has provided. And so that's what we would like to find out more about during our study.

Preeti Kota:  Okay. So just recovery in general or..?

Jagmeet Kanwal:  Yeah. For us, it'll be more like recovering from anesthesia after a surgery. So we are targeting currently people who have liver transplants, because those are well-defined, we know that they're going to have the surgery in advance and so we can prepare for that. It's a risky surgery and there is deep anesthesia involved. So that's the population we are targeting in the beginning. Later on, we may do other studies. We didn't want to work with patients who have had a stroke because then part of their brain maybe damaged. And we don't really know which part. And because we feel that the brain is playing a role in this recovery and that's what we want to study more, so that's why this is the patient population that we chose to start, at least, our study.

Preeti Kota:  Okay. And then how is this applicable to other situations and how do you think it might benefit people on a daily basis?

Jagmeet Kanwal:  Surprisingly, we may not realize this, but the music industry is clearly much bigger than the drug industry because all humans engage in listening to music, from the tinkling sounds placed in our crib soon after birth, and many songs we hear about twinkling stars to the more exciting type of music we hear as teenagers. And then the more calm and mellow music that people prefer in their older age. So we know that music plays an important role in our mental and physical health, even in normal individuals, we just don't think of it that way, that it may be continuously playing a role in our wellbeing. And so we hope that our study then will shed some light on this phenomenon so we can better understand and utilize this listening to music in the most appropriate way.

Preeti Kota:  Also, I just thought of a question about how you were talking about the amygdala before, but is there personalized music sensitivity that varies from person to person?

Jagmeet Kanwal:  Good point. Clearly, some people may not pay particular attention to music. Most people do, but then there are the musicians who are really tuned to the music. In fact, there are people who have perfect pitch, which means that if they hear a particular tone, they can immediately say what is the pitch or the frequency of that tone. So people have done the study studies and they found that their auditory cortex is very well-organized. Over there, it's not like a diffuse activation, a particular frequency only activates a particular band in their auditory cortex.

So basically, musicians are much more sensitive to music, probably it plays a more important role in their lives. And I've heard musicians say that they literally could not live without music. So it does vary with people, as do many other things, but in general, it seems to have a big effect and role in most of us.

Preeti Kota:  So to precisely assess the effect of music, what do you plan to measure in the body?

Jagmeet Kanwal:  To precisely assess the effect, we hope to measure many of the brain and body parameters that may be associated with the healing effect of music. These include tracking the heart rate, blood pressure, breathing rate, as well as brain activity. So we would also like to measure the level of cortisol changes in our body by taking saliva samples and also determine if the levels of oxytocin, the hormone that is known to play an important role in bonding, may facilitate our health and wellbeing, because it's been shown that even when we hear some sounds, even two people talking, leads to increased level of oxytocin. And oxytocin appears to have many benefits in our body and brain. And so we want to also look at that.

Many of these physiological parameters are already being measured in patients within the ICU. They're already measuring the heart rate, the blood pressure and so on, and tracking that. Therefore, we think that this is a unique opportunity to take advantage of these data that are already there and being recorded. And so now what if we play some music and then be able to see the effect on those data? In the ICU setting, we don't even have to do a lot of things on our own, those are already being recorded. And so we said, "Oh if we look at the effect in this situation, then we will easily get a lot of data." That's the goal, using all of the... And then a few additional things that we do. And then hopefully we'll be able to put that together and see what effect it had and whether when we started playing the music, that triggered or facilitated an acceleration in the recovery of the patient.

So perhaps patients who listened to ICU music on the whole will recover faster. Maybe they get out of the ICU a day before than the other patients who didn't. That would be a big saving right there, in terms of being in the ICU and additional stress, nobody likes to be in the ICU and plus all of the cost of the patient being in the ICU.

Preeti Kota:  Just out of curiosity, how do you measure levels of oxytocin?

Jagmeet Kanwal:  That's a little tricky, but one of the ways that people have seen, also you can measure that in the saliva. So the same saliva sample that we take to measure cortisol, which is much more standard is thought to be also one of the best ways to measure the level of oxytocin.

Preeti Kota:  Okay. Very interesting. Lastly, is there anything else you would like to share with our listeners in general or about your research?

Jagmeet Kanwal:  Yeah. I would like to say that much of my past research has been aimed at achieving a basic understanding of how sounds are encoded within neural activity in the brain. So I've always been very interested in animals, as I mentioned earlier, and their behavior and have been studying social communication behavior in bats.

So about 30 years ago, I helped to restart the field of neural processing, of communication sounds that had come to a halt because of the difficulty of the complex and relatively difficult-to-study brain mechanisms associated with the processing of complex sounds. So speech and music can be thought of as complex sounds basically. And so at that time, and to a great extent, even now, to obtain funding for auditory research, it was necessary to relate one's research to speech processing because speech is considered to be unique in humans and everybody accepts the importance of speech. And so that was one of the ways that people would justify their getting funds to do their research, especially on animals.

So it's one of our unique abilities. Everybody understands that. So when I started studying how bats use sound to not only echolocate, but also to communicate with each other, then I gradually discovered that some of the brain structures involved in their processing are primarily designed to process emotions. So that's like, I was talking about the amygdala, when I mentioned that we were among the first to report the activity of sounds in the amygdala.

That suggested to me that music does not exist only in humans because there are other sounds that can affect our or the animals' emotions too. So these emotion-processing brain structures are more primitive, because they are there, we know in animals, compared to other brain structures in humans, such as the frontal cortex and so on.

And yet we consider that music is something that humans invented. So we say, "Oh, we play this music and invent, obviously no other animal does that." And so music is very new. It makes us human, this is our thing. But when you look at the brain structures, where it's being processed, they're very primitive and other animals have those too, the emotional brain structures. The limbic brain, I mean the reptilian brain, even they have that.

So how come music is going in those structures? That was very intriguing to me. So this suggested that music does not exist only in humans, but the social communication sounds that I was studying in other animals are probably more closely is connected to our music than to our speech, because both have this emotional component. And yet people were using their studies to justify speech processing, getting a better understanding of speech processing and so on.

So in fact, looking around, we see that music is everywhere in nature. From the many songs we hear birds sing in the morning to the sonic and ultrasonic songs of crickets and bats. Yeah, bats sing as well in the evening. And the thumping of their chest by gorillas in a forest are all reminiscent of music that is not only ours, but exists universally in nature.

So understanding and studying the brain and body mechanism by which these sound are perceived and can improve our wellbeing is a privilege, I feel that I have the good fortune to experience and be engaged in. So I hope that this type of basic research with many potential applications will be supported not only by the scientific community, but also by society at large, until their human benefits become more clear.

That's something that I wanted to share with you and hopefully others, that just trying to understand some basic phenomena can eventually lead us to many results and information that can benefit in the future, even though we may not think it's relevant when we are doing those studies.

Preeti Kota:  That's fascinating how it ties into even evolution.

Jagmeet Kanwal:  Exactly. Right, because these brain structures are evolutionarily primitive, but we never really considered there. And yet they're really important because they are the ones that control the vital functions of the body. So what we label as feelings is really, actually, they're very important. We say, oh we should not base our decision on feelings and so on, yet we really rely on our feelings for a lot of decisions and they have a direct connection with our physiology.

So when we think of feelings in a scientific way, we call it feelings, but they actually are vital physiological mechanisms that are important for our survival. So if we feel that we are afraid of something, that means we should get out of that situation, that will be good for our wellbeing. So, it's that system that I think we are activating by music and that system is clearly important.

Preeti Kota:  Your research is very exciting.

Jagmeet Kanwal:  Good to know that. Thank you.

Preeti Kota:  Definitely. But on that note, I just wanted to thank you so much for sharing your career and your research and all your work. It's very thrilling to hear about. And I just wanted to thank you for your time and hope you enjoy the rest of your day.

Jagmeet Kanwal:  Wonderful to know that. And I want to thank you for your interest and your questions and for your eagerness and interest to participate in our study. So we look forward to working together and finding, hopefully, new things.

Preeti Kota:  Yes, of course.

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


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


Psychiatrist Lantie Jorandby on Addiction Recovery

An Interview with Psychiatrist Lantie Jorandby

Dr. Lantie Jorandby is a board-certified psychiatrist with certification in addiction psychiatry and addiction medicine. She is currently the chief medical officer of Lakeview Health Addiction Treatment and Recovery in Jacksonville, Florida.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us psychiatrist Lantie Jorandby. Dr. Jorandby is a board-certified psychiatrist with certification in addiction psychiatry and addiction medicine. She is currently the chief medical officer of Lakeview Health Addiction Treatment and Recovery in Jacksonville, Florida. Dr. Jorandby also has a blog on Psychology Today's website, where she regularly writes articles on topics related to addiction and addiction therapy. Before we get started, Dr. Jorandby, could you please tell us a little more about yourself and what made you interested in studying addiction?

Lantie Jorandby:  Thanks, Theresa, for having me. Yeah, I would love to share that. It's a personal journey of sorts. I had gone to medical school, thinking I wanted to do obstetrics and gynecology, and ended up just falling in love with mental health. And part of it is that I have family members, my father specifically, who really struggled with anxiety, depression, and then addiction. So, it was really a tug for me to go into. And another feature around it was that I was working with veterans early on in my career. Veterans coming back from the wars, Afghanistan and Iraq, and a lot of them were struggling with not just PTSD, which seems somewhat obvious, but they also had addictions that they developed on the battlefield, and they were also dealing with these co-occurring kind of disorders that you see. So, this all came together for me, and really spurred me to go ahead and do a little bit more training. And that's why I went into addiction. And being in addiction really just feels like exactly where I need to be. It's a field that I love. It's very challenging, and it's an addiction that affects everybody in that person's life. So the family members, loved ones, partners. It really is wide-ranging. So when you help that one person, you're helping several more people that are in their lives as well.

Theresa Nair:  That's wonderful. It sounds like you've really found your calling. You mentioned how you can tell that it's what you should be doing, right. It feels right. So.

Lantie Jorandby:  It really does. It feels like just where I should be, especially during the pandemic. That obviously is something I'm sure we'll talk about a little bit later too. But we have seen such a side with people struggling with relapses, and overdose rate is high, higher than we've ever seen. And so knowing that here I am in this treatment center, not having any clue that we're going to be facing something unprecedented and then being at the forefront, being able to, where a time that of the world really haven't seen at this level before. It's very rewarding.

