Physiologist Jagmeet Kanwal on Music in the ICU

An Interview with Professor Jagmeet Kanwal

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Jagmeet Kanwal:  Andrew Schulman.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Preeti Kota:  Your research is very exciting.

Jagmeet Kanwal:  Good to know that. Thank you.

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

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

Preeti Kota:  Yes, of course.

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

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

Advocate Lauren Johnson on Environmental Justice

An Interview with Advocate Lauren Johnson

Lauren Johnson, MPH has a graduate degree in environmental science and policy, and is a Climate Corps fellow for the Environmental Defense Fund. Lauren founded the Environmental Justice Action Network at the George Washington University and specializes on advancing environmental justice.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. Today, I'd like to welcome with us Lauren Johnson, who has a master of public health in environmental science and policy, and is a Climate Corps fellow for the Environmental Defense Fund. During her time as a graduate student, Lauren founded the Environmental Justice Action Network at the George Washington University, which is a student-led organization working to address environmental justice issues in the metropolitan D.C. area. In her current fellowship with the Environmental Defense Fund, she focuses on advancing environmental justice through strategic planning, scientific research, data-driven project management and community engagement. Before we get started, can you tell us a little more about yourself and what made you interested in environmental justice?

Lauren Johnson:  Yeah. So, hi. My name is Lauren Johnson. I'm from Northern Virginia, the D.C. area. And I just graduated with my master of public health in environmental science and policy from George Washington University's public health school. And ever since before public health school, even, I fell in love or became passionate about environmental justice issues when I was teaching high school chemistry in Miami, Florida for Teach for America. And there, I was confronted with various systems of oppression, such as lack of literacy, deteriorated infrastructure, school to prison pipeline, and was very disheartened by seeing how our nation's most vulnerable groups of people are treated, and left with little resources and so much instability, to reach their full potential. And that's what motivated me to focus on these issues at a systemic level. And I saw that public health was an avenue of doing so. And brought my passion of environmental justice into public health school, which led to the founding of the Environmental Justice Action Network at GW.

And that was founded by me and about seven other people that were also passionate about environmental justice, but did not see an avenue of expressing it at the school. And even though there's been a lot of mentioning of it, there really wasn't organized effort for students to get involved and give back to their surrounding community, because that's also a central tenant of environmental justice, of having real impacts in communities, and especially communities that are most vulnerable. So we found ourselves in Southeast D.C. doing park cleanups, urban gardens. We also held a lot of webinars, bringing more disadvantaged speakers, such as Indigenous environmental activists or food justice activists, so that we can start elevating these intersectional issues to the forefront, and also challenge traditional environmentalism that does not have these issues in the forefront, but is so needed to us actually reaching our climate goals. So that perspective informs my career work at the Environmental Defense Fund, which I am going to be a permanent member in a couple weeks.

Theresa Nair:  That's wonderful. Congratulations.

Lauren Johnson:  Thank you.

Theresa Nair:  And so going back a little bit to when you started the Environmental Justice Action Network, what types of environmental justice issues did you see in D.C., and how did you decide what was important to prioritize?

Lauren Johnson:  Yeah, so we were starting EJAN, the shorthand for it, during COVID-19. So we were quite limited in terms of direct engagement with people, just for social distancing guidelines and guidelines that the school laid out for that, as well, that we had to abide by. But we saw there was a pressing need with pollution in Southeast D.C., Ward 7 and 8, and how a lot of people did not have proper trash pickup. So we would drive into these areas and just see trash littered everywhere. And you kind of have to keep it in perspective, well, if you don't have proper trash pickup, where are you going to put the trash? So that's when you can't blame the individual, but the system that allows these conditions to persist, and how they are inequitably perpetuated, because we saw some parks that are managed by the National Park Service that was full of trash. When you go to Rock Creek Park, you don't see that. What's the difference between the two areas?

Theresa Nair:  Right.

Lauren Johnson:  I think you can answer that in terms of income and race. So, we saw those issues most aptly and saw that that was a way to socially distance and engage in these types of work. And we also partnered with an urban garden called the Franciscan Monastery Garden Guild, that produces a lot of food to food insecure individuals by donating a lot to food kitchens and pantries. So, we saw those were the main ways we could engage in EJ within COVID-19. But other than that, our activities were virtual; in terms of meeting, holding webinars, and just trying to educate ourselves as future EJ practitioners.

Theresa Nair:  Okay. And just before we continue, I want to make sure, if any listeners are not familiar with the term environmental justice, could you explain a little bit more about what exactly it is and what it means and how it impacts different communities?

Lauren Johnson:  Yeah. So environmental justice came out of the late 1970s where... I believe it was PCB. There was this new industry being proposed to be put in a predominantly Black community, Warren County, North Carolina. And the residents organized extremely well and were able to stop those efforts by literally putting themselves on the line. You look at pictures of that protest and you saw kids laying on the ground trying to stop trucks going into their neighborhood. That's how pressing the issue is for these communities, because literally their lives are on the line, so they have to put their lives on the line to stop it.

And that's what spurred the movement. And since then, in the '80s, there was a report called Toxic Waste and Race that found that the strongest predictor of whether a pollution source is in a community is race, regardless of income is race. So again, I'm talking about systems. That is evidence of systemic racism and how these trends perpetuate all over the country. And then from then, environmental justice became this movement that kept becoming academic. What is environmental racism? Well, just dependent on the environment, you are subject to lack of clean water, polluted air, mold, pest infestations, things that, even if you control for income, affects our predominantly Black and brown populations.

And then that notion just kept perpetuating until in 2021, Biden released an executive order that was pretty much codifying environmental justice at the forefront of their priorities, because prior to that in the 1990s, there was an executive order assigned by Clinton that also recognized environmental justice and how federal agencies need to confront it. But this executive order put it to the forefront with an initiative called Justice40 that says that any Federal... I think energy and infrastructure investments, 40% has to go to disadvantaged communities. So that's really huge, right?

Theresa Nair:  Yeah.

Lauren Johnson:  Because when you want change, you need to have the capital follow with it. So basically, environmental justice captures a lot of things. It captures how people are adversely affected by the environment, disproportionally predicted by race, most strongly; very place-based in terms of the surrounding industries and factors that lead to pollution; cumulatively burden certain communities. And achieving environmental justice means upholding the principle that everyone has equal protection to environmental, housing, criminal, other such laws that affects every aspect of your life. That's the environmental part, expanding the definition of environment for everything that externally affects you. And EJ is about rectifying that.

Theresa Nair:  When we were talking a few minutes before the interview started, you mentioned how systematic engineering can help to solve some of these problems. Would you mind discussing that a little bit, and how systematic engineering could be applied in these situations?

Lauren Johnson:  Yeah, yeah. So this is a new discipline that just kind of happened. When I started working in the Environmental Defense Fund, I saw that someone was doing a similar study that I was, from a systems engineering perspective. And essentially, there are some tools available from more technical disciplines to assess the inputs and outputs of a system, and everything that takes place in the system that mediates or negotiates the resulting outputs. That can be applied to a social context where, for example, I'm doing a study on net zero and equity and justice. And I'm trying to create recommendations for my organization to uphold their equity and justice goals.

So the equity and justice goals are the output. Now, what can the input be? Well, to achieve that, you need to really have resources, meaning time and people and capital to be put in the types of projects that prioritize people-centered solutions that do not perpetuate existing injustices. But if you don't view that from a systems lens, then you could easily result to just blaming individuals, like, "We have some bad actors here. If we get rid of those, we'll be good."

Well, we know that doesn't work when, let's say, a similar issue is police brutality. You know firing a few bad cops is not going to change the system of people being systemically murdered, predicted by race. So in turn, you need to think about things in that lens, and the mental models, the different structures. Everything interacts with each other to produce a certain output. And to reach the output that you want, you need to change everything within the system and outside the system and how it's structured, to reach it.

Theresa Nair:  That's a great point, because I think a lot of times people do just want to blame one person or a handful of people, but it's so much of a bigger problem than that, that it really needs a much bigger solution. If I could do one more spinoff, just because we were talking about such interesting things before I started recording, could you talk a little bit also about the relationship between the environmental movement and environmental justice, and how those two can sometimes conflict a little bit?

Lauren Johnson:  Oh man, I was just having a conversation about this. So it helps to talk about the history. Environmental movement was spurred by... I believe his name was John Muir, who was pushing the national parks movement. And I may be getting this wrong. I also know Teddy Roosevelt was involved in the national park system, but hey. "We're concerned about the environment. It's pretty. Nature. Wildlife. Let's preserve it." Well, who was on this land before? Indigenous peoples. They lived for thousands of years, existing sustainably on the land. So prior to colonization, people are like, "Oh wow, this nature, it's so well kept." That's because people were keeping it. And we're finding now that there's some practices that are ingrained in Indigenous knowledge that we need to start doing, such as controlling fires in forests or cutting some of them down so it's not densely populated. Indigenous peoples figured that out thousands of years ago, and now we're coming around and realizing we need to do stuff like that, because we have so many wildfires now.

So there's always been this tension of people, typically white liberal, "We need to protective the environment. We need to protect our wildlife." That's true. We also need to protect the people that is in that environment. And that's the intersection that is left out, and many others. Gender, race, income, all those things factor into how much you can take care of the environment and how much the environment impacts you. And coming from an environmental justice side to that, there's a lot of tensions because like... we were talking about systems. EJ really pushes for you to confront those issues. And that makes you very uncomfortable with it.

So a lot of people, when they become uncomfortable, they'll shut down and say, "Well, that's not my focus. That has nothing to do in the environment." The environment is everything around you that affects you. So yeah, you should have a stake in all this. And if you're doing environmental work, you also need to talk about healthcare. You also need to talk about housing, the criminal justice system, because these are things that impacts everyone's environment. And we all need to be an equal stakeholder in solving it, because otherwise we can't have a systemic change that is needed to solve the climate crisis.

Theresa Nair:  Yeah, I think that's an important point. You can't really separate all of it. It's kind of the one-health approach, that everything is connected together and it all relates to each other. When you've been working with communities and residents on some of these environmental justice issues, what types of mental health impacts have you seen on the communities who are experiencing some of these disparities or discrimination?

Lauren Johnson:  Yeah, I would say I was confronted with that quite aptly when I was teaching. I decided to Teach for America in Miami, Florida, a very hot and humid place that... I read one site that says that the number one most economic risk to climate impacts. So for the students I taught, one time, I got a grant to do a hurricane disaster preparedness workshop for those students. And somehow during that workshop, we started talking about air pollution. And I ended up asking those students, "How many of you have asthma?" And over half the class raised their hand. That's not-

Theresa Nair:  That’s significant.

Lauren Johnson:  ...random. That's the system at play where you're in these conditions, like I said, hot and humid, you have a lot of mold, you have a lot of pests, you have on top of that industries near you that are affecting your health through air pollution and water pollution. And then now you're compounding that with climate change and sea level rise, extreme weather. All those things are going to heighten those existing conditions there.

And so that's kind of what climate justice is all about. And the ways that we are addressing our climate-related causes, you need to make sure that the people that are most adversely affected are uplifted in that transition because, well, one, usually they're the ones that are least responsible for causing it; just looking upon income, the more income you have, the more greenhouse gas footprint you have. And oh man, I can't even get into a large conversation about how corporations are part of that too, but-

Theresa Nair:  You can feel free, if you like. Yeah.

Lauren Johnson:  But these factors, they compound. And it causes a lot of anxiety. I even had to make a suicide attempt call to report that.

Theresa Nair:  Wow.

Lauren Johnson:  And I mean, these are environmental things, but this also controls people's behavior. If you're in this bad environment and you're also not concerned about education, even though it's a school, that's another thing, you're going to have all these things mentally impact the students that you have. And oftentimes I just had to put on my therapist hat and just be there talking to students, had some people cry on my shoulder, just know that I care about them. And if anything, sometimes that's one of the few times they even heard that, which is also really sad.

Theresa Nair:  Wow, that is.

Lauren Johnson:  Yeah, mental health is very tied into it. But one thing you need to make sure is that climate anxiety has become something very real. It's a very real thing, but that is because this might be the first time you have this existential threat to your livelihood.

Theresa Nair:  Right.

Lauren Johnson:  To keep that in perspective, that has already been a thing for many groups of people in this country, whether it be slavery, Jim Crow, migrant workers, elderly, just people with disabilities. They've already had these existential threats affecting their livelihood. So, you have to recognize your identity and your privilege when you're addressing these issues because you might be like, "Oh my gosh, you need to do something about it at all costs. Everyone just needs to get in line." Well, that's not good enough for a lot of people that's already suffering from occurring conditions. So, you just have to keep things in perspective, even when it affects you mentally.

Theresa Nair:  That's a good point that a lot of groups have been dealing with these threats for a long time. And for some people, this is the first time they're experiencing something like this, but other groups have been dealing with this on an ongoing basis.

So, when people start to feel overwhelmed and feel like these are just huge issues, where do you even start addressing it? What advice would you give for people who are just feeling overwhelmed when they think about these topics? Because we're talking about these major systematic problems, right, that I think the average person feels like there's not really anything they can do much about. So what advice do you give? Like, you seem to be able to stay inspired and feel like you can make a difference. And I think that's amazing. It's one of the reasons I wanted to interview you. This is incredible, how you stay inspired in the face of all this. But I think a lot of people look at some of these topics and they just feel frustrated. So what advice would you give for people who just look at this and they just think, "I can't change any of this"?

Lauren Johnson:  Well, first, I'll say check your privilege, because there's a lot of people overwhelmed for hundreds of years in this country. But also, I'll take a quote from one of my environmental professors at public health school: "You need to find the bubble of people and work that you can influence, and just focus on that."

So, for me, I know that I grew up in a pretty privileged upbringing. And even though I'm a Black woman, I still had a lot of opportunities and came from a two-parent household that also was very stable. So that means I've been able to gain a really robust education. Part of my skillset is talking to White people, so I'll just call that out too. And then also, just thinking about the big picture. So that's why I found that I can make a lot of impact in a big environmental organization because all those skills I had growing up, but I can also keep things in perspective and saying, "Well, I know that I'm quite privileged, but there's a lot of other people that look like me that aren't. And how about I can do what I can to level the playing field, per se, and actually make an impact in doing that at an organization that has international influence?"

Very challenging and difficult work, but I found myself on a team that is designed to do just that. And they're extremely motivated. And what keeps me going is thinking about the students I had in Miami. They are suffering in many different ways. It seems like I might have some skills that can do something about that. And that might be me getting ahead of myself and saying, "I'm going to fix everything." No, no, no. But what I can do is expand the platform I have and try to get as many people on the same page as possible so that authentic and meaningful change does happen as we're addressing the climate crisis.

Theresa Nair:  That's great. And I think you hit on one of the key points, that you work with other people who are also inspired. Finding maybe a group or an organization to work with where people are working towards a positive difference, right, I think that that can help. And then you have also the inspiration of who you want to help, thinking about your former students.

Let's talk a little bit about your work in Texas. I know last year you worked with the North Central Texas Council of Governments to develop a greenhouse gas emission reduction plan that will mitigate risk for underserved communities. Could you tell us about your work there and how underserved communities in that area are being impacted by climate change?

Lauren Johnson:  Yeah, for sure. For sure. So that project you just mentioned took place last summer. And just as a context, Texas is actually divided into all these regional council of governments, and they assist the local governments in making decisions and providing funding. Well, a collection of those local governments approached the North Central Texas Council of Governments, which is the Dallas-Fort Worth area, saying, "Hey, we know climate change is a thing. Why don't you give us this repository of strategies and tools to address it in our own communities?"

So that was the basis for the project, which is looking at all these different plans that were cultivated in Texas or the rest of the country, even some international organizations, of these strategies. Well, I'll say a lot of them are untested though, because a lot of things that we're proposing to solve climate change, they're still in a development phase. But if a government wants to do something in particular, well, then they can... Well, I hope it's being turned into an online repository. I just did the strategies. They can look at some strategies that can reduce some emissions. But like I was saying, you can't leave out the other side of the picture, that there are some people that are burdened by emissions, but more specifically air pollutants. And those are the things that are most concerned.

So I tried to position the recommendations and the strategies around those different pollutions, and know that you can both reduce emissions from these industries, but also clean them up so that surrounding communities are not disproportionally affected. And that was the level of engagement I could have with vulnerable communities with that project. But I also was able to use some GIS mapping to look at the trends of different pollution sources, so whether that be natural gas or oil, power plants or Superfund sites, and look at some data that approximated the distribution of health impacts, whether that be asthma, cancer, diabetes, and then see how the location of those pollution sources interacted with those health disparities.

