Psychologist Priyanka Shokeen on Psych assessments

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An Interview with Psychologist Priyanka Shokeen

Dr. Priyanka Shokeen is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists. She manages the diagnostic evaluations and assessments sector of our practice and has extensive experience in working with trauma and personality disorders.

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of “The Seattle Psychiatrist” Interview Series. I'm Dr. Jennifer Ghahari, Research Director at Seattle Anxiety Specialists. I'd like to welcome with us, psychologist, Priyanka Shokeen. Priyanka is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists.

Her clinical work is focused on providing comprehensive psychological evaluations, primarily for diagnostic clarification. Before joining our practice, Priyanka was the clinical fellow at Columbia University. Can you tell our listeners a bit about yourself?

Priyanka Shokeen:  Oh, yeah. It's always difficult to think about where to start on a question like that, especially after the introduction you gave me. So, thank you for that.

Jennifer Ghahari:  Sure.

Priyanka Shokeen:  Well, let's see, I've been studying Psychology since the age of 16, and it never fails to amaze me each year as to how little I know, for the fact that I'm still interested in learning more. I'm originally from India, and for the better part of the last decade I was working in New York City.

I'm somebody who's always been interested in advocacy, and throughout my life that's looked different depending on where I am personally and geographically. Then, I'm an avid reader. I don't get as much time to read anymore, but that's a lifelong habit I plan on keep trying to be better at. So, that's a bit about me.

Jennifer Ghahari:  What types of books do you read?

Priyanka Shokeen:  Oh, mostly fiction. I used to read a lot more theoretical texts, old texts, based in Psychology, back in grad school, even starting as early as undergrad, but right now I think fiction is a good way to detach from work.

Jennifer Ghahari:  Yeah. Nice. So, what is it that got you interested in becoming a therapist?

Priyanka Shokeen:  Funny enough, fiction.

Jennifer Ghahari:  Really?

Priyanka Shokeen:  Yeah. This is why I like fiction, the ability to engage with it is so transformative in that it allows you to really flex your imagination. It teaches you to how to imagine the mind of a character, how to experience strong emotions in a safe enough manner.

So, I initially thought this interest would translate into a career in literature and writing. And that was a quick lesson in the fact that hobbies are not necessarily things you're good at, and they probably shouldn't be. It's a good thing that hobbies are not things you're good at.

So, I kept following my interest, not just in the experience of emotions, but also with regards to my curiosity in terms of the confidence that make people behave in the way they do. And those include race and gender and class and culture, apart from, say, biology and family environments. So, I followed a story.

Jennifer Ghahari:  Great. I'm going to put you on the spot. Who is your favorite fictional character?

Priyanka Shokeen:  Ooh. You know what, I'm not sure if this is a popular book, but it is definitely my most quoted book. It's this book called Shantaram. It's about this convict who escapes from Australia and reaches Mumbai, I think back in the '80s. And it's him getting involved with the underworld there. So, the main character for that is my favorite fictional character.

Jennifer Ghahari:  Awesome. Great.

Priyanka Shokeen:  Yeah.

Jennifer Ghahari:  Thanks for sharing. So, in clinical practice, are there any areas or disorders that you specialize in treating?

Priyanka Shokeen:  Well, let's put it this way, my professional areas of interests are the areas I continue to build specialization in. So, with that in mind, I have a lot of experience with personality disorders and trauma, and that's where my primary interest and work lies. I, in the past, enjoyed doing group work a lot. I've run inpatient groups, I've run outpatient groups, I've run groups in counseling centers. I think they have a lot more power than we give group therapy credit for.

Then, like you mentioned in my introduction, I do specialize in differential diagnosis, which again, the personality disorders or the trauma work, for me, remains an area of knowledge that I keep growing in.

Jennifer Ghahari:  Great. For our listeners, can you explain a bit about personality disorders, maybe which are the most common, just a bit about them?

Priyanka Shokeen:  Yeah, I think if we were to look at personalities as somebody's unique signature in that it is their way of relating to themselves, to other people and to the world around them, that's what we call personality, ideally. Personality disorder is when your characteristic ways of being either with yourself or with people or with the world, they become problematic, they start causing you harm or they start causing people around you harm.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  So, in the past, personality disorders have been, according to diagnosis, certain axes. So, the kinds that we see a lot, or that gets talked about a lot, even though it's not that common, is "borderline personality disorder", because that is one of the hardest to deal with. It comes with a lot of emotional dysregulation, a lot of identity instability, risk factors.

But just as common is, more common than BPD, is "avoidant personality disorder" (AVPD) or OCPD, which is different from OCD. So, OCPD is "obsessive compulsive personality disorder", different from "obsessive compulsive disorder".

Jennifer Ghahari:  Great. So, if anybody thinks that they may have one of these, reaching out to someone you would be good, to talk about and possibly get an evaluation-

Priyanka Shokeen:  Absolutely.

Jennifer Ghahari:  ... as an example. Great.

Priyanka Shokeen:  I think one of the first points of entry into getting help is if you have started noticing that your characteristic ways of acting are not bringing you what you want or that people around you have started noticing something before you have. So, they're giving you consistent feedback about certain ways in which you act, say, for people who have really explosive anger.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  People around them are the first to notice that, "Hey, I think you need to get help." So, yeah, absolutely, I would be very happy to help. And if I feel that I'm not the most competent person to help, I would absolutely provide a good referral.

Jennifer Ghahari:  Great. So, aside from something like explosive anger that people are telling you may have a problem with, what are some other signs or symptoms that people should be on the lookout for?

Priyanka Shokeen:  Well, it depends on different things. It depends on your priorities. So, let's say if you have avoidant personality disorder, the characteristics of life where we measure functionality, where you're functioning well, is what is generally agreed upon as health. Different degrees is, self-care, it is your relationships, it is occupation, student, whatever job you're doing.

So, if you start noticing something going wrong in either of these areas, that's important for you to know. So, if you, as I was mentioning with avoiding personality disorder, you do want to form relationships, but just the task of it, the fear of it is so much you avoid them to the extent that it starts affecting you, that you end up being self-isolated. And again, the last three years have taught us, self-isolation is especially punishing.

So, that can be one of the signs to look out for. For "narcissistic personality disorder", it's very hard. Self-reflection is not the first criteria for it. So, people around can start saying, "Hey, you take a front to seemingly small things." They feel very personal to you. And as somebody who's going through it, you may think, initially, that they're saying it to hurt you or they don't value you, but depending on the number of contexts you're getting that feedback in, it becomes harder and harder to deny.

So, people may come in for complaints of depression or anxiety, which, once resolved, you might realize, once those symptoms are done, there are still lingering symptoms in these areas of occupational functioning, your relationships, your self-care. And that's generally when personality disorders initially start getting addressed, unless there's something as dramatic or as explosive as, say, BPD.

Jennifer Ghahari:  Wow. Great. Thank you. That's really helpful. So, let's say someone contacts you and makes an appointment and goes to see you for X, Y, or Z, how can you explain your treatment approach? What can someone expect to experience if they're going to therapy with you?

Priyanka Shokeen:  Okay. So, I'm going to try and break it down into my overall clinical approach, and then say what an initial couple of sessions with me can look like and what the purpose of asking certain questions is. My approach to clinical work is largely integrative. Most therapists out there, you'll ask, that's what they end up following, because we've been taught so many things and we know how to draw on different things, depending on what the client is presenting with.

With regards to case conceptualization, which is an overarching view of what I think the nature of someone's presenting problem is, I have a psychodynamic approach. So, I use my training in, say, diagnostic tools in psychological tests, and I put a focus on developmental history. I keep an eye out for differential diagnosis. I try and understand, what is the larger family context or the cultural context in which someone's presenting complaints operate?

So, the psychodynamic framework, it allows me to start building a coherent narrative of someone's life with the data that I've gathered from different perspectives. That said, I also use a lot of CBT and DBT techniques in session, depending upon, again, what the presenting problem is and what the client needs. So, that's more my approach, overall, throughout the course of treatment.

With initial sessions, intake with me can take anywhere from two to three sessions. Those three sessions are a good place for me to decide if I have the clinical competence to provide you the best care with what you're coming to me with, and that's a good way for you to assess if you would want to, keep coming to me, if you like my style, if you feel comfortable talking to me, even if not about everything, just initially.

So, the goal of that initial exploration is to get an understanding of what the client is coming to therapy for, they're presenting complaints, the history of that complaint, and then the circumstances in which the client is, as well as their own personal characteristic that keep those situations that they have a problem with or those symptoms operational.

I say this often enough to most all my clients that you're not reacting in a vacuum. There's two parts to this. There's the internal and there's the external. So, as part of this initial exploration, there's a lot of attention that I pay to developmental history, so trying to gather data about someone's attachment patterns.

I try to attend to the mention of key figures or key moments in somebody's life, specifically in early development, but also crucial details or crucial figures clients either forget to talk about or avoid talking about, because for me, that's the beginning of trying to understand somebody's presentation.

So, in this manner, guided by this dynamic framework, the goal is to start bringing what feels nonintegrated parts of the client self in order to provide them with greater access to their own internal world.

Jennifer Ghahari:  Great. So, talking about all these different diagnoses that people may have, and you run our practice’s psychological evaluation program. Can you explain what that is that you're running and what people can expect to experience if they reach out for an evaluation?

Priyanka Shokeen:  So, generally speaking, psychological evaluation or assessment, it's an evidence-based approach which makes use of information from a number of different sources to arrive at a holistic picture of how a person's mind functions and the ways in which they experience the world.

So, psychological evaluation or assessment, it makes use of clinical interviews, it makes use of behavioral observations, and then standardized psychological tests to understand a more comprehensive profile of what your strengths and weaknesses are, and what are the next steps for your mental health journey. I think you asked me another question as part of this, but I seem to have forgotten.

Jennifer Ghahari:  No, that's okay. So, if I'm going for a test, what can I expect to do? Am I going to fill out one of those old-time Scantron sheets where you pick A, B, C or D? Is it going to be, do people actually take the Rorschach tests, things like that? What do you do?

Priyanka Shokeen:  So, yes to the Rorschach, absolutely yes to the Rorschach. It's one of my favorite instruments to use. When used well and in a standardized setting, it can be one of the biggest sources of information about somebody's personality. But let's, again, start from the beginning.

So, an assessment would involve either question coming from the client, their loved one, their psychiatrist, their therapist. They don't need to be in therapy with me for us to go through evaluation. So, the process begins with, what is the referral question? What are you looking to get assessed? Once we've had a referral question, we'll set you up.

The first point of contact is a clinical interview. And the purpose of this interview is to gather detailed information about what is your current functioning and how you were functioning at a previous time. After the clinical interview is done, comes the process of the assessment. So, yes, there are forms to fill out, there are Rorschachs to do, but these are all different standardized tests.

And they can be part of a whole battery of tests. So, it might just be you end up doing one big test, like the Rorschach or the MMPI, which is also a personality measure, or you end up doing a bunch of different tests, like we do with our ADHD assessment, to understand different aspects of the functioning and how best to answer the referring question.

Once testing is done, we score it, we explain the results to you, we compile everything into a detailed report. And the final part of the assessment is a debriefing session where we go over with the client about what we found, what test was meant to do what… And it carries actionable recommendations on what to do with this information that we've learned, where to go next.

So, a lot of the times, this assessment in and off itself is enough to answer the referral questions. Sometimes we might feel we haven't gathered enough information or you need some other kind of assessment that we're not yet providing. And in that case, we make those referrals in addition to the recommendations that we're providing.

Jennifer Ghahari:  Great. So, I think we're in a society where people want instant gratification, so I'm presuming that this whole process is not an instant thing. Like you said, there's a debriefing and a full report. In general, let's say I came to you for some tests and we did the test today, when could I expect to get my results and the debriefing and all that? How long does it usually take?

Priyanka Shokeen:  Yeah, again, I wish I had more of a straightforward answer to that, but it really does depend on the referral question. On average, you can think of budgeting anywhere between five to 10 hours for the entire assessment process. That includes the clinical interview and the debriefing session. So, the hours-

Jennifer Ghahari:  Is that at one time?

Priyanka Shokeen:  I'm sorry?

Jennifer Ghahari:  It all happens...

Priyanka Shokeen:  Oh, my God, I would never. I think it would defeat the purpose because exhaustion and fatigue are a thing that affect performance. No, it definitely happens over, again, depending on the test battery. So, let's say a particular test is supposed to take anywhere between two to three hours. For a particular client it ends up taking to four hours. So, that would be one. But that's all we're doing that day.

Then, the rest of the things that we need to get done, we'll do it over 2-3 hour sessions over the next couple of days. So, definitely not putting anyone through that in one go.

Jennifer Ghahari:  They don't have to bring pajamas or a pillow or anything?

Priyanka Shokeen:  If it comes to that, we will provide the sleeping bags. (laughing) But you also mentioned when you can get the results? So, oftentimes it takes a lot of hours to score the tests in a particular way, to consult norms, to make sure you're doing the right thing, and then compiling them into a report. So, if you think assessment is time-taking on the administration, and believe me, it's double that on the report end.

So, I generally give anywhere between three to four weeks from the last testing session for me to compile reports because I don't want to do it in a way that misses out on any detail or skims on any part of the report. So, 3-4 weeks for you to get the report, and that's when we'll have the debriefing session and we'll go over the report together.

Jennifer Ghahari:  Perfect. And I think what sounds really nice about this process is, there are surveys online that people could take for this or that, and you hit a button and that's instant gratification, especially put in your email address, for so many websites.

But with this, like you said, it's really customized. You're a trained psychologist who, again, knows what you're doing to be able to look at the nuances of what a specific answer means, especially in conjunction with other tests and other answers.

So, I think the fact that we can provide these detailed reports for people, even though it is slightly more time consuming, the quality of what you walk away with is so much better than more of the quicker, instant gratification type of things that people can do on their own. So, I think this is great what you're doing.

Priyanka Shokeen:  I'm glad. I don't begrudge people on what makes them reach out for the instant gratification of doing an online quiz. It is the most accessible thing. Going through an assessment requires a lot of time and resource, commitment as well, but it isn't just about our report being most tailored to your question, it's that it's accurate. The reason why I say that is oftentimes people can get versions of tests online, but they don't know how to read the report.

You can assign a numerical value, but people might not know how to read that numerical value. Does that numerical value mean a different thing for a clinical population versus research subjects? And psychologists are the only profession that are trained to do this kind of testing. Not to give that example, but do you remember when this part of the previous president's cognitive test, some part of it got leaked online and people thought it was very easy.

It was one question in a neuropsych battery, and people were making assumptions about easy or difficult, but that had nothing to do with what that test represents. So, misinformation is vast and very easily accessible also.

Jennifer Ghahari:  That's a great point. And I think too, if people walk away with not really having the right diagnoses, they're potentially going to take a wrong path then, which would hinder their mental health recovery even longer. If I am actually presenting with diagnosis B, but I think I have diagnosis A, I might follow the wrong path and, actually, potentially get worse.

So, by going through something this, you're able to get the treatment that you need or at least the guidance that you need in order to have a better recovery and get the outcome that you're looking for, right?

Priyanka Shokeen:  Yeah, absolutely. And the thing with diagnosis is also, there's a lot of emotion attached to it. It can be hard to get a particular diagnosis because of how it's perceived. For some people it can be very relieving to get a diagnosis. For most people, the diagnostic categories don't represent a 100% of what they're experiencing. So, even the nuance of why we're saying this is a diagnosis versus that, even that is an important part of treatment.

Jennifer Ghahari:  Great. Before our last question, I'm going to change directions a bit here. What's your favorite part of Seattle? It could be anything.

Priyanka Shokeen:  Oh, my God. It's the proximity to my niece. She just turned two, and, oh, my God. I used to think it was the summers here, which also, beautiful, but tiny, cute baby learning words…

Jennifer Ghahari:  Nice answer. Do you have any final words of advice or is there anything else you'd to share with our listeners?

Priyanka Shokeen:  Oh, I hope somebody, whoever's listening, to whatever extent, that they can derive meaning out of it. The idea of comparison is so extremely prevalent, be it you comparing yourselves to coworkers, to family members, to people on social media. It's very easy to think that somehow everybody else can do things that somehow are very difficult for you or they're getting to places that you're not getting to.

They look a certain way, they do a certain thing. And I think the weight of those comparisons can really run you ragged. Or the thing that I find a lot of clients doing and have over the past several years of working has been when people in extremely hard conditions finally seek help, and it is very hard for them to give themselves the space to be tired, to be exhausted, because somehow everybody else is going through it too, how come they get rest?

Or somehow other people have it more difficult than them. And I always tell them, we're not playing the “Misery Olympics”. So, we don't know what goes into making somebody function. We don't know if what we're looking at is the real picture. We don't know the kinds of support they have or the resources they have, the protective factors, or on the flip side, we don't know what they're hiding or how close they are to a break.

So, it's okay to look at those things and think of them as either places you'd want to be or things you'd want to do, but that does not need to be a determinant in how you should feel about yourself when you should seek help, when you should seek rest. So, I hope some somebody listening can find some meaning in it.

Jennifer Ghahari:  Well, I've found meaning in it, so thank you.

Priyanka Shokeen:  I'm glad.

Jennifer Ghahari:  Now, this has been great. Thank you so much, Priyanka, Dr. Shokeen, for joining us today for this installment of “The Seattle Psychiatrist” Interview Series. And if anybody would to reach out to Dr. Shokeen or perhaps schedule an appointment at some time or some type of evaluation, you're welcome to do so by contacting info@seattleanxiety.com, and we'll get back to you shortly. Again, Priyanka, thank you so much, and we wish you all the best.

Priyanka Shokeen:  Thank you so much. Have a good one.

Jennifer Ghahari:  You too.

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

Psychologist Joshua Miller on Narcissism

An Interview with Psychologist Joshua Miller

Dr. Joshua Miller is a Professor of Psychology and Director of Clinical Training at the University of Georgia. His research focuses on the connection between personality and personality disorders, with specific interest in narcissism and psychopathy.

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 Dr. Joshua Miller. Dr. Miller is a professor of Psychology and director of Clinical Training at the University of Georgia. His research focuses on the connection between personality and personality disorders, with specific interest in narcissism and psychopathy. He has numerous publications on narcissism, including one of his most recent publications on the topic, “Narcissism Today: What We Know and What We Need to Learn.” Before we get started, Dr. Miller, can you please let us know a little more about yourself and what made you interested in studying narcissism?