Theresa Nair:  I'm glad that you found that way to make a difference and have a positive impact. Since we are a psychotherapy practice specializing in treating anxiety, I'm wondering if you could talk a little bit about the relationship between anxiety and addiction, and if individuals who suffer from anxiety are at a higher risk of taking on addictive behavior.

Lantie Jorandby:  I think that's a great question. So, one of the things that we see a very high rate of here is what I mentioned earlier, co-occurring disorders. And those are disorders like anxiety disorders or depressive disorders that go hand in hand with addiction. So a lot of our patients, I'd say at least 50%, sometimes higher, have something else in common. So they're coming in primarily with, let's say, alcohol problems, or addiction to heroin or something else. But they also have these underlying conditions that really, if you are not aware you can treat, they will have a lot harder time into recovery, being able to prevent relapses. And so that definitely is a big issue. What I know is that for instance, our female population, we see about 75% of them have trauma. And trauma, I know the DSM waffles about this diagnosis being an anxiety disorder specifically, but for me, it is an anxiety disorder.

It's an anxiety of, or disorder of heightened awareness. Difficulty with their environment, difficulty with relaxing and being able to connect with others. And so, when we have the high level of trauma in our female population, being able to be aware of that and address it while they're also getting treated for their alcohol use disorder or their opiate use disorders is just super-critical. And then if we look at, for instance, panic disorder, social anxiety disorder, we see high correlations with, for instance, alcohol and sedatives. And if you look at the data, for instance, social anxiety disorder has a high hand-in-hand with alcohol. There's popular TV shows and movies about people that have such social or crippling social anxiety that they have to have a drink in their hand to be able to go to a party or meet somebody new. And that becomes a behavior, often, that can lead to addiction. And so we are very aware here when I work that we really need to look for and be aware of other conditions like social anxiety, like panic disorder, PTSD, to really get to the root of issues.

Theresa Nair:  That's interesting. I have seen that on shows before. It's almost kind of modeling that that's how you deal with anxiety, is have a drink in your hand, or-

Lantie Jorandby:  One of my favorite shows is The Big Bang Theory. It's off now, but they have that main character. And that's the only way he can talk to women is he has to have some alcohol in his system. And it's kind of a running joke, but towards the end of the show, they do show that he starts to get in trouble with alcohol. And it isn't, I don't think, anywhere to the level of addiction, but he is progressively becoming a pattern for him, that kind of behavior. And it's no longer the effective coping tool. It's become a behavior that's really causing him some trouble. And so that, when I think about addiction, and I feel like this is a message that gets lost, it's a progressive disease. And so, for the patient, a lot of them may have started out with something like alcohol or marijuana. That it wasn't initially problematic, but you add in stressors or bad coping skills, or even co-occurring disorders that might develop, and it eventually becomes a problem you can't ignore. So, I just feel like that's a very important message to share.

Something else, speaking about anxiety disorders, especially with addiction, is the idea of perfectionism. There is an interesting term I read in The Atlantic. This was actually pre-COVID. They talked about women specifically who get caught up in maybe alcohol addiction. And one of the things that's still out there, this myth of the superwoman, she can do everything. She can have a full-time, high-powered career. She can have a family at home, take care of the children, be at the soccer game, go to the board meeting. And then this article connected all of that, those demands on women now, with the idea that, okay, when they get home the end of the day, and they're making dinner for the entire family and still multitasking, they're going to have a glass of wine. And then maybe that leads to another glass. There is this connection of these demands that we put on people in society, women specifically, that if you go down that road, seem to be connected with patterns with alcohol, for instance. And I'm not saying every successful woman that's trying to do everything is going to end up with substance use problems. But more and more through the pandemic, we've seen women coming in, seeking treatment with those kind of behaviors and environment in their lives. And I think just following that context, I think we're going to see this more and more as we get past COVID.

Theresa Nair:  Speaking of that, and you mentioned a little bit about relationship between trauma and addiction, and you've talked a little bit about COVID and addiction. We've gone through such major historic events lately. It's been referred to in some articles as a cascade of collective trauma between COVID-19 and increasing political tension, racial tension, economic instability. Are you seeing in general an increase or any type of relationship between what's currently happening and addiction in your office?

Lantie Jorandby:  I would say yes, but it's interesting. What we saw in the midst of COVID, we go back to 2020 and even last year, people were still coming into treatment. But I think there was a delayed response. Like they were still in survival mode, and they weren't really recognizing all of what you just listed. You're right. Unprecedented global pandemic, all this political and this violent tension. And so now that we are, and I'm certainly not saying we're even past COVID, but it has shifted our priorities a bit. And now what I'm seeing here in the treatment facility and now, and I do talk to other colleagues in other areas of the country. They're seeing the same. Now there's this big rush to get into treatment. People are starting to recognize that two years later, their behaviors or their addictive patterns are no longer working.

It's like that progressive disease I mentioned earlier. In the thick of it, I feel like people weren't quite recognizing it. And now that we're getting a little perspective, a little bit of distance from COVID, people are recognizing now, "Wow, this has just been tremendously hard on myself and my family, and on my network. And I need help." And so that is good to see, that recognition. It's hard, though, because I mentioned earlier around 75% of the women we see seeking help are traumatized. And now we're seeing a higher uptick with our male population, younger adults in their early 20s or late teens are also struggling. And I do think the social isolation that came with COVID, the heightened use of substances to manage all of our collective stress and trauma is starting to show. It's really starting to manifest now.

Theresa Nair:  That's really interesting. So is that because people thought they were just doing these things temporarily to cope? They're stuck at home, there's a lockdown. And then they find when all of that's over, they're trying to return to normal life, that it's maybe harder to quit than they thought it was.

Lantie Jorandby:  It is. One of the things that I've talked a lot about over the last year is that you have people that have been working from home, those Zoomers. And one of the things about Zooming and working from home is that it sometimes is easier to hide your substance use. Say someone's going to drink at work. You can put your camera off, which I think in this time and age is a sign that either you didn't get up early enough to put on makeup, or maybe there is something more serious going on. And so initially, I think that a lot of us ended up just thinking, "Okay, this isn't going to stay forever."

And then it kind of did. And now, we're looking back on it, and we're coming back in the office. And I read all the time about companies that are struggling to get employees back, and some of the bumps in the road. And I think that is what we're seeing now, is that people hunker down for two years, develop some habits that weren't healthy. And now they're realizing that those don't work, now that you're back in more of a normal time or a normal environment. And so that's where they end up seeking for help.

Theresa Nair:  That's really interesting. Yeah, I think we're definitely in unprecedented times. Right? And so everyone's trying to figure out and cope, and figure out how to return to some semblance of normalcy. Right?

Lantie Jorandby:  I agree. And I think this is my own opinion, not basing on it on research, but I think we need to take stock of these last two years and understand that life is precious. There are a lot of good things in life. We've lost a lot of people that we love. And so to take each moment that we have here and just make it meaningful. Engage in something that you find enjoyable, whether it be art or nature, just take that moment because we're not really promised what's next week or even tomorrow. And so really understanding that, because COVID, I feel like, all of the terrible things have happened that shed a light on our national kind of work. Our work balance in life and understanding what's important.

Theresa Nair:  That's a good point. Yeah. I think there's a lot of people reevaluating. What is most important, right? It might as well face what matters most in life and reconsider our priorities. Switching gears a little bit, you had written an article recently about the benefits of ketamine with alcohol addiction. I was wondering if you could talk a little bit about recent research with that, and why you think that's a beneficial treatment method?

Lantie Jorandby: Well, I would say we haven't necessarily gotten to the point where you're absolutely proving beneficial results to treat alcohol addiction. So you look at the history of ketamine. It evolved from the beginning as an anesthetic drug on the battlefield in Vietnam to a club drug that was abused in the 80s and 90s, to a therapeutic drug now in the psychiatry scene. And the therapeutics of it are pretty well-studied for depression, and in fact the FDA has approved it for people that have depression that's refractory, meaning they've been tried on an anti-depressant, and haven’t improved or even those people that have --

Theresa Nair:  It's cutting out a little bit. I'm sorry. Could you repeat that?

Lantie Jorandby:  What I was saying is that the FDA has looked at and approved an inhaled form of ketamine, that looks to be beneficial for people with refractory depression. Meaning that they've been on a lot of other medications that haven't worked, and it's also where it appears to be pretty effective for people that have chronic suicidality. So we have seen ketamine go from one type of therapeutic use in anesthesia, to an abused drug and now to a therapeutic. So, some of the more recent research shows that there may be some benefit for addiction. And a lot of the research right now, most of it in the area of alcohol. What we are finding out is that ketamine can show good results if you pair it with therapy. It can be, show some really interesting data. People in the studies are able to interact better with their therapies to address the addictions or to address the appropriate resource, and so it's really interesting.

One of the things about ketamine, of course, is what I mentioned earlier. Usable. People can get addicted. It's not as common other drugs, but there is kind of this fine balance. So if we're going to use it to treat people that have an addiction, we really have to be very careful about who we're choosing to use ketamine on. You have to be aware of things like trauma in that person's past or in their current issues. You have to be aware of how they cope with their coping strategies, their support system. Because if you introduce something that is addictive, and they don't have some of those other things in place, it can cause more problems than you're looking for. And then the other thing I think really that I came away with looking at the research is, therapy is really key to this. You can't do anything in isolation. Ketamine is not that quick fix that we're all, I think, looking for. Just like an antidepressant isn't a quick fix, either. I firmly believe that medicines can be very helpful, but if you're not pairing them with change. Whether that change is being navigated with a therapist or with someone else that's helping person, someone support them or change their coping styles, you're not going to get as far as you need to. And so that's where I think the real message is, that ketamine looks exciting for this population, but there's more data to learn. And I think ultimately we're going to use it in conjunction with a lot of other tools in the toolbox.

Theresa Nair:  That gets to another topic I wanted to discuss. Where in a recent article, “The ‘Aha’ Moment in Addiction Treatment,” an article that you had written, you talk about how once individuals get through the detox phase, the real work can begin. But people are often terrified at that point. So how do you work with individuals to get past that point when they have detoxed? And then they're just terrified, how do you get them to move forward?

Lantie Jorandby:  What I really love to do with people who do absolutely have their fingernails, just clinging to the side of the pit, and it’s just scary. Especially when they have with no history of treatment. So, this is brand new. What we really find helpful is peers. People that have been in the facility a little bit longer, been in treatment a little longer, can help them navigate. Who can really speak to them with credibility, knowing that they've been down that thing there.