It was almost very upsetting how much those health disparities aligned with where those pollution sources were. And I used something called the CDC Social Vulnerability Index  that takes into account a lot of social factors like age and race and language proficiency to measure the vulnerability of certain communities. And I found the most vulnerable were right near these pollution sources. And that could just be a highway right next to you. But some of the most burdened communities... There was one in Fort Worth. It had the lowest life expectancy, I believe in the whole state of Texas. And they were actually right across from a hospital, but because it's this really major roadway was separating them and the hospital, they were completely cut out from any healthcare access. And likely the effects of the roadway near them and a number of other pollution issues, that causes them to have ridiculous rates of different diseases, and then caused such a lower life expectancy.

So, when I talk about environmental justice, this really is a life and death matter, and should thus be treated with that urgency, because as we're trying to change our society to affect climate change, you need to make sure that there's communities already suffering, and this is an opportunity to do something about it.

Theresa Nair:  Yeah, sometimes people don't realize what a difference even just living right next to an interstate makes on your overall health, just breathing in that pollution every day. And of course it's usually wealthier people tend to live further from the interstate and aren't impacted as much, right? Something like that can have such an impact on your health.

We've been talking about these environmental justice issues that are in Texas and D.C., and we talked about Miami a little bit. Many of our listeners are in the Pacific Northwest, and they may not know what environmental issues are in their city or even how to find out about that topic. How could the average person who may not be very familiar with the environmental justice problems in their area find out more about some of the problems in their local communities and the disparities that exist?

Lauren Johnson:  Yeah, yeah. So, it's good that I've learned a lot of cities or local governments are really thinking about these issues, especially with the Biden administration setting high priorities for environmental justice and like Justice40 providing funding to vulnerable communities. So, I would say the first resource you can go to locally is check your local government website. See if they have something listing what they're doing about environmental and social issues that are affecting the area. I think that's the best way to get more local base. But if you could quickly search what local organizations are also confronting those issues, like type in "Environmental justice" and your community. You can see if there's any other organizations there that might have some local knowledge.

But there is also a lot of just national organizations and movements that are trying to put these issues into light. And that could just be some of the renowned environmental justice organizations like we have for environmental justice, the Deep South Center for ... Deep South Center for Justice ... Oh, man. I messed this up.

Theresa Nair:  That's okay.

Lauren Johnson:  But this is an organization led by Dr. Beverly Wright in the Cancer Alley area. It does a lot of work there. And even the major environmental organizations too, like I work at Environmental Defense Fund, we're also thinking about these things. There should be a decent amount of resources there to think about it. And also nationally, the EPA, Environmental Protection Agency, DOE, the Department of Energy, they're also putting out resources to think about these issues, but also mapping and screening tools to actually you can go in, type in your address, and you can see the different pollution sources or demographic issues that are coming into play your area.

So for example, the EPA, they have something called EJScreen, that you can do this. The CDC has Environmental Public Health Tracking Program, that you can do this. And if you live in California, the California EPA is really on top of these issues. And you can look to see how they're affecting you through a tool called CalEnviroScreen. So, there's a lot of resources and things sprinkled throughout here, but what we need is a more robust movement of joining forces and understanding we're on the same side of trying to figure things out, and working together to do so.

Theresa Nair:  Yeah, I think that's the important point, because a lot of times people might want to help if they know about it, but they may not even know that some of these problems exist in their neighborhoods, or where the tools are to find out about it. And I will link to some of the tools that you mentioned below this interview as well, so that people at least listening to this interview can find them.

If a person is experiencing anxiety due to living in an urban area, and maybe they're worried about things like the pollution from the interstate, if they live nearby, or heat islands, or they've noticed that they have higher rates of asthma in their neighborhood, some of these topics that we've discussed, what type of advice would you give to them?

Lauren Johnson:  Yeah. Yeah. I would say just really try to figure out what those different things are; like you said, the urban heat island, it could be a lot of allergens that you're affected by, the interstates. Just really understand how all these issues are. And then find people trying to do something about it, because there's a lot of really great local nonprofits that provide free assistance to ... let's say you're in an urban heat island and don't have good AC. Well, there's a lot of nonprofits that have programs funded for you to get that for free. And then that can intersect with healthcare as well. There's a lot of great organizations that may be local to you that can do that as well.

But really the issue isn't individually how we respond to this, the issue is our representatives, the people we elect, pushing policies that can actually do something about this. For example, why isn't it mandated in affordable housing to have AC? Isn't that a necessity nowadays, especially with heat waves and climate change?

Theresa Nair:  Right.

Lauren Johnson:  We need to petition our representatives and senators to do something about it. And if you not just send an email, but if you are able to get on the call online with someone, then I've been told by number of local legislators they will listen to that and try to do something about it, because maybe they have a ballot initiative coming up and are debating it, if you could be someone in the public forum or speaking setting to talk to these people directly. And I would advise, start at the local level too, because those are the people that really are making decisions that impact you locally. You can bring your perspectives up, and they may pivot entirely. You never know. So there are ways to stay empowered throughout this. And really just realize knowledge is power, and you do have something to do about it.

Theresa Nair:  Have you seen that happen? Have you seen someone completely drastically change their mind after being contacted on one of these issues?

Lauren Johnson:  Not directly, but I have heard offline, these are ways to really make an impression, because for example, part of the reason why I fell into EJ is I started working with a nonprofit called Catalyst Miami in Miami, Florida. And they did a lot of free training and resources to empower local residents to talk to their representatives or a city board meeting, and how to do that. A lot of it is just telling your personal stories and how things have personally affected you, and then saying a solution too. They'll be empathetic, but if you don't put anything on the table what to do about it, they probably won't get there either. So you could go there. And like I said, there was a local nonprofit that was training us to do that. And I saw people throughout that program really find their voice, encouraged to talk about these issues, how they affect them, and what is something we can do about it.

Theresa Nair:  That's an important point, because it's true, a lot of times people who make these decisions aren't in the community, and they might make decisions that wouldn't even work for the community. But if community members who are affected themselves are the ones suggesting solutions, then they know that that's the solution that would work best, from their perspective. And then they can at least consider it, whereas they may not even think about it if somebody doesn't contact them.

Lauren Johnson:  Right, exactly. It's very powerful, the storytelling really is. So, I hope people don't lose sight of that because there's been such a push to quantifying things, big data, technical. Well, I'm finding with EJ, the social dimensions of all that is being left out. So that's why I'm training myself to be a social science practitioner, where my current study, I'm talking to a lot of people through ... well, I'm actually doing my own interviews. I'm having a focus group tonight to start talking candidly about these types of issues, and what are some ways we can do them ... well, for me, as a big environmental organization, do something about it, and not leave people behind?

So, there are things. Again, we were talking about, what are things you can influence? Well, that's my sphere. I think about people in communities and try to bring them in the conversation. Well, you can figure that out for you too, whether that be from a more technical side or social side. We need everyone, all hands on deck to meaningfully and authentically address these issues.

Theresa Nair:  Yeah, you're right. That's true. Well, as a professional who's building your career around advocacy and addressing environmental justice issues, do you have any parting words or final things you'd like to share with our listeners?

Lauren Johnson:  Well, I'll say the fight is long, the fight is hard, but it's still worth doing it. And it sounds cliche, my favorite MLK quote, but this one's good, and he's also said a lot of things that are good. They're just kind of whitewashed over time. But this one is, "The moral arc of the universe is long, but it bends towards justice." So if you are fighting for something you truly believe in and truly believe in helping people and pushing us forward as a society that's more fair and equitable and just, we're going to be going to that position naturally as people.

Whether we'll get there fast enough with climate change happening is another question, but things are already moving that direction. So, if you feel like you're the only person caring about these things, if anything, people will come around to it. But the urgency is that we kind of are on a ticking clock now with how worse issues can be if we don't reach our greenhouse gas emission targets. So be urgent, know that these issues matter in our life and death, but try to remember that this fight is worth having at the end of the day, because you can truly improve lives to the better doing so.

Theresa Nair:  Right. That's a great note to end on, that it's worth fighting and that it's worth going through and worth continuing to work towards these solutions. Well, thank you so much for speaking with us today and participating in our interview series. I really appreciate you making time in your busy schedule to meet with us.

Lauren Johnson:  For sure. Thank you for having me. If anyone wants to follow up, I'm happy to put my email address there. I can send that to you.

Theresa Nair:  Okay, great. We'll put your contact information there. And so yeah, if anyone feels like they would like to contact you, we'll provide the information on how they can do so. Okay. 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.

Psychiatrist Christine Adams on Tantrums & Meltdowns

An Interview with Psychiatrist Christine Adams

Christine Adams, M.D. is a child and adolescent psychiatrist who is double board-certified. She is an award-winning, best-selling author regarding how emotional conditioning effects relationships.

Nikayla Jeffrey:  Thank you for joining us today. I'm Nikayla Jeffrey, research intern at Seattle Anxiety Specialists. I'd like to welcome with us child and adult psychiatrist, Christine B. L. Adams, MD. She is co-author of the bestselling, award-winning, Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships. A double board certified psychiatrist, some of her work deals with topics such as tantrums and meltdowns in adults, and that's what we'll be discussing today. Before we get started, Dr. Adams, can you please let us know a little bit about yourself and some about the work and writing you've done?

Christine Adams:  Sure. Thank you for inviting me. I've been a child and adolescent psychiatrist and also worked with adults for 42 years, and I've worked primarily in private practice doing psychotherapy rather than medications with people to help them understand the roots of their problems. I also was a professor at a medical school and worked in community mental health centers. I also, for 25 years, was a forensic child psychiatrist who gave expert testimony in child abuse cases, mainly sexual abuse, and also divorce and custody and parental alienation cases. I worked for a while with the Social Security Administration doing disability appeals on children, and I worked with the Department of Defense for a while. So that's kind of my work background.

My writing background is pretty varied. I have a blog at PsychologyToday.com where we look at all sorts of issues having to do with relationships, how people manage emotions, custody disputes, whether sole custody or shared custody is best for children and under what circumstances, and also parental alienation. My book, Living on Automatic, is a study done by two psychiatrists, me and my mentor, Homer Martin, and it covers 40 years of work for him and 40 years of work for me, and we looked at the development of people's personalities and how parents shape them early in their lives. By age three, we found the personality is rather set. So that has been the bulk of my writing interest over the last 10 years.

Nikayla Jeffrey:  Wonderful. What do you think made you first become interested in this field? What sparked your interest in these topics?

Christine Adams:  Well, when I was in training, I began to observe things, and I didn't understand, and so I began asking my supervisors. And Dr. Martin was one of my mentors. And the things that I began to observe were things like why are siblings so different when they're raised in the same family? And why are people that I would see in psychotherapy from different families so similar to one another? And that perplexed me, and I started asking questions, and he encouraged me to keep observing and to research more on this. But that's kind of what got me started, questions that I couldn't really answer, and that most of my supervisors couldn't answer.

Now, what got me into psychiatry was that I was kind of overloaded with psychiatry as a child. My father was a child psychiatrist. My mother's grandfather was a psychiatrist at the turn of the century, the early 20th century, and my mother worked for a psychoanalyst in New York City. So I had all these books available. I heard all this talk all the time about psychiatry. I thought people were fascinating, because I didn't understand them as a child, and that's what got me into the field. And then as I got older, I realized children need a voice. They often get lost in their families and they need a voice. They need somebody to help them articulate what they're thinking and feeling, and to learn how to tell their families, because it will cut down on their emotional suffering.

Nikayla Jeffrey:  In one of your pieces, you write about tantrums and meltdowns specifically in adults, rather than in children. Can you touch on what the differences are between these two things and perhaps how one can maybe turn into the other?

Christine Adams:  Sure. I think this is from a blog that I have on Psychology Today that you read. A tantrum is an emotional blowup when somebody is thwarted from getting something that they want. When they don't get it, they pitch a fit. That's what a tantrum is. A meltdown is an emotional blowup or an emotional shutdown when a person is unable to cope with a situation, so it's a coping problem. They're totally overwhelmed. Now, it may be something extraordinary that is overwhelming, like a divorce or a custody battle or the death of somebody that you're close to. Or it may be, depending on your personality, something rather trivial that you can't cope with. And the example I often use is a person who can't get to work on time gets reprimanded by their boss for being late, and they have a meltdown because they just can't cope with the idea that they need to get to work on time every day. So we can discuss later, some personalities suffer tantrums and some personalities are more prone to meltdowns.

Nikayla Jeffrey:  So it has to do a lot with your specific personality type, whether or not you'll be prone to tantrums or meltdowns as an adult?

Christine Adams:  Yes. And the circumstances will be very different for the two personalities is what we discovered.

Nikayla Jeffrey:  So with talking about types of personalities, you mention in that same piece something about divergent personalities. I was wondering if you could define that?

Christine Adams:  Well, this gets into our research that's in our book, Living on Automatic. What we discovered is that there's two main roles or personalities that people form. These are formed by the way parents shape you emotionally, unbeknownst to you and unbeknownst to parents, early in your life, so that by age three, your personality is pretty much set, which is kind of scary, because that happens before you're largely verbal. But you learn all these emotional cues from your family about how you're to see yourself and how you're to see other people.

And it turns out that they're pretty much opposites. We call them one type, the omnipotent personality, and the other type is the impotent personality. And the omnipotent personality is very, very strong. They're very high in self-control. They give unlimited care to other people. They give very poor care to themselves. As a child, parents expect a great deal of them. So when they grow up later on, they expect a great deal out of themselves. And you can see how as I describe these two types of personalities that emotional problems set in with each type of a different variety and in a different way. But the way parents condition people makes them prone to emotional illnesses or suffering and relationship conflict down the road.

Now, the impotent personality is just that, impotent. Feels very helpless about themselves. Feels they can't conquer things. They expect others to care for them. They expect others to meet their needs. They expect others to take responsibility for them and troubleshoot for them, and they have very poor self-control. Parents overindulge them and expect very little from them in the way of accomplishments and in the way of giving care to other people that they care about. So you can see how these are divergent. These are very opposite and different. And, of course, we go into tremendous detail from infancy through people in their 90s in the book, Living on Automatic. So you can read more about it in the book if you're curious.

Nikayla Jeffrey:  And this stronger omnipotent personality, they expect more from themselves, that you mentioned is connected to experiencing meltdowns, correct?

Christine Adams:  Yes. What happens with an omnipotent, is omnipotents rarely have tantrums, because they're not good at promoting things they want. So they will easily acquiesce to other people, so they will rarely have tantrums where they pitch a fit for something they desire. But if they're totally overwhelmed by somebody asking or wanting something from them that they want to deliver but they can't because it's impossible, then they will have a meltdown. Tears, lots of guilt over failing the other person's request. They can have rage at themselves. Their suicide risk can go up at these points. So that's what their meltdowns look like.

Now, an impotent can have a meltdown, the example I gave before, being reprimanded for being late at work, they can say, "This is awful. This is unfair." And be full of tears and rage and anger. But the anger is not at themselves. The anger is at the person who's reprimanding them. So they project the anger that should be their responsibility onto the person who's complaining about them. So the meltdowns are for different reasons in the two personalities, and only the impotents have tantrums. Omnipotents don't have tantrums when they need to have a tantrum or should have a tantrum.

Nikayla Jeffrey:  In discussing tantrums, you said that it's important to decide whether a tantrum is a reasonable response for that situation for these people. They've said whether a tantrum is called for, almost. And I would ask, is a tantrum ever a reasonable response?

Christine Adams:  Yes. What I often advise omnipotent patients is you need to have a... I call it designated tantrum with the person who's asking too much of you. You need to pitch a fit or do something to get their attention so that they know they're being unreasonable with you. Because an omnipotent personality tends to acquiesce and say, "Okay, you're being unreasonable, but I'll try and do what you want." So it's reasonable for an omnipotent to occasionally throw tantrums with people when they're overstepping their boundaries with them. But for impotent personalities, they so often easily resort to tantrums that there's really no need to promote that behavior. There's the opposite need to promote not having a tantrum and to letting them assume responsibility for what they have done.

Nikayla Jeffrey:  And when it comes to these emotional blowups that happen, you also mentioned that a reality check is needed. Can you give an example of what a reality check might be? And then talk about whether one personality type may be more resistant to a reality check than another.