Joshua Miller:  Sure. I've been a professor at UGA since 2005. I did my graduate work at University of Kentucky and then an internship in post-doctoral scholarship at Western Psychiatric Institute at Department of Psychiatry at University of Pittsburgh. In terms of studying narcissism, it was really sort of just happenstance to some degree. I was studying psychopathy, which is sort of like a fraternal twin of narcissism in a lot of ways, coming out of grad school, and then doing cluster B personalities sort of in general in my post-doctoral fellowship. And then, when I moved to the University of Kentucky, we had one of the foremost experts in narcissism from a social psychology perspective, Keith Campbell, and we just sort of hit it off and just started collaborating and talking about the differences in how I, as a clinical psychologist, thought of narcissism and how he, as a social psychologist, and it just sort of led to a fruitful collaboration and sort of kickstarted this whole line of research I've pursued really for the last almost 20 years.

Amelia Worley:  So to begin, can you define what narcissism is?

Joshua Miller:  Yeah, I mean, I just think of it as a suite of traits organized around an individual who values sort of a sense of superiority, status, recognition over almost anything else in their lives. That means even the willingness to denigrate, devalue those around them so as to maintain themselves in a higher position. So, narcissistic people tend to be grandiose, entitled, require others admire them, feel upset and angry when they don't receive those from others, while simultaneously being sort of callous and non-empathetic towards others. They expect particularly good treatment from others while providing very little of the same to those around them.

Amelia Worley:  What are the different types of narcissism?

Joshua Miller:  Yeah. And I think of the sort of two main dimensions we talk about, and they're not really types as in a narcissistic person has to be one or the other. Rather, they're modestly related dimensions. So, you could be mostly one, mostly the other, or you could have features of both. We talk about grandiose narcissism, and that's the one that most people will think of. The person that is explicitly outgoing, assertive, domineering, grandiose, entitled. And then, the vulnerable one is sort of sometimes harder to recognize because the person tends to actually have lower self-esteem. It's sort of this weird paradox of oftentimes these individuals dislike themselves, can have intense self-loathing, while also feeling quite entitled and having sort of grandiose fantasies, believing that others should treat them better, should recognize within them their special talents to some degree. These are the ones that sometimes in the literature they were called covert narcissists. The idea that it was more hidden, it would take longer to recognize some of those traits.

Amelia Worley:  That's really interesting. I know you briefly covered this, but what are some of the most common signs that someone may be a narcissist?

Joshua Miller:  For what we think about, the most defining features to me are things like grandiosity, a strong sense of entitlement that you deserve better things than others, that the rules shouldn't apply to you, that you shouldn't be treated like the average Joe. When we see those things, those are probably the clearest signs that someone is narcissistic. Tend to be egocentric, self-absorbed. Even the more vulnerable individuals who don't always have as much grandiosity, they tend to be quite self-absorbed. They believe the world should focus on them, should revolve around them. And even that self-absorption can sometimes revolve around their sense of sort of fallibility, and distress even. It's not like, "I deserve better things because I'm the best." It can be, "I deserve special treatment because of how wounded, how fragile I am." This is the sort of dimension we may see more in outpatients oftentimes.

The grandiose individuals may not be coming in to therapy very often. In fact, they're not likely to come in. And if they do, it may be later in life when they sort of have failed, they're starting to recognize that they can't maintain this grandiose sort of belief system. But, we're going to see lots of sort of more vulnerably narcissistic individuals who believe the world, their significant others, their clinician should accord them special treatment in part because of maybe past trauma, past difficulties, the amount of distress they're experiencing.

Amelia Worley:  Is there such a thing as a healthy amount of narcissism?

Joshua Miller:  It's hard to say, right? I mean, I think within some reason, some degree of believing that you're good at things, that kind of stuff, believing that you're entitled to fair treatments, right? The higher you are, the more impairment we're going to see. The more difficulty you're going to cause in other people's lives, the more difficulty you're probably going to cause in your own life, the more impairment. So, any degree further like lower we can help someone get is probably better. I think when people say healthy narcissism, they're really just thinking about self-esteem really. Self-esteem is almost entirely healthy. It's actually not that correlated with grandiose narcissism. It's negatively correlated with vulnerable narcissism. It's positively correlated with grandiose narcissism, but at a correlation about 0.3. That's pretty small. The reality is that most people who have high self-esteem aren't that narcissistic, and many people that are narcissistic don't actually have that much high self-esteem.

This one study we did in my lab that really compared them over about 5000 individuals, and multiple studies, they're similar in that high self-esteemed people and grandiosely narcissistic individuals are outgoing, they're approach-oriented. They sort of go out and attack the world. They go for what they want. They believe in themselves. They're assertive. They take on leadership roles. The difference is that high self-esteemed people are more communal. They're more other people-oriented than narcissistic individuals. The way I would describe it is if I'm a high self-esteemed person, I can feel good about myself without having to denigrate you.

Let's say we're both clinicians. We both could be good clinicians. We both could be good parents. We both could be good spouses. Whereas, the grandiose narcissistic person views the world more hierarchically. There isn't room for both of us to be good. If I'm going to say I'm the best clinician, that means I need to denigrate you. They view the world almost like a ladder. You can either be above someone or below someone. Not equal. And I think high self-esteemed individuals can allow the space for others to feel good about themselves without being threatened by that. Does that make sense?

Amelia Worley:  Yeah, definitely. And digging into that further then, where do you draw the line between someone who is just highly confident versus someone who's a narcissist?

Joshua Miller:  Again, it comes down to these more disagreeable traits. Is the person callous? Do they have a sense of entitlement that they expect treatment that other people wouldn't get? Are they constantly talking about themselves as being better than others? I think people who are just high self-esteem have a quiet self-confidence about themselves. They don't need to trumpet it everywhere. They don't need that kind of persistent, nonstop validation from others. They don't need that admiration because within themselves, there is just a general sense that, "I'm a good person." And self-esteem is usually built on a sort of a broader base. If you think about it, good self-esteem is built like a house with multiple sort of parts of the foundation.

I might think, "I'm a good researcher, but I also value that I'm a good husband and a good parent and a good friend. So even if my work isn't going well, let's say I get multiple papers rejected, I don't feel terrible about myself because I still know my kids love me and my spouse loves me. And that I have friends and a supportive social network." But, a narcissistic person builds themselves up, their foundation, on a much smaller, narrower set of things. They tend to be agentic things. Narcissistic individuals don't tend to think they're better than others in all things. They tend to think they're better in agentic things, like smarter, better-looking, more athletic, better leader.

They don't tend to actually report that they're better people. They know that they're not necessarily as nice as other people, as kind. And they don't value that as much. These interpersonal things. So, for a narcissistic individual, if my whole sense of who I am is built on being a great researcher, well, if I start getting negative feedback on my papers, that's going to be really threatening to me because I have nothing else to build my sense of self on. That's one of the differences that makes self-esteem largely quite a healthy, psychological construct. And narcissism, a more mixed bag in some ways, for sure, with more maladaptivity.

Amelia Worley:  Can narcissistic personality disorder be treated? Can a narcissist ever change?

Joshua Miller:  It's a great question. There's been remarkably little funding from NIMH about treatments on narcissism. I don't know if there's ever actually been like an RCT on narcissistic personality disorder specifically. There has been some work from more like sort of psychodynamic perspective, looking if short term psychodynamic therapy can make changes in these individuals. And I think they've shown some positive results. I certainly don't know that there's a panacea or an easy cure for someone with really persistent, longstanding narcissism. I believe with kind of constant, consistent feedback in a supportive way of the ways in which a person's narcissism is negatively affecting others, even the clinician, the clinician giving that in the moment feedback, that you know, "Hey John, when you say that, it makes me feel devalued," like that kind of consistent feedback, but you'd have to have a patient that's really motivated to get treatment, to improve, to recognize that their narcissism is standing in the way of a fuller, healthier sort of life.

Without that, I'd be much more sort of pessimistic that you would see much change. There's got to be some insight into the problem. There's got to be motivation to make those changes first. And then, it's probably going to take some substantial time with a supportive, trained therapist to make some gains, I think.

Amelia Worley:  Is there a link between being around someone with narcissistic tendencies and anxiety and depression?

Joshua Miller:  I don't know specifically of empirical study and looked at that exactly. We published a paper in 2007 where we did find that people who were rated as, these are community participants and patients, those who had more narcissistic personality disorder were rated by our research group as causing their significant others more distress. So, to the extent that we could think that people being distressed probably means having anxiety, depressive symptoms, marital instability, it probably is likely that really severe narcissistic individuals probably can cause those in close proximity, spouses, parents, children, friends, coworkers, some of those kind of symptoms, for sure, if they're not able to sort of remove themselves from the situation. Which, of course, if you have a narcissistic parent or a child, it's not so easy to remove yourself. If it's a coworker, you might be able to find ways to psychologically or even physically distance yourself from that person such that they can't do as much damage.

Amelia Worley:  So, digging into that further, at what point should someone consider cutting ties with a narcissist? What can someone do if the narcissist is a coworker or superior at work?

Joshua Miller:  Yeah, I wish I had really clear cut answer to, "Oh, at this point, you should do..." I think whenever a person recognizes that someone is really bad for their psychological wellbeing, then it's reasonable for them to start thinking about how they can take steps to mitigate that harm, whether that's ending a relationship, like if it's a friendship, but I don't like to be too glib about the idea of ending a relationship because of course that's not always that easy. It's not that easy to, say, cut off a parent or cut off a child, or decide to end a romantic relationship. With a coworker, I think, again, we can do whatever we can to mitigate the time we spend dealing with that individual. If it's a coworker, potentially talking to those higher up. If they're trusted about working less with that person, not being assigned to those same kind of teams, being asked to move off of a team.

If it's a narcissistic boss, it's hard to know what exactly are your mechanisms to exert change. If you have someone even higher up, you could consider talking with them. It could be that if it's bad enough, you look to move within your job or move to a different job. Again, I would never want to speak for someone without knowing the circumstances. Sometimes, working with someone narcissistic is mostly just annoying. You feel frustrated, you feel put down, but it may not be something that you're willing to, say, change a job or ruffle feathers. I trust someone's autonomy to make that decision. If it's much worse where you come home feeling beleaguered every day, put down, denigrated, dismissed, then I think we're talking about things where if it's starting to really adversely affect your mental health, then thinking about bigger changes is certainly worthwhile. And if the person is in therapy that's doing this, that's the perfect thing to talk to a therapist about.

One of the cool studies that this guy, Drew Westen at Emory did was look at countertransference with narcissistic patients. So, that is like, what are the feelings that a therapist has towards a narcissistic patient? They're really noteworthy like dreading those sessions, not feeling like they're going to make much change, feeling put down, feeling dismissed. If therapists who are trained to deal with patients and try to put their own feelings aside feel that way, then certainly it's reasonable for us to expect people with less psychological training to struggle even more to deal with people in their lives that show these kinds of traits.

Amelia Worley:  That's fascinating. Lastly, do you have any advice or anything you would like to say to someone who may be involved with a narcissist?

Joshua Miller:  Again, there's no easy glib answer to that. If it's, again, persistently, negatively impacting your wellbeing, their traits, their grandiosity, their need to put themselves before others, if they're showing a lack of concern, if the relationship doesn't feel bidirectional, if it's like, "Wait, I'm only here for this person as a sounding board. I'm here to support them and validate them. But when I need a chance to talk about this trouble I'm having, they're disinterested," then I think rethinking, again, the parameters of that relationship are reasonable.

But, again, relationships are really complicated, and I get that. If you're in a relationship with someone and have children with them, I don't want to say quickly, "Oh, well, just end that relationship." And it depends on the severity of the person's narcissism. If the person seems narcissistic but it is unaware of it and that they might be willing to seek treatment, then it might be something where the couple can have meaningful discussions about whether or not that's something that could be dealt with in couples counseling and individual therapy, things like that. Each case is so specific. It's really hard to give an overarching answer to that.

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

Joshua Miller:  You're welcome. Yeah. Thanks for having me.

To learn about gaslighting, click here to access our article.

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

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

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.

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

Internist Howard Schubiner on Mind-Body Connections

An Interview with Internist Howard Schubiner

Howard Schubiner, MD is an internist and both the founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. Dr. Schubiner is a clinical professor at the Michigan State University College of Human Medicine and is an expert in the mind-body connection, as it relates to one’s health.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Nicole Izquierdo, a research intern at Seattle Anxiety Specialists, and I'd like to welcome with us Dr. Howard Schubiner. Is that how you pronounce it? Is that correct?

Howard Schubiner:  It is.

Nicole Izquierdo:  Okay. So Dr. Schubiner is an internist and both a founder and director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. He is a clinical professor at the Michigan State University College of Human Medicine and is a fellow in the American College of Physicians and the American Academy of Pediatrics. He has authored more than 100 publications in scientific journals and books, and lectures regionally, nationally, and internationally. So before we get started with the official questions, would you like to share a little bit more about yourself with our listeners, and what made you interested in becoming a physician?

Howard Schubiner:  Well, that's a great question. First of all, it was a long time ago. It just seemed like a good idea at the time, I guess. I wanted to do something that would be useful and meaningful. I wanted to work in a community. And I was in university at the time, and I don't know, I just thought I would see what it was like. I took a few science classes and I found them to be not too difficult, and it just kind of led from there. I started volunteering at a free clinic and learned more about healthcare and medicine and some of the problems in medicine, frankly. Even way back then in the 1970s, it was becoming very clear that the biotechnical approach to medical problems had tremendous potential and tremendous value, but it also left things lacking. And it turned out, as my career has meandered and wandered over the years, that I've come to a place now where my main work has to do with the failings of biotechnological medicine and the promise of more simple and more patient-centered approaches.

Nicole Izquierdo:  Thank you. Thank you for sharing that. So you specialize in the mind-body connection as it relates to one's health. Do you mind defining what that is to our listeners?

Howard Schubiner:  Sure. Everyone knows the brain and the body are connected. The mind and the body are connected. When you get embarrassed, your face turns red. When you have to give a speech, your stomach may flip into knots. Everyone knows that. But it turns out it goes much, much deeper. It goes deeper in the sense that we have learned, in the last couple decades or so, that our brains actually create all of what we experience. Which is really a revolutionary concept. And it's called predictive coding or predictive processing. And so when you touch a hot stove, it's not your finger causing pain. It's actually the brain. The nerve signals go up to the spinal cord into the brain, but the brain makes a decision. It sounds weird, but the brain makes a decision whether to turn on pain or not. And we know that, because a lot of times, people have injuries without any pain. And we also know that the brain can activate pain or anxiety or fatigue or depression or insomnia when it's under stress. It's like a warning signal.

And so pain is a protection. We need pain. The reason we have pain is that it warns us that there's something wrong, usually wrong physically in the body. But our brain can turn on pain, the same pain, exact same pain, when we feel trapped or emotionally in danger, and that pain is real. And so it's really important for people to understand that pain and anxiety and depression are actually generated in the brain, and they're generated in the brain as a warning signal, as an alarm, like a smoke alarm.

And so it's up to us to figure out what the message is, why that's happening. If you have pain in your back and it's a kidney stone, then that's the message. You need to deal with the kidney stone. But if you have pain in your neck because you're in a job that's untenable and harsh or you're in a relationship where you get betrayed, then that's the message. But the pain can be exactly the same. The anxiety can be exactly the same. So once you understand that the brain creates what we experience, now you have an inroads for understanding how we work, what makes us tick, and how to deal with it.

Nicole Izquierdo:  So would you say that those instances where it's more like a psychological stressor causing let's say neck pain or a headache or back pain, would that be, what's the term, psychophysiological disorder, or is that something else?

Howard Schubiner:  No, that's exactly right.

Nicole Izquierdo:  Okay.

Howard Schubiner:  In the old days, they used the term psychosomatic. They still use that term in Europe, but we don't use it here because it seems mean. But the fact is, since our brain controls what we experience, it's not mean. The fact is that we are psychological beings, we are emotional beings, we are social beings. And so the fact that we can get... If I have pain and I know it's from my brain as opposed to from my body, I'm happy. It shouldn't be stigmatizing, because the symptom is real. It's not imaginary. I tell people, anyone who says the pain or the anxiety or the depression or the fatigue or the insomnia is all in your head, it doesn't understand how things work. It's real. It's not your fault. It's not because you're crazy. It's not because you're weak. It's not because you're deficient. It's not because you want it. It's because your brain is sounding an alarm. There's something important that's going on in your body or in your life, and so it's up to us to figure that out.

Nicole Izquierdo:  Yeah. That's nice that the terminology is changing to capture that change of... Because it is invalidating, telling someone, "No, it's fake. It's not as bad as a 'real' injury or 'real' pain." And "real" in quotation. Are there any specific examples of these disorders? Like diagnostic names, diagnostic criteria?

Howard Schubiner:  Well, yeah. We have developed a lot of diagnostic criteria for these disorders. And, well, first of all, people who develop these mind-body conditions or what I sometimes call neurocircuit conditions are more likely to have stressful childhoods, more likely to have histories of trauma, more likely to feel like they have been criticized or feel they are not good enough or put other people first and not stand up for themselves. They're more likely to be in difficult situations currently in their life.

And the symptoms that they have are more likely to turn on and off, to shift or move. And we see, what's interesting is we see, because as we understand the brain creating these conditions, we frequently see that some people may have headaches for a while, and then the headaches go away, and then they get back pain, and then the back pain goes away, and then they get anxiety, and then the anxiety goes away, and they get fatigue, and then the fatigue goes away and they get irritable bowel, and the irritable bowel goes away and they get depression. And these can shift and move, sometimes within days or hours or weeks or months. And you can see the pattern where you can see that someone's been under stress and their brain has created a variety of different warning signals. And so we're looking very carefully at people's stories and listening to them. And, as you said, validating them, caring for them, being compassionate toward them, and helping to understand them and understand that their symptoms may be reversible, as opposed to being incurable.

Nicole Izquierdo:  How would you recommend that sometimes to get to that point, once you check everything else off the list that is let's say a kidney stone, for the back pain. How would you recommend going about it so that patients that do struggle with this aren't also struggling with the toll of going through a bunch of tests or the cost associated with those tests?

Howard Schubiner:  Yeah. That's a great question. We always recommend getting testing. If you have anxiety, you need to have your thyroid checked to make sure that you're not hyperthyroid. If you have anxiety, you need to have your heart checked to make sure you're not having a tachyarrhythmia or something like that. If you have depression, you need to have your thyroid checked, you need to have your hormones checked. These are obvious. If you have back pain, you need to get your back checked.

But we don't want to over-interpret things and we don't want to make people think that just because their symptoms are chronic that means that they're incurable. There has been a lot of research showing that, for example, in neck and back pain, that most people have abnormal MRIs. The MRIs are going to be abnormal. They're going to have degenerative disc disease, spinal stenosis, things like this. But those things are common in people who have no pain at all. So you shouldn't be saying, "Oh, that's the cause of your pain, because you have these mild abnormalities that everybody else has."

Similarly, with anxiety and depression, I feel strongly that we shouldn't be telling people that... And I know this is controversial and some people in your groups may disagree with me, but when we tell people that the problem is inflammation of the brain or it's genetic problem, what we're telling them is that it's not fixable. What we're telling them is that they're doomed and that they'll just have to cope with it. And that's the same thing doctors tell people with back pain when they see an abnormal MRI. And so we're trying to break out of that rigid biotechnical model to embrace this mind-body model or this predictive processing model, because it's much more optimistic and much more hopeful about making changes and getting better.