We also engage family. I think family is so important. They are often the reason people come to treatment. The family members giving them an ultimatum, whether it's a husband or a partner or a parent. And so they're here, somewhat unwilling to be here or against their will. And when you engage family, it can be very impactful. And in fact, a lot of times, to get people past that terror moment, we will ask family to send us impact statements, things that tell that loved one that's in treatment. "I'm so proud of you. I'm so glad you're in treatment. This is why. Because in the past we have struggled with seeing you hurt yourself. We have struggled with seeing your health go down. You have not been present with us, and we love you." And so having family within can be very, very powerful because they're a big reason these groups come into treatment. And then just having them understand. And I do this a lot with our medical team, is just walking them through the medical piece of it. Because a lot of times, they may not be aware that their liver function is not doing as well. Or they may not be aware they've developed a pneumonia because of their alcoholism. And so going through the clear basics about that. And then finally, I always like to encourage folks. This is a fine balance, but really encourage them to understand, being in treatment and having the addiction doesn't mean that they're bad people. It doesn't mean they have a character flaw or something wrong with their personality. But they've really developed it, unfortunately, a progressive disease. And it's disease of brain activity. And so destigmatizing it some can help them, our language.

Theresa Nair:  You were just mentioning the importance of involving family. And often, if a family member or a loved one has someone in their life with addiction, they're told to take them to detox or to take them to rehab, and to get treatment. Do you find that if a person is coerced into going and seeking treatment, and they're just going for a family member that it's beneficial, is that the best approach for family members to take if they have loved ones with addiction?

Lantie Jorandby:  I think it's a fine line. Honestly, people that come in with family coercion, they do very well, as much as the folks that are coming in on their own. But I think it's really a surrender moment. If those folks are being coerced or somewhat encouraged strongly to come into treatment, often they kind of get fixated on, "Okay, I'm only here because my husband said that he's going to file for divorce." Getting them to go beyond that and just render and see all the other things that are happening in their lives, beyond just feeling like someone's turned on them, is really important. I speak with the experience of having a loved one who had an addiction. And it's hard to sit down with that person, especially as a parent and just say, "I'm so worried about you."

"This is what I'm seeing. X, Y, and Z. Please go to treatment." Because it feels in some ways, a lot of times, that person's going to take it as a betrayal. And so, you have to separate yourself from that feeling and just do the best that you know from that person. And getting them into treatment is the best thing. If you think about, this is the way I see addiction is often that person's been taken hostage by the drug or the alcohol. And you have to be that hostage negotiator of sorts, to try and get them freed. And sometimes the only way to do that is to get them into some form of treatment inpatient. Doesn't always have to be inpatient, but often it does. And that's where the real work starts. It's tough. I mean, it's really an individual case by case, but I think both sides can be very successful. The person that comes in separately, and then the person that comes with family.

Theresa Nair:  Okay. So that's interesting. So you don't necessarily have to wait for that person to realize on their own that they have a problem.

Lantie Jorandby:  We have a young woman here now who I'm so proud of. She came on her own. And what she shared with me a few days ago was that her family just took a collective sigh of relief when she told them that she was going in, because they were ready to agree. And they were just so worried about her. She was doing some really interesting stuff. So it's great when they have the insight like that, when someone can see, "Okay, this is really unhealthy. I'm starting to understand." But you don't always get there. And so that's where you kind of have to take that initiative.

Theresa Nair: Okay. Well, I think that's good for people to know that it can still be beneficial, even if you're pushing somebody to go in for treatment.

Lantie Jorandby:  Absolutely.

Theresa Nair:  Another thing you've written about are the changes in the brain that take place during addiction. I'm wondering if, when somebody goes through recovery, if you see those changes reversed, or if there are any other changes within the brain that occur when somebody has gone through treatment. Do you see a reversal in the trends that had occurred during addiction?

Lantie Jorandby:  Yes, we actually do. Usually, those changes start to show up around 30. Really, I want to say 30, but up to 90 days is really where the beginning stages of change start to happen. We see it with their behaviors, kind of that "Aha" moment I mentioned earlier in the blog I wrote. You just see everything click for them. They start to engage in the groups. They're starting to show positive peer relationships. They're often voted by their peers to lead for the week. And so those are really positive things to see. And it's so rewarding, but it can take some time. And the reason is, if you get into some of the science behind it, the brain, it's part of that reward center of the brain that can be taken over by drugs and alcohol. So that individual thinks they need a chemical to survive.

They need heroin, or they need alcohol, or they need a Xanax to just survive day to day. So, it's going to take some time to take that part of the brain back, and to also rewire it. Not to get too technically, but we know that neurotransmitters are unbalanced. We know that particular pathways are affected and injured during addiction. And so, to really rewire all of those pathways and rebalance the chemicals, we see that it even takes up to a year to 18 months. But in that first 90 days is really where you start to see the behaviors manifest. And I think that's what keeps all of us in this field is that when we see people change and their lives the better, and then their families come in for the family workshops, and they see the changes, they just can be so transformative for the whole system.

Theresa Nair:  That's wonderful. I'm sure that's just a great experience to be able to see somebody come back, right. Come back to who they are and-

Lantie Jorandby:  Absolutely. Yeah, it really is.

Theresa Nair:  Great. Did you have any other parting words or advice, or anything you would like to share with our audience?

Lantie Jorandby:  You know what, I feel like education is so important for addiction in the field. And for so many years, even 20, 30, more years or longer, it's been a field that has a lot of stigma to it. People are ashamed to tell someone that they have an alcohol problem, or they're ashamed to tell someone that their family members have a problem with addiction. And so really getting education out there about what addiction is, how it affects the brain, destigmatizes it. And when you destigmatize treatment, more people go.

I'm going to call out some celebrities, people like Demi Lovato, or some popular stars that have a lot of recovery, like Eminem or Pink. And they've been very vocal about all of their struggles and how they went to treatment and how they got healthy. Really helps in some ways, it obviously very alluring to see stars getting help, because we're all fixated on gossip and stars. But it's also really rewarding for me to see this, because the general population sees them and think that they're so successful, but they don't understand that these people have also fallen prey to addiction or to mental health issues. And so they see them getting help, that destigmatizes it so they can work and get help too.

Theresa Nair:  I think that's a great point. I think there are a lot of people who still want to keep these things as a family secret, not discuss-

Lantie Jorandby:  Yeah definitely, it happened in my family. Yeah. And it goes on and on. So you have to break that pattern in your own family, and just be very willing to break down those barriers. Because people, this is a treatment with these. If I was to say one more thing, and I could say many more things,

Theresa Nair:  That's OK.

Lantie Jorandby:  If I could say one more thing, this is an issue that's treatable. People can get healthy and then can lead healthy lives and be happy. It's not the end of the world, but they have to get into treatment first to do it.

Theresa Nair:  I think that's an important point. That it can, I don't know about cured, if that's the correct word, but you can get past that. You can move on from it and-

Lantie Jorandby:  You can, but I love to see, yeah, we have a very strong alumni group that they have their own private Facebook page, but periodically some of our staff will share just some positive stories that come out of the alumni group. But it's so nice to hear, because people will say, "I've had five years sober, I've had 10 years sober." And they will even have little clocks on their phone, and it'll show that the days that they've been in recovery. It's great, because they have transformed their lives.

Theresa Nair: That is great. It just has me thinking one more thing I'd like to ask you here, last minute. Do you have advice if somebody is seeking for a program as to what types of programs they should look for? I know you hear sometimes that maybe some treatment programs might just be scams. What should a person look for if they're looking for a successful treatment program?

Lantie Jorandby:  I think you want to make sure that it's accredited by JCO, or Joint Commission, I think that's very important, because that is an organization that goes around the country and looks at these to make sure they have the basic elements of treatment. So that means nursing care, physician or provider medical care, therapy. That they're meeting standards. So, I think that's very important. I also think it's important to have a strong medical presence at the facility. Because people that are coming into treatment with addiction often have medical issues that need to be addressed, whether it be liver disease or infections, or problems with heart disease. There's a lot of different things that go hand in hand with addiction, and so you want to be able to treat those medical conditions. And then being a psychiatrist myself, I feel like having a very strong mental health presence in that facility. And so having someone that's going to treat co-occurring disorders and evaluate for more serious conditions, and be able to treat them is also very critical.

Theresa Nair: Thank you. That's wonderful advice. I appreciate you speaking with us today, and thank you for participating in our interview series.

Lantie Jorandby: Well, thank you for having me. I appreciate it.

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.

Therapist Terrence Real on Relationships

An Interview with Therapist Terrence Real

Terry Real, LICSW is a family psychotherapist, best-selling author, internationally-recognized speaker. He is a senior faculty member of the Family Institute of Cambridge, MA and the founder of the Relational Life Institute (RLI), which offers workshops for couples, individuals, and parents who wish to develop deeper connections in their relationships.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Mr. Terry Real. Mr. Real is the family psychotherapist, best-selling author, and teacher. He is also the founder of the Relational Life Institute, which offers workshops for couples, individuals, and parents who wish to develop deeper connections in their relationships. Mr. Real has numerous publications on relationships, depression, and psychological issues that men face, including his upcoming publication, “Us: Getting Past You and Me to Build a More Loving Relationship.” Before we get started, Mr. Real, can you please let us know a little more about yourself and what made you interested in studying relationships?

Terry Real:  Oh gosh, there's an old saying, a psychotherapist are people who need to be in therapy 40 hours a week. I first became an individual therapist 40 years ago, and I think I did in order to gather the skills I needed to have the conversation with my depressed, violent, loving father that I needed to have in order to free myself from the legacy and not become him. And I did. I learned how to be an individual therapist and I healed a lot of my trauma. I then went on to family therapy and couples therapy, literally in order to learn how to have a relationship. I come from a really dysfunctional family, we all come from a really dysfunctional culture, and I didn't know how to do it. So, I became a professional, and then in 1995, I published a book called, “I Don't Want to Talk About It,” which was the first book ever written about male depression. And it did real well to a lot of depressed men in America. And I was getting calls all over the country, "Can you help me with blah, blah, blah, blah, blah, blah?"