Christine Adams:  Yeah. When I talk about a reality check, it's evaluating how reasonable your thinking and your behavior is for the situation you find yourself in. So it's sort of saying to yourself, well, let me take a time out with myself and let me look at the situation not with my emotions, but with my brain, and think about what am I doing here, what am I feeling, what am I saying, how am I behaving, and is this reasonable for the situation?

So an omnipotent might say, "My boss has asked me to work all weekend on a project. I was going to go on a short trip and now I have to cancel the trip and turn in this project first thing Monday morning. And I'm going to cancel my plans and work on this all weekend." So they might say to themselves, "Is this reasonable behavior on my part in thinking that I believe I can do this and should do this?" Now, an impotent will be late to school repeatedly and need to say to themselves, the reality check, "Am I being reasonable here being late to school every day? Everybody else gets there on time. I'm missing classwork. I'm disturbing the classroom when I come in."

So it's a way of evaluating for the situation whether you're being reasonable or not. And it's difficult for both personality types to do reality checks. And we talk in the book, Living on Automatic, how you do this with yourself, regardless of your personality, because both personality roles or types need to do this. So we talk about how you do this, because each role must work diligently through their lifetime to undo some of this emotional conditioning and bring themselves sort of from afar back to the middle where they can be more reasonable with themselves and other people.

Nikayla Jeffrey:  So both personality types need reality checks, but it looks different for each type of personality?

Christine Adams:  Yes, absolutely. You got it.

Nikayla Jeffrey:  Okay. Perfect. Those are all my specific questions, but I know you wanted to talk a little bit about the research that you're doing, correct? The new research about your book.

Christine Adams:  Well, I also wanted to say, if you encounter a situation with yourself or with a family member or coworker who's having emotional blowups, you might be able to help yourself or them by looking at two different issues. The first is what kind of person am I dealing with? Am I dealing with an omnipotent who rarely blows up at anybody or am I dealing with an impotent person who blows up a lot and has tantrums a lot? And then you can help them do a reality check. Ask yourself or them, okay, what circumstances provoke the episode you're having? What does the person talk about or focus on? Are they upset with themselves or are they upset with another person? Who do they lash out at, themself or another person? If it's a tantrum, is anything really reasonable wanted? Or is it in the realm of it's just something you want and it's not very reasonable? If it's a meltdown, is it an overwhelming event or is it a trifle situation? And I would ask them or ask yourself what can you say or do differently next time to see if there's any learning involved in how to better manage the situation? And this sometimes makes people pause and think about what they're doing, and it's a way to help others and it's a way to help yourself.

I am doing a lot of book marketing for Living on Automatic. I have podcasts, media interviews, articles, Psychology Today blogs, all on my website, DoctorChristineAdams.com. I'm going to be teaching a webinar that will be posted on my website about emotional conditioning and these two personality types. And I'm also on LinkedIn, Facebook, and Twitter. And if you want to write me, ask questions, you can do that through the website. I have a newsletter that you can join. And I'll just hold up the book one more time, so you can see it. It's got a picture of two people with cogs in their head, one's a man and one's a woman, and the cogs are turning around.

Nikayla Jeffrey:  Perfect, thank you.

Christine Adams:  Yeah. Thank you very much. Do you have any other questions?

Nikayla Jeffrey:  I don't think so unless you have any last parting words of advice on how to work with the different personalities in your life. Or any parting words. But besides that, no more questions.

Christine Adams:  Well, I just think it's most of the time we go through life and we think other people are like us, and they're not. People are very different. But we found that they do kind of fit into two opposite, divergent roles or personalities. So if you can learn to identify the different types of people then you know better how to deal with them.

Nikayla Jeffrey:  Thank you very much.

Christine Adams:  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.

Therapist Sari Cooper on Couple's Sex Therapy

An Interview with Therapist Sari Cooper

Licensed psychotherapist, Sari Cooper, LCSW, CST is both supervisor and director of the Center for Love and Sex in New York City. An AASECT certified sex therapist, Sari has been in practice for over 25 years and is an expert on relationships, sexuality, and sex education and has been featured regularly across various national media channels as well as in print.

Jennifer Ghahari: Hey, thanks for joining us today. I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I'd like to welcome with us licensed psychotherapist, Sari Cooper. She is an AASECT certified sex therapist and both supervisor and director of the Center for Love and Sex in New York City. Sari has been in practice for over 25 years and is a highly sought after expert on relationships, sexuality, and sex education in the media. She's also the founder of Sex Esteem, LLC, a company providing coaching, talks to adults, parents, and organizations to empower folks to get more embodied and informed.

Before we get started, can you please let our listeners know a little bit more about yourself and what made you interested in specializing in relationship issues?

Sari Cooper: Well, I came out from the performing arts world. I was a modern dancer. That's what brought me to New York City. I danced professionally after graduating from the Julliard school. So I was very much an embodied person in my first career. And then I started reading family therapy books and watching some family systems videos by some of pioneers. And I just thought as a second career, this was something I could bring a lot of my own talents to, both from an embodied sense and also reading nonverbal communication. So I fell in love with couples and family therapy, and in order to attend the Ackerman Institute, which is one of the oldest family therapy institutes in the country, I had to go and get a master's degree in social work.

And then that was sort of the beginning of this long sort of journey. And then once I started doing a lot of couples therapy, I realized that I didn't have what I really needed in terms of education around sexuality and sex therapy, because there are some biological, medical, predetermined kind of conditions that affect sexuality, not just the psychological ones and social ones.

Jennifer Ghahari: Great. You've written an article this year, titled “Seven Critical Talks to Have Before Your Wedding Day”. And the pandemic has clearly put a hold on many people's plans over the past few years. In your article, you mentioned that 2022 is supposed to have a 15% increase in weddings this year compared to 2021. Since we're in the height of wedding season right now, can you explain the “Seven Critical Talks” that couples should have?

Sari Cooper: I will. I actually printed that so had it in front of me. After years of working with couples, I see all those sort of holes in their agreements or nonverbal agreements or implicit versus explicit agreements. And I really felt like, to help people before they get going on their marital and marriage journeys, they should have these really important talks. So the first one is about creating boundaries with your family of origin. And a lot of people find this tension and anxiety early on when they're planning their weddings, because that's when these two families actually get to meet each other in person, but also the loyalties and rituals and sort of things that you would take for granted actually become challenges for this new couple. And I always say to couples, you are creating a new family. Even if you don't have children yet or ever, you are a family and you have to each be an Emissary to your families of origin in order to figure out for yourselves what your new family entity is going to do in terms of your values, in terms of your priorities.

And so a lot of times, couples/partners feel tons of pressure from their families of origin. It shows up like full force around wedding plans. So this is a great time to start discussing with each other, how do we feel about this? And then going back and saying to our families of origin, "Here's what we decided to do. It may be different from what your expectations are, but this is kind of, we've agreed that this is the way we would like to do it.”

The other one that is I've always found somewhat surprising is the discussion around having children. A lot of partners go forward into marriage with an unclear vision in terms of the priority and value of whether or not they're going to have children. And that's really critical because if you have one partner who definitely has always wanted to have children, there's been research done about people who are early-deciders about having children and late-deciders and the other partners saying, "Well, I'm not sure I have to decide later." I mean, this is a really important sort of distinguishing line and boundary. And so I always encourage people to talk about what that would look like, whether it's biological children, whether it's adopting… all of these issues, I think, are really important and yes, people do change their minds later. Maybe you have two partners who agree they don't want to bring children in the world for a variety of reasons. A lot of young people are saying climate change is a reason and they may change their mind later on. But I think that it's important to talk about it right now, before you go down the aisle.

One of the other things is it takes a village. And I've seen so many couples through the pandemic who have been so isolated from family and are going it alone and raising children and working. And I really think that whether or not you have ties with your sort of blood family, you need to create a chosen family around you to help in terms of supporting your marriage, in terms of supporting your family once you have, if you have children. I just think it's hard to expect everything from one person.

Jennifer Ghahari:  Right. And so are you referring to maybe bringing in friends or maybe spiritual leaders? Is that what you're referring to?

Sari Cooper:  Yeah, I think that we all have different parts of us and our partners can be there and compliment a lot of different angles of who we are, but not all. And so whether it's a spiritual or religious leader, whether it's just friends, whether it's people you decide to do monthly brunches with that really speak to some parts of you that maybe your partner doesn't get, I think it's important. Otherwise, one can feel like the marriage itself gets too weighed down with the expectations.

Jennifer Ghahari:  Okay, great.

Sari Cooper:  Yeah. Another one is infidelity and fidelity, which so I see a lot of couples after some sort of infidelity has been discovered. And I think that a lot of times, there's while someone might say, "Well, that's clearly infidelity if someone had penetrative sex." There are so many other sexual behaviors that one partner may consider being cheating or unfaithful that the other partner doesn't. They never discuss it.

Jennifer Ghahari:  Can you give some examples what those may be?

Sari Cooper:  Yeah. So people have come in saying, "Well, my partner said that he used pornography before we got married, but that he would stop using once we got married and that partner didn't stop using pornography or watching it" or sexually explicit media, as we call it. Or someone might go to a strip club. And they don't consider that being unfaithful because they're not actually physically encountering anybody. They're not having kisses or even touching anybody, but their partner may consider that cheating or against their values. So those are things, there are so many more nuanced things, whether it's flirting, whether it's an emotional relationship that you have with someone, either in person or online, that you're kind of sharing very intimate details, not only about yourself, but maybe about your marriage and your partner. And it's sort of... The partner feels like it's taking away from the intimacy you're sharing with them. And so that's where this terminology of emotional cheating came into being.

Jennifer Ghahari:  And I would imagine too, with the prevalence of social media and just the ways that you can interact with people, maybe this type of perceived infidelity is rising too. Correct?

Sari Cooper:  Right. So there are so many ways you can have a whole sexting relationship with someone, never even meet them in person. And yet, it's quite sexual and erotic in nature, and you're doing it with someone outside your supposedly monogamous agreement with your partner. So, yeah. Definitely.

Jennifer Ghahari:  Great. Okay.

Sari Cooper:  Another one was telling your partner, you appreciate them. I think one of the most longstanding complaints that people have with one another after sort of the first two years of being in love and having that kind of what we call limerence period, is that we take people for granted and we don't say thank you for even doing small things or paying them compliments. Just did a lot of research around couples and over many, many decades now came up with this ratio of a five to one ratio, meaning five compliments or five positive statements to each sort of request for change.

Jennifer Ghahari:  Oh. Seems pretty fair.

Sari Cooper:  Most people don't have a hard time doing that five.

Jennifer Ghahari:  Right. Yeah.

Sari Cooper:  And then the other one is to discuss religious and spiritual beliefs. I think a lot of studies have shown that those people who say they practice some sort of religion has been decreasing and people attending places of worship, research and census and surveys have shown us that people are going less and less often to institutions, but they may define themselves as spiritual.

Jennifer Ghahari:  Right.

Sari Cooper:  And so I think going forward, it's important to sort of distinguish for yourself, what you're feeling in terms of religion or spirituality. And it may require some sort of compromise on how you're going to honor that spirituality, honor your community. If you come from a more religiously attuned community or family, ahead of time and not sort of say, oh, we'll figure it out as we go along. Because a lot of people can get into a lot of battles around that.

Jennifer Ghahari:  Oh wow. And I think we covered all seven, correct?

Sari Cooper:  I think I did.

Jennifer Ghahari:  Okay, awesome. In terms of when people should talk about these things, I would imagine it shouldn't be the week before they actually get married. Right? Is there an approximate time that is really ideal to kind of hash all of these things out?

Sari Cooper:  I think depending on how serious it is, I would say for some things like children, where you're going to live, religious practice, things like that… I would say, 10 months ahead.

Jennifer Ghahari:  Wow. Okay.

Sari Cooper:  Or a year. I mean, I've had people come to me three to four months before their wedding vows, with really serious discordant issues that they're trying to solve right before they get married, including trauma, where one partner has had background of trauma and may not have even revealed it to their partner.

Jennifer Ghahari:  Oh, wow. Okay. Yeah. So it definitely sounds like maybe even aiming for a year or longer, to have all these important discussions because when you're getting married, it's stressful enough. You don't need to have all of these other issues on top of it. And just start out the gate running strong.

Sari Cooper:  Yeah, exactly. Well, you think about it. A lot of people get engaged and leave a year at least to plan their nuptials. Well, why not give a year to really iron out some of these differences. So you know you're going in fully cognizant and fully confident that you're on the same page. Even if you've compromised, it's still you're on the same page.

Jennifer Ghahari:  That's great. Thank you. And it seems one positive thing that's maybe come from the pandemic is that are people are reevaluating their lives and what matters to them. In your article, you mentioned that couples feel less pressure to participate in religious or conventional wedding traditions, that really aren't meaningful to them. Can you discuss that a bit? What types of shifts are you seeing?

Sari Cooper:  I've seen people who elope, who say, "I feel strongly about this person. I don't need a huge party. I don't have to wait for COVID to sort of recede. I just want to move on with my life and take the next step." So that's one thing I've seen. Another I've seen is not having a religious leader or clergy person conduct the ceremony itself, who gets sort of certified by online as a life minister. I don't know what they're called. Because they find it actually more personal, someone who's known them, someone who maybe had even introduced them. Yeah. Other sort of rituals where you think that a parent will escort their kid down the aisle, their adult child, I should say. They walk by themselves because they feel they've come a long way. They're an independent adult. They're not being “given away”. I mean, there's that sort of feminist slant to it. They're not being “given”, they're walking into a relationship they've chosen. It's sort of like of their own agency. So things like that are... You don't see as often in the movies. These are new ways of coupling.

Jennifer Ghahari:  That's great. It's really nice to hear that people are making it what they want to be and truly encompassing themselves in the relationship as part of this ceremony. It's great.

Sari Cooper:  Yeah.

Jennifer Ghahari:  Getting back to, unfortunately, infidelity, we had touched upon before, you've written an article about that as well this year. And you mentioned that 25% of committed monogamous couples experience some degree of infidelity at some point in their relationship. What are the typical causes of infidelity? And is there any way that people can lessen the likelihood of it happening to them in their relationship?

Sari Cooper:  I think that going back to what I was saying, I think talking about potential things that are going to tempt you, what embodied experiences might make you feel abandoned, anxious, resentful, that might lead you or tempt you and so you should discuss on just how you are going to protect your monogamous agreement. And one of the other things I didn't mention before, which is really important in terms of critical talks is erotic interests.

Jennifer Ghahari:  Oh, okay.

Sari Cooper:  So frequently, partners go into marriage without necessarily sharing all of the things that they're sexually into. And they end up in our offices because they feel very ashamed about them. They feel scared of losing their partner if they came forward and said, "I'm really into X behavior. I'm really a kinky person and I know you're much more vanilla. How are we going to negotiate that?" And it's due to shame, right? Most people, when we do our sexual histories with them, their parents didn't talk to them about sex. They didn't talk about, give them really good books or resources to learn the real facts. And so many young people now are being brought up, seeing these sexually explicit entertainment videos and thinking that's real sex. That's entertainment for some people, not for everybody, but it's not what really goes on between two partners who are more open and loving and interested in pleasuring one another.

So I think that forging those, consistently, not just at the beginning, but having ongoing conversations where you check in with each other quarterly and say, "How are we doing? Have you been happy with the kind of sexual engagement we've had? Is there something that you've been interested in exploring that we haven't? What would that entail?" But very neutrally because what happens sometimes is sometimes one partner will float some sort of idea. Maybe they saw it in a movie and then they see their partner's reaction and tone of disgust, shuts down that conversation right away. And so one of the things, we tell our partners is if we're going to open up this conversation, here are the rules of the road. You can't be critical of what you're hearing. You can't make someone feel more ashamed than they might already feel about something that a lot of... It's a huge diversity of interest out there in terms of erotic and sexual interest.

Jennifer Ghahari:  It sounds like communication is really key across all of these different venues that you're talking about, in order to have a good relationship.

Sari Cooper:  Yeah. And I would add noncritical communication.

Jennifer Ghahari:  Good point. Yeah. Great. And if people can just communicate upfront and be noncritical ahead of time, then it would save them the headache and the heartache and having to go to therapy to discuss things.

Sari Cooper:  Exactly. Yeah. And I also think the other thing that goes on sometimes in infidelity, I've seen is there's this real life shifting event. So sometimes people have said to me, "My best friend died from cancer." And in that moment I thought, I have to go get what I need, because I've been suffering and throwing myself into withholding and hiding for so long. I'm going to go out now and get what I want because I've been so repressed and so resentful.