Nicole Izquierdo:  So one of your books is titled Unlearn Your Pain, and we actually have several clients that come to us seeking relief for chronic health issues, many of which included chronic pain. So without giving the entirety of the book away, can you explain how this could be possible?

Howard Schubiner:  Sure. Well, it starts with what we've been talking about. It starts with understanding predictive processing. It starts with understand how the brain works. And then it's an assessment, so it's making an assessment to make sure that there's nothing actually structurally wrong. And most people with chronic pain do not have a structural condition. Most people with headaches, fibromyalgia, irritable bowel, chronic abdominal pain, chronic pelvic pain, chronic neck and back pain, do not have a structural problem in their body, and I would assert the same is true for people with chronic fatigue, insomnia, anxiety, and depression. So the first part is that assessment. And then after that, there's three types of things that we help people to work with. One is we call pain reprocessing therapy. The second, we call emotional awareness and expression therapy. And the third is making changes in someone's life and dealing with their current issues in their life.

Pain reprocessing therapy can also be used for anxiety and depression, and what it is, it's a process of changing your relationship to the sensations you have in your body. Instead of fearing them and focusing on them and trying to figure them out and trying to fight them, it's actually being with them and tolerating them and knowing that they're not serious, that they can't hurt you, that you're going to be okay, and it's practicing graded exposure to gradually do more and more and tolerate the sensations of these uncomfortable, unpleasant physical sensations, and by changing your relationship to them, you're calming that danger alarm mechanism in the brain, which will then turn down the symptoms. That's the first step, the first treatment.

The second treatment is emotional awareness and expression therapy, which I developed with my colleague, Mark Lumley, and that involves dealing with the emotional issues that people have been through. Dealing with the emotions of anger and fear and grief and sadness and guilt, and moving through those to compassion for one's self. And it's a process instead of trying to just moderate the emotions to actually feel them, identify them, feel them, and express them in safe and healthy ways.

And then the third step is what do you have to do in your life? Sometimes, people need to make a change in their life. You need to set boundaries or make changes in their relationships in order to free their danger signal from continuing to create the pain or the fatigue or the anxiety or whatever.

Nicole Izquierdo:  Thank you for sharing that. Would you say that there is an evolutionary reason for something like the brain turning on those pain signals when there is no physical or structural issue?

Howard Schubiner:  Yeah. It's speculative, of course. We can't really go back in time and understand. But the way I think of it is that pain is a protector. Anxiety, depression, fatigue, they're protectors. Our brain is turning them on as a message to protect us from something, to alert us to something. When we get a broken ankle, our brain turns on pain in order to tell us to stop walking on that ankle, get rest, get help. So way back in hundreds of thousands of years ago, Neanderthals lived on the earth and homo sapiens did. Neanderthals were bigger, smarter, faster, they had bigger brains, they were better hunters. Why didn't they survive? Homo sapiens survived because they worked in clans. They got together in groups and they communicated and they hunted together and they looked out for each other. And that's, we think, why we, so to speak, survived.

And so if you were back in those days and you got bit by a tiger, obviously, your brain, you want pain. You break an ankle, you want pain. But why would you want pain or other symptoms in an emotional situation? Well, if you survive because of your clan, if you get kicked out of the clan, you might die. That's a life-threatening thing, to get kicked out. Why would you get kicked out? Because of shame, because of guilt, because you did something wrong, but you beat up somebody or you betrayed somebody. And then the group would enforce the rule by shaming you or yelling at you or criticizing you, or whatever. And then you would be in danger of ostracism, which could mean death. So from my point of view, it makes sense that our brain would turn on a very strong reaction not only to a physical injury but also to an emotional injury. And I think that's why that occurred, but it's a bit of speculation, of course.

Nicole Izquierdo:  So you were featured in a new documentary titled This Might Hurt, which follows three chronic pain sufferers and offers solutions to such suffering. So your paradigm for diagnosis and treatment was found to be effective in several randomized trials, and it was actually listed as a best practice by the HHS's taskforce to combat the opioid epidemic. Can you speak a little bit more about this film and what has led to the ongoing opioid epidemic in the US?

Howard Schubiner:  Sure. The film is This Might Hurt. It was directed and produced by Kent Bassett and Marianne Cunningham, two young people. Kent himself had chronic pain and cured himself by changing his mind, changing how he related to it, changing his understanding of it, without any medical intervention. He had very severe chronic pain that it was incapacitating for quite a while. So he wanted to make this movie, and the movie kind of shows the real-life issues that people with pain have. One of the women in the movie was bedridden for eight years with chronic abdominal pain. And after going through this program, she got up, she got out of bed, she could work. She went back and got a job. I mean, it's amazing what can happen when you have this different way of looking at it, as I was describing, this whole different way of looking at it and different way of treating it.

Because the main paradigm for treating chronic symptoms in our medical world, chronic pain, is that you're going to have to cope with it. We'll give you medications, injections, physical therapy, acupuncture, meditation, all these things to help you cope with it better, but they're not offering, actually, to make it better. And the research shows that the coping method doesn't work all that well with chronic pain. And similarly, I would argue, with anxiety and depression and chronic fatigue, we're finding that the coping model of doing a little bit of this and a little bit of that doesn't... It has kind of a ceiling effect. You're saying, "Well, you can get better, but you can't get all the way better." And so you're stuck in this danger signal in your brain. And so we're trying to think of these things in a different way, which I think is actually scientifically valid. It's not pie in the sky or just rose-colored glasses. It's actually based on the neuroscience of how the brain works.

And so the opioid epidemic was a response, but it was a kind of neurobiotechnical response. You have pain. There must be something wrong in your body. We have to treat the pain. We'll have to give you medication because there's nothing else we can do. And so over time, more and more people got more and more medications. Of course, the drug companies were complicit in this, in trying to tell doctors that these medications weren't addicting or weren't as addicting as people were concerned. And in addition to that, our society has basically been falling apart in a lot of ways. And so that clearly weighs on people's minds and makes people much more likely to turn to pain relievers, because their lives are so difficult.

Nicole Izquierdo:  Thank you. So our practice specializes in treating anxiety and anxiety-related disorders, and so we were particularly interested to see you have another book titled Unlearn Your Anxiety and Depression. Do you mind elaborating on how this might be possible, and whether this is something that someone can do by themselves, or whether it has to be under the care of a mental healthcare provider like a therapist or a psychiatrist?

Howard Schubiner:  Yeah. Good question. When I started working in the field of pain, and so I saw a lot of people with pain and I learned a lot. I've been doing this for almost 20 years now. So I just learned a lot about pain, and what I saw over time was that frequently, the people who had chronic pain also had anxiety or depression. If you're in a counseling center and you're seeing people with anxiety and depression, about 50% of your patients are going to have a chronic painful condition. So there's a tremendous overlap in these conditions, number one. Number two, there's tremendous interchangeability of these conditions, as I mentioned before, where you see people where symptoms will kind of come and go, and anxiety may be replaced with pain and pain may be replaced with fatigue and fatigue may be replaced with insomnia and then depression. And so when you see that in people, you can see, well, gee, the brain may be turning on one set of symptoms and then may be turning on another set of symptoms.

And what I've found over the years is that if you apply the similar diagnostic assessment tool mechanism to people with anxiety and depression as I did with people with chronic pain. Again, really not a structural problem, and looking for the clues that suggest that it is a neural circuit problem, number one. And then number two, using the changing your relationship to the symptoms. For example, if someone has anxiety... What I'm doing is not rocket science, not super complicated, but it's very optimistic, and it's saying that you can change.

And so if someone is having anxiety in a certain situation, in elevators or in work meetings or in family situations, the first step would be to have them imagine that situation in their mind. And when you imagine that situation in your mind, what happens in your body? What response do you get? And so if you're imagining being in a work meeting and your stomach starts to flip into knots and you feel a little bit trembly, then that's your brain turning that on. You're not actually in the situation. You're just imagining it. And that's a low-level exposure. And then we help people to smile at that, to calm their brain, to soothe the brain, to treat the brain like a scared child lying in bed, fearful of a monster in the closet, and to give themselves love and compassion and caring, give their brain love and compassion and caring. Recognizing their brain is not the enemy, it's just afraid. It's just afraid of the situation.

And then we use these techniques to help calm those symptoms, calm the stomach, calm the trembling. And then go back and imagine the situation again, and then calm the sensations. And then imagine the situation again. And you keep doing that, and then it's just like the old classic way of treating a phobia of snakes. Desensitization. And then you gradually get people to go into those situations with this calmness, with these techniques. And the techniques are not all that brilliant. They're just the normal calming techniques. But it's knowing that you can do it. It's knowing you're going to be okay. Knowing it's just your brain that's afraid. And that's the key that can really help people to propel themselves to changing their symptoms. And then, of course, certain people may also need to deal with some of the traumas in their life, some of the emotional situations. And that's what we talked about with the emotional awareness and expression therapy part of it, as well.

Nicole Izquierdo:  So you would say it's ideal for this to happen under the care of a practitioner, developing the exposure hierarchy? Or even having someone there when you're experiencing those stressful situations to make sure they're not in danger?

Howard Schubiner:  Yeah. I mean, some people clearly need help and need a therapist. But there's not enough therapists in the world to deal with all the people who have chronic pain and have chronic anxiety and depression. There's nowhere near enough therapists in the world. So my view is that a lot of people can do this on their own. A lot of people can learn these techniques. And that's why I've written these books into a self-help guided recovery program that people can use. And I get emails all the time from people who are using these on their own.

And so it's really a question of what level of worry and concern and what level help people need, and what level of underlying trauma people have, what the severity of their situation is. So I think it's kind of a mixture. When I work with people, I work with them individually, but then I give them lots of homework, and I say, "Here's how you can start to practice this on your own. Here's how you can do this on your own." Because ultimately, we want people to be in charge of their own health, as much as possible.

Nicole Izquierdo:  Thank you. Yeah, I see something similar with that and what we're trying to do with our website with interviews and writing articles. Because some people can't afford to start treatment or continue treatment forever, so.

Howard Schubiner:  Absolutely.

Nicole Izquierdo: Nice that that was your goal with those books. I appreciate that. So we're approaching our final question. As a doctor specializing in the mind-body connection, do you have any other words of advice or parting words for our listeners?

Howard Schubiner:  No. I really think that the most important thing is compassion. So many people who have been brought up in difficult situations have learned that it's much easier for them to be compassionate to others than to be compassionate to themselves. We see this all the time. And if they can begin to do that, if they can begin to look out for themselves, stand up for themselves, speak up for themselves. If they can recognize that they are, it sounds silly, but, worthy and deserving and worthy of being loved, just as everyone else is, that is just such an important step for people to take. And there's ways to do that, and there's books written about self-compassion, for example, that people can follow and learn to take care of themselves. Because what's happening is that their brain is reacting out of fear and worry, and some of the fear and worry they're actually putting on themselves because they're feeling inadequate. And so, to me, it really starts with compassion.

Nicole Izquierdo:  Thank you. So to wrap things up, we just wanted to let our listeners know that Dr. Schubiner has a series of animations on YouTube that are very insightful, so we will be linking those on our website. And I just wanted to say thank you so much for joining us and sharing your knowledge, Dr. Schubiner. We really appreciate you taking the time to speak with us, and we wish you the best.

Howard Schubiner:  Thank you. It's a pleasure. Thank you for doing what you're doing. I appreciate it.

Nicole Izquierdo:  Thanks.

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

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

Psychologist Bethany Brand on PTSD & Dissociation

An Interview with Psychologist Bethany Brand

Dr. Bethany Brand is a Clinical Psychologist and Professor of Psychology at Towson University. She is an expert in trauma and specializes in the assessment and treatment of trauma-related disorders, including PTSD and dissociative disorders.

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 Specialist. I'd like to welcome Dr. Bethany Brand. Dr. Brand is a professor in the Department of Psychology at Towson University. She also maintains an independent practice in clinical psychology, specializing in the treatment of trauma disorders, including dissociative disorders and post-traumatic stress disorders. She has numerous publications on trauma and dissociative disorders, including one of her most recent publications on the topic, “An Examination of the Relations Between Emotional Dysregulation, Dissociation and Non-suicidal Self-injury Among Dissociative Disorder Patients.” Before we get started Dr. Brand, can you please let us know a little more about yourself and what made you interested in studying trauma?

Bethany Brand:  Yes. Thanks for having me. Well, if we go way back, I had a friend in high school and she had been traumatized, and so had her sisters, and they had very different responses, and it just intrigued me trying to figure out how could people go through similar traumas and have very different outcomes? So then when I was in graduate school, I started pursuing it more seriously and asking supervisors if I could treat trauma. Then, I did my master’s and my dissertation on trauma. When I looked for my first position after grad school, I found a postdoc at Sheppard Pratt, and at that point they had a trauma disorders unit that was just opening. So, in that case, I was at the right place at the right time, and I got to work on their unit, which had mostly people with serious dissociative disorders, so I got great training early on.

Amelia Worley:  Wow. So, to begin, would you mind defining what dissociation is?

Bethany Brand:  Sure. Dissociation is a disconnection of what are normally integrated psychological constructs or functions. So, for example, a person may feel disconnected from their body. They may literally see themselves at a distance and be looking down on themselves, or they may feel very numb when they should have emotion. It's an emotional time. They're talking about something with that they might normally feel terrified about or ashamed about, and they feel nothing. So, that's that kind of disconnection. You can also have disconnection from your environment. So, it may be they're in a place that's familiar or with somebody they know well, and suddenly they don't look familiar or they don't recognize fully who that person is. They have some sense that they know them, but they can't really place them. They may have a disconnection in their memory where they feel like there's gaps in their memory.

They can't recall, it might be hours, days, or even potentially, from childhood. There might be years that they really don't recall. Within their identity, they may have a sense of being kind of fragmented where they feel like, more than people who are non-dissociative because we all have parts, but they may feel like they act so differently, seem so differently, behave so differently that at different times they feel as if they're almost different people, although nobody can have more than one person inside them. It's states, dissociative-self states. They also may have disconnection from behavior. So, they may find themselves doing something, see themselves doing it, and they literally can't stop what they're doing. Those are just some of the examples.

Amelia Worley:  How is dissociation linked to trauma? Are some traumatic experiences more likely to cause dissociative disorders?

Bethany Brand:  Yes, they are. So, we know that if it's particularly life-threatening, you might be more prone to dissociation. We know that children are more likely to dissociate, and they lose that ability a little bit over time. So, for example, if there's ongoing childhood abuse, and especially if it's done by a caretaker, somebody who's in charge of the child, should be protecting them, and instead they're betraying them, we know from betrayal trauma theory that they're more likely in those situations to dissociate. So, it's particularly severe, ongoing trauma, but it can even happen for a one-time really serious car accident. Like I know somebody who, when they were in a car accident, they were actually seriously injured, but they didn't feel any of the injury. It wasn't, they hadn't had nerve damage. It was that they were at for a little while having what's called very traumatic dissociation, which is dissociation during the actual trauma itself.

Amelia Worley:  Wow. How might someone know whether or not they're suffering from trauma-related dissociation? What does it feel like?

Bethany Brand:  It's a good question, but it feels very different according to which one of those constructs is, they're disconnected from. So, do they, generally speaking, have emotions? Do they generally feel like the body is theirs or do they sometimes feel like that's not my body? It's not like, it's not a person getting older and looking at themselves thinking, that's not how I look. It's more profound than that. Like they might look child-like, or they may feel like they look at themselves and suddenly they look decades older, and it just, it's a strange sensation. They may look in a mirror and not recognize themselves. If a person is, has experienced or is experiencing a number of the things I've talked about, problems with feeling connected to their body, connected to their emotions, connected and oriented and aware of their surroundings, that probably means that they don't dissociate much.

But if sometimes their surroundings look far away, even though let's say, if they're hand looks like it's a mile away, like their arm has suddenly grown, there's really a huge distance, that's a type of depersonalization. Or if, let's say they're talking to a therapist and suddenly the room looks foggy, that's derealization. The world around them looks different. Or they can't hear their therapist speaking, even though there's nothing wrong with their hearing, that's a type of derealization. So, if somebody's experiencing any of these things, that might give them some indication that they possibly have trauma-related dissociation, and of course, have they been exposed to some kind of trauma? That's a prerequisite for trauma-related dissociation.

Amelia Worley:  So, what can trigger dissociation in an individual after the traumatic event has occurred?

Bethany Brand:  It may be that they're just hearing a sound that reminds them, a trigger. It could be a sound, an image of the light being a certain way. They might hear, they might smell a certain smell. Smells are very, very likely to trigger traumatic associations. So, it's when they feel triggered that then they may also start to dissociate. So, I'm careful, I'm a little cautious that some listeners might be a little triggered about what I'm going to say. So, I'm going to advise them if they want to just tune me out for a minute, but let's go with the example of smells. So, if somebody was traumatized by somebody who'd been drinking alcohol, if later, they smell alcohol, they can be triggered by that, and start to have their heart race, feel terribly vulnerable, like something dreadful is going to happen, or they may do that for a bit, and then disassociate, start feeling numbed out, kind of like things around them looking surreal in some way, or they might just really rapidly go to a dissociative state.

Amelia Worley:  That's really interesting. In your publication I mentioned earlier, “An Examination of the Relations Between Emotional Dysregulation, Dissociation and Non-suicidal Self-injury Among Dissociative Disorder Patients”, you talk about how this idea of emotional dysregulation. Can you explain what emotional dysregulation is, and how it relates to trauma-related dissociation?

Bethany Brand:  Yes. So, you know how we like to have very big terms in our field? Emotion dysregulation is basically difficulty dealing with emotions. Okay? So, people who have got, who've experienced a lot of trauma, whether they're highly dissociative or not, they tend to feel too much or too little. So, for example, let me go back to that past trigger example I gave you. Maybe that person normally has normal feelings. They can feel some happiness, some sadness, some anxiety before a test, whatever. But when they get around, let's say they are abused by a man. When they get around men, then they start feeling really scared. Their heart starts to race. They feel like, oh, I've got to watch behind me. I've got to watch this guy. That's feeling too much. The opposite can also happen where they feel too little. The examples I gave where somebody is numbed out, they don't feel connected to their body.

So, emotion regulation is when you have the capacity to know what you're feeling. They can identify the emotions, and emotions, how do we know we're feeling emotions? It's in our bodies. So, if somebody's angry, they might feel I'm imitating it for anybody who's not watching the video. I'm clenching my hands. I'm kind of raising my shoulders. I'm tensing up muscles. A lot of people feel that kind of muscle tension and agitation energy in their body when they're angry. If you're feeling, if you go back and forth between too much feeling, too little, if somebody starts getting angry and they're very uncomfortable with that emotion, they may shut it down and disconnect from their body. Maybe anger is very scary, because maybe they were in a relationship that was physically abusive, and so they disconnect if there's anger. So, what happens when somebody's traumatized, trauma by its definition, it's overwhelming.