And what I began to realize was that moving men out of depression was synonymous, in my mind, with opening their hearts and reconnecting them. The way we turn boys into men traditionally in this culture is through disconnection. Feminism has worked for 50 years on girls and women's disempowerment. The womb for boys is disconnection. We teach them to cut off from vulnerability, from their emotion, from others. And I began to believe that the healing move for boys and men is reconnection, connecting them to their hearts and to others. And so my work was grounded in the restoration of relationality with men. And I began to feel like the best way to do that is in their current relationships. So, I began to invite partners and, in some cases children, into the therapy room to teach these guys how to live relational lives, how to live lives of authentic connection to themselves and to others. And so the work naturally gravitated away from doing individual therapy to working to transform people individually, but through their relationships and the restoration of relational capacities.


Amelia Worley:  So to begin, can you describe what relational life therapy is and what methods it uses to help couples in therapy? Additionally, how is it different from regular couples therapy?

Terry Real:  We break a lot of rules. Let's see if I can name some. The relational life therapy, first of all, we're not neutral. And when I was a couples therapists, the corner rule was thou shall not take sides. If you took sides, you had to go to your supervisor and talk about your mother for a while. We're not neutral. Some issues are 50/50, but some are not. Some are 70/30, some are 99/1. And specifically, I came out of it through my work with men and through a feminist perspective. Women across the West are asking for more emotional intimacy from us guys, then traditional masculinity raises us to deliver. The essence of traditional masculinity is invulnerability. The more invulnerable you are, the more manly you are. And women are asking men to move into vulnerability, to move into their emotions, to open their hearts, to be less defensive, to be more sharing. In other words, to have a broader, a repertoire of relational skills.

So we agree with that. We take sides. We side with the person who is asking for more intimacy in the relationship, and the way you're going about asking for it may not be very skilled. I'm not saying women are angels, but the demand for increased intimacy is good for us. And so we're not neutral. We're perfectly capable of saying, "Mrs. Jones, you're a nut and Mr. Jones, you're an even bigger nut, and here's why, let me tell you what's going on." The other thing is that we're lovingly confrontational. There are three phases to relational life work. The first, I call: waking up the client. This is where you hold the mirror up to the client about what their maladaptive responses may be born of childhood trauma and adaptation that are blowing their own foot off. This is what you're doing that will never get you more of what you want.

And the confrontation is, I call it: joining through the truth. Anybody can club somebody with the truth, but this confrontation is so loving, so empathic, so on the side of the person you're talking to, that they feel closer to the therapist through the confrontation rather than more resistant and distant. So the first phase is waking up the client. The second phase is
trauma work. This is where that adaptation came from. You were adapting to something. So I do deep trauma work in the presence of the partner, another rule we break. We don't find trauma work out to an individual therapist, we do deep trauma work, inner child work while the other partner is sitting there. There's some contraindications, but if there're going to be vicious or whatever, but by and large... Excuse me. Sorry. But by and large, it's much more powerful to have the partner who's been on the receiving end of the person's immature adaptations, see where the whole story comes from. It opens their heart.

And then the third phase is: teaching. This is what you've done wrong, this is where that maladaption comes from, and this is what right would look like. And I think it's the combination of all three of these, confrontation, deep trauma work, and skill building that produces transformational change quickly. So that's what we do. We are not neutral, we judiciously self-disclose. We're not a blank screen. This is not transference-based therapy. And another thing is that we're at least as interested in grandiosity as we are in shame. For 50 years, psychotherapy has dwelled on helping people come up from the one down of shame. In RLT, we're also interested in helping people come down from the superiority contempt entitlement of grandiosity. And I believe as a couple's therapists, you must be able to help people come up from the one down and also down from the one up. Doing one without the other is insufficient. So there are a lot of things that are very distinct about relational life work.


Amelia Worley:  I really like that. Can you identify any common myths society believes about relationships?

Terry Real:  Well, my new book, if I can do this, “Us”, being released June 7th, it is all about taking on what I call the toxic culture of individualism. And what we know from interpersonal neurobiology these days is that the idea of a free standing individual is mythic. We don't self-regulate, we co-regulate one another all day long. Our central nervous system is not designed to be alone and self-cystic. We are designed to be in relationship. And this whole book is about shifting from an individualistic patriarchal model that says we're above nature and in control of it, whether the nature we're above and in control of is our bodies, “I've got to lose 10 pounds",” our thinking, “I've got to be less negative,” our partners, our kids, society, the world at large. And the whole book is about trading in that mythic idea of power over dominion, for a much more realistic idea of collaboration and cooperation.

When we move out of you and me, win, lose adversarial thinking into the prefrontal cortex, the part of the brain that can remember that we're a team, that this is a relationship that we are in a whole, all of the terms that we live with shift. For example, from a relational perspective, the question who's right and who's wrong is: who cares? What matters is how are we going to work in a way that's going to work for both of us? And so the first order of business is shifting out of what I call you and me consciousness, which is subcortical, triggered by trauma about survival into what I call the wise adult part of us, prefrontal cortex, the part of us that can remember the gestalt, the whole, that we are not striving above our marriage, for example, but we're in it. I call this replacing the hubris of power and control with ecological wisdom and humility.

Our relationships are our biospheres. We're not above them, we're in them. You can choose to pollute your biosphere by having a
temper tantrum over here, but you'll breathe in that pollution by your partner's withdrawal or lack of generosity over there. You and they are connected in an ecosystem. And once we wake up to an ecological systemic consciousness, this isn't about you versus me in some power struggle. This is about how we are going to operate together in a way that works for both of us, then a whole range of new skills and new ways of thinking open up to us.

Amelia Worley:  So, going off of that further, how does that shift from individualistic thinking to relational thinking. How does that heal problems in relationships then?

Terry Real:  Well, it is the difference between, for example, "You're a reckless driver." "No, I'm not." "Yes, you are." "No, I'm not." "Yes, you are." "No, I'm not." I call this objectivity battles. Who's right and who's wrong? And instead, think of this, "Honey, you may be a fine aggressive driver. I'm not arguing that, but I want you to know that when you tailgate and change lanes and speed, none of which you deny, I get myself very nervous sitting next to you. I know you love me. It would be the world to me if as a favor to me, you could tone down your driving so that I could feel safer in the car. Would you do that for me?" And the person next to them goes, "Sure, I'll do that for you." Problem solved. Are you an aggressive driver or not? That could go on for 50 years. “Could you tone down your driving for my sake so I could feel safer?” “Sure, I’ll do that for you, Honey.” Problem solved in 10 minutes. That's the difference between approaching an interactional problem individualistically and relationally.

Amelia Worley:  Okay. So also in your book, “Us: Getting Past You and Me to Build a More Loving Relationship”, you talk about how healing of the self can occur in relationships. You mentioned that this is not done by controlling our partner, but rather by coming to terms with the ignored parts of ourselves. Can you expand on that idea more?

Terry Real:  Well, we all marry our unfinished business, we all marry our mothers and fathers. Falling in love is the conviction that this person is going to heal me, or at the very least, I'm going to avoid all that nastiness that I grew up in. The real relationship comes when you realize that your partner is precisely designed to throw you into the soup. Now, that doesn't mean you're in a bad relationship, it means you're in a truly intimate relationship. What matters is what do you do once you're in the soup? Now, most of us in this culture will try and heal ourselves by getting from that partner what we didn't get, and by often retaliating when we don't get it.

The new news comes when we deal with our own inner wounding and our own adaptation. We stop asking the partner to heal us, but as we move from these triggered automatic adaptive responses to a more thoughtful adult response, we do something different in the moment and they do something different in the moment, and that heals our trauma. Not that they get it to us, but that something different happens between us because I have done something different inside my mind. Can I give you an example?


Amelia Worley:  Yeah, definitely.

Terry Real:  The essence here is understanding what I call the adaptive child part of us. Subcortical automatic response fight, flight, fix about survival. And when we feel unsafe, the autonomic nervous system scans our bodies four times a second, am I safe? Am I safe? Am I safe? If the answer is yes, we say seated in the prefrontal cortex, we're here and now we can be thoughtful. If the answer is no, I feel I'm in danger, which has everything to do with being trauma triggered. Then I will click into whatever I use as a kid to adapt to that danger. And I will repetitively do that in my relationship, even though it never gets me what I want. The essence of this book is about how to cultivate the skill, the wisdom of in the heated moment, shifting from that automatic response, what Dan Siegel calls the reactive brain, to the wise adult prefrontal cortex, the integrated brain.

So let me give you an example. A guy comes to me on the brink of divorce. I specialized in couples on the brink of divorce. He's a chronic liar. He's the kind of guy I say to him, "The sky is blue," he says, "t's aquamarine." He won't give it to me. So quickly, I identify what we call in relational life therapies, his relational stance. His stance is evasion. This guy has a black belt in evasion. So when you think relationally, you can figure this out. It seems brilliant when you're not thinking relationally, but I have a saying, show me the thumbprint and I'll tell you about the thumb. If he's evading, the question is as a child, who did he have to evade? And so, I ask him, "Whatever the adaptation is, what were you adapting to?"

So I say to him, "Who tried to control you growing up?" Brilliant. His father. "Tell me about it." Military man, how he ate, how he drank, how he dressed, everything. I said, "How did you deal with this controlling father?" He says, with a smile, that's the smile of resistance, he says, "I lied." Brilliant, brilliant little boy. I teach my students, always be respectful of the exquisite intelligence of the adaptive child. You did exactly what you needed to do back then to preserve your integrity and grow, lying. Brilliant. Only I have another saying, adaptive then, maladaptive now. You're not that four year old boy, your wife is not your father. So we surface all of those.


They come back two weeks later, it's an absolutely true story, and they're holding hands, "We're cured." "Okay, tell me." She sent him to the grocery store for 12 things, true to form, he comes back with 11. She says to him, "Where's the pumpernickel?" He says, "Every muscle and nerve in my body was screaming to say they were out of it. And on this day, in this moment, I took a breath, I looked my wife in the eye and I said, I forgot. And she burst into tears, true story, and said, 'I've been waiting for this moment for 25 years." That's what we're after. That's recovering.

Amelia Worley:  Wow. That's incredible, honestly. So in your opinion, what is the best way to transition out of being an adaptive child?