Jennifer Ghahari:  Oh, okay.

Sari Cooper:  And life is short. Look it, my friend just died. Or a parent passing on or parents splitting up. They're life-changing events that... And COVID-19, by the way, where people were actually faced with potential sickness and sometimes death. So they started questioning, it's an existential crisis. It wasn't just a pandemic, about “What do I really want in life and what have I sort of been missing out on and not giving myself permission to ask for?”

Jennifer Ghahari:  Great. So if infidelity does occur and as you said, there could be so many different perceptions of what's infidelity. When should a person generally try to make it work? When should they stay or when should they...

Sari Cooper:  It's an excellent question. And actually one of my associate therapists runs a women's coaching group for women whose partners had broken their sexual boundaries and it's called “Reclaiming Oneself After Partner Infidelity”. And we did a whole interview with each other, a discussion about a lot of myths. And one of these myths is, well, if your partner has cheated, it's over. And if you stay with that person, you're a loser. I'm being kind of hyperbolic here, but there is this sort of cultural belief that if you stay with someone who has crossed those boundaries, then you yourself should be embarrassed for yourself. So a lot of people feel really like they can't... And they can't tell people because they're afraid that if they decide to stay, they'll be judged forever more. They might lose their friendships. So I think first of all, start with: a lot of couples stay together after a sexual boundary has been breached. Why? Because there's enough there that they want to preserve. Maybe there are children involved and also, they want to feel intimate again.

Jennifer Ghahari:  Wow. Okay.

Sari Cooper:  For many of them, they breached the boundary because they weren't getting something from someone else.

Jennifer Ghahari:  Oh wow. Okay.

Sari Cooper:  Or they were working out something internally that may have been more related to their history than with their partner that they had never actually addressed before, including trauma and sexual trauma. So I think that we always ask people, "Are you ready to create a new marriage with new discussion points you didn't have before? How are you going to repair the trust?" And I would say that if you have one partner who is in kind of denial or isn't feeling much remorse about their behavior, I think that might be a telltale flag that the work that is needed, because there's a lot of work involved, to repair the marriage. It might not happen because you need two very committed partners. You can be committed and ambivalent, but committed to do the work and not continually making excuses for themselves. And the other part of it that we see is sometimes, the infidelity has to do with one person's hypersexual or out of control sexual behavior.

So their repeated casual sexual hookups that have been going on for years and the person feels out of control from their experience. And they may even have other addictive patterns that may be a lot of times, sometimes maybe people stop drinking alcohol and binging and then they increase these sexual behaviors. So that's actually the other group that I run virtually is a coaching group for men who have out of control sexual behavior who want to create new sexual health plans for themselves and need that support to sort of fortify their sexual health plans, based on their values and their priorities. Yeah. So I think that there are so many different avenues that people go down. I always say, having some group to support you as you're going through this very tumultuous and heart-wrenching experience is just helpful scaffolding to figure out kind of where you're going down the road and what you eventually want for yourself.

Jennifer Ghahari:  Yeah. Wow. So regarding people who have out of control sexual behavior, how does that impact their partners, if they're in a relationship? Like you said, they may choose to cheat or to seek things elsewhere. Are there any other impacts that could happen on the relationship?

Sari Cooper:  Right. Well, first of all, the broken trust. It's sort of the ground we walk on and what most people come in feeling is like a bomb went off and the ground upon which they're standing is totally shocked. So, that's a huge impact, but sexual health includes STIs. And many times I find people aren't asking the question of, "Well, did you use a condom?"

Jennifer Ghahari:  Oh wow.

Sari Cooper:  What precautions did you take? What risks did you take? Did you get yourself tested in between these behaviors? And so part of being a certified sex therapist is also kind of being a sex educator with a hat on at times to explore and inform people of the precautions they need to take for themselves. So, go get tested. And sometimes partners feel like so devastated by an STI they got because of their partner's infidelity that they just withdraw sexually for a very long time because their whole, not only emotionally and psychologically they've been impacted and the trauma of that, but their body has also been impact impacted. There have been also situations in which the partner who has the compulsive behavior has impregnated somebody else.

Jennifer Ghahari:  Yeah. So it's a full gamut of things that could happen.

Sari Cooper:  Yeah.

Jennifer Ghahari:  Wow. Your practice, you mentioned that you see both heterosexual and LGBTQ relationships. Are there any differences between these two types of relationships? Love is love. Do people in both cohorts endure the same types of struggles or are there actually differences that you find?

Sari Cooper:  I would say they all have the same sort of struggles, but I would add this, that many gay male couples have already negotiated and had the conversations around what infidelity is. And some of them are more open in terms of bringing a third party in. Now, not to say that with consensually non-monogamous or ethically non-monogamous couples, there isn't room for cheating or infidelity. There is. But I find that because their culture kind of supports that possibility and has for longer, than in the heterosexual community, I think those conversations and those rules around that behavior, for instance, we will only play together with a third partner. We're not going to do that individually or you do your thing, I'll do mine, but we won't have anyone in our home that we share with one another. So all those things I think are a little bit different, I would say.

Jennifer Ghahari:  Again, it sounds like communication is key with everything.

Sari Cooper:  Yeah, definitely.

Jennifer Ghahari:  So here's the million dollar question. Based on your research and experience working with couples, what's the best resource pieces of advice that you can give people to help them have the most fulfilling, lasting, happy relationship with their partner?

Sari Cooper:  I would say two main things.

Jennifer Ghahari:  Great.

Sari Cooper:  The first is know yourself. Really give your sign yourself the time to understand all the parts of you, even the dark parts of you that you may not like and do it in an embodied way because a lot of times, some of the parts of ourselves that we're not as in touch with are in our bodies.

So get to know yourself and then communicate with partner because then they're knowing all sides of you, the light sides and the ones that you might find a little bit darker and they know and you know what each of you is sort of set up for going forward. You're always going to have some arguments. I always say that couples have themes of their arguments that keep kind of having variations. It's sort of like choreography, there's the theme and the variation and it keeps coming back. Know it going forward. Then you can start to work on strategies on when we get into that rough place, how are we going to get out?

Jennifer Ghahari:  Was there another one or that was the combination, correct?

Sari Cooper:  It's the combination. It's knowing yourself and then knowing how to communicate and that's kind of, not kind of, that's why I created this term “sex esteem” because if you know yourself and you feel like you can be compassionate and give yourself grace around your interests and then be able to talk to your partner about it, you're in a much better situation going forward.

Jennifer Ghahari:  That's fantastic.

Sari Cooper:  Yeah.

Jennifer Ghahari:  Thank you. As someone specializing in relationship issues, do you have any other advice or parting words that you'd like to share with our listeners?

Sari Cooper:  I would just say, do your research. Really give yourself, I mean I created Sex Esteem, my sex esteem program as an adult sex ed and relationship ed for adults. Because I think we, as adults, did not as children did not get as much education and so go out there. Some great resources out there about what real sex should look like or be like, or feel like, learn how to ask questions instead of making commands. Be curious about your partner and yourself because we're growing. We need to keep growing. We're just growing people, organisms.

Jennifer Ghahari:  Wow. That's fantastic. Thank you so much for joining us today. We really appreciate it. For our listeners, we're going to link up in our transcription with a lot of Sari's websites/on different parts of her website. So feel free to check that out and thank you again, Sari, and we wish you all the best.

Sari Cooper:  Thank you so much, Jennifer. This is great.

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.

Professor Eri Saikawa on environmental pollutants

An Interview with Professor Eri Saikawa

Eri Saikawa, Ph.D. is an associate professor and director of Graduate Studies at Emory University. She is an environmental scientist specializing in: atmospheric chemistry, environmental health, biogeochemistry, climate science, and environmental science.

Theresa Nair:  Thank you for joining us today for this installment of the Seattle Psychiatrist Interview Series. I'm Theresa Nair, a research intern at Seattle Anxiety Specialists. I'd like to welcome with us Environmental Researcher Dr. Eri Saikawa. Dr. Saikawa is an associate professor and director of Graduate Studies at Emory University. She conducts interdisciplinary research on the environment, including atmospheric chemistry, environmental health, biogeochemistry, climate science, and environmental science. Her recent research contributed to understanding and mitigating chemical contaminant exposure among children in the west side of Atlanta, including heavy metal and metalloid exposure through the soil. Thank you for joining us today, Dr. Saikawa.

Eri Saikawa:  Yeah. Thank you so much for having me today.

Theresa Nair:  To get us started, I'm wondering if you could tell us a little more bit more about yourself and what made you interested in studying environmental pollutants.

Eri Saikawa:  Yeah. I really don't know what made me interested in environmental pollutants, but I was kind of a geek growing up and I was always very fascinated by pollution. Since I was a kid in elementary school, I always wanted to work on mainly some kind of pollution, and that has kept going. So, here I am, I guess, but I was always very fascinated by air pollution mainly. I wanted to find a solution to mitigate air pollution.

Theresa Nair:  That's wonderful. I think it's a really fascinating topic and I'm sure many of the people watching this interview will agree. We all have a little bit of that geek side. I think we can all appreciate that. Your research recently led to the Environmental Protection Agency's designation of a new Superfund site in western Atlanta. For audience who is not familiar with this designation, could you tell us what it means to be a Superfund site and why it was important for this neighborhood to receive that designation?

Eri Saikawa:  Yeah. I'm not a lawyer either, but as I understand it, it is designated as a Superfund site when there is quite substantial contamination that needs clean up by the federal government. What happened in the west side is that there was a brownfield investigation at first for a smaller lot. It was about 30 lots that was considered contaminated. But then, when the EPA started investigating, they found a lot of high lead levels in those 30 lots. And so, they expanded and then it just continuously expanded. At one point, they said, "Okay, it's not possible to clean up at the scale that was happening." And so then, they needed the federal funding to come, and that's when it became Superfund sites. And now, it's including about a little over 2000 lots because of the funding that's necessary. I think that was important.

How is it considered in the community? I think it's a very different story. I believe that some of the community members are probably not excited that it is a Superfund site. It's very well known that when it becomes a Superfund site, then the value of the homes, for example, go down. And the studies also indicate that after the Superfund sites is cleaned up, then the values come back up, but it is a difficult time for other community members. They are already overburdened. We hope that it was a good step so that it's going to be cleaned up, but I'm sure the people that are actually being impacted by it, there are mixed feelings.

Theresa Nair:  Right. It's positive and negative because the site's being cleaned up but then it decreases home values in the meantime.

Eri Saikawa:  Right.

Theresa Nair:  And that's interesting, you mentioned that there was some cleanup effort even before the designation of a Superfund site. If it's a smaller site, they're still able to begin cleaning?

Eri Saikawa:  Yeah. The EPA has some funds to clean up the remedial action. If it's a small area, then they can come at the regional level and then clean up. But because the number of lots that were high in lead was so much higher, they weren't able to cover that number of lots with the amount of funding that they have. They needed to clean up over a thousand lots, then they do need the federal funding. And I guess that is necessary to be designated as a Superfund site.

Theresa Nair:  Okay, thank you for that clarification. There was an article in the Georgia Recorder from 2021 which explains that you began testing the soil in Western Atlanta for slag in 2018. Can you tell us a little bit about what slag is and what the history is that caused the slag to appear in this neighborhood?

Eri Saikawa:  Yeah. What happened was we wanted to understand the potential soil contamination because there was a lot of urban gardening going on. And then, what we found was that in some of the residential lots, we were finding pretty high lead levels that were over sometimes 2000 ppm, when 400 ppm is the standard by the EPA. And one of the residents living in the west side that brought the slag pieces, which is industrial waste from smelting. They're like rocks. It's kind of like volcanic rocks. They have a lot of pores. They're the remaining from smelting. And the slag that we are seeing is most likely from the waste from lead smelting. There appear to be about 11 lead smelters in Atlanta in the past. And so, we believe that's the remaining of that. And because of that waste, we are finding a lot of lead in those pieces. I think what happened was they were buried as foundations for the land to build the homes, but then over time, the soil was eroded. And then, what used to be the foundation is now showing up as a surface soil.

Theresa Nair:  Right. I see. Was that material originally in the foundation of the homes then?

Eri Saikawa:  Yeah.

Theresa Nair:  Oh, wow.

Eri Saikawa:  That's what it seems like. And so, what happens now is that the EPA goes to dig the soil to clean up. In some cases, they dug about eight feet down and they still found slags.

Theresa Nair:  Wow.

Eri Saikawa:  And so, that is going very deep. So, now what they found is that they cannot dig everything to take out and so they are only digging about one to two feet. And if they still see the slag, then they put the plastics to make sure that the developers that would come later on know that it is contaminated with slag underneath.

Theresa Nair:  Okay so, the plastic doesn't necessarily prevent it? It's just kind of a warning for developers?

Eri Saikawa:  Right.

Theresa Nair:  Okay.

Eri Saikawa:  Correct.

Theresa Nair:  There's contamination past this point?

Eri Saikawa:  Yeah, exactly. They don't have the funds to dig that much to clean everything up.

Theresa Nair:  Wow.

Eri Saikawa:  Yeah. Because, what's happening is that the residents stay, living in the house when the cleaning goes on. They're trying to clean up as much as possible, as quickly as possible. The priority is to take the surface soil out and then replace with clean soil.

Theresa Nair:  Is the idea then that that amount will protect the resident that's living there, that that's enough of a buffer to isolate them from exposure?

Eri Saikawa:  Yeah, that's the idea I believe.

Theresa Nair:  Okay. And is the history that you just explained, is that similar to other Superfund sites throughout the country? Is that generally how these sites have begun, that it was near a factory or some type of production that contaminated the land?

Eri Saikawa:  I think there are very different types of Superfund sites. Sometimes, it's contaminated because of the current operation, so the EPA knows who is causing the pollution. In that case, they can go and the polluter is going to be responsible for cleaning up. But, I think there are also a lot of cases like what we are seeing in the west side where the past contamination is causing problems, so then it's hard for the EPA to figure out who the actual polluter might have been. And so then, the federal money needs to come in because they cannot get the polluter to pay.

Theresa Nair:  Okay. So if they knew who it was, then they might be liable?

Eri Saikawa:  Yes.

Theresa Nair:  But if they don't know, the EPA takes over?

Eri Saikawa:  Yeah, exactly. I believe that the EPA is still going after who might have dumped these so that they can make them liable.

Theresa Nair:  Right.

Eri Saikawa:  That takes a lot of time, I think.

Theresa Nair:  Yeah. I'm sure it does. And proving liability could be a whole issue.

Eri Saikawa:  Yeah.

Theresa Nair:  There was an article published by 11Alive on March 19 of this year that quotes the EPA administrator as saying that, “The new Superfund site is located in an overburdened and underserved community." Could you explain to our audience how this issue is tied to environmental justice and any relationship that exists between the site designation and neighborhoods that have historically experienced discrimination?

Eri Saikawa:  Yeah. I think for this historic west side, it is a predominantly Black neighborhood and also the income level is one of the lowest in the Metro Atlanta area. It is overburdened in a sense that they already have a lot of issues that they're going through. And it is also an energy-burdened area, meaning that it becomes energy-burdened when you pay more than 6% of your income towards electricity.

Theresa Nair:  Oh, wow. Yes.

Eri Saikawa:  Atlanta is pretty well-known for energy burden, but this area is especially energy-burdened. If you have low income and if you are already paying so much for electricity, you cannot pay for other things. That is a very big problem. And chronic issues and the water contamination, for example, has been seen in their creeks as well in the past. It's not just the soil contamination that they're dealing with, but it used to be also a food desert, meaning that they didn't have a lot of fresh produce around where they live. And because they didn't have vehicles either, then they couldn't get the produce they needed. It's unfortunate because having this urban agriculture movement is really great on one hand, but then if there is a lot of contamination in the soil, then that doesn't solve the problem at all and creates another problem. So when you are already overburdened, then it's a really complex issue that you are going through.

Theresa Nair:  I was actually going to ask you about that because I know you mentioned earlier that you did get into this because you were studying urban gardening. And urban gardening does have a lot of benefits for increasing food independency and increasing access to healthy food, but then you have this question of soil contamination. And I know that you have done some research with focus groups, studying safe gardening practices in urban environments. Could you tell us a little bit about... For anyone who might be using urban gardens, how people can protect themselves, or how people can know whether it's safe or whether they can eat the vegetables that are being grown in these environments?