They may feel at risk for their life, and so the feelings are huge, way, way, way too big. Like that example I gave earlier with somebody who had peritraumatic dissociation, if you're so terrified, sometimes the brain, it's an automatic kind of a brain-based response, may start shutting down emotion. The person's not willing it to happen. It just starts to happen. Parts of our brain start kind of metaphorically going offline. They're not very active. So, later on, if that happened during trauma, that the person started dissociating when they felt too much, if later on after the trauma, they're starting to get overwhelmed with feeling too much, they may get scared of that, and at first, they may consciously, like, I don't want to feel this. I don't want to feel this. I don't want to think about this, and they kind of push it away.

That's normal PTSD is you try and push away emotions and remembrances and memories, images. But over time, if somebody's also disassociated or starts to learn to dissociate, they can numb out and disconnect. If they avoid thinking about something enough or it's so awful, they really just, they're, they don't go there in their minds. Over time, they may have less access to that memory, and so they start maybe having the memory problems I talked about earlier. So, emotion regulation is intricately tied in with dissociation, because dissociation is a way of dealing with emotion, and a terribly threatening situation.

So, what we've looked at in some of these studies is, can we teach people who have very high levels of trauma-related disassociation other ways to identify what they're feeling, to not be so afraid of emotions, help them learn how emotions are helpful, and how to healthfully manage them in a range that's tolerable, so they're not flooded. They're not numbed out. They don't have too much or too little emotion. We found in this treatment study we did with dissociative disorders, folks, that as you teach them emotion regulation skills, then dissociation began to decrease some. They weren't needing to dissociate so much. We also found that self-harm decreased, PTSD symptoms decreased. Helping people learn to regulate their emotions is a really fundamental, crucial skill, in other words.

Amelia Worley:  So, continuing on that idea, can you talk a little bit about the most effective treatment approaches for trauma-related disassociation?

Bethany Brand:  Yes. So, the study I was just referencing indirectly is one called “The Treatment of Patients With Dissociative Disorders.” It's TOP DD, and that's for people who have really serious dissociative symptoms. We're in the process of doing a randomized controlled trial treatment, where we're checking out the program I was just referencing. So, we get people who have very high levels of dissociation, plus their therapist, who agree to be in the study. We have a number of videos where we teach them what trauma does in general, various symptoms related to trauma, then we get to dissociation what it is and how that was helpful, but also how in adulthood, when you're safer, if you're safer now, how it can get in the way. So, somebody not always knowing what they're feeling, maybe they're tuning out some important clues from their body, from their mind that a relationship's not safe, but if they're not in touch with their emotions, they may not feel that.

So, we know from research that people with lots of dissociation have high rates of being re-traumatized in adulthood. So, it's really important to help them learn to identify their emotions, and to gradually use less dissociation. So, we're, in that program, that's some of things that we're teaching and that's in general, whether somebody's in that treatment study or whether they're working with a therapist. The therapist, generally speaking, teaches them what dissociation is, the symptoms of PTSD, because they often have both. Then there's a technique called a grounding technique. So, let me, and I'm talking this out loud, just in case somebody can't see the screen. Dissociation’s on a continuum. At one end of the continuum is somebody is grounded and oriented in present reality. They can feel their body. They know where they are. They know what the date is. They're really hooked into present reality.

The other end is profoundly dissociated, where they don't necessarily, they don't recognize where they are. They're not feeling their body. They're really severely dissociated. Then in between, there's this whole range. What a therapist can help a client learn to do is recognize the early signs that they're beginning to dissociate. So, they might feel spacey or tingly. Those are just examples. So, the client learns when they start recognizing that warning sign, then they use these grounding techniques, and I'll just explain a very basic one that lots of people know. You can use this with panic attacks, all kinds of things, not just disassociation. But you put your feet on the floor. I'm going to do it, because when I teach people, I always do it along with them. So, I'm pushing my feet into the floor, and trying to really notice what that feels like. That is using muscle movement, contractions, and trying to get them to feel that part of their body, assuming they're okay with feeling that.

Then I would also be having them look around where they are. If it's a Zoom therapy session, look around the room where they are. If we're meeting together, look around my office and find something that they can describe with all the senses. So, I've got a cup of water here. If they've got something to drink, can they feel the weight of the cup? Can they feel the coldness or the warmth, taste it, using all their senses? That actually helps wake up metaphorically, the parts of the brain that have shifted, and kind of gone offline while they're dissociating. So, you use the senses, all five senses to get the brain back online in the normal way that it should be. Those are grounding techniques. So, a therapist would be teaching them grounding techniques and having them practice that in session, and then also, out of session. Those are just some of the basic tools we use when folks have got a lot of trauma-related disassociation.

Amelia Worley:  Wow. Lastly, do you have any advice or anything you want to share with our listeners suffering from trauma-related disassociation?

Bethany Brand:  Yes. I would say one of the most important things you can do is to learn exactly what I was just talking about. Learn grounding techniques, and practice them, and learn healthy ways of taking care of yourself emotionally. So, many, many, many people who've been terribly traumatized feel ashamed of themselves, feel dirty. They feel like they're bad people. That's, those are symptoms of being traumatized. It's not the reality of who they are. It's a symptom. So, hopefully they can start thinking about that, looking into that. There are good books out there to read for trauma recovery. If somebody has a really serious, a lot of dissociative symptoms, if they have a therapist, if they want, and they can look into this treatment of patients with dissociative disorders study, TOPDDstudy.com, and we have that website. They can go there and look and see if we're still running the study.

There's also a professional website that has a lot of information for consumers and therapists. I'll say it slowly. It's ISSTD. It stands for the International Society for the Study of Trauma and Dissociation. That organization does a lot of training for therapists, and they have frequently asked questions on their website about disassociation. They have some questionnaires, people could even try and fill out and find out do they seem to be scoring fairly high, and learn a little bit about, do they have dissociative symptoms, where to go to get help. They have a Find a Therapist page on that website.

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

Bethany Brand:  Thank you so much. It's been an honor to be here.

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

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

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.

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

Therapist and SAS ED Blake Thompson on Psychotherapy

An Interview with Therapist Blake Thompson

Blake Thompson, LMHC, MA is a Psychotherapist and Executive Director of Seattle Anxiety Specialists. He is a clinical supervisor and also provides both individual and group psychotherapy.

Nicole Izquierdo:  Hi, everyone. Thanks, Blake, for joining us today for this installment of the Seattle Psychiatrist Interview Series. This is a special one, it's called Meet the Team. I'm Nicole Izquierdo, I'm a research intern at Seattle Anxiety Specialists.

So Blake here, he is the practice's executive director. He serves as a clinical supervisor and he also provides individual and group psychotherapy. The first question for today is telling our listeners a little bit about yourself.

Blake Thompson:  Hey, thanks, Nicole. Yeah, that was a good introduction. Oh man, what to say about me? Well, I am married and I have a one-year-old daughter that keeps me up at night, but whom I love very much. I love reading. I find people really complicated and fascinating. A big part of what draws me to therapy still and to the field is that the more I learn, I feel like the more questions I still have. I feel like I haven't gotten bored yet. I still feel confused, so staying curious.

Nicole Izquierdo:  That's good. Let's start off with, what is it that got you interested in becoming a therapist?

Blake Thompson:  That's a good question. Well, one of my big inspirations for becoming a therapist was a comedy movie. I don't know if you've seen “I Heart Huckabees”. No? Yeah, older Dustin Hoffman, Lily Tomlin, Jude Law film. Great movie, very funny, but yeah, I think that put the idea in my head. I had been to therapy when I was younger and I think that experience really shaped me. Being a client, I think, was really impactful. But yeah I'd been really interested in philosophy in school and I don't think I ever really considered, you know, psychology. I think I took one psychology class in all of college. I was really not interested in psychology. The idea that I would do something professionally that was related to a subject that I just wasn't really interested in wasn't super appealing to me at the time, but as I went to graduate school in philosophy, more and more of the stuff that I was interested in philosophy started to bleed over into psychology and I got more and more interested.

In philosophy, a lot of what we're doing is conceptual analysis. We're thinking about not minds and brains, but the stuff that are the constituents of thoughts. We're really focused on ideas like justice and the good life and truth and causation and all of these ideas that are really central to the thoughts that we think on a day-to-day basis. I just got more and more interested in the machinery that realizes that and more and more aware of thinking processes as processes, and not just as like, you know, and less and less focused on abstract.

By the end of grad school, I think I was starting to think about a jump into psychology, away from philosophy. I was talking with people about just what there was in that professional space, and the idea of becoming a therapist hadn't yet coalesced, but I think talking with folks about what therapy was like as a profession, what was interesting in it, how it was different than other forms of healthcare, yeah that was definitely, those conversations really helped shape that direction.

While I was in grad school, I really didn't like teaching very much. That was not something that I found super rewarding, but I loved tutoring, doing one-on-one work with students. I think really reflecting on that process and how much more I liked tutoring than I liked teaching helped also solidify for me that I would like doing therapy, because it looks a lot like tutoring in a lot of ways.

Nicole Izquierdo:  With that extensive background in philosophy, how would you say it has impacted your therapy style and the way that you go about counseling?

Blake Thompson:  Yeah, cool. That's a good question. I think so much of what we do as therapists is we reframe things for clients. Clients come in with, something's happened, there's an event, a situation, or even just themselves presenting in a certain way, the various processes that make up our lives, and they've got a particular perspective on it. That perspective is part of what explains the way they feel, the way they're acting. We help clients to see different ways of looking at their lives, of looking at the situations that they're navigating. That helps them develop the psychological flexibility, helps them develop this ability to look at things from different perspectives and to free up the way they feel and free up the way they act to become less rigid, less stuck.

A lot of what philosophy is, is conceptualizing and re-conceptualizing things. It isn’t so much, it's not an empirical discipline, it's a discipline where we're thinking about, okay, well, what's a different way of looking at this, what's the right way of looking at something? It might not be contesting facts, it might be, it's often a question of what's the right frame to put on something.

So yeah, in terms of what philosophy looks like, there are a lot of similarities. It's less often a matter of what are the right facts and more often a matter of what's the right way to conceptualize a particular thing. So too for therapy, it's often not a matter of what are the right facts, like this person is just dead wrong about something, it's more a matter of like are they applying the right conceptual scheme to it?

Nicole Izquierdo:  Thank you. Are there any areas or disorders or age groups that you specialize in?

Blake Thompson:  I pretty much only work with adults, rarely see adolescents and I don't work at all with children. I don't work with couples. Yeah, I pretty much just work with adults. I work with a pretty broad range of people, but I really enjoy working with folks who've got cluster C personality disorders, like avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder (OCPD).

I really enjoy working with folks who've got high functioning or low support needs, autism adults that are like, especially folks who struggle with deficit in theory of mind, which is really pretty common for folks who've got high functioning autism. They might not necessarily lack social skills, which I think is often how that gets conceptualized, oftentimes they lack awareness of how social interactions work and how other people think. One thing that I find really rewarding about working with those folks is that a big part of the work is explaining how other minds work to them and working with them to help them see that. That project is, for me, really rewarding. It becomes a really interesting, like theoretical discussion about how to make sense of other people and how to understand interactions with them and how to navigate those interactions. Yeah, it ends up looking a lot like philosophy tutoring.

Nicole Izquierdo:  I know you've touched on this a little bit, but would you mind describing how your treatment approach is, to make it simplified for the viewers? Is it solution-focused, do you help them manage stress with CBT techniques, or do you have other ways to go about it?

Blake Thompson:  Yeah. I'm somebody who thinks that the different approaches to therapy are all valuable, for the most part. Maybe not all of them are valuable, there's certain things, like primal scream therapy, that maybe deserve to end up in the dust bin. But among the well-regarded extent approaches to therapy, those pretty much all have a place in my mind. First, second, third wave CBT I think is great, and that stuff is especially great for what used to be called axis one conditions: major depressive disorder, generalized anxiety disorder, social phobia, OCD.

I use exposure therapy, I use ACT, rely on DBT principles. You know, sort of like broad, everything that fits within that broad CBT umbrella I think is super valuable, all of these insights from behavioral psychology and cognitive psychology. That stuff, in some ways it can be really solution-focused, it can be really focused on symptoms, but yeah, at the end of the day, it's evidence-based and often it doesn't take a million years to see some positive impact in someone's life.

There are other people who come into therapy who have more characterological, what used to be called axis two, issues, like maybe they're struggling with narcissism or entitlement, maybe it's like they find it impossible to stand up for themselves, they're constantly subjugating their needs, maybe they're perfectionists or workaholics struggling with unrelenting standards, chronic sense of defectiveness that they can't shake, behaving in ways that kind of perplex them, like they find certain behaviors necessary or are driven to do certain things that in retrospect they can't really make sense of but in the moment feel like they have to do them.

A lot of that stuff is the stuff that when it's more intense, we would call it a personality disorder, but most people struggle with some of this stuff to some extent. We used to frame this stuff as just neuroticism. Neuroticism has taken on a technical meaning in personality psychology, but it's the kind of stuff that would make you a really great sitcom character. Depression doesn't really make you an interesting sitcom character, but an inability to stand up for yourself makes you a great sitcom character. Narcissism, entitlement, particularness, perfectionism, workaholism, all of these things make someone an interesting character. Yeah, I find working with these folks really endearing.

I think psychodynamic therapy is a really, really helpful approach for this kind of stuff. I think even the CBT world has really acknowledged this, that the best way to help folks deal with this stuff really is a more autobiographical approach to therapy, it's an approach to therapy that is focused on looking back and reprocessing the unmet emotional needs that were the foundation for these behaviors, that were the foundation for these, what at the time were adaptations, but are no longer adaptive.

There are still other reasons that people come to therapy. Sometimes it's not that somebody has a mental health disorder, it might be that they just have a lot of environmental stressors. There isn't something wrong with them, there's something wrong with their environment. If you're the director of an environmental nonprofit and the head of the EPA is cutting all of the funding to protect the wetlands or something, you're scrambling to figure out what to do, you're sweating bullets, something that you really care about is under threat, you might lose your job, whatever, therapy could be helpful for you, but probably it might not look like CBT and it might not look like psychodynamic therapy.

It might look more like supportive counseling, it might look more like Rogerian supportive counseling, where maybe the thing you need is not to explore your relationship with your parents, maybe the thing you need is not to identify cognitive distortions. Maybe you don't have any cognitive distortions, maybe the reason that you're so stressed out is that you're seeing things accurately, but you need to process that stress. You need some place, someone to be a sounding board and to help you think through what you could do that would be an adaptive coping response. That, I think, is a big part of the work too.

A lot of people come to therapy not because they've got generalized anxiety disorder, but maybe because they just found out that their spouse is cheating on them or their kid just died or they lost their job or they just graduated from college and they don't know what they want to do with their life. There are these reasons that people come to therapy that don't have anything to do with having a disorder. All of that stuff might be causing stress, but it's not anxiety in a clinical sense. CBT and psychodynamic therapy might not really be well-suited to addressing those issues. I think that, what's often called the third wave in psychology, like Rogerian therapy, I think is really, really well suited to working with folks who are navigating normal life stressors and do want support with that stuff.

Yeah, and again, I think they're even more like what's the right theoretical orientation. It depends on the person, there's going to be for couples, Gottman approaches, EFT approaches. I think existential therapy is really helpful for folks who struggling with questions about meaning and purpose and identity. Those are things that CBT might not be able to tap into very well, psychodynamic therapy might not be able to tap into very well, Rogerian therapy might not be able to tap into very well, but having a working understanding of some sort might provide you with a leg up as a therapist to help you tackle these questions.

Nicole Izquierdo:  Yeah, I like that. There's not a one-size-fits-all approach, every client is unique with unique needs and unique environments and pasts. I like that, thank you.

How would you describe therapy to someone who's not familiar with it at all, or who's hesitant to start treatment, especially with the stigma on mental health treatment? Like you just said, I feel like there's a big misconception that people go to therapy because they have a mental health diagnosis disorder, but some people just go, like you said, when there's overwhelming environmental stressors and they need help with coping mechanisms. How would you describe it or reframe it to encourage those people that are hesitant?

Blake Thompson:  Yeah. I think people are hesitant for different reasons, and I think getting clear on our own hesitancy can be really helpful. We're often afraid of things that we don't know and afraid of things that have been stigmatized. A lot of men don't go to therapy because they find it hard to get help from other people. I mean, there's the cliché about men not asking for directions, not asking for help at the store. I think there's an extension of that for a lot of men around therapy, that they shouldn't open up, they shouldn't be vulnerable, they shouldn't share things. A lot of that is culturally normed. If that's what someone's struggling with, I think recognizing that is really the first step.

But there are other reasons why people don't come to therapy. In terms of OCD, for example, sometimes people have horrible intrusive thoughts, thoughts of like murdering people, for example, thoughts of deviant sexual acts. They might worry that if someone, if their therapist were to hear this from them, they might think that they intend to kill someone or kill themselves or what have you, and so they don't go. Suicidal people might not go to therapy because they're worried about getting committed to inpatient, or people struggling with substance abuse might not want to go because they're ambivalent and don't really want to stop drinking or using whatever product they're using.

Often when people are struggling with the question of whether or not to go to therapy, there's some ambivalence within them. There's some part of them that wants to go and some part of them that is repelled by the idea. I think that it might be the right decision. I mean, I'm really open to the idea that therapy is not for everyone. Therapy is not this perfect cure-all that is going to save us from ourselves. It is really helpful. I became a therapist and I'm still a therapist because I really do believe that it is really, really helpful, and for some people really profoundly helpful.

But I think really what we can do, what we ought to do, is identify that ambivalence, try to articulate it. What is that, what is this tension? What's this part of me that, A, wants to go, why is that, and what's the part of me that's telling me not to go? What is that? Where is that coming from? There's a little microphone in my brain and who's at the microphone? Who's like issuing the instructions? This fear, is that being put into me by my culture, is that put into me by like my parents, is that my bully from my youth speaking to me? Trying to get some clarity on where did I get this idea from that I need to be afraid of this thing, why am I hesitant about this, just spending some time investigating that for ourselves, sitting with that ambivalence, trying to unpack it. I think that's really productive.

Nicole Izquierdo:  Thank you. You're also executive director at the practice. Can you tell me a little bit more about what this role entails?

Blake Thompson:  Yeah. As a mental healthcare practice, we've got a number of administrative functions that are just important on a yearly basis. We have to renew our malpractice insurance every year, we've got to renew our lease with our landlord, we've got to make sure that we've got working internet, we've got to make sure we've got tea and coffee for our clients, we've got to make sure that staff are getting paid on time. Basically, it's all of this kind of behind-the-scenes stuff.