Terry Real:  Well, I speak about what I call relational mindfulness, take a break. I'm a big fan of breaks. Take a walk around the block. Go to my website, if I can say, terryreal.com is a one pager on the 10 Commandments on how to take a time out. Physically remove yourself for a while, but get centered, re-regulate back in the part of you that can remember what you are about. Remember that the person you're speaking to you care about, and the reason why you're speaking is to make things better. Until you're in that place, shut up, don't try and resolve anything you won't. So the first skill, I call it the ER skill, is getting re-centered in the part of you that can use skills to begin with. Then from that place, open up your mouth and speak to your partner. But the first order of business is you tending to those triggered early child states inside your self.

Another one of my sayings is maturity comes when we deal with our inner children and don't foist them off on our partners to deal with. You deal with your triggering, you get centered, then you go back to your partner and say, "What are we going to do to make this work?"

Amelia Worley:  So, on the other hand, what are some signs that it is time to leave a relationship? Where is the line between relationship problems and relationship toxicity?

Terry Real:  You can get on my website, I have an article that I wrote for the psychotherapy networker called, “Rowing to Nowhere: When Enough is Enough”, in which I tackle this issue, when's enough enough? They're obvious, if there's drug addiction or alcoholism or acting out either sexual aggressive and the person doesn't want to do anything about it, if there's a serious psychiatric disorder and the person refuses to do anything about it, if one of the two partners wants to be a thoughtful relational accountable partner and the other one doesn't, just wants to be a big baby. One of the deal breakers is if there is a distinct discrepancy in the emotional maturity of the two partners and the immature partner doesn't want to do anything about it, then the more mature partner feels pain in living with the other person, and I would help them get out. But it mostly has to do with not what the difficult partner is struggling with, but whether they're motivated to do anything about it or not.

Amelia Worley:  So how can staying in a toxic relationship affect mental health and hinder self growth?

Terry Real:  I talked to people about, I wrote this in the book, about what I call becoming relational champions. That means that you get centered in a place in your soul in which you say, "I deserve, it is my birthright to be in a relationship that is essentially cherishing, a relationship in which I can cherish my partner, they'll let me, and I feel cherished by my partner. And if I am in a relationship that is essentially uncherishing, first, let me do something about it, then we go get help. And then we get help that really helps. A lot of couples therapy doesn't do much, so let me get help that really helps. And two, if all bets are off and there's nothing I can do about, it's bad for me to be in an uncherishing relationship, it's bad for our kids to see me in an uncherishing relationship, it's bad for the uncherishing partner, it's bad for all of us. It's time to pull the plug."

Amelia Worley:  So some people seem anxious or afraid to leave a relationship they know isn't healthy or good for them because they're worried about being alone or they're nervous to try and find someone else. What type of advice would you say to someone feeling that way?

Terry Real:  Well, that person is what I would call a love dependent or a love addict. They are filtering their sense of self-worth and well-being through connection to the other. They're using other base to seem the other person's warm regard for them as a prosthetic to supplement their own faulty warm regard for themselves. So that person needs to work on self-esteem, learning how to cherish themselves. And 9 out of 10 times that person's dealing with an
abandonment wound. As a child, they were not aligned with, they were not met. Adults don't get abandoned, adults get left, children get abandoned. And that a childhood ego state of abandonment feels like I'm going to die. A child will die unless they're cared for. So I would say self-esteem work and prom work on an abandonment wound. That's at the core of their terror about being alone.

Amelia Worley:  So if someone is unhappy or in an unhealthy relationship, but they stay together for the sake of the kids, is this typically the right move for everyone involved? Or is it actually better and healthier for children to have their parents separate?

Terry Real:   It all depends, but that's really case by case. How old are the kids? How long you're going to have to tough it out? If you stay together for the sake of the kids for a year because they're about to graduate high school, fair enough. If you're staying together for the sake of the kids and they're three, well, that's quite a different matter. And what are you putting up with? What are you passing on to your children as a legacy? What are you teaching them about how you're going to be treated? It's a very personal decision. It's not for me to decide that for you, but I will say this, on the one hand, you have the damage of the divorce and what that does to children. On the other hand, you have the damage of raising your children in a loveless environment, and what that does to children. There's no easy answer to this one. Either way, your kids are going to be hurt.

Personally, I believe kids do best when either or both parents are happy and in loving relationships. And I would rather have the couple split up by and large and find other people to be happy with. I think that's better for the kids in the long run, but this is one of those questions you ask six therapists to get 33 different answers.


Amelia Worley:  So lastly, do you have any final advice or anything you want to share with our listeners currently in a struggling relationship?

Terry Real:  Well, I would invite you to my workshop starting in June. It's the first ever Us workshop online, go to my website and find out about it. I would invite you to find a relational life therapist. Of course, I believe in my method, in those I've trained, they're on my website as well. Get help and get a therapist who will really support you. I don't think the traditional, uh-huh, uh-huh, tell me more about it, oh, that's what you think, oh, tell me what you think, is going to work. You find the therapist who's going to deal with what you're dissatisfied with and take your partner on and see if they can render themselves more pleasing to you. And if you don't have that support, find a different therapist. So my first order is find help and my second is find help that will really support you, take the issues on, not be so nice, not be so passive, and deliver a better relationship for you.

Amelia Worley:  That's great. Well, thank you so much. It was wonderful interviewing you today.

Terry Real:  Thank you. It was a great joy. Be well.

*Cover photo credit: Dennis Breyt

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.

Therapist Kate Willman on ACT & Writing Therapy

An Interview with Therapist Kate Willman

Kate Willman, LMHCA, MA, HCA is a Psychotherapist at Seattle Anxiety Specialists. She specializes in the use of ACT and the utilization of writing therapy in her practice.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Kate Willman. Kate is an associate therapist here at Seattle Anxiety Specialists. She is also a founder of Ben's Friends, a community support group for restaurant employees seeking recovery from alcohol and drug addiction. Kate has worked on numerous research projects regarding psycholinguistics and providing therapy for those suffering from addiction, traumatic brain injury, emotional experiences related to death, and military populations. Before we get started, Kate, can you please tell our listeners a little about yourself?

Kate Willman:  Sure. Thank you so much for having me. And about myself, you said it, in terms of therapy. I am a native of Texas. I spent many years also in New York City and then moved to Seattle almost five years ago. And working in mental health is my second career, definitely my most happy and fulfilling career, but I spent a lot of years doing hospitality and it's also very fulfilling. I actually still do some work with my partner in restaurants. And there's a lot of crossover, actually. And I think that's an important part of, I guess, why I'm here and who I am, in that I've always been interested in people's stories and always been interested in serving people.

Of course in hospitality, it's a very literal serving and in therapy it's a little bit different, but that's definitely a core part of me is like this continuing interaction with others, usually in some form of service to others. And not in a completely altruistic way either. Right? I get a lot out of that. I get a lot out of being in those really intimate situations with people and learning what they need and hopefully being able to help them get that. I also have two cats and two dogs, so I'm a very happy animal mama. I love animals. I have always loved animals. That's a big part of who I am too. And then, I live in Seattle with my partner and taking it one day at a time.

Amelia Worley:  What is it that got you interested in becoming a therapist?

Kate Willman:  Yeah. Like I said, I was always involved in one way or another, serving others. And the thing that got me very first interested in it was being a volunteer, they call it peer-to-peer counseling, and this was on the East Coast when I was living there several years ago. I guess, another giant part of me and this goes into Ben's Friends, is that I identify as a person in long-term recovery from drugs and alcohol. And I spent the better part of a decade, really not in the service of others, definitely in the service of myself. And that set of addictions really took over my life. And at 25, I found myself really, actually very close to death, and there's a lot of other stuff to that story.

And after that, I got sober January 30th of 2013. Part of my recovery and part of my success in recovery was speaking with other addicts and working with other addicts at various points in their recovery. So, this peer-to-peer counseling thing was happening in detoxes and hospitals, rehab centers out in New York, New Jersey. And I had done it at this one hospital, pretty regularly, weekly, basically, for a couple of years. I knew the nurses and the social workers and stuff who worked there and they were like, "You know Kate, this is a job. You are a volunteer, but you could really do this. It's a real thing."

And at that time, my career in hospitality was actually at its peak. I was working in really great, four-star, New York City restaurants. I had become a maitre d', which was my goal. And so, I was at an interesting crossroads too, of like, "Oh, shit, can I make a new career?" I had never even considered that. Getting sober and just living had been the really cool thing that had happened. And so, I sat with that for a while and decided to try my hand at school. I had gone to school when I was 18 and studied hospitality management.

So, I was 27 and just, "Oh, can I even do college? I don't know." And I decided to try community college. I took some psychology classes and I just fell in love, and it was such a great turning point for me to go back to school. I went to community college, then I went to a four year, got that degree in psychology. And at the beginning I was like, lots of addicts do this, "I'll just be a substance use counselor. I'll just go to school and get this certificate for substance use counseling." And no, the more psych classes I took, the more counseling professionals to whom I was exposed, the more I wanted to do more and more and more, and the more my interests really grew in this realm. So, I ended up moving to Seattle in 2017 and had tried on a couple different programs, local and national, and ended up doing Northwestern's online master's degree. I was really impressed with that program and that it was available online.

I am an advocate of telehealth. And even before COVID, I was very much an advocate of that because of the accessibility it allows for people. So, in terms of me becoming a counselor, taking those courses online and being able to say, "Hey, online is where we should be putting energy for counseling and for counseling education." That was really important to me too. The program was three years, as of course, you and everyone else knows, then COVID happens and everything happened online anyway.

So, now I find myself really, really full circle, able to be a counselor, be an advocate for folks in that substance use realm, the same way that I was nine-and-a-half years ago needing that counseling, needing that guidance. And a lot of other different folks that I get to see and really use my experience, not just as a counselor and someone who's educated in this way, but as a person who was really in many, many low places over the years, and who's experienced a lot of life transitions along the way. And in counseling, this is when a lot of people will come in, is for these life changes. And when things become different is when we find ourselves needing help. That was a lot of roundabout answer, but that's how I got here.

Amelia Worley:  What areas or disorders do you specialize in? I know you talked a little bit about the substance use.

Kate Willman:  Yeah, I definitely feel super at home with folks who are struggling in substance use, substance abuse, and then even to generalize it even more and zoom out even more, a lot of the discussions today are just about relationships to substances, alcohol, even lots of behavioral addictions, right? Shopping, gambling, sex, pornography, internet use. There are a lot of behavioral addictions that we consider as well. And again, having been absolutely enslaved by my addictions for many years, I feel really at home helping folks in those arenas.