Eri Saikawa:  Yeah. So, I think the best practice is really to be cautious before you actually start it. If you are worried about it, I would highly recommend that you would test the soil. That's why we are also providing this Community Science SoilSHOP opportunity for people to test the soil for free for lead. Lead is not the only toxicant, but that can be a way to screen. And I think that's one of the most important chemicals that you want to avoid. Also, if you're now able to really test the soil, you might just create the raised beds and make sure that you are not having any potential contamination in the place where you are gardening. Because, it's the most unfortunate, I guess, consequence of this great cause that you're doing. And I believe that urban agriculture also does a lot for our mental health as well. It really improves your mental health, I read somewhere. There are really good benefits. Taking precautionary measures, I think, is pretty important.

Theresa Nair:  Okay. There are some good suggestions. So if they do think their soil's contaminated, using raised beds, putting in potting soil would help offer some protection then.

Eri Saikawa:  Yeah.

Theresa Nair:  Okay, good. You mentioned the mental health impacts of urban gardening, how there’s some benefits. I'm wondering if you could talk a little bit about the mental health impacts of lead exposure. We hear a lot about the physical health impacts. Could you talk about anything related to mental health, how it affects mood, memory, or brain development in children?

Eri Saikawa:  Yeah. I think lead exposure is really linked to the brain development of children. When you're exposed as a small kid, then that can have developmental issues. And I think what's really important is that once you're exposed, it's very difficult to go back to preexposure. Yeah, I forgot to mention, I think washing your hands if you are potentially exposed can really do a lot. And sometimes, we think that if you're growing food in your own garden, then you might not wash your vegetables or something, but that's really essential that you wash. You make sure that you are not having any contamination. And if you have pets, making sure that they don't bring in the contamination at home. That is pretty crucial too.

Going back to the brain development, I think the IQ can be impacted quite a bit. What I usually want to think about is the people that are going to be impacted by lead are also already overburdened. The distribution is not equal, and so we really need to make sure that the kids in the vulnerable neighborhood are really given the safe environment and we should do more to make that happen for those children.

Theresa Nair:  Thank you. That's a good point. One of the things I found really impressive when I was reading about your work was that you're not only a scientist researching this topic from your office, but you also joined the West Side Health Collaborative and were doing some hands-on work in the community, passing out leaflets to residents and urging them to get their children's lead levels tested. Since you were going out within the community and raising awareness, I'm wondering if you could tell us how this information was being received by community members. Were people experiencing increased anxiety or fear or depression, or were people feeling more optimistic that this was going to be a short-term problem that would be easily resolved?

Eri Saikawa:  Yeah, I don't think anybody was optimistic that I've seen. There were so many devastating, I guess, cases that I saw and that sometimes made me wonder if that was a good thing that we found contamination. For example, the partner that I work with in the community, she had a garden in her lot that was especially for children. She called it Children's Garden. And then, there were her grandkids that were gardening in that soil. And that was the spot where we found high lead levels and it was really with a lot of slag. And that was really devastating because that is somebody that I know well and she had this to do good things for her grandchildren. She was really worried obviously and she took them for blood test. And actually, I remember so well she told me that the test came back and one of her grandchildren, the level was high.

Theresa Nair:  Oh wow.

Eri Saikawa:  It was very, very devastating for me and for her. Yeah, thinking about that actual impact that it has when we talk to the residents, I think it is really difficult. How can we actually go over that, it's not something easy. Because if you're already exposed, you can always do a lot to mitigate, but that impact is going to stay. And so, the resident is asking me, "Is this child having developmental issues because of lead exposure?" And I cannot answer that. I think there is a potential that might be the case but I'm not a doctor and it's very difficult to say. And so, seeing those people, I think, struggling, what can we really do is, I guess, make that impact as less as possible, knowing that they are already very much impacted and they have to suffer from that.

Theresa Nair:  Right. I'm sure that's really difficult, especially for that grandmother who was trying to make healthy food, grow healthy food for her grandchildren. I guess the best thing you can do at that point is try to clean it up for everyone from here on to move forward. But, I'm sure that's difficult. I'm glad you were able to work with them to help them clean it up and help to find solutions. I wanted to broaden out our conversation a little bit. So far, we've been talking about the Superfund sites in Western Atlanta and the impact in that community. However, I do want to point out that below this interview, we're going to be placing a link that shows where people can find Superfund sites near them and find out if they are near any of these neighborhoods. It is that EPA's website, and that will allow everyone in our audience to check their own proximity to Superfund sites.

Since many of our audience members are in the Washington state area, I think it's important to note there are currently 69 Superfund sites listed within the state. However, when you dive into descriptions for these sites, many are listed as deleted, final, or non-NPL. Could you explain a little bit about what these designations mean and how concerned for environmental exposure people should be if they find that they're living near one of these sites?

Eri Saikawa:  Yeah, that's a very good question. The west side just got listed on the National Priorities List. NPL. NPLs are considered to be the national priorities for cleaning up. If you are living in or proximity to the NPL site, then that is one of the most contaminated sites in the U.S. And so, your exposure, I think that's something that you would really want to think about. And even if that is, I guess, you mentioned deleted... So, deleted, I think, happens after the cleanup is over. And so, hopefully, that is already when it's clean. Sometimes, not everything is going to be completely clean, but I believe that the cleanup process usually works so that it is much cleaner than how it used to be. And so, over time, hopefully, the value is going to increase and then you are going to have a better environment.

Sometimes that even though it's a Superfund site, it cannot be designated as an NPL. And that's often a political reason, it seems like. I believe that if you are in one of the, even the brownfield areas, the Superfund sites areas, you do want to be mindful of what kind of toxicants you might be exposed to. And if there is an opportunity to test for either blood test or whatever test that's available, I think you should take advantage of that.

Theresa Nair:  That's good advice. If a person is experiencing anxiety due to learning that they're living near a Superfund site, or if they suspect they may be living in an area that's undesignated but may have some environmental pollutants present, what practical steps could they take to protect their health and the health of their family members?

Eri Saikawa:  Yeah. This is so important. If you do suspect that you might be having some exposure, the data is very important. Community science, citizen science, I think that's taking a lot of power. So if you are able to find somebody that can work with you to figure out what kind of contaminants might be there, or if you already know what might exist, I think getting the data and then bringing that to the EPA, that is so important. And then, once they have the data, it is their responsibility to really look into it. I would really urge anybody, if you are finding any issues, see who you can partner with and then try to get the data that you need and bring it to either the EPA or the health organization. For Georgia, the department of public health. Georgia Department of Public Health is very interested. I'm sure there are agencies like that in Washington state that would work with the community.

Theresa Nair:  Okay, that's a good recommendation. To start with maybe something like soil analysis, would you recommend contacting the local university first, somewhere like that to start?

Eri Saikawa:  Yeah, sorry. ATSDR, Agency for Toxic Substances and Disease Registry, they usually host what's called soilSHOP. They might be willing to help figure out if there might be contamination of that soil. And then, I guess, just contacting the person that you are aware of, any scientists. It doesn't have to be somebody that you know. I'm happy to hear the concerns and then try to find the scientists near the people in your area in Washington state, for example. I think just reaching out to anybody that you find on the internet might be one step. And then, I think talking to your doctors is also important. If you're feeling some anxiety, talking through with your doctor, and then they might be able to refer to somebody else that can potentially help. I think seeking help earlier is a pretty important step.

Theresa Nair:  It's very good advice. Was there anything else before you go? Did you have any parting words of advice or anything that we didn't ask about that you might want to share with our listeners on this topic?

Eri Saikawa:  Yeah, I think I would really want to say that if you do see some problems, talking about it with your community members and then potentially testing. I think that is very important in trying to make everybody safe, especially your children. I really would like to encourage that. We don't talk enough about these potential contaminants that really affect us, so raising awareness amongst ourselves first and trying to distribute that knowledge to others, I think that's very important.

Theresa Nair:  I think this has been a very interesting discussion and I want to thank you for taking the time to speak with us and sharing such valuable information and information about resources and where people can go if they have these types of concerns. And I just want to thank you for participating in our interview series today.

Eri Saikawa:  Yeah. Thank you so much for having me.

* To check if there is a Superfund Site near where you live, click here to access the EPA’s search site.

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.

Psychiatrist Evelyn Nelson on Psychiatric Care

An Interview with Psychiatrist Evelyn Nelson

Evelyn Nelson, MD is psychiatrist at Seattle Anxiety Specialists, PLLC. Dr. Nelson specializes in the treatment and medication management of anxiety related 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 psychiatrist Evelyn Nelson who's one of the psychiatric providers at Seattle Anxiety Specialists.

Evelyn specializes in the medication management of anxiety related disorders and utilizes a holistic approach in her patients' care. Before we get started today, can you tell our listeners a little bit about yourself?

Evelyn Nelson:  Yeah, sure. Thank you for the introduction. I'm Dr. Evelyn Nelson, I am an adult psychiatrist. I live in Seattle, and I live with my husband and two-year-old daughter, Emmi. And so, we just moved into the area about a year ago, so we're just kind of getting used to the area, loving exploring, being outdoors. And originally I'm from California and so, it's a very different climate, very different environment, but yeah - just getting used to the area.

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

Evelyn Nelson:  Oh, I love being outdoors, and I love the greenery. I've always lived around water, so that's really important to me. So, being around the water, being around greenery, taking ferries just seeing the islands just is my absolute favorite, and was a big reason why I wanted to move into the area. And so, just the outdoors scene, and the greenery is just the best part honestly.

Jennifer Ghahari:  Do you have a favorite outdoor activity, or is it like everything?

Evelyn Nelson:  I love hiking with my daughter just because we're starting to get into hiking with her. And so, there are a lot of new things, and seeing her just kind of explore the trees, and slugs, and different animals is very cool and exciting.

Jennifer Ghahari:  Wow, that's awesome. Great. Thank you for sharing that.

Going back a little bit and a few years back now, what is it that got you interested in becoming a psychiatrist?

Evelyn Nelson:  Yeah so, it originally started with just an interest in, at baseline, “What motivates people? What drives people to do what they do?” And so, that interest started with my majoring in religious studies as an undergrad. So, that's kind of where this theme started. And over time, as I started to study religion and psychology, my interest expanded into more of an interest in being more active in that study, and being more active in the role of helping people. And then, so that's kind of how that developed into psychiatry.

There was a point where I was considering becoming a therapist. But I also was very interested in medication management. And so, that's why I went down the psychiatry route.

Jennifer Ghahari:  It's like the best of both worlds in your case.

Evelyn Nelson:  Exactly. And I wanted to make sure that I had the full realm of ability to help people. And I wanted to make sure that I wasn't kind of ruling anything out. And so, going into medical school, I actually knew that I wanted to be a psychiatrist. I was kind of one of those rare cases where I went into medical school to do psychiatry. Whereas, I think, a lot of people go in with an open mind, see what is interesting to them. And I always knew.

Jennifer Ghahari:  Wow, that's great. It was kind of a long-term calling for you.

Evelyn Nelson:  Exactly, yeah.

Jennifer Ghahari:  Can you speak to the reasons why a person may see, or should see a psychiatrist?

Evelyn Nelson:  Yeah, of course. So, I mean, the reasons that people see a psychiatrist are just so expansive. I think there's a misconception that you have to be really struggling, or really not functioning, or just things have to be dire to see a psychiatrist. And that's just not true.

I see a full range of people. So, people who have been engaged in mental health care for years and are very involved in the system. But then, I also see people who don't really know what psychiatry is, don't even know if they want to take medications. They tell me their struggles, and sometimes we decide maybe medication isn't appropriate. So, I see a full range.

And so, what I hope for people is that they're not scared out of a misconception that we're going to push medication on you. Or you have to be at a certain point in your life to see a psychiatrist. It's a huge range. And really it's not harmful to just have a conversation to be able to just see what's going on, and see how I could potentially help. And sometimes it's not medication, sometimes it's therapy. Sometimes there's just kind of a natural transition in life, but it's hard to know without that initial conversation. So, the reasons are just huge.

Jennifer Ghahari:  Great. And at its core you are, as you said, a doctor, you went to medical school. And so, I think what might be helpful for people to know too is that they shouldn't be afraid to see a psychiatrist. It's really akin to going to any doctor in many regards.

Evelyn Nelson:  Exactly right. And you don't have to have an established diagnosis. You don't have to know that you want to take medication. That's part of our job to see if medication is even appropriate. In an intake and follow up appointments that's part of the conversation. People don't go into visits 100% needing medication. That's just not the reality. And so, it's important for people to know that.

Jennifer Ghahari:  Thank you.

Are there any disorders that you specialize in?

Evelyn Nelson:  Yeah, so I specialize in anxiety disorders, PTSD, mood disorders, so including bipolar disorder and depression, and ADHD. Those are the multiple things that I specialize in, but I see a huge range of diagnoses.

Jennifer Ghahari:  And can you talk a little bit about your treatment approach?

Evelyn Nelson:  Yeah. So, the most important thing is that the person coming to me is on board with whatever plan that we have. So, the way that I approach medication management is just getting input from my patient, and just making sure I have an understanding of what's going on with them, and what is really bothersome for them. And then, understanding what they're feelings about medication is.

And then, from there, getting a sense of comfort level. Are they afraid of a certain type of medication? Are they afraid of a certain type of side effect? And it's really important for me to know these things before I even suggest a medication just because there are so many things that are avoidable, or things that we can kind of work around. Or if someone's really afraid of something, it's just so important for me to know. So, that's kind of my approach is just taking a team approach with my patient. And then, going from there.

I also tend to be pretty conservative in terms of starting medication slowly, monitoring for side effects. And that's just always been my approach. And I think it's helpful for people, especially who are afraid of taking medication to have that approach.

Jennifer Ghahari:  And, from my point of view anyway, it's really nice to hear that things are very customizable. It's not a one size fits all type of treatment where everybody just gets the same type of thing. So, that's great that you really take the time, and trust people's fears and concerns.

Evelyn Nelson:  Yeah, exactly.

Jennifer Ghahari:  So, let's say, that I sign up for an appointment with you. And right now, I have no idea what to expect from the process. I presume that there's some type of paperwork to fill out, like when I go to any doctor.

Evelyn Nelson:  Yeah.

Jennifer Ghahari:  Can you explain what the process actually is, and what I can expect in a first session with you?

Evelyn Nelson:  Yeah. So, initially, if somebody signs up for an appointment with me there's some paperwork, just getting some basic medical history, getting information about the medications they're on. And then, basic assessments in terms of mood, and anxiety, and other kind of psychiatric symptoms, just so I can get a sense of what the person can be potentially coming in with so I can prepare for the visit. So that's initially. And once the visit comes, the intake is usually scheduled for 60 minutes. And our interaction would be like 45 to 60 minutes is usually standard. And then, so initially what we talk about is just what's bringing them into the visit? What's been bothersome? What concerns do they have? So kind of getting a sense of current symptoms. And naturally, that can kind of go into some history. But then, we talk about any history with mental health, any medical history.

And then, after that, I get a sense of who they are as a person. Like what is day-to-day life for them? How is their life affected by what's been going on in terms of their current symptoms? What it was like for them growing up? Just to kind of get to know who they are as a whole person 'cause it all relates. It all comes together. And then, toward the end of the visit I take a pause and I say, "Is there anything that we didn't talk about or you feel like is important for me to know to kind of move forward?" And a lot of times people do bring things up because it's hard for me to know what's going on in the person's mind without taking that pause. And sometimes things are hard to bring up, or things can be scary, or embarrassing. And I just, I like to give that space and that option for people.

And then, after that, we just talk about if I can get a sense of diagnosis... Sometimes I can't there are a lot of times where in a intake appointment, I just got a lot of general information. But I do give some ideas. And then, I talk about how I could potentially help in terms of the plan. And, again, that can include changes to medication, starting a medication, or even not starting medication at all, or just referral to therapy. So, the ways that we can kind of go toward the end of the visit are pretty varied.

Jennifer Ghahari:  Great.

And you actually bring up a good point. So, if someone is receiving psychiatric care somewhere else, and it's maybe been a while, they're on certain medications, and they're maybe wondering, "Is this the right path for me?" They could always come to you for an intake maybe to see if they are on the right track, right path, or maybe there's another option?

Evelyn Nelson:  Yeah, exactly. And so, just because we have an intake appointment doesn't mean that we necessarily have to continue. I can always throw out options, and my kind of opinion and recommendations. And they can see if that sits well with them.