Our office manager, Jonathan, he focuses on really the day-to-day administrative functions of the practice. He's answering the phone, he's sending faxes, he's scheduling people, he's dealing with billing issues and all that kind of stuff. I deal with the longer-term administrative stuff, so I'm talking to our lawyers, I'm talking to our insurance companies, I'm talking to our landlord, I'm making sure all our contracts are in order, making sure paperwork for our clients gets updated as it needs to be. It's not like the most glamorous stuff, but it's important. It's all stuff that allows our therapists to just focus on being therapists and not have to worry about all of those questions and concerns that come up when you're in solo practice. Part of the benefit of being in a group practice is that, for most of the clinicians, not me, but most of them, they get to just focus on being a therapist, which is really nice for them.

Nicole Izquierdo:  This question is steering into the more personal direction, but how has becoming a parent impacted the way you view the world or the way you interact with your clients? Because it's this whole new identity, parenthood, that you're grappling with. If you don't mind.

Blake Thompson:  No, no, that's great. It's definitely opened my eyes to what parenthood is like. Obviously, not what parenthood is like for everyone, I have my own experience of parenthood. But I think being a parent is a lot more difficult and a lot more rewarding, both, than I sort of imagined it would be. I think it really does change the way that I look at, the way I think about my clients who are parents. It's helped me understand their perspective a lot better. It's also helped inform the way I interact with clients who are struggling with the question of whether to have kids. It's given me a lot of perspective there. I think in both of those areas, it's really had a positive impact on my work.

I think the area where it's had a negative impact is I get a lot less sleep sometimes now and that has unintended consequences. I think even during this interview, I'm probably rambling more than I would normally, but I'm running on like four hours of sleep. It is what it is.

Nicole Izquierdo:  Thank you. Thank you for sharing that. Again, another personal one, but where do you see yourself in five years?

Blake Thompson:  Oh, cool. Well, I'm really excited to continue to kind of grow SAS. I mean, I think that the one thing that we haven't done much of up to this point but that I'd like to see us do a lot more of is develop continuing education. I think that's an area that I'd like to have us devote more resources to, I think both in terms of providing good local, evidence-based therapy education, which is the thing that there's often not enough of, but also my particular background and my particular strengths as a therapist, I think having a background in philosophy, also having a background in psychology, I'm, I think, really well positioned to both provide existential therapy, but also to provide good instruction in it. I think over the next five years, I'm going to really work on developing curriculum so that I can provide really good continuing education in existential psychotherapy.

Nicole Izquierdo:  That's great. Last one, if you have any last words of advice for our listeners or anything else you'd like to add.

Blake Thompson:  Oh, well, if you watched, thanks for tuning in. The one thing that I'm really, I think, struck by, and that is, there are plenty of trainings in plenty of different kinds of psychotherapy, but one approach to therapy that I think doesn't get enough press time that I think is a really, really innovative and really, really helpful approach to therapy is ACT, A-C-T. I would encourage anyone who's a clinician or who's a client who's trying to figure out what else they can do to promote their own personal development, their own personal growth, either as a provider or as just a person in the world, I don't think ACT is everything, like I said before about approaches to psychotherapy, I don't think that any one approach can fully capture everything there is to being a person and address every sort of concern that we have, but I think ACT is uniquely helpful for how simple it is. I think it is remarkable how beneficial it is and how intuitive it is.

There's a great self-help book by Steven Hayes, who is one of the main developers of ACT, called “Get Out of Your Mind and Into Your Life.” There are millions of copies of this thing that have been printed, but I would encourage anyone who has any questions about how to apply therapeutic principles to their life, how to take the next steps. Sometimes therapy is too expensive, sometimes therapy is inaccessible, sometimes you feel like the therapists that you're finding aren't a good fit for you. There are really, really great therapeutic workbooks out there that are based on evidence-based psychology. This book by Steven Hayes, “Get Out of Your Mind and Into Your Life,” it's a phenomenal book and the ACT principles that it's based on are super, super helpful. I'd encourage anybody who's considering therapy, who's ambivalent about it, checking it out. Again, it might not be the thing for you, but it's about as close to a one-size-fit-all, helpful across the board approach to therapy that I've ever found. I really want to shout from the rooftops, everybody should know more about ACT than they probably already do.

Nicole Izquierdo:  Well, thank you so much for sharing that, and thank you so much for joining us, Blake. We really appreciate you taking the time to speak with us.

Blake Thompson:  Hey, thanks, Nicole.

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

Therapist Jim McDonnell on High-Stress Employment

An Interview with Therapist Jim McDonnell

Jim McDonnell, LMFT is a Psychotherapist at Seattle Anxiety Specialists. He specializes in working with clients in the tech industry and high-stress environments. Jim also has extensive training and experience providing couples therapy and family therapy.

Anna Kiesewetter:  Hi, thank you so much for joining us today on this installment of the Seattle Psychiatrist Interview Series. My name is Anna Kiesewetter and I'm a research intern at Seattle Anxiety Specialists. I'd like to welcome with us today our own Seattle Anxiety Specialist psychotherapist, Jim McDonnell. Before becoming a therapist, Jim had a successful career in technology across two decades. With his experience as a researcher at NASA's Ames Research Center, as a senior program manager at Microsoft, and also as a senior business intelligence analyst at T-Mobile, Jim is an excellent resource for clients working in high-stress careers. So before we get started, could you please just tell us a little bit more about yourself?

Jim McDonnell:  Sure. Hi, Anna. Nice to meet you and thanks for organizing and running this. A little about me. I grew up in New York. I was raised just north of New York City. I've spent years in the restaurant industry, and then I transitioned into technology. I worked in startup companies in Silicon Valley and then moved up to Seattle, worked in the tech industry in Seattle for a number of years. I'm an outdoor enthusiast. I like being outside in the woods. I love to exercise and keep my body in shape. It helps my mind stay clean and clear. I'm a father, my daughter's in college, and I don't know what else to say beyond that. Yeah.

Anna Kiesewetter:  Yeah. That's awesome. So you mentioned you worked in tech in Silicon Valley before you came up to Seattle. Could you tell us a little bit more about what got you interested in making that switch?

Jim McDonnell:  Sure. The switch from being in tech to a therapist?

Anna Kiesewetter:  Yeah.

Jim McDonnell:  I've always enjoyed helping people and making people feel better. When I was younger I used humor a lot to do that. I can make people laugh relatively easily, and if a friend had fallen down and hurt himself, or if something happened, I would sort of employ goofiness and jokes and physical comedy and stuff to bring someone out of their sadness into happiness and laughter and sort of lighten the mood. And I really leaned into that early in my life. I was a joker, a jokester, a prankster, and I just liked laughter.

I also loved gadgets and technology and loved programming and trying different... I was always sort of buying the latest gadgets when I was a kid. I had these electronic dictionaries in the early '80s when they were super rare and I loved them. I was a bartender and I was going to college. My undergrad is in industrial organizational psychology. I had a research methodology focus so when I graduated, I got a job at a startup company doing statistical analysis and database programming. I really loved that.

And so I sort of left the helping laughter stuff behind and really leaned into this, and the whole country and the world was sort of embracing this and I thought maybe I was going to be a gazillionaire and get all sorts of stock options and stuff like that. And I pursued that for many years, but in the background was always this desire to be a helper.

And I should point out that I originally wanted to be a therapist when I was in college. And I had an advisor who, for whatever reason, I'm assuming their reasons were sound, but they advised me against it. So I was in a bit of an existential crisis, like, “Who am I? What's my purpose in this world?” And so I leaned into the research methodology. I still wanted to be in the psychology domain, but I, for whatever reason, just accepted that fact that I couldn't be a therapist. So I went that route.

And so for many years I was leaning into that. I really enjoyed my time in technology, in the tech industry. I really loved the people that I was working with and the projects I was on. But there was this sort of transition in my mind where I was becoming a bit disillusioned with the industry. I wasn't finding deep meaning in it. And it wasn't really resonating with this core value of wanting to be helpful to the world and to reduce suffering.

And so, as I progressed through my career, I started getting closer to a point in my life where maybe some people have a midlife crisis or something like that, and I just was like, "I'm no longer satisfied. I'm not happy." I was actually super anxious. I was having panic attacks and anxiety attacks in the workplace. And then I decided to make a change. So I had some people in my life that were pushing me towards this. They recognized that I had particular skills and personality temperaments, and some gifts and traits that would be really, really helpful to people. I actually received formal training in being a therapist.

So I made the choice to just try. I applied to a couple of graduate programs. I was accepted and I kept saying, "Okay, I'm going to do this for a semester. If I don't like it, I can always just drop out and I still have..." I was working full time my first year in graduate school. So I was holding down a 50-hour-a-week job and I was going to classes and working in the classroom while I was learning. I just really liked it. It resonated with me. And so I've just stayed with it.

I think the question was what prompted the shift. It was sort of like this awakening. To be more specific, my father passed away when he was 46. I was 46 at the time, around the time that I wanted to be a therapist. I was maybe 44 when I finally decided to start applying to graduate schools. But it was sort of like, "What am I doing with my life?" If I was my dad, I would've been two years away from death. "Is this the legacy I want to leave for myself?" That really pushed me out of my comfort zone, as well.

So all of that is the reason why I shifted out. Looking for more meaning, finding something that was better aligned with my skills and my values and partially just sort of a life cycle change of like, "What do I want next for myself?"

Anna Kiesewetter:  Wow, that's really powerful. I think it's really inspiring that you pushed forward to doing that, making that change and showing what you value. Do you feel like you kind of fulfilled that, that kind of wanting to find more of your life's values in the change, the switch between careers?

Jim McDonnell:  Yes. When I first started off in graduate school, my vision was to be working more with youth and teens. And so I did that at a community mental health during my internship, and it turns out it wasn't a great fit for me. It wasn't really aligning with my passions and through, I would say, serendipity, maybe, what's the word, synchronicity. Some kind of, if you want to think more spiritually, woo-ish. I found Seattle Anxiety Specialists when I was looking for a group practice. And the more that I started thinking about the practice's mission and the focus area of specifically treating anxiety disorders, the more it just sort of was like, "Duh, you've been anxious your whole life."

So to be able to help people who are in the industry that I used to be in, learn how to recognize why they're anxious, to help interrupt feedback loops and disrupt patterns that reinforce their anxiety and to find more confidence in themselves, in their ability to experience distress, to reduce how long it lasts and how intense it is, and to just generally understand how their particular mind works and why it responds a certain way, is so fulfilling to me.

I go to sleep at night happy, knowing that I haven't helped every single person in the world, I'm never going to eradicate all of the distress on the planet, but every person that I interact with, from a client-therapist relationship, I feel like I'm doing the best job that I can to make the world closer to being in that state than it was before I started, if that makes sense.

Anna Kiesewetter:  That's amazing. How do you think that being in the tech industry yourself has helped you to help these people now that you're working with them? Especially people who have been working in tech industries?

Jim McDonnell:  Yeah. I mean, I don't know what it's like to work at every single company. I don't have a visceral understanding of every company culture. I've never worked at Amazon or Google or Facebook or Apple. So I don't know what it's like specifically to work at those companies. And I know what it's like to work, generally speaking, in the industry. I know the expectations that are put on people. I understand how software is created and managed. So project management perspectives and program management perspectives and different kinds of software development methodologies.

I understand those enough to be able to speak the language of the person. So when they come to me and they're trying to describe what's going on in their life, they don't have to explain the culture of the company. They don't have to explain why it's stressful. I get it and I am able to speak their language. I use metaphors a lot in the work that I do and I bridge kind of how we go from, this is the way the product is now and here's how we want the product to be in the next revision, and here's what we're doing to make that happen and here's our timeline and our plan and all of the schedules and milestones.

And I kind of use that same approach for mental health. So here's how you are right now, version, whatever, one, of you. And then you want a new version where you're not as anxious and you're not as stressed out and you have a more adaptive response to these stressors. What do we have to do to get you from here to there? How long is it going to take? How do we know we're making progress? How do we measure progress along the way?

So that sort of understanding, being able to speak the language. I know the different terminologies and review cycles and pressures and sort of the cultural contextual factors that are feeding and reinforcing the anxiety. I'm really rambling on a bit here, but it's helpful for me and I think my clients appreciate that I have been in similar spaces to them and understand, generally speaking, what it's like and why it's stressful. So I think that's probably the best way that I can answer that question. It's just like there's familiarity with the context and yeah, I'll leave it there.

Anna Kiesewetter:  Yeah. That makes a lot of sense. You mentioned anxiety is one of the things that you see a lot in people experiencing workplace stress and having to deal with these issues. What other kinds of areas or symptoms or disorders do you often see in your patients who are working in high-stress environments?

Jim McDonnell:  Other symptoms? Well, if we're thinking about this from an experiential perspective, like what are they experiencing? Obsessive, intrusive thoughts that are generating distress, physiological distress. So there's muscle tension and dysregulated breathing and fidgeting, elevated heart rate, perspiration, that sort of thing, racing thoughts. Really, there's a lot of what are we call cognitive distortions in cognitive behavioral therapy. So a lot of stories that people are telling themselves about what's happening now and what's going to happen in the future.

Anxiety's generally a future-oriented experience. We're thinking about the future and we're worried about it. And then the predictions that we make. Our mind is a model maker, modeling the future constantly, trying to figure out how to make sense of the world. And that model has some distortions in it. Maybe it's predicting a tragedy constantly. Like, "This is only going to turn out bad," or we can only see things either or, either good or bad. I think I've forgotten the question. I'm a little lost in my answer now. Can you restate that question so I can refine it?

Anna Kiesewetter:  Yeah, of course. Of course. I was asking what kinds of typical, or maybe not typical, but what kinds of different symptoms and disorders do you see in people who are experiencing high-stress work environments?

Jim McDonnell:  Right, yeah, so symptoms versus disorders. The disorders tend to be generalized anxiety disorder. There's a lot of obsessive-compulsive disorder, but maybe less on the traditional or the technical way of interpreting that diagnosis. I look for obsessional thought patterns and disturbing, intrusive thoughts, and then compulsive responses to that. Things that people are doing in response to those thoughts that try to protect themselves from it.

I see a lot of that OCD, generalized anxiety disorder, panic disorder, so people who, really, just there's runaway anxiety that leads to panic attacks, depression, as a result of that. So when you start to feel scared about your future over and over and over again, you can't figure out how to solve a problem, you end up becoming hopeless about the future. And so you can have people experiencing depression and anxiety simultaneously, which is a double whammy. That's not very fun.

I'm trying to think if there's other things. That is generally the areas that I focus on, things that I'm looking for or listening for. And then all of the physical symptoms that people are describing or experiencing, and the cognitive side of that as well. And the behavioral side of it. So what behavioral choices are people making? And again, it's typically in response to some sort of a trigger that's dysregulating a person, cognitively and physiologically, and then in response to that, they're making choices to protect themselves somehow. And sometimes it's just like fight, flight, freeze sorts of choices. Yeah.

Anna Kiesewetter:  I see. So when you're experiencing the patients with these different symptoms and disorders, can you talk a little bit about your treatment approach and how you approach therapy with these people?

Jim McDonnell:  Yeah. I'm generally using cognitive behavioral therapy as a therapeutic modality. I lead with a discussion around... How do I want to answer this question? My goal is to help people have an adaptive response to stressors. When you're in a state of constant anxiety, that's a maladaptive response to the stressor. So I want to help people get to that place where they can experience that stressor. They know how to process it, digest it, and instead of being stuck in an anxious feedback loop, they're able to resolve the thought, the feeling, the behaviors, and leave with confidence that they know what to do. Even if they don't know exactly what to do, they know generally what to do.

That sort of guides my approach. I want people to become consciously aware, explicitly aware of, what triggered me? I was doing fine and then suddenly I wasn't. What was it? Was it a thought that I had? Did I see somebody that reminded me of something? Did somebody say something to me? Was there an event that just happened, the anniversary of something that was traumatic? What is it? Because we're not just suddenly fine and then not fine.

So getting really clear on that and then getting really clear on what happens in your body when that happens. So that thought passed through your head and then your muscles tensed up and your breathing became shallow and quick and your heart rate elevated and you started sweating. Okay, great. So you understand the connection between why you're feeling this way in your body right now and what just happened. And then what stories do you tell yourself, your model-making machine, meaning-making machine? How do you make sense of this? Your prefrontal cortex has to tell you a story about, "Well, you don't feel good right now. Why? Oh, it must be because..."

And then that's where the cognitive distortions come in. "This is always going to be this way." I don't know. "I'm going to get fired. I'm going to get a bad review. My partner's going to leave me." Something. It's some tragedy. And then we feel hopeless about that. So getting really clear on the story, what's happening in our body, why, what the trigger was, being really clear on the behavioral choices we make as a result of that.

I want people to get bored with this because I'm going to keep asking them every session so it becomes rote so that when they feel something, they go... It sort of spurs a meta awareness. So like, "Oh yeah, I'm feeling anxious. Let me engage in this higher-level process to understand why." So then once they have that skill, how do we disrupt this pattern, this as-is experience?

There are physiological interventions, like learning how to regulate our breath and how to relax our muscles. There's cognitive interventions, like recognizing cognitive distortions and challenging them, coming up with ways to not lie to ourself about what the stressor is and why we're feeling this way. And also to feel confident that we know what to do in response to it. So appropriately sizing the stressor. So maybe I'm responding to it as though it's a 10 out of 10, but in reality, it's like a four out of 10.

So really right-sizing the way that we're thinking about problems, and then what can you do behaviorally that's different? So we're looking at this as a system and as a pattern, a template of a response to a stressor. And then we want to disrupt that pattern and template and replace it with a bunch of different choices along the way. And then if we score, how do I feel with version one versus version two? So long as we're feeling better with version two, then that's good. We're making progress.

So that's the approach I've taken. Lots of validation. There's no judgment in the process. What purpose does judgment have, right? We need to be able to just be honest about what we're telling ourselves and why. Positive regard. It's important for people, I think, to feel good about who they are, even if maybe they've made choices that they're not proud of, that at their core, they can feel as though they're good and they're seen as good. I think that's really important.

And I use humor along the way, as well, a little bit of levity. And then ultimately aligning all of this stuff with personal values. What's important to you? Who are you as a person? How does this map to your identity and how you see yourself? That's the best I can do in sort of summarizing. It feels complicated sometimes when I'm trying to describe it, but I try to keep it finite and relatively discreet so that it's not overwhelming, that a person kind of understands what we're doing. There's goals, there's structure, there's a plan, we're moving forward towards something. So that hopefully also communicates some confidence in the process, so that's how I do that.

Anna Kiesewetter:  That's amazing. Awesome. Yeah. Thank you so much for sharing that. Okay. We're approaching our final question: so, I'm just wondering if you have any other words of advice or anything else you'd like to say to our listeners before we wrap up.