I also developed a very clear interest and, hopefully one day specialty, in grief counseling. And I found that a lot of my experiences personally and then with these addicts and self-described alcoholics that I was working with over the years, a lot of people were dealing with various versions of grief. And some of them, it was like, "Oh yeah, I had this near-death experience." Or like me, I was so addicted, I almost died. Or, I have a couple suicide attempts, right? There's a lot of people who have
considered suicide and who have really thought about suicide. And how does that affect a life? And we can use a lot of grief counseling in that area.

And then I mentioned, life transitions. A lot of grief being applicable in divorces or just changes, breakups, changing a job, losing a job. COVID was just a gigantic paradigm of lots of different layers and kinds of grief for people. So, I really find myself diving into more and more of the grief world, and all of the different applications of that. Certainly, within death, dying, bereavement. I volunteered in hospice for a while here in Seattle, too, for about a year, and really wanted to be in that world of death and how that affects us, the living.

And anyway, I could go on about that forever. I really like grief counseling and lots of different applications. And then, my time at SAS has really directly introduced me to the populations of folks who are aligning with symptoms of OCD, of ADHD, of these really specified types of anxiety, trichotillomania, excoriation, which is hair pulling and skin picking and stuff. And so, really, really niche, specified presentations of anxiety. These are things I was exposed to certainly in school and in my internships and some in my volunteer work for sure, but I've really gotten some great training and some great experience head on with these specific presentations as I've worked at SAS.

So, that's been a fun world to live into and to get exposure to doing exposure therapy and to just learning more about these struggles that folks go through in those areas and getting to see therapy, really nitty gritty therapy, and what real behavioral change can look like with a person. It's very, very exciting.


Amelia Worley:  Can you talk a little bit about your treatment approach?

Kate Willman:  Yeah. The easy, very general answer is that I'm eclectic. I think every grad student wants to believe that they're eclectic. And eclectic just meaning like, "Well, I'll do whatever the client needs, and I want to learn everything." And as we get more and more into the actual profession, it's quite impossible to be specialized in all of these approaches and get really good at them. It feels good to be good at something. Right?

So, I think there's a few that I come back to over and over again. Number one is
ACT, acceptance and commitment therapy. This is such a beautiful iteration of cognitive behavioral therapy. It's so flexible, its main goal is flexibility, not for nothing, but it's so flexible in terms of its application, what presentations we find it helpful for people when we engage in ACT. And so, I really like that. It's nonlinear. It's not really focused on symptom reduction, right? It's focused on a meaningful life. The word acceptance is in the name. And so, I find it really, really helpful for, again, a lot of different presentations, but even as therapy goes on for people and maybe their symptoms have reduced a little bit, to go a little bit further in finding how to live a meaningful life, despite what's going on with anything that's happening, any life change, any type of grief or whatever, any sort of internal experience. There is always, always, always this universal need for a meaningful life, and getting to explore that with people via the ACT method has been really, really cool.


And then, I pull from certainly an evolutionary approach. I really found it helpful in my own journey to look at comparative animal behavior, to look at the lives and the struggles of early humans, as we understand it at least. And see how these different parts of our brain, having evolved the way that they have, why do we have something like a fight or flight mechanism? Right? And why are there these ancient, ancient mechanisms in our brain that we just rely on so primally. And when we can identify those, even in our 21st century modern life, with this big old frontal lobe, being logical all the time, there's so much acceptance that can happen for people when they realize, hey, this anxiety that you're feeling over X, Y, Z, is not just because you're a bad person. It's not just because you are defective in some way. Actually, early humans or the animal brain really relies on this function to keep us safe. Anxiety in most of its forms is really there to keep us safe. And so, we find that with this evolutionary lens, there can be quite a bit of just normalizing, I guess, and a deeper understanding of self, that all of these things, they're causing us trouble, but they're really there to help us. And that shift in relationship to our anxiety, it can be so, so powerful. So, I love that one as well.

I definitely do some existential stuff, which is on the other end of the spectrum from any kind of CBT. But when we talk about meaning making and what is my purpose in life? There can be some fun, especially in the realm of grief, there can be some fun discoveries of self when we are looking through this existential lens for ourselves. And then in terms of techniques, CBT has a whole host of really cool techniques from ACT, from DBT, that I will employ as needed. And then I also really enjoy narrative therapy. There's a lot more even coming out now, narrative therapy-wise. Here's that frontal lobe again, we were talking about the other parts of the brain before, but we have a lot of research that's showing the power of narrative therapy in engaging and re-engaging that frontal lobe part, the decision-making part.

And when we are able to look at our lives and our struggles and our relationships, or our questions in that narrative form, we're employing and re-employing all of these tools that are already there for us. And it's really a discovery of self. I think that I say that a lot actually, but I guess to wrap up treatment approach, I'm very much an advocate of helping people see they already have everything they need to be successful, everything they need to even define what success is. Some people have never been given that chance. What is success? What does a meaningful life look like to me? And then how do I get it? It's not going to be, because I give it to them, it's not going to be because they picked the right self-help book or YouTube channel to watch. All of those things might be useful in self-discovery, but it's really a matter good counseling, in my opinion. The best approach in my opinion, is being willing to try on all these different things with a client, with a person, and watch them and assist them in discovering for themselves, what is most meaningful and what is best for them and their life experiences. And for that meaning, defining that meaning and then approaching that meaning for them. That is the best approach all of the time, no matter what.

Amelia Worley:  That's great. Would you mind sharing your experience in using writing as a treatment approach? What are the benefits of writing therapy?

Kate Willman:  Yeah. Yeah. So, you can tell how much I love it, because I was already talking about it. And again, humans, we know a lot or we think we know a lot, we know it as best as we understand it, other animals, while definitely really advanced in a lot of their communication, as far as we know other animals do not have this writing thing. Right? So, we can guess from that, that it is a purely human function, purely human mechanism that we are able to write.

And so, when we look at that spectrum of evolution, of mammalian evolutions specifically, we are again, hypothesizing that this ability to write and the benefits to write, from the evolutionary perspective, the theory is we don't do anything that isn't of benefit to us in some way. Right? So, there are these surface level benefits of writing, right? Okay. Well, now I'm living in a society with other humans and the writing will enable us to communicate in a different way, in the here and now. We also know that writing of course, allows us to communicate with generations past and future.

So, it's really, really cool that writing as a mechanism, really came out of evolution in that way. So, those might be the external benefits of the writing for us as a species, as organisms, but internally there's got to be usually a benefit too. And so now, over the last 20, 30 years especially, our brain scans have gotten so much more advanced. And when they've looked at these brain scans and they've learned more about that internal function of writing and looked at the frontal lobe, what they realized was in its most simplest form, and I hope I'm not minimizing in any way or being a reductionist in any way, but it's really just very simply, I have to think about something, right? If I want to write about my experience in COVID, let's say, if I write about that, I have to think about it, to come up with the words and the language, then I have to involve all these other mechanisms with my body and my brain to write it down.

And then, the third time is if I'm going to reread it. And we know that reading involves some other areas of the brain, but the point is there's at least three times, usually much more, but at least three times when I'm involving my brain to go and review this thing that I wrote. And it's just like hearing a story from somewhere else, that I might learn if I'm hearing that story three different times or 10 different times. And then I hear someone else tell that same story, 10 different times, of course, logic says I'm going to get some different things from those stories.

So, in the case of writing and in narrative therapy, what we try to do is employ those different inherent lenses and perspectives, but all within here and in that person's writing just for themselves. So, the therapist's role is to provide provoking questions sometimes, right? That if I just go and write my story in COVID, okay, I'm liable to learn a bunch of different things because of, like I said, the brain is automatically reviewing it. And that means that even the next day, I might be subconsciously thinking about it, even if I'm not actually reading it or rereading it. Right? So, that's happening.


And then, if the therapist is like, "Okay, Kate, you wrote your story of COVID, here's some provoking questions." That's going to cause me to, “ooh, now I have to use my critical thinking, which is also up there. And my problem solving mechanisms are all activated in that frontal lobe.” And so, you see the infinite nature of narrative therapy in engaging and activating all of these different parts of our brain to allow us to see things from a different perspective and thereby, gain things from those different perspectives that we couldn't do if we were just sitting here trying to think about, "Well, what was my COVID experience like?" We get that really cliche, "I'm stuck in my head about it. I'm stuck in my head about it."

There's definitely a magic to putting it on paper or putting it on a computer, just as there's a magic to putting it in the universe, telling it to somebody else like your therapist or your friend, but we are taking that to the next level, writing it, rereading it, having these provoking questions that we didn't really
come up with on our own. Well, shit, that gives me a lot of more perspectives, a lot of more answers that might come, that I'm just unable to retrieve from my brain alone.

The last piece, and this is my ACT brain coming in, ACT cheerleader maybe, not my ACT brain. ACT has this component of cognitive diffusion, right? That it behooves most of us and we have evolved to be fused to our thoughts and our feelings. So, when we defuse, that's that act of, we are not our thoughts, we are the thinkers, right? And we know when thoughts are so troublesome and we're dealing with OCD or anxiety or grief or whatever, by getting away from them for a moment, we are able to look at them a little bit differently and guide a little bit more, how much we want to connect to those thoughts, if we want to believe them or not.

And narrative therapy, in most of its forms, will also inherently engage in that cognitive diffusion, that I'm putting it out from me, again, in that same way when I tell someone, but it's on steroids, right? This ability to defuse and defuse and defuse. And we know that we just have much more autonomy and agency over those troublesome thoughts, while accepting them as there, and then deciding where we want to go forward. Yeah. That's narrative therapy.


Amelia Worley:  Do you have any words of advice or anything you want to say to our listeners?

Kate Willman:  Willingness is the key. We talk a lot and thankfully there's a lot of stuff out on the internet now, that's so accessible for people, maybe on social media, on TikTok or Instagram, people are getting help in ways that they have never been able to before. And so, I would want to say that I used to go to an AA meeting in New York City and it had on the wall, "There's no wrong way to get sober." And that used to piss people off. That used to make people really mad, like, "Oh, of course there's a right way to get sober." And I apply that now to therapy. There's no wrong way to try to feel better.

And that's a hot take, it's an unpopular opinion, right? Are there bad therapies out there? Yes. Are there bad therapists out there? Unfortunately, there are. There are people who might be more harmful than helpful, but I think the hardest step for most people is being willing to ask for help. And for some person that might be, I'm just willing to follow some accounts on Instagram and try to get some engagement from these people. And maybe I need help, being willing to say to ourselves, "I need help. I can't do this alone anymore."