Even if they have another psychiatrist that is managing their medications, I can throw out ideas. A lot of times I validate what their other psychiatrist is doing. But then, ultimately, we like to have people just have one psychiatrist managing medication, just so it's less confusion, and more safe. But there are a lot of times where I can kind of give my recommendation. And then, I give them the space to think about it, and they can always let me know. There's never any pressure to go down a certain route, or continue with me.

Jennifer Ghahari:  Fantastic.

At our practice, we have a form of psychiatric concierge care. Can you explain what that is and how it differs from a traditional practice?

Evelyn Nelson:  Yeah. So, that's a really good question. So, with the concierge model, people pay a monthly fee. And with that monthly fee it includes any follow up appointments. It includes any contact with me, so emails, or messaging, or phone calls. And follow up appointments we just charge a dollar, meaning that it's a really low fee. So, we can follow up as many times as we need to. And a lot of times people need a good amount of follow up, especially if they're kind of in this really acute phase, and maybe things are really difficult.

And so, in that way, people won't have to worry about paying for each follow up visit. And I can just follow up with them as many times as I feel like I need to with taking out that financial aspect. Whereas with other kind of private practices, they tend to charge per visit.

And so, this can work for a lot of people. But I think, for me, I prefer the concierge model because I think what dictates follow up is just based on clinical need, and not if they can pay for this next follow up visit or not, or if they want to pay for the next follow up visit. So, it's nice to just have this kind of catch all. All services are just kind of available with me without having to think about that financial aspect.

Jennifer Ghahari:

Great.  And you brought up a good point before that some people can have some trepidation, or nervousness about starting a new medication, or there might be side effects that... With any pill, you wonder, "Wait a minute, is this normal? Is this okay?" And so with our practice, patients would be able to reach out to you at any point, like you said, through an email, or a call, and that's all included there's no extra charges, right?

Evelyn Nelson:  Exactly.

Jennifer Ghahari:  That would provide some peace of mind, and also help get the right dosage, right?

Evelyn Nelson:  Yeah, exactly. And so, the most common way that I communicate with my patients is through secure messaging. And I always encourage, especially if we're making a medication change, or if we're starting a medication for them to message me. I always counsel about side effects, but things can come up and people have questions about it. And so, a lot of times we don't need to have a follow up appointment. They can just ask me like, "This is going on. Is this normal? Will this go away? What do you think?" And it's really easy for me to just message back. And so, I love having that ability to communicate with my patients without thinking about charging an extra fee. It puts the patient at ease. And I think, for me, it's nice to be helpful in that kind of quick way.

Jennifer Ghahari:  That's great. It sounds like there's peace of mind on both ends. That sounds really helpful.

Evelyn Nelson:  Yeah, absolutely.

Jennifer Ghahari:  Wow.

Well, this has been flying by. So, for our final question, do you have any final words of advice, or anything else that you would like to say to our listeners today?

Evelyn Nelson:  Yeah. So, a couple of things. So, number one, is that no matter what provider you have, whether it's me, or anybody else, it's really important that you feel heard, and you feel like your concerns are being taken seriously. That is extremely important. And you deserve that relationship with your mental health provider. You just do. And so, for anybody pursuing care in mental health, I know it's really hard to even find a provider, but just know that you deserve that trust, and that kind of relationship.

The other thing too, is that if you are feeling apprehensive or afraid, it's okay to voice that to your provider. I think it's really helpful to be able to say that so that we can take a little bit more time into talking about the concerns, because a lot of times that's just as important as the symptoms that are going on. That can be a huge barrier to care. And so, I just encourage people to kind of advocate for themselves, and speak up to any fears, or concerns that they have because, again, they deserve to be open with their mental health provider. If you can be vulnerable and open with anybody, it should be your mental health provider.

So, I think those are the biggest things. And it's really important for my patients to know that and my future patients to know that.

Jennifer Ghahari:  Dr. Nelson, thank you so much for finding this time in your schedule to speak with us today...

If anyone is interested in scheduling an appointment with Dr. Nelson to discuss psychiatric care, any concerns that they may have, or medication management you can do so at seattleanxiety.com and we will be happy to set you up.

Thanks so much.

Evelyn Nelson:  Thank you.

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

Psychiatrist Lantie Jorandby on Addiction Recovery

An Interview with Psychiatrist Lantie Jorandby

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lantie Jorandby:  Absolutely.

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

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

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

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

Lantie Jorandby:  Absolutely. Yeah, it really is.

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

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

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

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

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

Theresa Nair:  That's OK.

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

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

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

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

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

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

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

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

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

Attorney Wendy Patrick on Predators & Manipulation

An Interview with Attorney Wendy Patrick, J.D., Ph.D.

Dr. Wendy Patrick is a deputy district attorney, author, media commentator, and veteran prosecutor. In addition to her law degree, Wendy Patrick has earned a doctorate in Theology. An accomplished trial attorney, Dr. Patrick’s research focuses on a variety of topics related to interpersonal violence and sexual assault.

Amelia Worley:  Hi. Thanks for joining us today for this installment at the Seattle Psychiatrist Interview Series. I'm Amelia Worley, a research intern at Seattle Anxiety Specialists. I'd like to welcome Dr. Wendy Patrick. Dr. Patrick is a deputy district attorney, author, media commentator, and veteran prosecutor. She's completed over 165 trials, including cases of domestic violence, hate crimes, stalking, human trafficking, and first degree murder. She has also been involved with the San Diego Domestic Violence Council, the San Diego Child Protection Team, and the Sexual Assault Response Team. Dr. Patrick researches, advises, and publishes on a variety of topics related to interpersonal violence, sexual assault, and working with victims, including her book, “Red Flags: How to Spot Frenemies, Underminers, and Ruthless People.” Before we get started, Dr. Patrick, can you please let us know a little more about yourself and what you made you interested in dealing with dangerous people, sexual assault, and domestic violence?

Wendy Patrick:  I've been a prosecutor for my entire career, I would say since before you've been born, but it lends a little bit of credibility to what I'm talking about. For whatever reason, during the 25 years plus I've been a prosecutor, I've dealt with a steady stream of dangerous people. One of the things that really struck me, Amelia, about this is the sometimes very worldly, intelligent, savvy victims, people you wouldn't expect to be victims because they don't strike you as particularly vulnerable in any arena, yet there they were. I went back to school to earn a Master in Divinity and then a PhD mid-career. It was my mid-career crisis if that's a term, and really became in love with research, as I suppose I was. That's what led me to want to go on and further my education because there's an enormous amount of research behind why, why people fall for dangerous people, how dangerous people corner victims, how they manipulate even very street smart savvy professionals. It is with that combination of the anecdotal, the empirical, and I would say the experiential, given the work that I've done for 25 years, that really brought me to a lot of the information that I cover in that book.

Amelia Worley:  Yeah. That's great. To begin, can you describe the acronym “FLAGs” that you created to separate the dangerous from the desirable?

Wendy Patrick:  Well, my first book was the revised version of the New York Times bestseller “Reading People,” which I coauthored with a famous jury consultant. That talked about the seven colors of what somebody looks like, how they behave. Red Flags is a deeper dive. Flag stands for focus, lifestyle, associations, and goals. Let me explain each one of those so your listeners can understand a little bit about why this gives you more of an idea of who is this person behind the persona.

Focus is the F, and the reason I wanted to use that for flag, it also talks about focus being attention reveals intention. For example, I think on the back cover of the book, the publishing company has the red flags on a first date, your body, your brain, or the ball game. What is somebody focused on when they're with you? Well, that tells them what they're interested in. If they're not interested in you, why are they spending time with you. Oftentimes in the child predator world it's because they're interested in the child. I cannot tell you how many trials I've had where you've had spouses and girlfriends and boyfriends that had no idea that honestly believed they were the prize. They were the ones that the perpetrator was after, but if they looked back at the focus, that was never really it.

Lifestyle is what you might imagine. I sometimes call this red flags after five. If you want to know what somebody is like, you have to know more about what they do during the work day. You may see them all day at work, nine to five, and have no idea who they really are unless you know what they do when they're off the clock. I say, lifestyle is personality revealed. What are their hobbies? What are their interests? Where do they go if they have a free day.

Now, Associations stands for who do we spend our time with? When I was growing up my parents used to say, show me your friends and I'll show you your future. My law students now tell me that, I suppose, the updated version of that is show me your friends and I'll show you who you are. Either way, it proves the point, birds of a feather. What sort of company do we keep? Are we guilty by association? I mean, who do we choose to spend our time with if we have a choice? What organizations do we belong to? What philanthropic activities capture our attention.

Then Goals is really a profile in priorities. If I knew, for example, Amelia, what you prayed for at night or what you wished for when you toss a coin into a wishing well, you're too young, but we used to do that back in the day, I would know a lot about you. Knowing what somebody's goals are tells you a lot about them as a person. All four of these FLAG areas taken in combination gives you a much deeper picture of what a person is really like.

Amelia Worley:  Yeah. What are some recognizable signs of people who have ulterior and self-serving motives then?

Wendy Patrick:  Well, one of the things you really have to look at goes back to that focus component. It would be like, I'm a Rotarian, so I'll use the rotary example. Lots of people join service organizations, but why are they there? Are they there to put it on a resume? Are they there because they genuinely want to help serve the homeless? When you're looking at somebody's motivation, some of the signs have to do with where they focus their attention and on what aspect of belonging, I'm just using that as an example, are they interested in when they go to a social hour or a networking event? If you look at their focus, if you look at the fact that they're not necessarily interested in building business, but gathering business cards to maybe put on a mailing list. So, it's really paying attention to what somebody does.

We used to say a picture is worth a thousand words. Actions speak louder than words. That is the takeaway from being able to tell what a person is really like. A dangerous person, their actions speak for themselves. They're not philanthropic actions. They're only asking questions designed to elicit the kind of information that might give them an idea of an area of vulnerability. I gave the example of the focus and some of the women, in particular, that were married to child predators or married to pedophiles. They would often find that looking back, right, that's always sadly the way that many people look at red flags, looking back, there were tons of signs that they really only wanted, they were almost only a conduit, a way in which the predator could gain access to the person they were really interested in. Some predators use people to gain access to resources, time, money, favors, all the kinds of things in a workplace setting, for example, that shows they're not really interested in a coworker, but in what that coworker can do for them. It's that end game that sometimes we have to really keep an eye on.

Amelia Worley:  Yeah. In your book, “Red Flags: How to Spot Frenemies, Underminers, and Ruthless People,” you talk about how dangerous people use selective attention to manipulate their victims. How and why does this work?

Wendy Patrick:  Well, it works because to somebody that's not used to receiving attention, that can be the most intoxicating experience of their life. I'll give the example of somebody that isn't drop dead gorgeous, somebody that's perhaps not attractive is not used to getting attention really from anybody. It's a terrible situation. As a Christian, my heart goes out to those people. They're the most beautiful people sometimes that I will ever meet, but their experience is not getting double takes on the street by men in whom they might potentially be interested in. If a manipulator, and we see this a lot in the human trafficking arena, if a manipulator, a trafficker, somebody that has ulterior motives, swoops in and gives them the kind of attention they've only dreamed about receiving, that is uniquely attractive to somebody that's not used to receiving that type of attention. Of course, a predator, a manipulator, somebody that's interested and has ulterior motives, of course they're going to use that approach.

Now they have to be careful because sometimes people that are not the most attractive people in the room might be the smartest, so they have to be very subtle about the way in which they're approaching these people so they don't raise the antenna. Let me tell you what the research shows. This is going to surprise some of our listeners and viewers. Sometimes, even when you have somebody that suspects somebody has ulterior motives, even they can't help being flattered by the attention. How do you like that? It's almost like an emotional cognitive override. Emotionally it feels so good that even though cognitively you suspect ulterior motives, you still respond favorably to the flattery. That is the bread and butter of people, dangerous people that have ulterior motives is knowing that people are susceptible to that kind of attention.

Amelia Worley:  That's really interesting. What role does physical appearance play in misjudgment and wrong perceptions? I know you've talked about this a little bit, but additionally, how does this relate to the halo effect?

Wendy Patrick:  Well, the halo effect stands for, and all of our psychiatrists and psychologist guests will appreciate this, as they know, it talks about this phenomenon that if somebody looks good, sounds good, is pretty, is attractive, we tend to ascribe to them all of these positive qualities they don't have. Some of the research, there's a lot of research behind the halo effect, maybe some people that work with you have even authored some of the studies, but it has to do with us saying things like, “Oh, I bet she's a really good mother. I'll bet he can be trusted,” only because they're good looking. There's many studies that show that attractive criminals, which is of course my line of work, are treated more leniently. They sometimes get more favorable plea bargains. Juries give them the benefit of the doubt.

I've tried about 160 cases. That's a lot of cases if you're a lawyer. In that time period, I've had the opportunity to speak to almost all of my jurors that have waited around after the fact and found that they often really do give my pretty defendants a break. It's one thing to say, this woman is charged with being a child molester and sleeping with her students at school and all the rest of these nasty things, it's quite another to look over and see those jurors smiling, looking at the pretty lady in the polka dot and pearls sitting at the defendant's table. That sometimes translates into a very lenient verdict or a non verdict in the form of a hung jury. It is very difficult to overcome the halo effect because, again, it's something that is emotional, not necessarily cognitive.

I'll tell you one exception of that. There's been some research that has shown that if a jury finds that a pretty or a handsome defendant used their looks to facilitate a crime, they don't like that because that's almost a counterintuitive backdoor way of using what they might otherwise have been susceptible to as the triers of fact in the way that they committed the crime.

Amelia Worley:  That's fascinating, actually.

Wendy Patrick:  It is.

Amelia Worley:  Also in your book, you talked about helping behavior. How can this create a power imbalance and eventually lead to a dangerous situation?

Wendy Patrick:  Well, helping behavior creates dependence. Many of the cases that I've tried have involved predators, child molesters, sexual assaulters. They gain access into the victim's life. They weaseled their way in by being helpful. They're the handyman. They can do anything. They can fix the internet. They can fix the car. If they engage in enough helping behavior, a victim becomes dependent. There have been some cases in which that's been illustrated, sadly, in grand fashion where you have a neighbor that's interested, for example, in a next door neighbor's child. He becomes indispensable to the next door neighbor. I mean, he's over there fixing her car, fixing anything that goes wrong in the house, sometimes even beginning to show up unannounced. It's a boundary probing kind of insidious progression, creating vulnerability.

Sometimes when he shows up unannounced, the neighbor that is so used to this man fixing everything, doesn't even stop him because she doesn't want to lose access to that free labor. Nothing's free. It's only a matter of time before this man will ask to babysit a child. Now, is it true that there are some really kind people that are helpers? Absolutely. That's why there are four flag areas and not just one. You just want to make sure that if something seems too good to be true that sometimes it is. Make sure you go through all the areas of interest, that some people are as good as they look, but not everyone. I'll leave it at that.

Amelia Worley:  Yeah. Once you realize someone in your life is manipulative or deceptive, it can be anxiety-inducing or depressing. What steps should you take when you realize someone like this is in your life? What if it's someone you love?

Wendy Patrick:  Ah, depression and anxiety are something that everybody struggles with. Those are conditions that transcend any kind of boundary, socioeconomic. I mean, no matter who you are, where you live, what you do, you're vulnerable. Part of the reason you're vulnerable is exactly what you just mentioned. Sometimes you find out the hard way that it's somebody very close to you that's manipulative. One of the ways in which you deal with this is exactly what you do in your line of work. You got to talk to somebody about it. People think, oh, I can handle this on my own. They can't. However, it's often very empowering to speak with those who've also gone through the same kind of circumstance. In my line of work, we call those survivors. Human trafficking victims are often helped along towards the path to survivorhood by other survivors who have been through the exact same thing.

So too, those who've had the wool pulled over their eyes, those that have been manipulated, who have been fooled by somebody they thought really loved them, are sometimes very much helped by others who have been there. Sometimes reviewing the red flags will empower them not to fall forward again. Part of what I often teach in connection with these programs I give, because I do this as a speaking series, I've done it all over the world, and I'm going to give you some takeaways along the lines of how can you prevent yourself from being in a position that you're asking a question, what do you do once you recognize you're in that scenario. Maximize first impressions. In other words, don't trade in your reading glasses for rose colored glasses. You're wearing reading glasses when you first meet somebody or first go on a date. Perceive as much as you can when you are most objective.