Jim McDonnell:  I'm not sure exactly what to say other than perhaps we don't get to choose what happens to us in this world with 100% certainty, but we do get to choose how we respond to those things and suffering, while probably inevitable, is optional in many different ways. I didn't mention this before, but the core metrics that I communicate to clients is, how frequently am I triggered? When I am triggered, how intense is the response and how long does it last? So frequency, intensity, and duration.

We can't really always choose how frequently we're going to be triggered by something or how frequently the trigger is going to happen, but we do have agency on how intense the response is and how long that response lasts. So if people are experiencing a lot of anxiety, I think it's important for them to know it doesn't have to be that way. The world doesn't have to change in order for them to feel more at peace and they don't have to lie to themselves. It's not one of these toxic positivity sort of cycles where we just say, "It's all going to be great and everything's okay and stop worrying." I think that just actually reinforces the power of the stressor so we can't look at it with open eyes and accept things as they are.

So if a person is anxious and they've been anxious and they continue to experience anxiety, more often than not, it doesn't have to be that way. And there are people who can help transform the way that they're thinking and feeling in response to those stressors so that they just generally enjoy their life more. We don't get to live forever. We might as well learn how to use our brains to have a better time on the planet while we're here.

Anna Kiesewetter:  Awesome. Yeah, I like that a lot. All right. Well, okay. Thank you so much for your time and your insights coming on here today. I wish you the best and really hope to have you back for another interview in the future, if you're down for that. So this concludes this installment of the Seattle Psychiatrist Interview Series. Thank you so much for listening and we hope you'll tune in next time.

Jim McDonnell:  Thanks, Anna.

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

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

Psychologist 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.

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

Psychologist Sarah Gaither on race & Social Identity

An Interview with Psychologist Sarah Gaither

Dr. Gaither is an assistant professor of psychology and neuroscience at Duke University. She is a social psychologist specializing in diversity and inclusion.

Nicole Izquierdo:  Thanks for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Nicole Izquierdo, research intern at Seattle Anxiety Specialists, and I'd like to welcome with us Social Psychologist and Diversity and Inclusion Scholar, Dr. Sarah Gaither. Dr. Gaither is an Assistant Professor of Psychology and Neuroscience at Duke University, and she earned her PhD in Social Psychology from Tufts University, and is currently the Director of Duke's Identity and Diversity lab. She's an expert in social identities and inter-group contact, and her research focuses broadly on how a person's social identities and experiences across the lifespan motivate their social perceptions and behaviors in diverse settings.

So before we get started, do you want to add anything else? Can you tell us a little bit more about yourself?

Sarah Gaither:  Sure. Well, thanks for having me. I'm excited to be here. I think, you know, for me, it's really important for everyone to kind of know my framework of where I come from for why I study what I do.

So I'm Biracial, so I'm Biracial Black/White, but I look like a strange White person, and so it's kind of my lived experience, right, of having this invisible versus visible identities, that's really pushed me in wanting to understand how our group memberships can shift our behavior and identities in different ways. So for me, it's always been this lifelong question of growing up in a mixed-race household, constantly being questioned about why I don't match my dad, why my brother looks different than I do. Those kinds of identity-questioning experiences really what's fueled why I study what I do today.

So I think that's just an important thing for everyone to keep in mind as we discuss things today.

Nicole Izquierdo:  Thank you. So I guess you kind of answered this a little, but besides social psychology, growing up, did you play around with any other career paths or like you always knew from day one social psych-

Sarah Gaither:  I definitely did not think I'd ever be a Psychology professor. I was not even a Psychology major in undergrad; I was a Social Welfare major. So I thought I'd be a Social Worker. Turns out I'm not a strong enough person for that. After working on a case, it destroyed me, and I knew I really wanted to study people and behavior and understand, you know, why we make the decisions we do, why we interact with people in positive versus negative ways. So I've always just been a people person. I think for me, growing up kind of confused about my own mixed-race identity, my toys were all super multicultural and multiracial so I knew I was lots of things at the same time, but I didn't really have the words to explain those things.

So during my gap years after undergrad, that's when I realized doing literature reviews, as boring as that can sound to some of you listening to this right now, I discovered within the Psychology field, at least, there was very little published research with Biracial samples. So my group, my existence really just didn't exist within our current findings, and so that's what motivated me to want to apply to grad school. Try and give a voice to these populations and experiences while also using Biracial, bicultural experiences to help us understand more broadly how our identities kind of function, even if you aren't a member of one of those groups.

Nicole Izquierdo:  So for the people listening who don't know what social psychology is or what diversity and inclusion research is, do you want to go into a little bit more detail about that and even the specific questions that you aim to answer?

Sarah Gaither:  Yeah, yeah. So being a social psychologist, I think everyone in the world is a social psychologist, even if you have no training in it, basically because we all judge each other all the time. So social psychology is our social judgements of each other, our social judgements of ourselves. It's the psychology behind the decisions we make, the role that the context plays in shifting how we perceive things in our social world. So social psychology really shapes everything we do. It's also the lens that we process things that have already happened to us at the same time.

So in my work as a social psychologist, I look not only at the present day and sort of, "What are your current attitudes and how you feel about your own identities or other people or other groups?", but I also look developmentally, when you were little, when you were growing up. "What are the types of experiences you had with people from different diverse backgrounds?" that might actually predict whether you're more inclusive versus an exclusive person later on as an adult. So that's sort of how I see social psychology and why I think all of us are technically social psychologists deep down inside.

Nicole Izquierdo:  Yeah. So I wanted to ask you about, I don't know if this is the right term, but like implicit bias, and basically you said that it affects people in the future when interacting with others. Are people doomed when it comes to their implicit bias? Is there a certain limit or, like what can be done? Like what are some interventions or early childhood teachings?

Sarah Gaither:  Yeah. So implicit bias, for those of you who might not know what that is, that's kind of these internal automatic associations, stereotypes that you might have about someone you don't know, right? So that gut reaction, that gut response that you have when you see someone new for the first time, those are usually our implicit responses to that individual or to that group. So, lots of people ask me all the time, "Is there a critical age point where we should intervene and make everyone magically inclusive?" There's not one age point, right, where we say, "This is when change happens." Early on, early childhood is one of those critical periods. We know exposure to people from different races, cultures, ethnicities, if you can travel to different regions of a country that you live in, those are really prime opportunities when you're a young child, because you're learning what words mean and what these associations mean to different groups.

So if you're only exposed to people who look like you the whole time growing up, the first time you see someone from another group who looks a little different, you're only going to have those stereotypes you've maybe learned from the media or other sources of influence. So, diversity contact is super, super important early on in childhood. Adolescence is another time that we know is ripe for interventions, mainly because that's when kids are switching school environments, and so changes in context are always ripe for opportunities in people trying to reassess themselves or reassess their biases. Same thing goes for entering college. This is a very important identity period in particular, because when you move off to a four-year institution, if that is the type college you may have gone to, that's usually the first time people are moving away from their home, their family, their friends, and they're forced to navigate these social worlds for the first time, without any help from anyone that they've known.

So college is one of those identity-ripe periods where people are often experiencing new things for the first time. Maybe they lived in a context where they could never acknowledge an identity or an aspect of themselves until they got away from that home environment or that home context. So those are kind of main age points that I focus on a lot in my work, mainly because I am very interested in those moments of change. So to answer your original question, no one's doomed. Everyone can change, but some people might take a little more effort to change than others. The same thing goes for negative contact you might have. So if you have lots of positive diversity contact, that's going to change your attitudes in a positive direction, but you could have negative contact, and that's going to work against those attitude changes. It can actually reinforce those negative attitudes you might already have. So, contact can work in both positive and negative ways.

Nicole Izquierdo:  When you talk about college, I wanted to talk a little bit more about the kind of work you've done on Duke's campus. I'm familiar with your random roommate study, but I was hoping you can elaborate a little bit more on that as well.

Sarah Gaither:  Yeah. So Duke, a couple years ago, changed their roommate policy for incoming freshmen. So, they used to allow a freshman to either be randomly assigned to a roommate or they could choose their own roommate, and Duke decided to change that policy a couple years ago where all incoming freshmen are now randomly assigned. They did this because they wanted to see if it actually changed how inclusive the freshmen class felt, and they asked me if I wanted to study it. I had some work from grad school I had published that showed if you were a White freshman living with anyone but another White freshman, so a Black, Latino, or an Asian individual, that experience living with someone from another racial background your freshman year, by the end of that freshman year when I brought you into the lab to meet a Black student you had never met before, that interaction went way better. Way more positive eye contact. You smiled more. The Black students also felt better in those interactions as well. So this wasn't just a gain for White students, but for students of color as well.

So Tufts and I did that project during grad school in Boston, and then Duke knew that I had done that, and so they asked me to follow this cohort here at Duke. Really, what we're seeing is similar types of effects and changing some of our White students' social behavior in these future settings who have been randomly assigned a roommate from another racial or cultural background, but we're seeing that I think is even more interesting in a way as we also recruited minority students in the sample at Duke, and regardless of what your racial or ethnic background may be, everyone's friend networks are becoming significantly more diverse by the end of that freshman year.

So by forcing you to live with someone who's different just for that first year of college, we're seeing this expansion of one's sense of self, as we call it. Your in-groups become bigger, your social networks become more inclusive, and it's actually making Duke not seem as exclusive. Still has some issues to work out for sure, but that's one of our main positive findings right now, which I'm really excited about.

Nicole Izquierdo:  So the positive effects are happening for both the White racial majority and the minority groups. Okay.

Sarah Gaither:  Yeah, for both groups. So that's, you know, and that's rarely studied with students of color on different college campuses. It's tricky at Duke since we're still a predominantly White campus to kind of control for how much White contact versus minority contact students are getting, but the fact that everyone's friend networks are actually becoming more racially diverse, gender diverse, sexual orientation diverse, religiously diverse. The only one we're not moving, it seems, is politically diverse, but Duke's campus is also politically liberal, pretty biased in that direction so I think there's not quite enough room to move those friend aspects around, but all the other categories seem to be expanding.

Nicole Izquierdo:  And we all know the pandemic kind of messed up all our life goals, research, et cetera. So how would you say it impacted your research both like practically, and also, did it change the kind of research questions that you want to ask moving forward?

Sarah Gaither:  Yeah. COVID, you know, shifted a lot of things, and of course, millions of people around the world have died from COVID, and so that's really the real thing we should all be focusing on, on how COVID has impacted things. From a research standpoint, for me in particular, it ended all in-person research. So what I really love studying is the actual social behavior between people when they're talking to each other face-to-face, but when COVID hit, we couldn't run in-person studies, everyone was wearing masks. So if I'm wearing a mask, you can't see my face. You can't see my emotions. It makes coding whether these interactions are going positively or not pretty much impossible. So we had to stop all behavioral in-lab data collection.

We also do work with young kids and families. Since kids under five still are not able to be vaccinated we're actually still running kids online even today, even though COVID is becoming less of a problem, just to keep all families and parents safe. So, that's the main way it's affected us really, is not being able to do any in-person data collection.

The other way is even online data collections since we can collect some of our work through online surveys. Those prices have also skyrocketed because everyone got moved to online platforms. So following classic economics, right, supply and demand, they can charge what they want when all of us were forced to collect our data online. So, grants became more necessary during COVID, and just thinking creatively about how to adapt some of the questions that I'm interested in into an online Zoom format, right? How can we still relate this to real world outcomes through these weird little black boxes we all exist on for the last two years?

Nicole Izquierdo:  Thank you. So now I want to move into a little bit more, most of our listeners are either interested in like therapy, mental health. So have you done or read up on any work about Biracial individuals in therapy, or anything related to like racial trauma and like Biracial people's role in the Black Lives Matter movement?

Sarah Gaither:  Yeah. So lots of responses there. So the bulk of my work focuses on Biracial and bicultural experiences because of my own lived experiences. The most common stressor we have for both of these groups is something we call "identity denial" or "identity questioning." So if someone's ever asked you, "What are you?", "Are you sure your dad's your dad?", these kinds of very direct identity-threatening situations, over time, they serve as small little microaggressions that science has now shown really add up to being strong mental health stressors. It develops people in an inability to form a positive sense of self. It's negatively impacting their self-esteem. So a lot of the multiracial and multicultural literatures actually cite higher cases of different types of mental health outcomes, such as depression and anxiety for these groups, and the reason they cite this sometimes in clinical work is because they have twice amount of the exclusion in their lives, right? If you're part White and part Black, you now have White people and Black people both excluding you for different reasons, right? So it's twice the amount of social exclusion.

So Biracial people aren't experiencing more discrimination than other racial or ethnic minority groups importantly; we know monoracial minorities tend to experience more direct discrimination and prejudice, but from a social exclusion standpoint, which is what's directly linked to a lot of negative and mental health outcomes is higher for our Biracial and bicultural populations compared to other racial and ethnic groups.

So that's something our lab's been trying to measure, and we actually have the first paper where we measured cortisol responses for this specific identity denial experience that Biracial and bicultural individuals face. So you see your cortisol, which is a biomarker, inside of your body that elevates when you have a stressful experience. We find that this increases for both bicultural and Biracial people, and if you live your life at higher rates of cortisol all the time being elevated, it can lead to early death, weight problems, sleep problems, things of that sort as well.

So, what I think is tricky from a therapy counseling angle is most of the research that exists has excluded multiracial and multicultural people from their demographics. They're difficult to categorize and to fit into boxes. So we don't know if you need a certain type of multicultural therapist to feel included in your sessions. We don't know what cues, right, and what to train people on since there's so much variability within the multiracial and multicultural demographic. It's hard to come up with a one-size-fits-all kind of training model on what to do in these therapy sessions.

I think what this all stems down to is just this notion of belonging, right? When anyone has an issue with belonging, they feel like they don't belong or they don't fit in, this is what leads to those negative mental health downstream consequences. That's what led to me writing my own piece on being involved in the Black Lives Matter movement, as someone who presents very White. Those are those particular contexts, right, where you question where you belong, what your space is, what your space is not, and to also question your privilege; if you're White-presenting, you clearly have privileges in our US society that other people do not, but knowing where you can still fight for those who are marginalized, fight for those who are having more difficulties in their life is still an internal stressor for many multicultural and multiracial people.

So I wrote that piece as a way to hopefully motivate others who maybe felt similarly as I did where we wanted to be involved, but weren't sure if that space was a space we were welcomed in or not, right. Making sure that we give the stage and the platforms to people whose voices have not been heard over time. So that's really what motivated that piece that I wrote earlier.

Nicole Izquierdo:  Do you see anything with children of, let's say, your Black father and your White mother, where they experience, I wouldn't say it's like secondhand, but like you witness the racial minority parent experiencing discrimination. So even though the child doesn't firsthand because they're White-presenting, they see someone they love experiencing that. Have you done or heard about any research that analyzes that?

Sarah Gaither:  Yeah. There's very little research in that direction—sorry. My dog is barking. There is clearly a delivery person outside. He's going to be very loud for a second, but he's a lovely dog, everyone. Yay for working at home. That's the other way COVID has impacted me.

To answer your question there, there isn't a ton of research looking at offspring of mixed-race parents and sort of, what are the instances of discrimination or prejudice they witness from their parents. That's a great thing that should be studied. I know from my own firsthand experiences, for me, that's what made me hyperaware of race relations growing up, right? Knowing that I was never targeted, but it was always my dad being targeted, right? He would be accosted when we were at the shopping mall. People saying, "Hey, are you kidnapping this little girl?" They would never come up to me; they would direct all of their accusations toward him. We had skinheads living down the street from us growing up and they would only throw rocks on his side of the car, but not my side of my car.

So there are these explicit exposures and that's how kids learn. Kids learn through these experiences, and I think that's what makes being multiracial a complicated thing to study developmentally. It depends on if you're in a two-parent versus a single-parent household, that also hasn't been studied a ton, which parent is doing the kind of racial or ethnic socialization. Also not studied a ton, but our lab is currently collecting some data on that, so stay tuned. So I think those inputs of how kids learn, particularly from multiracial and multicultural backgrounds when they're little, it's just not documented that well. Sociology has a couple papers on it, but there's hasn't been any large-scale psychology studies yet.

Nicole Izquierdo:  Thank you. That just came up when talking about this.

So you mentioned that inclusion, sense of belonging have been linked to mental health outcomes. Can you just elaborate a little bit more on that? Like how much sense of belonging is enough to prevent those things from developing or is just like one instance of ostracism detrimental?

Sarah Gaither:  Yeah, yeah. So needing to belong, it's this kind of core fundamental human desire to just want to fit in. You want to feel like you have a home. You want to feel like you have a family. You want to feel like people understand you and your experiences for who you are without any questions whatsoever, right? So this can be measured in lots of different ways in psychology research, but the way we know it affects mental health outcomes in particular is for people who really feel like they never belong anywhere, right, or if they're trying to get into certain groups, but then there's people that keep saying, "No, you're not enough of X to be in this group," or "No, you're not good enough to be in this group," it's those constant kind of combinations of wanting to be in a group but then having that identity denial experience of not being able to attain that group membership that ends up leading to these increased stress outcomes, increased anxiety outcomes, etc.

So, how much needing to belong people have, everyone varies on this. There's not a magical number. If you have too many friends and none of them are very close friends, you're going to have a lot harder time dealing with identity stressors and identity threat experiences. You really need a couple good core members within your social circle. These could be family members, these could be friends, these could be romantic partners, any of those things, but you really need more than one. I'd say somewhere between three and five good core people, and the question that I post to all of my classes, which Nicole here has actually heard me already say once is, you know, if your car broke down at 2 o’clock in the morning on a very dark highway in the middle of nowhere, do you have at least a couple people you could call who would come and pick you up, no questions asked? Right?

That's the level of belonging, that level of social bonds that people strive for, and if you don't have those social bonds to latch onto when you're feeling threatened by society, by a peer, by a colleague or an employee, that lack of a social bond connection is what causes us to have these drops within our self-esteem and leads to that increased depression and anxiety outcomes.

So that's really one of the number one reasons why we see people in therapy and counseling sessions because they feel like they just don't know where they fit in.

Nicole Izquierdo:  Something else we learned about in your class, which I guess is another avenue I say that negative mental health outcomes could result from is compartmentalization and conflicting identities. So you still belong, but you're not able to, let's say, express that other conflicting identity within that group. Can you like give an example or why compartmentalization is so detrimental versus being able to integrate all your identities?

Sarah Gaither:  Yeah, yeah. So, you know, a big area of research is called identity integration within this kind of identity circle, and so if you have lots of your identities, the more integrated they are, the more in harmony that they are, the more they get along together, usually the less negative mental health consequences you're going to face because you can navigate very flexibly between your different identities, but if you view your identities very separately or they're in conflict, or one's in secret, you can't claim that identity based on a given context you may be in, that ends up leading to more stress, right? And it's because you're constantly fighting this battle of who it is you really are with this kind of secret invisible identity perhaps versus who it is you think you should be, right?