And so, what I would say to people is, any level of willingness, wherever you are at in your mental health journey, in your becoming a counselor journey, on whatever journey you identify with, the willingness to keep going, the willingness to show up, the willingness to ask for help, the willingness to say, "I need a break today. I can't go any further right now. I'm not sure what to do." The willingness to say, "I don't know." Oh my gosh, what courage that takes.

So, willingness is the key to, so, so, so much in terms of success, in terms of meaning, in terms of contentedness and serenity. So, if you're feeling stuck and you can identify that, the next question might be, "What am I willing to do? How far am I willing to go?" And then, "Who or what am I willing to ask help from?" And just to love yourself, that's really one of the hardest parts too, huh? So, if you can find place for some love in your heart for yourself, I always recommend that too. No matter what.


Amelia Worley:  That's great. Well, thank you so much. It was really great interviewing you today.

Kate Willman:  Yeah. Thank you, Amelia.

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 Michele Bedard-Gilligan on Trauma & Recovery

An Interview with Psychologist Michele Bedard-Gilligan

Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery.

Amelia Worley:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us, Dr. Michele Bedard-Gilligan. Dr. Bedard-Gilligan is an Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. She is an expert in the field of trauma, focusing specifically on post-traumatic stress disorders and the mechanisms of recovery. She has numerous publications on PTSD and individual responses to trauma, including one of her most recent publications on the topic “PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies,” co-authored with her close colleague and collaborator Dr. Emily Dworkin. Before we get started, Dr. Bedard-Gillian, can you please let us know a little more about yourself and what made you interested in studying trauma?

Michele Bedard-Gilligan:  Sure. Thank you so much for having me. I'm so grateful and happy to be here today. Yeah, I actually got my first experience working with people who had survived traumatic events right after I was an undergraduate. So after I graduated, I worked for a bit at the VA hospital in Boston and worked with veterans returning from conflict either recently or many years ago and did some work trying to understand mechanisms of recovery and how trauma affected them and really just became very passionate about trauma recovery from both a research and clinical perspective. And so from there, pursued that path of really that being my career in terms of studying and treating clinically working with and individuals who've been exposed to trauma.

And so, I'm a Clinical Psychologist by training. I, like you said, I'm faculty at the University of Washington School of Medicine in the Psychiatry Department. I have a clinical practice where I see patients for a variety of reasons, including reactions following traumatic events. And then I have an Active Research Program. So, I'm the co-director of the Trauma Recovery Innovations Program at the UW School of Medicine and the associate director of the UW Center for Anxiety and Traumatic Stress, which is affiliated with the Department of Psychology.

Amelia Worley:  That's great. So to begin, would you mind defining what trauma is?

Michele Bedard-Gilligan:  Yeah. It's a great question. Trauma is something that actually means something very specific in the mental health field. So in the field of the study of mental health disorders, when we talk about trauma, we actually talk about something very specific. So, we define trauma exposure as being exposed to an event that either causes injury or threatens injury or threat of death or is a threat to personal integrity or physical integrity. So that is meant to characterize events where maybe there was no injury or maybe not even threat to life but they were characterized by violation of one's physical being, if you will. So, things like sexual violence fall into that category. And those types of events that meet that bar or threats of injury or threats of violence have to be either experienced directly by the individual, witnessed -So you watch it happen to somebody else, or something that you're confronted with. So, you learn about it happening to someone you really care about or someone you love or someone you're close to.

And then finally, exposure to being confronted by a lot of violence or really negative outcomes or negative harms to other people if it's in the line of work. So, this is things like emergency personnel or people who work in combat zones or war zones who are exposed repeatedly to really terrible things that happen to others that they don't know. They don't know those people personally, but they're just constantly exposed to it because of their occupation. That is also concluded in our definition of trauma. And so really specific actually in terms of how the mental health field defines traumatic events or trauma exposure.

Amelia Worley:  How does trauma relate to post-traumatic stress disorder? Are some traumatic experiences more likely to develop into PTSD?

Michele Bedard-Gilligan:  Yeah, that's a really great question too. So post-traumatic stress disorder is one set of symptoms, one diagnosis that can develop following trauma exposure. But I also want to be clear that following exposure to the kind of events that I just described, it can lead to a host of negative outcomes. So, we can see people develop mood problems or anxiety problems, which I know is your specialty. We can see people develop substance use problems or thoughts about suicide that they didn't have before. So, it can lead to a host of negative outcomes.

The post-traumatic stress disorder, PTSD, is one of those and it's a specific set of symptoms that really involve the traumatic events specifically. So, it's a set of symptoms where the individual re-experiences the event in terms of having nightmares or intrusive images or really strong cued reactions to things that remind them of the traumatic event. It involves avoidance of things that remind them and things that are objectively faced. But because of their association with the traumatic event, the person goes out of their way to really avoid them, which can really narrow life and cause a lot of impairment.

PTSD also involves mood and thinking disruptions. So, if we see things like anger or lots of pervasive sadness or guilt. We see things disconnecting or isolating from others, as well as really impacted belief structures, negative beliefs about oneself, negative beliefs about the world. Sometimes people take on responsibility for the event that isn't necessarily accurate, but how they view it in terms of holding themselves responsible or accountable for what happened to them. And then we see lots of hypervigilance and hyperarousal type symptoms in PTSD. So, this is on-edge,
difficulty sleeping, feeling very easily startled, and very hyperalert about your environment. Those kinds of things. And so PTSD really refers to that specific symptom constellation of having symptoms in all of those categories that I just mentioned.

And following traumatic events, we see PTSD develop in what I would call a substantial minority. So, if we look across the spectrum of people who in their lifetime meet diagnosis for PTSD, it's around seven to ten percent, something like that. So, it's not most people who experience trauma exposure actually, but it's still enough and it's a substantial minority of people who will go on to suffer in this way from these specific types of symptoms.

And yes, some events are more likely to lead to PTSD than others. So we see events that are characterized by interpersonal violence in particular having higher rates of PTSD develop. So you can think about my definition of trauma exposure per the mental health field, and that encompasses the huge range of events, from natural disasters, to motor vehicle accidents, to the whole host of things life-threatening illnesses that come on very suddenly. And then it also includes things like violence that's perpetrated by someone you know or by a stranger, sexual violence, childhood abuse, so things that happen early in childhood that fall into the physical abuse or sexual abuse category. It's a huge range of traumatic events and some of those, particularly the ones that are characterized by being interpersonal in nature are more likely to lead to PTSD diagnosis than some other types of events.

Amelia Worley:  Do you often see substance use overlap with PTSD?

Michele Bedard-Gilligan:  Yeah, so we do. We see PTSD as something that is commonly comorbid with a variety of things. So we see very high overlap in PTSD and depression, for example. We see overlap in PTSD and other types of anxiety disorders, like experiencing panic attacks. But one place where we particularly see overlap is with substance use.

So this is true for both people who identify as male and people who identify as female. But it's actually a little more common in people who identify as female, where we see rates of maladaptive or unhelpful substance use be increased. So, people with trauma exposure and then people with trauma exposure and PTSD, specifically, will show higher rates of using substances in a way that is problematic, in a way that is getting in their way in some way shape or form. And often we think of that as sort of likely attempts to cope with some of the distress and the symptoms that develop. So substance use can be a way to either deal with negative emotions or to try to cope with those negative emotions. But unfortunately over time, what can happen is that it can then escalate in this way that it can cause problems to the individual. So we see elevated rates there for sure, yeah.

Amelia Worley:  So in your experience, what is the most effective treatment for PTSD?

Michele Bedard-Gilligan:  Yeah, that's a great question, and fortunately we do have really good treatments for PTSD. So I think for a very long time there was a myth that PTSD was something that couldn't be treated. After being exposed to traumatic events and developing distress related to those, that was a burden that would be there for an individual's lifetime. And fortunately, we actually know that, that's not true.

Just like any other mental health disorder, we don't have treatments that work for everybody all of the time in all circumstances, but we do have treatments that we would call pretty effective. So we have medication options. Which is not what I do, because I'm a Clinical Psychologist. But we do have medication options. So medications such as SSRIs are often used and they have effects sizes of about 0.5 and response rates of about 50%, it's about that ballpark. So a number of people who are prescribed to those medications will get a lot of relief from taking them for their PTSD symptoms.

There's also a lot of alternative therapeutics that are being investigated right now, which I won't go into too much because it's not my area really. But things like cannabis, which I do a little bit of work on. But then also things like MDMA-assisted therapy and ketamine-assisted therapies that are being looked at for helping with PTSD. Early stages, but there might be some initial promise there. But really when we think about treatment for PTSD, a lot of where it's at is in therapy approaches. So a lot of where we can be really effective has been therapy behavior change treatments for PTSD. And there's a number of them out there, so there's a number of different approaches and they have a lot of overlap with how we might approach anxiety disorders more generally.


So, for example, a lot of the treatments that we do have a sizable exposure component. So this is about helping the individual approach the reminders of the traumatic event that are causing a lot of fear, a lot of anxiety, those re-experiencing and hypervigilant symptoms that I talked about earlier. So really decreasing their avoided symptoms by using these exposure approaches. So it's involving going out into the real world and doing things that are reminiscent of the trauma but actually safe. So for an example, someone who's in a motor vehicle accident who has developed a fear of driving, and most of the time driving is actually a safe activity. And so helping the person gradually expose themselves to driving again is often a key component of treating trauma reactions.

In addition, in that same exposure realm, we think of PTSD as being a disorder that is also characterized by the memory itself and the memory taking on a very dangerous quality. So when individuals think about the traumatic event, it triggers a lot of anxiety and guilt and distress more generally. And so the exposure really involves helping individuals reprocess that memory. So go back to that memory and approach it in a way where they can sit with it, they can feel some of those emotions that that brings up. But also have that experience of gaining new perspectives and new meaning about the memory to really being able to shift their relationship with that memory, shift their relationship with the way it's impacted, the way they see themselves in the world, and also sit with those emotions so they can start to feel some decrease in them. So, it's really about processing through that memory in a way that helps them make sense and meaning out of something that, quite frankly, is quite senseless, as trauma is. And so really helping them figure out ways that they can see it and find ways to see it, so that they can gain some new perspectives and move forward. And also, correct any beliefs that might have developed that are really triggering a lot of emotion that may be not 100% accurate. So, we talked a little bit earlier about taking responsibility for traumatic events when in fact they were not your fault. And so doing exposure to the memory can help people see the places where, although they've been carrying this burden of guilt or carrying this burden of blaming themselves, and in reality that's not actually true. And so going back and going through that memory can help people shift there.