Be wary of under exposure. If there's an area of somebody's life that they don't share with you like that unaccounted for hour or two after work, you want to know where they are. Why are they off the grid during certain times of the day or night? Most people are very transparent. Sometimes we make the joke TMI, as my students say, too much information, that's preferable to too little information because secrets breed suspicion. Time lapse photography is the next one. You notice I'm on a photography theme, which of course was a thing when I was growing up. Observe somebody's behavior over time. You can't tell what somebody's like if you just have a snapshot of their day. Maybe a continual snapshot, like you work with them. You only know what they're like when they're on the clock. You have to know what they're like in different settings and across time to be able to get a good read on them.

That would also be, I suppose, using a wider angle lens. You're looking at behavior in different settings, in different contexts. Solicit multiple exposures. Introduce people to your friends and family. You may trade in your reading glasses for rose colored, but I guarantee you, your family and friends will not. Anybody who has been second guessed by an objective sounding board, i.e., parents, spouse, family, good friends, colleagues, coworkers, they're going to tell it like it is because they care about you. We live in a day and age of vision enhancement. You can go online and look at social media. Sometimes you look at other dating sites if that's the way you met somebody and see how they describe themselves on other dating sites. Shocker, news flash, yes, people use multiple dating sites and don't go off of those sites just because they start dating you.

There's a lot of information available to make sure that you are not the one that ends up in that scenario where you are involved and are just now recognizing that you're involved with the wrong person. Now, let me temper all of that with what we'll call, I don't know if we really want to put a word on it, but the tendency we have to believe. It's easier to believe. It's cognitively more challenging and difficult to doubt. When we first meet somebody, we're disinclined to go online and look up and fact check everything. Nobody has the time for that, and we don't want to do it because we're sometimes enamored with a new love interest. Those are some of the reasons that even very smart people sometimes fall for the wrong individuals.

Amelia Worley:  Yeah. That's really helpful. Thank you. Lastly, do you have any advice or anything you want to say to someone regarding dangerous or deceptive people?

Wendy Patrick:  I think I just said it. I think that laundry list of ways that you would make sure you don't allow somebody to get too close to you until you've gone through all of those steps is probably the best way to prevent yourself from being in that scenario to begin with. The reason my book has all those chapters, it talks about all the different ways that we are captivated by somebody when we don't really know who they are. That's one of the reasons that there are just so many ways, counter intuition, when the optics don't match the topics, make sure you use all of your senses all of the time when you're getting to know somebody. That is the single best way to make sure you are not fooled.

The last chapter in my book, as you know, is green lights because I don't want anybody to think that my years as a prosecutor made me a skeptic. Some people are as good as they look. Go figure. I'm going to give a big amen to that, because that sometimes is what we find out when we get to know somebody better is it's authentic, it's genuine, and that creates a healthy, happy relationship.

Amelia Worley:  Well, that's great. Thank you so much, Dr. Patrick. It was wonderful having you on our interview series today.

Wendy Patrick:  Thank you for having me.

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

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

Psychologist Larry Rosen on Technology & Parkinson's

An Interview with Psychologist Larry Rosen

Dr. Rosen is past Chair and Professor Emeritus of Psychology at California State University. He is a research psychologist and recognized as an international expert in the psychology of technology. Upon his diagnosis of Parkinson’s Disease, Larry Rosen has sought to educate, mentor and guide others utilizing both a humanistic and scientific approach.

Jennifer Ghahari:  Hey, thanks for joining us today! I'm Dr. Jennifer Ghahari, research director at Seattle Anxiety Specialists. I'd like to welcome with us Psychologist Larry Rosen. Dr. Rosen is past chair and professor emeritus of psychology at California State University. He is a research psychologist and recognized as an international expert in the psychology of technology.

He has given keynote speeches to Fortune 500 companies and nonprofit organizations in the US and internationally. Larry has been featured extensively in national television, print, and radio media. Before we get started today, can you let our listeners know a little bit more about you as well as your current research endeavors?

Larry Rosen:  Sure. Thanks for having me, and I'm looking forward to chatting with you. I've been studying what I now call the psychology of technology since the early 1980s when there were no laptops, no smartphones, no nothing. You wanted to use the computer, you punched cards. You handed them to somebody who went into a very cold room, and they ran them. If you were lucky, you got to print-out this thick. If you weren't, you got a print-out that thin, and it meant there was an error, and you had to do it all over again.

What I was interested in way back then was something called computer phobia. And this is when computers were coming out. People were trying to use them. People were a little scared of them, a little frightened, a little weirded by them. Then we just kept changing what we were studying as life changed.

So, we went from computer phobia to technophobia, and we then went to tech and stress. Back I can't remember how long ago, I wrote a book called TechnoStress, which is funny because I reread it the other day. Most of what we said in my book was true, and yet it's probably 15 years old, if not more. We were looking at TechnoStress that you had at work, at home, and at play. So, it was invading everything.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  Then, since then, I've just kind of gone with the flow, whatever's interesting. I always tell people that whatever my kids are doing and my grandkids are doing is what I want to study.

Jennifer Ghahari:  Nice.

Larry Rosen:  I have a very low boredom threshold. So I'll study something for a while, and then I'll think I've got it. Then I'll move on and study something else. So I have worked my way to what I'm working on now. By the way, I'm retired, although retired just means I'm retired from teaching. I still do research, and I'm still very active on boards of directors for a lot of these groups.

One of the areas that I'm very interested in, I can only do this now that we've got newer technology, is what are people doing on their smartphones. As a corollary to that, what are teenagers doing? What are millennials doing? What are adults doing? We haven't really had the tools to do this until now, really till the iPhone got screen time and Android got digital wellbeing, I think they call it.

We were able to actually in the background have something track what people are doing, and what we get is an assortment of really valuable information. What I've done is had groups of teenagers and millennials at the end of their week when it pops up on screen time and says, "You've used 18 hours a day this week," or whatever the hour is, and then they can go back and get seven days' worth of data.

Because Apple doesn't allow them to download it, they take screenshots, they send us the screenshots. We then analyze them. What we're able to get from screen time is really quite a good picture of what people are doing. First of all, we get the gross amount of hours per week, hours per day. That sometimes can be telling if they're spending a lot, a lot of time on, particularly kids, perhaps video gamers, a variety of people who spend time on their phone.

We also get information on what apps they spent most time on. We get information on when they unlock their phone... Whether they have a face ID or a number ID or whatever or none, when they unlock their phone, what is the first app they tap? We also get how many times a day they unlock their phone, and we also get how many notifications they got each day and where they came from.

So, you can imagine we're compiling this set of data to be able to look at what everybody's doing out there because it's very clear. People are on their phones all the time. I mean, that's undeniable. I can't tell you how many times during the day I'll be at a stoplight, and there'll be a car in front of me. Light will turn green and be waiting and waiting. Oh, yeah. They're looking at their phone. Honk. "Oh, yeah. Sorry. I'll move on."

We take those 45 seconds and think we have to do something. We have to look at our phones, and we have to keep up. Otherwise, we think we're missing out on something, which is, by the way, why FOMO, fear of missing out, has developed because we have this sense that we're missing out on something.

Another attack that we tried to do, which, by the way, was a dismal failure, was to see if we could give teens and millennials strategies of how to treat their phone in a way that they might use less time on their phone. They might pick it up less often. We first tried giving them all sorts of choices. Some of them were take your icons for your social medias, put them in folders, scatter the folders all over the place so you don't know where they are thinking, "Well, they have to keep scrolling, and find the folders, and put the folders inside the folders, and whatever." That didn't work.

We tried to teach them how to meditate in order to be a little more calm when they approached their phone. That didn't work. We tried to teach them how to integrate technology into their work, such that instead of taking work breaks, they were taking tech breaks. That didn't work. I won't say it didn't work. It worked for the three weeks that we did it, and then as soon as we stopped, they went right back to where they were before. So then we tried it with fewer choices, but six weeks, and the same exact thing happened. They just went right back to where they were.

So, who's to blame for this? Because that's really what people are asking us. Who do we blame? Where do we point the finger at people who can maybe make changes? Obviously, one place to point your finger is at yourself. I think that's the first choice is you got here yourself. You didn't just stumble on it. You developed this habit, this way of treating your phone and in such a way that even if your phone is not in your pocket and you feel a little itch down there, you think that your phone is vibrating, which by the way is called pocket vibration syndrome, and is real. We experience it all the time.

The other thing we noticed is that when people walk around, say, from class to class at a campus or just walking around the campus, they are always carrying their phone in their hand because it is close. There is a point where women, girls used to put it in their bra, tuck it in there so that they really felt that vibration immediately, and then take a look, and see who's there.

Jennifer Ghahari:  Wow.

Larry Rosen:  The feeling is... It's when someone beckons you, whether it's instant message or whatever. When they beckon you, you feel compelled to go. I use that word, compelled, as part of the phrase, OCD, obsessive-compulsive, compelled, compulsive, behavior because a lot of what's going on is we are acting based on anxiety.

What are we anxious about? Well, we're anxious about missing out on things. We're anxious about not being Johnny on the spot when somebody texts you and texting them right back. We're anxious about a lot of things that take place on our device. Usually, it's the smartphone. Some people, it's the iPad, but in general, it's a smartphone, and in general, it's an iPhone. I will use iPhone as the whole generic category of Android and all those.

What we find is that we have lost control. What I mean by losing control is that we really don't understand why we're doing what we're doing. We just feel compelled, and that's the anxiety part. For example, take a typical teenager. They unlock their phone. They tap on an icon. We even have them take a picture of what icons are on the front screen. They're almost all the connection, text messaging, other kinds of messaging, instant messaging, lots of icons for social media. They're all there. They're all sitting there, waiting.

So, of course, you open your phone, the first thing you do is tap. The one you tap first may very well be the one you use the most, or it's the one that stands out the most, or it's the one that notified you. We have a compulsion to do that because if we don't, then chemicals in our brain and body start to build up and make us more, and more, and more anxious. So when we can't do it, we get anxious.

One of my colleagues, Dr. Nancy Cheever, did a really interesting study. You can actually see the study in action. If you go on my website and look at the very top where it says, "Anderson Cooper. Watch Anderson Cooper on 60 Minutes." So Anderson Cooper came into our lab and, Jenn, really nice guy. Came into our lab. Nancy sat him down at a desktop and said, "Okay, what we're going to do is show you a video and have you answer some questions later. We just want to put a couple of little things on your fingers," which now most people recognize one's an oximeter. Because of COVID, they know that.

The other one is more important. It's called galvanic skin response, which is the sweat on your skin. The sweat on your skin is equated to arousal, and arousal can be either positive arousal or a negative arousal. I mean, if I'm going to give a speech, my hands get very sweaty. It's not that I'm anxious about it. It's I'm excited. I'm excited to do it. But if I'm facing a really difficult thing that I have to do that's very uncomfortable, my hands might sweat, and that's anxiety.

So told Anderson, "Just put your phone upside down next to you," and then Dr. Cheever gave him about a minute or so of starting. She said, "Wait, wait, wait. We have to stop. That phone that you put down to the side is interacting with the two little clips, and so we're just going to need to move it behind you." She put it on a table behind him, and then she started texting him, but he could not answer.

She texted him four times. Every single time, galvanic skin response... spikes.... spikes... spikes four times in a row. We've done this with a lot of people, famous people, news, media, whatever. The interesting thing is it's always the same, except for one case, and I'll tell you the one case. What Anderson Cooper told us very clearly is, yeah, as soon as that beep went off, he felt a little rush in his body, which is galvanic skin response, and he felt like he was missing out on something, and he had to-

Jennifer Ghahari:  Wow.

Larry Rosen:  He felt like he had to check it right now, but he couldn't because we wouldn't let them. Now, interesting enough, people have very different ideas of why they need to check it. couldn't because we wouldn't let him now. Katie Couric, for example, felt like when her daughter was texting, she needed to pick it up quicker.

Steve Aoki, who I don't know if you know who he is, but he's a very famous DJ, and he travels with an army of people, all who monitor his social media, so he showed nothing because he didn't need to. His social media was being monitored by all of his team, and so he didn't show anything.

Two teenage girls, however, were brought in, and they showed not just spikes, but spikes. It was like, "Oh my God. What am I missing out on?" Part of it is because you know that if you get a text, for example, from someone, and you don't respond immediately, they'll text you back and say, "Are you mad at me," or, "Why aren't you answering my text," or something.

This is part of the problem, and I think this is the main part of the problem, by the way, is anxiety. We simply build up this anxiety over, and over, and over again, and the chemicals build up. Then our job is to do whatever we're anxious about so that the chemicals get reabsorbed.

For most people, cortisol is a pretty well-known chemical in our body and our brain. And we know that cortisol is the fight or flight chemical, but it's also in little amounts, not fight or flight at all. It wakes you up. Cortisol is what wakes you up in the morning. You get a little drip of cortisol. During the day, you get cortisol, and it kind of keeps your level of intensity at a pretty good state.

Another interesting study, not by our lab, but another interesting one is that somebody took... They recruited families with a mother, a father, and a teenager. Then what they did is beforehand, they had them fill out all sorts of questionnaires. How many times a day do you check your social media? How much time do you spend on social media? How much time do you spend on email and all sorts of various questions?

They went to sleep. As soon as they woke up, they took a Q-tip, took a swab, saliva swab, put it in a jar, sealed it, put it in the refrigerator, and then eventually sent it into a lab that records how much cortisol, right? They did it right when they woke up, and they did it 30 minutes later. Then they did it other times during the day, but that's not the point.

The interesting point is they were looking at what would cause your cortisol to jump from when you wake up to 30 minutes later. Now, nothing with moms, nothing. No use in general. No use of technology specifically predicted an increase. The dads' email did. Those dads that used more emails showed a bigger response in 30 minutes, which makes sense because they're working, and they get a lot of emails, and first thing in the morning, they got to check them to make sure what's going on.

For teenagers, the only thing that predicted an increase was those who use more social media. So you can already see this building up. You wake up, and you're already anxious. Even the first 30 minutes, you get more and more anxious. You just get more and more anxious. So the anxiety can be very debilitated, and particularly because, I mean, this is not an unknown fact, you can't have a lot of anxiety in you all the time. I mean, it would make you crazy. I mean, if you're always anxious all the time, they'd probably lock you up someplace because anxiety's reached a big peak.

And so, what I have always been interested in is trying to figure out ways to help people be aware of this, first of all, and then figure out a way for them to reduce their anxiety because the anxiety gets in the way of everything. It gets in the way of your thinking, your choice of attention, your multitasking ability, pretty much everything. It all takes place, by the way, right here in the prefrontal cortex, but the anxiety chemicals are buried in the brain and in the body. And in the brain, they're typically right behind here in the amygdala, which then measures your emotions and a bunch of other things.

So, my interest has really moved over the years to trying to figure out what is going on and what can we do to fix it. The first part's easy. The second part's not easy because as I said before, we tried to fix it, tried our hardest. Couldn't do it. We tried. Now, that's not to say that there aren't strategies to do it. I have a lot of strategies that I recommend to people, not a lot, but that we know work. But we're still facing this anxiety reaction all the time.

Jennifer Ghahari:  For, I think, a delight for our listeners, we actually are going to hear about two topics from you because it seems that you're kind of budding into a specialist into another field as well. Unfortunately, you were diagnosed with Parkinson's disease a few years ago, and you have started researching this and writing about your own experiences through a blog.

So, I was wondering if you could talk and share with our listeners a little bit about that. What are some of the first signs that you experienced? Especially as a researcher, you're going to have, I think, a different take on this type of diagnosis than someone without your skills.

Larry Rosen:  Right. And Parkinson's is a disease. It is a confusing disease because you can exhibit myriad symptoms, and no two people exhibit the same symptoms at all.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I noticed, for example, that when I walked, my left arm did not swing. When we walk, our arms swing back and forth, back and forth. Yeah, they swing. My left arm did not swing, which, I mean, it's a little strange. I also noticed when I was brushing my teeth that my arm was rigid. My left, my other arm was rigid and not moving also.

Jennifer Ghahari:  Wow.

Larry Rosen:  And didn't really know what it was, but I knew I'd better have an MRI to figure it out. Had an MRI done, and the MRI came up pretty clean in the sense that it really didn't show the Parkinson's because it's hard to do that, but Parkinson's is a biochemical issue. The chemical there, which is interesting, is dopamine.