So a way we frame this a lot in psychology is looking at these conflicts between your actual self versus your ideal versus your ought self, right? This ideal self of who you would ideally be in an ideal space. The ought is who you think you should be, right, maybe based on social pressures, family pressures, but the conflict that you have between your actual self and either of these ideals or ought selves, that's where we see this increase in mental health negative downstream consequences for individuals.

So, I always try and tell people, you know, if they're feeling down, they really should work on why it is this one identity or this one experience seems to be so separate from the rest of them because our identities are multifaceted. They are intertwined with each other, but sometimes one can get very detached, but figuring out a way to get that more encompassed with your other identities is the best way to try and lift yourself back up in those moments.

Nicole Izquierdo:  Thank you. So now we're going to switch back the spotlight onto you. So, you recently became a mother to twins. So has becoming a mother impacted the way you view the world and impacted the way you are as a researcher?

Sarah Gaither:  I think for me, I had twins last summer, so they're almost a year old. I've almost made it a year now with twins, which is a whole thing on its own. I think, A: being pregnant is a new identity, right, that people don't really talk about within the identity structure, and it's a temporary identity, right? You're not pregnant forever, but being a pregnant person is definitely an identity experience that I don't think is quite understood. And then you're not pregnant anymore randomly and these beings have come out of you. It's a totally weird transition, right? You go one day from being this, you know, wobbly person who can barely walk, and now you have this person, or in my case, two people who are completely dependent on you in every way, shape, and form.

So I think for me over the past year, what I've become hyperaware of is, A: how incredibly gendered our world is. I have boy/girl twins. We're trying not to gender them as much as possible, but it is everywhere and it's how people interact with them. It's even the language that people use with them, the toys that they choose to give them if they have choices of toys across a room. I think that's been a big kind of eye-opening experience for me, but for my own identity experiences, I think I didn't know how multifaceted I really was until I became a mom. I think being a mom makes everything else kind of click together. Now I know my experiences of cooking and liking food can now make them the food that they need. I know that my experience and the love for travel and exposure to diversity, the things I strive for in my own research are all the opportunities I look for to take my kids to, right, to make sure that they're getting that exposure at different cultural events here in Durham or whatever the case may be.

So, I think I am much more thoughtful now than I was before and where I go and what I do with my time, and making sure that each thing my kids are exposed to is hopefully going to lead to this positive identity change that I measure in my own research. So, it's kind of made me a double researcher in a way where I don't want my kids to not practice what I preach, right, is sort of my approach with them.

I think the other thing that it's made me really think about is how much we don't know how people are going to change, right? Identity is malleable across everyone's lives, and you asked earlier, right, "Is bias malleable?" Well, your identities are malleable too, right? So the experiences my kids are having right now is definitely going to shape some of their attitudes, some of their preferences, but that can also change drastically later on, right? There could be things that I'm doing, limiting certain things that they don't have a chance to experience, right, and trying to make sure that I'm open enough with letting them identify how they want to identify, right? Because identity is definitely malleable over the lifespan too.

So I think those are the things that keep me awake at night because they're actually pretty good sleepers. So I think about those things a lot.

Nicole Izquierdo:  And what advice would you give to parents of Biracial children, being one yourself, and like researching Biracial children?

Sarah Gaither:  I think it's, you know, exactly what I just said: let your kids, and even if your kids aren't Biracial, let your kids identify how they want to identify. What we know from so much research and psychology, sociology, education, health research is that when people feel their identity is forced on them in any way, taking away their autonomy, taking away their freedom to really identify for who they are, that's what leads to these negative mental health consequences. So, as much as you want to put your culture, your race, your background, your upbringing, your favorite foods, whatever it may be on your kid, if they don't like that favorite food, try to be nice about it, right? Because when things feel forced, that's when we know this identity conflict starts sort of arising between a parent and a child, and it can affect their overall identity development.

So let them be kids. Let them explore, let them learn, and realize that you too are going to make mistakes, right, in how you talk about things with them and you can learn from each other. So that would be my advice, I think, for anyone out there.

Nicole Izquierdo:  Is there a limit to what can be considered an identity?

Sarah Gaither:  Yeah. That's a good question. I'd say no. I'd say people can frame an identity in lots of different ways. Some people, being a runner really is a core component of who they are, right? If they lost their ability to run, they would lose their sense of self. I hate running, right? So for me, that would never be an identity, but for some people that's a very strong identity and that might be stronger than their gender identity or their racial or ethnic identity. I think when we think about identities broadly, we tend to think of race, gender, religion, sexual orientation. We don't always think about these other aspects: being a foodie, being a mom, being pregnant, right? There are lots of identities out there. What I think is important is knowing which identities are more important to you and why, right?

So that's what makes things shift your behavior and shift your judgment, is certain identities are going to cause you to change what it is you buy at the store, who it is you want to date, or what kind of graduate school program you might be considering, and not all of your identities are going to play as strong of roles in shaping those decisions down the road. So I think identities can be anything, but some of them are going to have more power over you than others.

Nicole Izquierdo:  And finally, another personal question, but where do you see yourself in the next five years, and how would you like your career to grow while at Duke?

Sarah Gaither:  Yeah. Well, hopefully I'll be tenured within the next five years. You listening, Duke? I hope that happens. I'll be submitting for tenure this summer. So we'll see what happens in the next year. So hopefully I'll be tenured. So I think for me, my biggest outstanding questions are really trying to figure out, what happens if you have negatively stereotyped identities? How does that function within a lot of these kind of multiple identities, flexible thinking kind of outcome spaces? I'd really love to understand more about that. I'd also really love to understand more developmentally with little kids when they really claim something as an identity. It's very hard to measure, but when does that young kid realize, "Hey, this is actually who I am," right? What are the different age points where race versus gender versus being a runner or whatever the case may be, when does that become important to kids, and what are the contexts or the pathways that lead to that strong, positive identification?

Those are things I'd love to still be studying going forward. I think the other thing I'd love to do is to also take this out into the real world. I think we do all these nerdy psychology studies in these controlled lab settings. That's why this roommate study was really interesting for me to do because it's real-world behavior, right? It's students living in the dorms with their roommates. So trying to extend some of this work into more naturalistic settings, I think, is absolutely key for us to truly understand the power that our identities have over our choices.

Nicole Izquierdo:  Do you see your work translating into the relationship between a therapist and their patient?

Sarah Gaither:  Yeah. I think identity always matters, right? I think there's lots of work out there; people are trying to measure identity matching, right? If that's something that helps within therapy sessions or not, or identity signaling, identity cues.

Another project we've been doing here on Duke's campus is called DukeLine, which is a peer texting program. So undergrads are helping other undergrads. I'm just a faculty member helping to fund it and run it, but I play no role in the peer coaching that happens, but what we've been trying to do within this peer coaching texting framework is to not necessarily tell you which anonymous peer coach you have if you happen to text in for help. You don't necessarily know what their individual identities are, but we have bios of all of our coaches we're putting on our website that show all the different identities that are represented within our coaching team, and our coaching team works really close together. We have a searchable database of the 600-700 most common stressors for Duke students that are actually curated by people from all of these different identity backgrounds, right, to make sure that when a student has a question, if you don't belong to that group or you haven't had that experience, we have people who have had those experiences, right, that we can pull from.

So I do think, from an identity matching angle, that type of connection is absolutely key. It's impossible, I think, to always match people based on certain identity qualities for therapy sessions, but it's not impossible to give people cultural tools and cultural knowledge, right, to make sure that the advice they're giving them, the help that they're giving them is culturally sensitive, and that's where I think we need to be improving.

Nicole Izquierdo:  Yeah, I wrote a, I forgot what class it was for, but I wrote an assignment about this, and yeah, like the same thing: there are so many barriers for those minority identity groups to even enter the field and become therapists. So obviously matching by those identities is like impossible. So the first step should be to equip these White majority, or not even White: any other majority group, whether it's religious or sexual orientation, with like these cultural tools to implement them, so-

Sarah Gaither:  Yeah. Not all identities are visible when someone walks into a therapy session also, right? Like no one would know walking into a therapy session with me that I have a Black parent, right? So I think these assumptions that we sometimes make as clinicians also should be checked, right? We should have, you know, thorough kind of demographic explorations with patients to make sure that we know their multifaceted selves are all of themselves that they bring to each session, right? It might be one identity that's being targeted in that moment, but I argue all the different identities, again, whether they're in harmony or not, are all contributing to the stressors that someone's facing and how they're processing them in that moment. So if you're only targeting one identity, you're probably not going to be that successful in healing the whole self, because it's all intertwined.

Nicole Izquierdo:  Thank you. So yeah, we'll just be wrapping up now. I guess the last thing is, is there anything you'd like to share or any advice you'd like to give to our listeners to close us off?

Sarah Gaither:  I think just be bold and brave and experience new things, right? This is the number one thing that when people ask me, "Well, what can I do for my kid?", or "What can I do for myself?" Go out and explore the world. We live in such a segregated society. We talk to people who think like we do all the time. Go make a new friend in a new group, go to a new cultural event. Go to a part of the state or the region you live in you've never gone to before and just feel it out. We know that even just temporarily vacationing somewhere different, right, can force you to think about the world in a different way, and these perspective-taking experiences I think are so key, not only for how you learn about your whole world and society, but how you learn about yourself.

So just, you know, get out there and do some new things, and even just taking a walk around your neighborhood if you don't even do that is a good start.

Nicole Izquierdo:  Well, thank you so much for joining us, Dr. Gaither. We really appreciate you taking the time to speak with us.

Sarah Gaither:  Yeah. Thanks for having me. I had a great 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.

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

Venerable Thubten chodron on meditation & anxiety

An interview with Venerable Thubten Chodron

Ven. Thubten Chodron is the founder and Abbess of the Buddhist monastery, Sravasti Abbey.

(note: this interview is also available as a podcast)

Jennifer Ghahari: Thanks for joining us today. I’m Dr. Jennifer Ghahari, Administrative Director at Seattle Anxiety Specialists. I’d like to welcome with us Venerable Thubten Chodron. She’s an author, teacher and the founder and Abbess of Sravasti Abbey, one of the first Buddhist training monasteries for Buddhist nuns and monks in America. Today we’re going to discuss how one may mitigate anxiety through meditation. Before we begin, can you please tell us a little bit about yourself, some of the work you’ve done, as well as some of the work you’ve done with His Holiness the Dalai Lama.

Venerable Chodron: Ok. Thank you for having me here. Let’s see… I wasn’t raised Buddhist. I went to a course when I was working as a teacher in the Los Angeles city schools and that really interested me; it was like an incredible psychology of the mind.  But it was also a spiritual path – and the course was taught by two Tibetan Lamas who had a monastery in Nepal. So, I went there and one thing led to the next and I wound up becoming a Buddhist nun. So that was back, I met the Dharma teachings, the Buddhist teachings in 1975 and I was ordained in 1977. I spent a good deal of time living abroad in Asia and also in Europe and then found myself coming back to the US and, you know, working as a resident teacher in a Dharma center in Seattle for about 10 years, and yes, I know the city, and then began Sravasti Abbey, we’re in the eastern part of Washington State. So, I’ve always been interested in psychology. I found that the Buddhist teaching explained how the human mind works in a way that I had never heard before and it really was quite amazing to me and one of the main things that the Buddha taught was that our happiness and our suffering depend on what’s going on inside of ourselves and this is different than our usual take on life where we think happiness and suffering come from outside, from other people, places, situations, your job, the government, whatever… but the Buddha said those things may be conditions but whether we’re peaceful, whether we’re satisfied, whether we’re happy or miserable that comes from our own mind, the way we look at situations, the way we, how we frame situations when we describe them to ourselves. So, I found that very interesting, not only intellectually but because there was practice associated with it, I found that when I did the Buddhist practice, it really helped me personally with a lot of my different issues. So, I just have kept practicing since then.

Jennifer Ghahari:  And then you opened an Abbey…

Venerable Chodron:  Yes!

Jennifer Ghahari: That’s fantastic.

Venerable Chodron: An abbey is as a Buddhist monastery and we have 17 monastics now but we also have many programs and retreats and courses for other people. So, people come actually from all over the world to do courses with us. We keep busy!

Jennifer Ghahari:  Fantastic; thank you. So, to get started today, the American Psychological Association defines anxiety as an emotion characterized by tension, worried thoughts and physical changes like increased blood pressure. This definition of anxiety has physical and mental components and I was wondering do you think of anxiety in this way?

Venerable Chodron:  Ok – in Buddhism, when we talk about emotions, we talk about mental states. And we say there may be a biological connection or something going on in the brain but those are physical things that are happening with biological, chemical elements. But the real emotion is the emotion that you feel. So, I would say that feelings of tension in your body or, what was the other one?  Increased blood pressure? I would say that those are physical factors that let you know that you may be feeling anxiety. Yeah? So, some people, when they are anxious, may have those physical factors, but I think you can possibly have those physical factors without being anxious or you could be anxious and maybe your body & brain doesn’t react with those kinds of physical factors. So, when I talk about anxiety, I’m talking mostly about emotion. 

Jennifer Ghahari:  Ok. Why do you think people tend to develop anxiety or be anxious about certain situations and how do you think that underlying assumptions about ourselves and the world work together to create anxiety?

Venerable Chodron:  Oh boy… ok, so there’s two things there. Let’s start with the first one… so the first one was why do people go from like just being in a regular mental state to getting anxious. So, there I would say anxiety is related a lot to fear and to worry and it could be worry about our physical protection, our financial situation, our relationships, our status, you name it, we can get anxious about it. Ok… really seriously, you know, I mean you can get anxious because your plant isn’t growing…

Jennifer Ghahari:  It happens.

Venerable Chodron:  Yeah, it happens. So, what I think is going on with anxiety or what I also know from my personal  experience is that I am weaving stories in my mind, yeah?  When we were all in English class in high school, you know, we all thought “I’m not a good creative writer, I can’t write.” Actually, we are spectacular creative writers. When we are anxious, we are creatively writing a whole fictional story and who’s the star of the story… ME… not somebody else, I am.  And then we write this story so there’s a few, maybe situations happening externally or somebody said something to us or whatever and our mind takes the situation and imputes all sorts of meaning onto these, the actual facts of the situation and then we think that what we have imputed is the reality of the situation. 

Jennifer Ghahari:  Right.

Venerable Chodron:  So, we are creative writing and what we’re creative writing about is usually something that will not happen or that is very unlikely to happen and, even if it did, if we check in our lives, we have internal resources to deal with the situation. We also have resources in the community and our family and whatever to handle the situation but when we get anxious the story we write is I am all alone, this horrible thing is happening, what if it happens, what am I going to do… nobody else can help me, nobody else cares about me, I don’t know what to do, I’m going crazy and I might be out on the streets by Tuesday and my marriage is over by Wednesday and my kid is going to flunk out of school because he couldn’t spell cat in 1st grade, he spelled it with a K instead of a C and how he’s not going to get into university if he can’t spell cat correctly. You know, I’m exaggerating things, but this is exactly what the story writing behind anxiety does.  And the thing is that we believe it. But it’s completely made up by our mind. So, it’s so interesting because I watch my own mind, you know, when I get anxious.  I’ll tell you a little story about… So I was writing a book, this was many years ago, maybe 20 years ago, and the publisher did something I didn’t like and this happened and that happened and it was a whole huge mess and I didn’t know if the book was going to get published or not and I was just really, you know, anxious about it because I was responsible for writing it to some other people but I didn’t appreciate what they were doing because they were interfering… and so… yeah I was really a mess, quite anxious. And so, I happened to go to Dharamsala in the springtime, His Holiness the Dalai Lama, would give teachings. So, one day I went to the teachings and I was walking back to my room from the teachings and again my mind is ruminating about the situation. You know, I’m in India, halfway around the world from Seattle but this situation is alive and well, screaming at me with anxiety in my mind and all of a sudden as I’m walking, I said, you know, there’s over 7 billion human beings on this planet and how many of them are as worried and upset about this as I am? 

Jennifer Ghahari:  Ok…

Venerable Chodron:  And I thought nobody else, there’s only one human being on this planet who is so upset and that’s me. 7 billion minus 1 couldn’t care less about what was going on with this book and the manuscript…and I thought if 7 billion minus 1 don’t think this is important, why am I so anxious about this? Why am I ruminating about it?  It is clearly not earthshaking, you know. Although when we are anxious, we feel like the situation we are in is a national emergency or equivalent to one. In other words, like everybody should be stressed about this. But actually, everybody else is too busy thinking about themselves and I’m the only one stressed and why am I stressed, because my mind is creating a situation and then spinning, spinning, spinning around my creation so at that moment when I thought like that I just said LET GO – this is not earthshaking, it is not so important, you will find a way out to remedy this. So, I let it go and then I had a great time for the rest of my trip in India. 

Jennifer Ghahari:  So, touching upon that, I was wondering can you speak about the relationship between suffering and permanence and anxiety, how do they relate?

Venerable Chodron:  Ok… well this gets into another… there’s so many avenues from which we come to anxiety, you know, and one of them is our expectations about how life should be. 

Jennifer Ghahari:  Right.

Venerable Chodron:  So, I have a little thing that I call the Rules of the Universe. They are, of course, coming from me, they are my Rules of the Universe but everybody and everything should follow them even though they don’t know. So, people should treat me according to my Rules of the Universe. If they haven’t asked me what my rules are, that’s too bad for them… they should know already and treat me according to them. So, part of my Rules of the Universe, you know, are my expectations and one of my expectations is that the things that I like do not change. 

Jennifer Ghahari:  Ok.

Venerable Chodron:  Ok? They are permanent. Yeah… so if this situation, if this relationship is going south, it’s always going south… there’s no hope for it. If my financial situation is horrible, it’s always going to be horrible, you know. So, this, the mind that fixes things in time and doesn’t consider that things change. So that’s one way I trap myself, by I think the bad things are permanent…

Jennifer Ghahari:  Oh, ok.

Venerable Chodron:  But the good things in my life I get anxious about because I think they’re going to end. Ok? So, the bad things which are going to change, I fix in time. The good things, which are going to change, I expect not to change at all. Ok?

Jennifer Ghahari:  Right.

Venerable Chodron:  So, this is my misperception, isn’t it? That I’m expecting people not to change or at least the good qualities of the people that I care about and the relationship I have with them are not supposed to change.  That’s one of my Rules of the Universe. Now, of course, everybody is changing moment by moment, they’re not the same. But when I expect everybody who, you know, who’s my loved one and my friend always to be kind to me and always be my loved one or friend, I’m creating a situation for anxiety because I know that things change and I am rejecting the fact that they can change. Ok?  And that makes me anxious… like ok now this person is my friend but what if they like somebody more than me? What if they move away, what if one of us gets sick? What if, what if...  Again, we’re creative writing what if situations. 