In addition, a lot of the trauma treatments that we do, so the empirically supported therapies for post-traumatic stress disorder also involve more general cognitive approaches. So, helping people identify the ways that the traumatic event has impacted their view of themselves in the world. Like how has it impacted how they think about things and learning concrete skills for being able to take those beliefs and when they're not accurate, be able to shift them to be more balanced. And so for an example there, we might have people who after a traumatic event have developed very strong beliefs that the world is just always dangerous. It's just a dangerous place. And there's a kernel of truth to that maybe. Bad things do happen and the world can be dangerous, and people who've survived traumatic events know that better than anybody. And the world is probably not 100% dangerous 100% of the time. And so helping people learn the skills to be able to see the places, “where am I safer” or “where are things more dangerous.” Being able to see that nuance again, because after traumatic events that can be really challenging and so helping them learn skills in that area.

And then finally, most of our ... all our treatments for post-traumatic stress disorder really involve a high degree of validation and support. So, following traumatic events, it's just hard. It's challenging to connect to people. It's hard to feel safe anywhere. And so really these events enable people a safe place and a safe space and hopefully a really strong, supportive environment in which to approach all this stuff. To
approach their beliefs and approach their memories and approach the things in the environment that scare them and to do it in a way that's supported and gradual and systematic, and we can really make strong gains with those approaches. Yeah.

Amelia Worley:  So, in the publication I mentioned earlier, PTSD in the Year Following Sexual Assault: A Meta-Analysis of Prospective Studies. You talk about how it is common for PTSD to develop following a sexual assault. Additionally, the first three months post-assault may be a critical period for natural recovery. Can you explain that idea of a critical period for recovery a little more?

Michele Bedard-Gilligan:  Yeah, absolutely. So, as I mentioned earlier, when we think about PTSD and the development of PTSD, it is a substantial minority of people who develop and so it's not everybody. But immediately after a traumatic event, particularly a really severe traumatic event, we will see symptoms of PTSD, symptoms of distress in almost everybody. So, the normative reaction to something really traumatic and terrible and horrible happening is these symptoms of re-experiencing it and having nightmares about it and wanting to avoid and all of those things. But for many people, fortunately those things will go down on their own with time, and we often call that natural recovery, this idea, and what we mean by that it's just recovery that happens without intervention. It just innately or inherently occurs for the person.

And what we mean by this period, this critical period, is that what we've seen from the data and what we observe clinically is that when that natural recovery, that recovery without intervention, that organic recovery happens, it usually happens within those first three months. So those first three months, those first 12 weeks or so. I mean, obviously it's an estimate. But around that time, is really crucial for whatever learning and whatever meanings going to happen for the person innately and organically, it usually occurs in that time. And probably a lot of what that is, is people who in that aftermath of traumatic events are getting that support and that validation that I talked about or they're getting that encouragement to talk through what happened and to really confront the emotions that it's bringing up. And they're doing that on their own naturally. And so, we see this decrease in symptoms that will occur. And again, it occurs for quite a few people or quite a big chunk of people exposed to trauma. And then it seems that as the months go on, if that process hasn't happened in that natural way, then we often see people get stuck with the symptoms that they've developed and so we see those symptoms persist.

In the article you're talking about, the percentage of people who had PTSD symptoms following sexual assault one month after was quite high. It was a very large majority. And then when we followed them or we looked at the studies that have been done and we looked over time at them, we find by a year out it's less, it's slightly less than half who still have the symptoms. And that's actually high. So, for sexual assault to look and see that in a year out, almost half of the individual studied had symptoms that still met criteria for PTSD is pretty high. When we look at other types of traumatic events, we definitely see it being lower. It's lower than that. And so sexual assault and that interpersonal violence is definitely one where we see less of the natural recovery.

Amelia Worley:  So digging into that further, I know you talked a little bit about the positive way that the environment can help with the recovery during those first three months. What are some environmental factors that may be harmful to the individuals' recovery during those first three months?

Michele Bedard-Gilligan:  Yeah, yeah. It's a great question, what keeps those people at risk. So, we see some of the resilience surround where people are able to recover on their own comes from some of the things I talked about. And some of the risk probably comes from the inverse of those.

So people who for whatever reason aren't able to not avoid, they're not able to go back and engage in their world, either because it feels intolerable or because they're not given the opportunity. So they stay isolated or they stay, are really avoidant of things that trigger trauma thoughts or trauma memories. People who don't have natural avenues for support, either because they don't exist, social support is what I mean, either because they don't exist or because they're not able to take advantage of them or because they are experiencing so much avoidance, there's so much distress that they don't reach out or they don't share or they don't talk about it. Or because sometimes what people, sometimes even well-intentioned, reactions we might get in our natural social support environments just aren't helpful.

And again, this is in our culture pervasive. Something really bad happens, you reach out for support in your natural environment and some of what you might get back is, "Just don't think about it. Just try not to think about it." But that's actually the opposite of what we think is helpful. And it's well-intentioned and I see where people come from when they give that kind of feedback and it can also really backfire. If we think what we need is actually to process and to feel the emotions and to really engage with the experience and the memory in order to make sense of it and move forward, not talking about it is the opposite of that.

And then of course there are also extremes. So, we know from the research that's been done that, unfortunately, a sizable number of people when they disclose traumatic events will get what we would call negative reactions. So, they will get either somebody blaming them for what happened or telling them that it was their fault or telling them that they should have done something different or telling them that if they were stronger, they would've just moved on from it. Those kinds of things that we know are actually incredibly harmful. So, for people who get those reactions, they're at much greater risk for developing long-term symptoms.

And then finally, substance use and the overlap of substance use with PTSD is something I care passionately about and something that I do a lot of work on. And we also know that substance use in the immediate aftermath of a traumatic event can keep people stuck as well. So, when people are using substances maybe to cope or for other reasons, it can prevent that processing and prevent that adaptive coping and can unfortunately cause more negative outcomes as well.


Amelia Worley:  That's really interesting. I noticed that you have many research projects working with young adults. What are some differences in the way adolescents and young adults process traumatic experiences compared to older adults?

Michele Bedard-Gilligan:  Yeah, it's an interesting thing to think about, about how age and developmental period impacts how we might make senses of the really difficult things in life and how we might cope or find resources following traumatic events. In general, age has not been found to be a very robust predictor of who's likely to develop PTSD. So it's not something where we think about as a background characteristic that's really going to impact whether or not someone goes on to develop distress. That being said, I do think there are some things that we know about what is important to pay attention to. So younger people in general are more likely to be exposed to traumatic events and so there's just a slightly higher risk there. So, in terms of being exposed to trauma, which then obviously puts you at risk for developing post-traumatic stress disorder.

In addition, I think depending on developmental period that younger individuals sometimes have less access to resources, less access to outlets for support. They may be living in environments that are perpetuating the traumatic events or trauma exposure, and not have a whole lot of control on how to get out of those environments. Just because, generally speaking at younger developmental ages, we often have less agency over our environments and in what's going on around us than we do as adults.

So that could be a difference. As well as depending on how young an individual is, what cognitive and emotional resources they have to make sense of things, that can be challenging as well. And so those are some of the main differences, whereas ... Yeah, I think I would just stop there. Those are some of the main differences, I think in terms of how we think about how different age categories might respond to traumatic events differently.

I think your observation that a lot of the work that I do is with younger adults really reflects that first point. That when we are doing studies or where we're intervening and promoting trauma recovery with various therapeutic approaches and we're looking to the community for people to come in and participate in our study and help us learn about these therapies we often see a bias towards individuals who are younger wanting to do those things and or having more of a need for it.

So when you do a research study, for example, where we're providing treatment free of cost. This is really helpful to individuals who may fall into a bracket where they don't have health insurance or the health insurance plans their parents and they don't really want their parents to know that they're doing this. So something along those lines. And so, I think some of it is also a resource thing as well as a need and a vulnerability thing. Yeah.


Amelia Worley:  Lastly, do you have any advice or anything you want to share with our listeners suffering from exposure to trauma or PTSD?

Michele Bedard-Gilligan:  Yeah. I think hopefully some of the things I've talked about in terms of what it looks like and the treatments that are out there for it is helpful to people in terms of if they're looking for options and they are feeling like they need help. I think the couple of things that I would really want to drive home I guess.

One, being that trauma exposure is actually incredibly common. So, when we do big national surveys, it's anywhere, it's over 75% of Americans who've experienced, or people living in the U.S., who have
experienced at least one traumatic event by our definition. So, this is an incredibly common thing and so experiencing trauma, it's not unusual and it doesn't make you an outlier in any way actually. And then that it does lead, we know that it leads to all kinds of increases in distress and makes people vulnerable for all outcomes. It's not a guarantee. Many people are very resilient, and like I said, many people can use the resources and the things they have around them in order to not develop things, distress that is impairing. But many people do and it's not abnormal and it's not something to feel ashamed of. It's not about strength, it's not about being weak, it's not about any of that. It's just about the real effects that these really kinds of horrific experiences have on us as human beings. And because we know this, because we know it can have these predictable effects, I think anything we can do within our communities, within ourselves, within the people close to us to decrease stigma around it. To decrease this idea that experiencing trauma is something that we should be ashamed of or something that leaves us to be marked for life or any of that, is something that I really hope we can start to move past and instead really think about it as something that shapes us as people.

And when it causes distress that's impairing, when it causes symptoms or problems that are getting in the way of us functioning or leading the lives we want to live, that there are things we can do about that. And there're treatments out there that are helpful, that we can start by just reaching out for support if we have people in our lives who can provide that. But when that's not enough, there's other more professional, higher level care options as well. Yeah, and so I think those are just some of the things that I would hope people would be able to hear and understand and that hopefully would be helpful.


Amelia Worley:  That's great. Well, thank you so much, Dr. Bedard-Gilligan. It was wonderful having you on our series today.

Michele Bedard-Gilligan:  Thank you. I appreciate it.

For more information, click here to access an interview with Psychologist Robyn Walser on trauma & addiction.

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.