Jennifer Ghahari:  Hmmm…

Venerable Chodron:  Meanwhile, the people where I have difficult situations with, I fixate and then I get anxious about those. Like “Oh, you know my brother said this now I can’t talk to him and this and that and it’s never going to change. And oh, he really revealed how much he can’t stand me and we’ve been competing with each other since we were kids… how am I ever going to deal with this? I know he’s never going to change”. It’s toxic; that’s a good one.  As soon as I label it toxic, you know, he’s toxic, the relationship is toxic… what’s toxic? My proliferating mind that is projecting stuff onto people that’s what’s toxic, you know because I have my Rules of the Universe, you know. My brother should always be like this, he should always treat me like this…. and he’s a living being who changes all the time and I change all the time, too. But I get anxious because I think it’s always going to be like this and how am I going to deal with it.

Ghahari:  Wow. Thank you.

Venerable Chodron:  This is what I mean, we can, we just can create things.  It’s quite amazing. Now, going back to your other question about assumptions that might underlie anxiety.

Jennifer Ghahari:  Yeah.

Venerable Chodron:  I think the foremost assumption is that, now it’s quite embarrassing to admit this, but we’re all friends so I think we can be open.  We think that we’re the most important one in the world. Yeah?

Jennifer Ghahari:  Sure.

Venerable Chodron:  I’m the most important person in the world!  And that’s why I have my Rules of the Universe that everybody should follow and my happiness, my suffering matter more than anybody else’s. I don’t care what’s going on in Syria, what’s going on in Israel and Gaza. I don’t care about the craziness in America, you know, American politics, nothing, you know.  What happens to me is the most important. And that fixation on ourselves makes us so miserable. Why? Or how? Because we relate everything in the world to ourselves. 

Jennifer Ghahari:  Hmmm. Right.

Venerable Chodron:  And so, we joke about this at the monastery, the abbey.  I’ll hear two people talking in another part of the room and I’ll joke, “Oh you guys… I know you’re talking about me, criticizing me, I can tell it, you’re not talking very loud… I know you’re talking about me. Look at that look on your face.” And I tease them about it because this is how we function, isn’t it? In your work place, if you walk in and two people are talking and their voice is low, they’re talking about me they’re saying something bad, ok? Anxiety… oh no, what did I do? They’re talking about me! What happens if they tell the boss, I won’t get the promotion, I might even get fired and then everybody in the office thinks I’m terrible, anyway what they’re gossiping about me didn’t happen and how to I clear this situation up and nobody likes me and I’m going to get fired and how am I going to tell my family I got fired… you know. So, it’s because everything is so self-referential, yeah?

Jennifer Ghahari:  Right.

Venerable Chodron:  Then we get upset, stressed, anxious about it. I’ll tell you another story. I think stories are really good examples.

Jennifer Ghahari:  Right.

Venerable Chodron:  So, one of my friends, her son was engaged to a woman and she was from a different religion, a different culture. My friend didn’t care, she was cool about that. And, obviously, her son was, too. Anyway, they had – the fiancée’s family – was having a big party down in Los Angeles; my friend lives in Oregon. She went down to Los Angeles. You know, she didn’t know anybody there except her son and the fiancée. She didn’t know anybody else. So, she walks in, it’s at the family’s home – she walks into the home and here’s, ok, and what she said, ok, when the first time she told us the story I walk in and there’s my son’s fiancée talking to somebody and she doesn’t even acknowledge that I walked in the room. She doesn’t turn around and say hello. She knows I don’t know anybody here, except for her and my son.  You know it’s just common sense, common courtesy…if you’re going to marry somebody, you try and be nice to your future mother-in-law.  She should have come up, at least said hello, introduce me to her family, made sure I feel comfortable. What’s going to happen? My son is marrying this woman and she is so rude and so inconsiderate! How are they going to have a happy marriage? Ok. So, this is the story she tells. So, we said, ok, cause we do some non-violent communication work here at the abbey – so we said ok, first, tell us the facts of the situation. No interpretation, no embellishment, no emotive words or words that exaggerate what’s going to happen.  So, it took her a while to actually do that cause she was so worked up.  What she came to, the facts of the situation, was I walked into the house, my son’s fiancée was talking with somebody and she continued talking to that person. That’s all that happened. That’s the facts of the situation…that’s all that happened. Now compare that with what she got anxious about.

Jennifer Ghahari:  Right.

Venerable Chodron:  You can see that the facts of the situation and how she interpreted things, how she imputed motivations on the woman, all of that was coming from her mind, her creative writing mind.

Jennifer Ghahari:  Right.

Venerable Chodron:  That made herself the centerpiece of the situation.  There was whole room full of people? How many people were in that room?  Did any of the other people, were they as upset about this as her? Nobody else noticed.

Jennifer Ghahari:  Right.

Venerable Chodron:  Yeah? So, it’s just another example of like – wow – if I go back to actually the raw facts of what happened, you know, why am I getting so anxious? I could have gone into the situation and introduced myself to somebody, yeah? “Hi I’m the groom’s mother.” And then they would have said, “He’s such a wonderful boy,” you know? But she didn’t do that; she just stood there frozen, feeling offended. 

Jennifer Ghahari:  Right

Venerable Chodron:  But you see, she could have gone into the situation and just said, “Wow,  you know, I’ll just go in and introduce myself. My son’s marrying into this family, I want to get to know these people. 

Jennifer Ghahari:  Right. And everybody could have been feeling anxious at the same time…

Venerable Chodron:  Right! Yeah, because they don’t know everybody at the gathering either.

Jennifer Ghahari:  Right. Thank you. So, in terms of anxiety and trying to mitigate that, can having a spiritual path help lessen anxiety and, as a Buddhist, how does the practice of Buddhist teachings help you with anxiety?

Venerable Chodron:  Ok. So yes, I think a spiritual practice can help us. No matter what faith you are, I think what’s common in all faiths is that we think there’s something more than our own ego and we think that there’s something more than just the happiness of this life. 

Jennifer Ghahari:  Ok. Right.

Venerable Chodron:  So whatever what religion one is, if one has a practice in that religion, you know, that can help you expand your vision, ok, because anxiety, stress, is very narrow vision. It’s all about me in this situation right now and my misery. If you have a spiritual path, your mind thinks about other people, it thinks about the future, it thinks about being an ethical person and keeping good ethical conduct. So that’s common in all faiths.  In Buddhism, in particular, we have a genre of teachings, in Tibetan it’s called lojong, it means mind training or thought training and it’s a series of teachings that show you how to describe things from another perspective so that your anxiety, your anger, your fear, your greed, your jealousy, whatever it is, dissipates. In other words, you’re not suppressing emotions or repressing them but you’re learning to look at a situation from a much different perspective, a much broader perspective and when you do that then the emotion that is so much based on self-centeredness automatically fades. So, this genre of teachings, the mind or thought training teachings, are the ones I rely on so much in my own life to deal with situations because, you know, whenever you work with people things always come up and you have to figure out a way to resolve problems. You know, as we all know, people do not follow the first Rule of our Universe, you know. My first rule is everybody should be, do, think and say exactly what I think they should be, do, think and say.

Jennifer Ghahari:  Right, yeah.

Venerable Chodron:  My parents should be this way, my mother should be this way, my father should be this way, my brother, my sister, my pet frog, you know, the turkeys that are wondering around the abbey, everybody should fulfill my expectations. And, it’s not just that they should be, do and think what I say but they should all like me. And they should all think I’m wonderful, right?

Jennifer Ghahari:  Yeah.

Venerable Chodron:  And the problem with the world is that people do not realize that I am the center of it. That is the big problem. So, these people, they’re so stupid, they think they’re the center of the world, they don’t realize that I am, you know. So, they need to change. So, you know, of course, I get anxious, especially if I have kids, I’ve got to rear my kids so that they become exactly what I’m not, they fulfill all my aspirations, they become what I could never become. So, you get anxious about that. But, you know, this is all from seeing things from the wrong perspective. So, you know, we have a practice, one of our practices is called seeing the disadvantages of being self-centered. So, we contemplate those. Another practice is seeing the benefits of cherishing others.

Jennifer Ghahari:  Ok.

Venerable Chodron:  Oh, you mean when I’m anxious, I should think about other people. Really?? You mean other people exist as something outside the drama that concerns me?? You mean they have feelings? That they want to be happy, they don’t want to be miserable… just like me??

Jennifer Ghahari:  Right.

Venerable Chodron:  That people right now, you know, their houses have been bombed and they have no place to go? Now how would that feel, to be in that situation? Right now, we’re in the aftermath of the Israel Gaza thing. So, in both Israel and in Gaza, houses were bombed, people were killed, you know. How would I feel if I was in that situation?  Or how would I feel if I were a refugee? Fleeing from Syria or who knows where…there are so many places in the world now. And how would I feel if I was a refugee having to go to another country where I didn’t know anybody and I didn’t speak the language.

Jennifer Ghahari:  Yeah, right.

Venerable Chodron:  Oh my goodness, you mean there are people like that? They’re in that situation? And then, you know, so we start to open our mind to see much, what’s happening in the world. But then our mind might go oh yes, well there’s all these rich people, they live in, you know, Beverly Hills. They live in… I forget in Seattle what the rich neighborhood is, but they live in that. They live in New York, Upper West side, Upper East side, you know – whatever it is. Those people, you know, they’re happy… No, they aren’t, no they aren’t. You know I’m sure you’ve dealt with people who on the outside look, you know they have everything, but they aren’t happy at all. They have personal problems, they have all sorts of problems that, you know, wealthy people who have a good front, have a whole other set of problems. So, we begin to see oh my goodness, you know, I’m not the only one. 

Jennifer Ghahari:  Exactly.

Venerable Chodron:  And so, instead of just focusing on myself, what about doing…you know, we do a meditation practice where we um, there’s one meditation practice called metta – which means loving kindness – where we think loving, kind thoughts towards other people and just sit there and generate these kind thoughts, wishing them to have happiness in the process of happiness. And a compassion practice wishing people to be free of suffering and the cause of suffering. And you don’t have to limit to human beings. Animals also.

Jennifer Ghahari:  Definitely.

Venerable Chodron:  Yeah? Really when you what’s happening to many animals it makes me so sad. So, you can sit there and just wish other people well. It’s a fantastic practice and, you know, you can start with people that you know if you want to. They usually recommend starting with somebody you know who’s not somebody you’re really attached to emotionally, you know – but somebody you know and you wish that person well… may they have good health, may they have good relationships, may they feel successful in their life. May what interferes with them opening their hearts to others, may that kind of hindrance may they be free of it. May they have love and compassion for the others. May they have all their physical needs met. And, you know, and just thinking about all these things. You start with somebody that you know, that you’re not close to; then you do the same thing for somebody that you’re close to; then you do it for a stranger, you know, somebody at the grocery store. Maybe your neighbor… people don’t even know their neighbors nowadays, you know, and thinking about your neighbor, may they have happiness and what kind of things would make them happy? And what kind of problems could they have in their life that I wish them to be free of and then, you know, so you’ve done kind of somebody you know, a dear one, a stranger, now you go to somebody you don’t like.

Jennifer Ghahari:  Ok.

Venerable Chodron: Somebody you fear even, maybe even somebody who abused you. And you think , you know, ok, somebody who abused you , are they a happy person? Somebody who was mean to you or harmed you or cheated you… did they do that because they were happy? Happy people don’t wake up in the morning and say I think I’m going to abuse somebody and cheat them and lie to them, make them all feel miserable. Happy people don’t think like that – so this person must be suffering, they must be very miserable. So, I know – and it’s their misery that made them do what was harmful to me or harmful to the people I loved.

Jennifer Ghahari:  Yeah, right.

Venerable Chodron:  Or harmful to the country – whatever it is. It was their misery that made them do that because in their confusion, they thought acting that way was going to alleviate their own misery and, of course it didn’t. They were acting out their own suffering under the delusion that it was going to alleviate the tension in their own minds and, of course, it didn’t. It made them more miserable because they have to live with knowing what they did. So, they’re actually more miserable than they were before they did what was harmful. So, aren’t these people who are so confused and so miserable, aren’t they objects of compassion?

Jennifer Ghahari:  Right.

Venerable Chodron:  So, can I open my heart to have compassion for people like this? Knowing that they also have the ability to change? That what happened was one part of their life, but they are more than the worst thing that they did in their life. And, of course, the worst thing they did in their life was in relationship to me, not in relationship to anybody else – it was always involving me, because I’m the victim of everybody else, right? But actually, you know, it’s like something is going on – can I wish them well?  What would happen if they were happy? What would happen if their minds were peaceful and they had some wisdom and they realized that acting in this way wasn’t going to bring anybody any benefit, including themselves?  And so, to wish them to be happy. I do this meditation with politicians a lot. For me, I won’t mention names, there’s a lot of people out there in the government who need some compassion.

Jennifer Ghahari:  Yes.

Venerable Chodron:  Or people out of the government who need some compassion. Because they’re doing things that are so harmful and they don’t understand what they’re doing. They’re so confused and so wrapped up in trying to promote themselves that, you know, I don’t know how some of them can live with themselves. So, to practice wishing these people well, may they have wisdom, may they feel secure so that they don’t need to take revenge on other people. May they have a magnanimous mind so that they wish other people joy and can take, and can feel happy by creating the circumstances for other people to be happy, you know. So, wishing that for those people it’s a fantastic meditation… it really helps.

Jennifer Ghahari:  One question I have is, if you’re internalizing and you have all this anxiety and you want to try to meditate, sometimes it can be hard to focus and actually meditate. So are there ways to get over your anxiety so that you are able to start meditating. It’s like a vicious cycle, I think?

Venerable Chodron:  Yeah, it is. Um, one meditation that they recommend is just to watch your breath. You, um, you focus at your belly, there’s two points. You can either focus at your belly and your belly expand as you inhale, watch it fall as you exhale or you can focus at the nostrils and the tip of the nose and watch the sensation of the breath as it comes in and as it goes out or you can just sit there and feel yourself breathing and feel how the breath connects you to the universe. But your object of focus, your object of attention is just the breath. Now, it’s very easy to get distracted because we are used to being distracted. So, when you notice you got distracted, don’t criticize yourself. Just know, ok, now I’m thinking about this or I hear a sound or whatever – come home to your breath. So, see your breath as home and just the peaceful flow of your breath as it goes in and out, don’t deep breathe don’t force your breath in any way but just imagine sitting there being peaceful and breathing peacefully and you just bring your attention back to your breath and watch your breath and relax.

Jennifer Ghahari:  Ok. It sounds like you can really do that anywhere. You don’t have to do it in a special place or wear special clothes or a special pillow?

Venerable Chodron:  Right, all of Buddhist practice is like that. You can do it anywhere; you don’t need special props or anything.

Jennifer Ghahari:  How long would you recommend that someone do that for?

Venerable Chodron:  The breathing meditation?

Jennifer Ghahari:  Yes.

Venerable Chodron:  Um, you know start out maybe 5 minutes and then you know then go to 10, then go to 15.

Jennifer Ghahari:  Oh ok…

Venerable Chodron:  And then, like I said, there’s other mediations that people can do. Then you might switch into another meditation because in Buddhism we have many kinds of meditation so watching the breath is one kind, but another kind like I just told you about the meditation on loving kindness, mediation on compassion there’s that one. We have visualization meditations that are also really very effective, I think for dealing with anxiety and so forth. Just to give you, if I take a Buddhist mediation and secularize it because I don’t the audience, you know you may have Catholics and Muslims and Jews and non-believers. So ok, so you know a visualization could be think of the good qualities that you really respect in others that you would like to develop in yourself – qualities of love and compassion, ethical conduct, generosity, patience, forgiveness, humility, you know – and imagine those qualities manifesting as a ball of light in front of you. If somebody were a Buddhist, I would say it can manifest as the Buddha figure, if you’re a Christian it could manifest as Jesus or just keep it as a ball of light. So, the good qualities manifest as that ball of light and the ball of light is radiant and it just spreads in everywhere in the universe and the light from the ball also, especially comes into you and it comes in through the top of your head and through all the pores of your body and it completely, your whole body is full with this radiant light which is the nature of all those good qualities.

Jennifer Ghahari:  Ok.

Venerable Chodron:  So, you’re sitting there imagining that this light is coming into you and that you are experiencing those good qualities that you can now relate to the world as somebody who has those qualities, as somebody whose kind and peaceful and compassionate and you think you know that light has come in – now I’m enriched by it, you know, and so I can, you know, start to become like that in my interactions with other people. And so you focus on that visualization and then, at the end, you imagine the ball of light comes on top of your head, it’s very small and then it comes to the top of your head and it comes to the center of your heart and you think now, you know, the center of my heart, the middle of your chest, not your heating heart, and you have light there and so the light of your own love and compassion and wisdom and so forth it radiates, it fills your body and it goes outside you body and now you start radiating light to other people. So, to your friends, to strangers and also to the people you don’t like and the people you’re afraid of and the people who have harmed you and you imagine that all those people, you know, absorb that light. And then you just stay in that state of just feeling, feeling good about yourself and feeling good about other people.

Jennifer Ghahari:  Right. Thank you. This has been beyond amazing and I want to thank you for speaking with us today. Is there anything else, before we wrap up, that you would like to add or anything else that you would like to share?

Venerable Chodron:  You know there’s one thing. What I think is very important is having  a sense of humor. We’ve got to be able to make fun of ourselves.  And to laugh at ourselves and not take ourselves so seriously. And to have that kind of sense of humor, we have to be kind of transparent, it’s like, you know, usually we have faults and we hide them away and hope nobody notices them. But, hey, people notice our faults and so going around like this saying I don’t have a nose (covering her face), I don’t have a nose even though everybody knows we have one is ridiculous, you know. It’s like so ok we have faults, can I laugh at my faults, can I talk about my faults, can I be open about them without feeling ashamed and without blaming myself and telling myself what a horrible person I am… can I just say I have this fault and I’m working on it and I can also laugh at myself.

Jennifer Ghahari:  Right.

Venerable Chodron:  I can laugh at when I act out this fault because sometimes what I’m doing or saying is so ridiculous that I have to laugh at myself. I think that’s also quite important.

Jennifer Ghahari:  Perfect. Well, thank you again for being with us and for sharing this wisdom. I know you guys offer a lot of different lectures and classes at the abbey so we’re definitely going to share the link on our website to your website so people can check that out.

Venerable Chodron:  There’s the abbey website and then there’s my personal website, thubtenchodron.org.  

Jennifer Ghahari:  We’ll put both of those on our site.

Venerable Chodron:  And our YouTube channel because everything is about us!

Jennifer Ghahari:  Exactly!  Again, thank you for having all that information out there; that’s wonderful.

Venerable Chodron:  Thank you.  Take care.

Jennifer Ghahari:  Thank you.

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

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