Now, when we talk about kids being addicted to technology, for example, being addicted, dopamine is the main chemical we talk about. It's also the main chemical that those... part and parcel of Parkinson's. So one of the nice things is they can measure... Technology's so amazing. They can measure with a device sort of like a CAT scan or an MRI, but a simpler one, how much dopamine you have in your brain. They print you a nice, pretty picture, and the pretty picture has this orange-ish stuff showing the active dopamine. It usually looks like two little circles with commas coming out. If you have the requisite amount of dopamine, that's what you'll see. Mine had no commas-

Jennifer Ghahari:  Oh, interesting.

Larry Rosen:  ... just two circles. So that was pretty interesting. I am a scientist as you can tell from the science t-shirt. I am a scientist. This one says, "Science doesn't care what you believe, by the way," which I think is a good model for people to understand.

I had been looking at dopamine anyway, particularly with video gamers, because it's such an important part of what happens when you're addicted to video games, is this drive for more dopamine, this drive for more dopamine. You got to have it. You got to have it. You got to have it.

Well, so Parkinson's is a dopamine-related problem, and I started thinking about what to do about it. Now, you have to know that I'm a very open person, so I tell everybody everything, and so what I decided to do is to blog about it. I've been writing a blog for Psychology Today for years and years, and not very often, just maybe... Well, they yell at me if I don't do it every 90 days, so try to do it three or four times a year.

I like writing about technology because that's what I do. It's been writing about new generations, and kids, and video games, and all that stuff. All of a sudden, I'm sitting here looking at Parkinson's, and I go, "Well, why don't I write about Parkinson's?" So the first one I wrote called was called something like A Scientist Grapples with Parkinson's Disease because that's what I was grappling with.

I laid out in there some of the symptoms I have. I mean, for example, one's called micrographia. You write very tiny. Your writing gets tinier, and tinier, and tinier. There are other symptomologies that show up. Different people have different ones. Tremors. I have tremors in my left hand, but not my right, which was interesting, but that's not uncommon. Most people just have them on one side or the other to start. Sometimes they migrate.

So, I'm sitting here with a person sitting on my shoulder on this side, being the scientist, looking into it, and the person on this side being the person experiencing it. I thought I'm kind of in a unique place to be able to talk to people about what I'm feeling, and so I wrote that one. I wrote one the second year, and I just posted one for the third year a little late, mostly because I'm doing it kind of for me, my family, my kids, people I know.

I've seen symptoms come and go, more come than go, unfortunately. As you get deeper into Parkinson's and you start reading the research on Parkinson's, there are no two people who have the same Parkinson's. It just isn't. It isn't. Once it's diagnosed, you've can look at things. My neurologist has me always walk down the hall, watches my arm, whether it swings or not, but also watches how I turn to come back. Parkinson's people turn like this in little steps to turn around. I turn... I literally swivel like a ballet dancer. These are some common symptoms that you can see.

One of the interesting things is Parkinson's is a balance issue to people. People who have Parkinson's often fall, and that's really one of the major problems with... And people, by the way, do not die of Parkinson's. They die of something else that Parkinson's brought on, often Alzheimer's, often some form of dementia, often some other neurological problem, fall, hurt themselves. At the very end, you have trouble swallowing.

I just kept thinking, "What can I do to help myself?" Because part of the reading I found was, well, there's this boxing class, and boxing is good for your balance. I went to this boxing class. I joined a boxing class called Rock Steady Boxing. It's made for Parkinson's patients.

Jennifer Ghahari:  Wow.

Larry Rosen:  It's a franchise. People open their own little gyms or use other gyms. Couple times a week, I was going to this boxing class. It was great fun, by the way, hitting a bag, bam. Just a picture of somebody you don't like, bam.

What happened out of that is... First, the pandemic started, and so you can't be in a closed gym with a bunch of people, but there were a group of us. At that point, there was a group of four of us who'd kind of gotten to know each other, just chatting here and there. We decided to form our own little support group. Now, this is the pandemic, so every week, we met on Zoom. For a year-plus, we met on Zoom.

Then we decided to branch out and meet out in the open where we had lots of fresh air coming and everything. That was an important step, I think, because what that said to me is support is really important. Now, obviously, I get support from my family. I get support from my wife, soon to be my wife. We've been together for 18 years. We're finally getting married.

Jennifer Ghahari:  Oh, congratulations.

Larry Rosen:  Don't ask me why because I have no idea why we decided to do it, but 18 years seems fine. So they lend support, but it's a different kind of support when you get it from somebody who's experiencing the same thing. We talk about medications. We're all on different medications. We all have different symptomologies. One of the people walked in like this all the time. Why? Because he wasn't taking these meds.

Other people would talk about varying their meds. Their neurologist would let them take maybe a pill in the morning and another half if they felt uncomfortable. The medication, by the way, is exactly the same medication they've been using forever. It's called levodopa, which they always talked about that with Muhammad Ali and various other people who had Parkinson's. Levodopa is the drug of choice. It's actually called Sinemet because it's combined with another drug so you don't get nauseous and constipated, I think, are the two bad things for that.

I started on a very low dose, and my hands shook like this. Also, interestingly enough, my thumb would often stick to my finger, and I would have to pry it off. I've never met anybody with that symptom, by the way. It'd just stick.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I go, "That's weird." Well, I pry it off, and then it's fine.

I have had to increase my Sinemet, my medication quite a bit. The maximum you're supposed to take is 2,000 milligrams. I take 900. My doctor swears that's fine. I'm in a great range. Don't worry about it. We're really good. That took away all my tremors. I rarely have tremors, unless I get stressed. If I get stressed, the tremors come right back.

Jennifer Ghahari:  Oh.

Larry Rosen:  Yeah. Because stress-

Jennifer Ghahari:  Even with medication?

Larry Rosen:  Yeah. Stress exacerbates the symptomology that we ha, particularly the tremors. Stress just knocks the tremors back in. Along the way, I mean, I've experienced it. I've written what I've experienced. There's cognitive deficits that I have. There's physical deficits that I have.

The interesting thing is the cognitive deficits are hard to deal with now because I'm 72. How many of the cognitive things that happen to me, like not being able to remember names, happen because I'm 72, not because I have Parkinson's? So, trying to disentangle those is very difficult. You just have to kind of accept that they're either/or and talk to your neurologist about what they may be.

Then over time, I mean, the symptoms come and go. I have some interesting new ones. One's called REM behavioral disorder, which is when your REM sleep, we have movements. When we sleep, Parkinson's patients, those who have this disorder, will act out their dreams. I will pound things. My wife told me last night that she woke me up because she said I was just pounding and talking.

Jennifer Ghahari:  Oh, wow.

Larry Rosen:  I was just literally acting it out. That's all again caused by the dopamine.

Jennifer Ghahari:  Wow. So in addition to these physical and cognitive implications, what about comorbid mental health conditions? Are anxiety and depression common or any other...

Larry Rosen:  Yeah, all of them. Anxiety and depression are common. In fact, when I was prescribed my first Sinemet, I was also prescribed an antidepressant-

Jennifer Ghahari:  Right off the bat?

Larry Rosen:  Right. Because my neurologist said, "You're going to be depressed for a while. Sorry." Then as things went on, I also was prescribed an antianxiety because certain things were making me anxious. So you have to balance the mental health aspects, but they're always going to be there. There's just no way you can skate through this and just go, "Ugh, I'm not feeling bad at all." It's depressing.

It's depressing particularly because the way they show Parkinson's is more end-state Parkinson's Michael J. Fox is not the Parkinson's norm. He's trembling all over the place, and his speech is problematic, and his throat closes up a bit. Yeah, he's not the norm. The norm are people who are like me. They have some symptoms. They try to get rid of the symptoms.

Part of what I'm trying to do in my life is give back because I taught for 45 years, a college profession, and I've done research, and I've participated out there, and given speeches, and all sorts of stuff. I felt like I needed to give back what I knew. Part of it came from our little support group.

I live in San Diego County. There's an organization here called Parkinson's Association of San Diego. There's Parkinson's associations everywhere. One of the things they did is open a mentor program, and so I immediately put my name in to be a mentor. I suggested that I'd rather mentor newly diagnosed people. Interestingly enough, I haven't really mentored any newly diagnosed people, but I've mentored a bunch of people who are really like me, kind of older, scared, concerned, everybody with different symptoms.

I talk to this one guy every week or so on the phone now. When I started talking to him, his mouth movements were not very good. He was a very slow speaker because of it. Over time, it's been interesting because he's now developing speech better, and so he and I can have a conversation where I'm not just sitting there waiting for the next word to come out.

Everybody's different. That's what's so interesting. Everybody's different. I feel like coming from a scientific tradition, I was really raised as a statistician, what that allows me to do is to look at the research and decide whether the research is good or maybe only suggestive. That's an important thing, I think, because research is tricky. Over the 40-some-odd years, plus graduate school, that I was doing research, there are tricks of the trade. There are ways to make a study good. There are ways to make a study bad. There's ways to make conclusions that shouldn't be there.

So, I read those things voraciously. People send them to me, and I read them. I don't talk about them on my blog because I don't want to shame anybody. But I do talk about with new people, here's some new things that are coming up, and I do talk in interviews like this about here's some of the things that might expect.

By and large, it is being diagnosed more, which I think is very interesting. Part of the reason why, by the way, it's diagnosed more is because now we have the testing, the DAT scan to really test it, and we have MRIs that are better. We have tests of fives or something the MRI takes, which is really great stuff, the fine brain stuff.

I will keep writing about it, and I will keep letting people know the symptomology that I have. By the way, because of my cognition problems, I did take a whole neuro workup. I just got the report, and I read part of the report. There are some neurological deficiencies, not horrible ones, but there are some neurological deficiencies, which is helpful for me to understand.

Interestingly enough, attention is one of the major ones right now, and I have a lot of trouble attending. I used to be a great multitasker. Don't do it. Can't do it. I used to think quickly. Sometimes my thoughts get a little muddled, and I have to kind of hold them inside until I get them out. I miss things. I see something on TV, for example, and somebody will say, "What did that person say?" Oh, I don't know. I don't know because my attention waned. So I'm able to say all those things, and I hope people who need it will read it.

Jennifer Ghahari:  So those issues that you just spoke of, how do you know what the difference is between a symptom of Parkinson's versus just normal aging-

Larry Rosen:  That's the million-dollar-

Jennifer Ghahari:  Or there's no real way to know, right?

Larry Rosen:  Million-dollar question. No, there's no real way to know. The interesting thing is I think it's good that there's no real way to know because as we get older, those aging symptoms will be there as well as the Parkinson's. Who cares whether it's aging or not? It's still interacting with your Parkinson's.

If I have trouble attending things, it's going to interact with my Parkinson's. If I have trouble remembering names because I can't pull them out of my hippocampus or whatever, it's going to be... Whether it's old age or Parkinson's, it doesn't really matter quite honestly. I mean, most of the people who get Parkinson's are older, so it's all mushed together. How can you tell?

But one of the things I do talk to people about is that they should be very careful to have someone watching over them because part of what happens and because this is dopamine... By the way, we always think of dopamine as the pleasure chemical, but it controls motor motions. And so if you have less dopamine in your body, you have poorer motor motion. One of the first questions the neurologist will ask, "Have you fallen in the last X amount of time?" Because that's a real strong indicator of potential Parkinson's problems.

So, I try to walk more. I try to make sure my balance is there. I also have a spiral staircase in my house, and I'll hold on. At times, I'll take two feet on one step, make sure that I'm not going to fall. I've not fallen yet, but I've definitely stumbled a lot and just been able to grab myself, but I've missed the bottom stair of our stairwell before a couple times. I stumble. Luckily, there's a wall right up there, so I put my hands against the wall. Saved my life.

Those are kind of all things that are individual. The anxiety, by the way, is pretty common. The depression is very common. And so from a psychological point of view, those are the kind of things. Yeah, am I depressed because I'm older? Am I anxious because whatever? Those things are also all tied up in one.

Interestingly enough, because of my work with technology, I'm able to talk about the biochemistry of it because of all the stuff that I've done with the biochemistry of the brain with technology. It's a pretty natural step, I found, to go from looking at that kind of biochemistry to looking at the biochemistry of Parkinson's.

Jennifer Ghahari:  Talking about social support and how important that is, you mentioned family, friends. You're part of this boxing group, which morphed into just a social support group. You're also mentoring people. In one of your blogs, you said something like, "I'm not complaining. I'm just reporting." I'm wondering, especially when you're trying to be in a supportive type of setting, whether you're talking to family or in a group, how many people feel like they are actually complaining and they might want to hold back what they're feeling? Is that common or are people more comfortable to talk about things?

Larry Rosen:  From my experience with Parkinson's patients, they are embarrassed. In our little group of four... ended up being five. Now, one passed away, so it's four of them.

Jennifer Ghahari:  Sorry.

Larry Rosen:  We don't meet anymore in the boxing because the person running the boxing program is not vaccinated. I mean, none of us... Even with Parkinson's, you don't want to be anywhere near that stuff that might have an effect on you. There's not been proven a link, but it's still there.

I think that the support you get is the way that you're able to judge aging versus not aging. In our group, there are people in their 60s, 70s, and one is in his 80s. We all reacted differently. I told everybody because that's me. One person only told her husband. That was it. Hadn't told her whole family that she has it. Another person told selective people. I think it's important to be able to see people in a similar situation as you are. I don't know if you know this, but Alan Alda has Parkinson's.

Jennifer Ghahari:  Oh, I didn't know.

Larry Rosen:  It's funny. He's actually done a lot, and I like what he's been working on. He was in a movie. The movie was the one where Scarlett Johansson and Adam Driver were getting divorced. He was playing Adam's attorney, and so they're sitting at a round table, and you see his right arm is down to the side, and his left arm is here. Then every once in a while, he brings his right arm up, and it's shaking a little, so he put it down. It's a little bit more... That wasn't maybe part of the script, and so they made it as innocuous as possible, but if you go on his Twitter, he talks about it a lot.

Having people do that helps normalize it. I think that's going to be real important for people. I mean, Parkinson's sounds like a really crazy, bad disease, which, I mean, on the whole, it is, but it's not as scary as we always thought it was. We're not going to be Michael J. Foxes. I mean, because he literally has a bad case of the tremors on both sides, as well as speech problems, and all sorts of things. He's at the end, and some of the people I know are spread out in there. I would consider myself maybe not at the other end, but sort of third of the way in because I don't tremor much.

Jennifer Ghahari:  And you were diagnosed how long ago?

Larry Rosen:  August 2019.

Jennifer Ghahari:  Okay. So you have had the disease for a few years now.

Larry Rosen:  Okay. So what's interesting is, yes, most people have Parkinson's for a lot longer than they know. One of the first symptoms is loss of sense of smell, and not everybody again, but it's a pretty common symptom. I lost my sense of smell, most of it, 10 years ago, which they would say is because you have Parkinson's.

Jennifer Ghahari:  Wow.

Larry Rosen:  I don't know how long my left arm wasn't moving because I wasn't paying attention to it. My guess is it was a long time before I was diagnosed. The only reason I was diagnosed is because I felt like there were some things that were just different that I didn't understand neurologically.

Jennifer Ghahari:  Wow. That's great. And I appreciate that you're coming on here, and speaking with us, and showing, as you're saying, a more normalized version of Parkinson's, that not everybody's going to have the absolute extreme version, especially right off the bat. So, if anything, this is going to be a really huge help, I think.

Larry Rosen:  Michael J. Fox has had it for like 30 years and-

Jennifer Ghahari:  Right. Yeah, it's been a long time.

Larry Rosen:  Yeah. What I think in the long run is the diagnosis is going to be made more often. By the way, there's all sorts of sub-varieties of Parkinson's, essential tremors. There's a Lewy bodies part. There's a whole bunch of little subcategories. We can have those or full-out Parkinson's. They have different symptoms and different effects.

I think because of our technology now, and because we're just more aware of it... I mean, Michael J. Fox is out there. Other people are out there talking about Parkinson's. Because of that awareness, I think more people then go to the doctor and will be diagnosed. We'll get better ways of diagnosing them, and we'll get better ways of treating them.

There are a tremendous number of research studies going on right now on other treatments other than drug treatments. For example, there's something called DBS, direct brain stimulation, where you literally have a little thing here, and it stimulates... It's like a nine-volt battery and stimulates the prefrontal cortex, which has been shown to help with your thinking and your attention abilities if one of the symptoms is you're losing your attention.

I mean, I have high hopes that the more we see out there, the more we'll understand out there, but it's scary. I mean, I would tell anybody that has Parkinson's. The first thing I would say is, "I bet you're scared." The answer is always, "Yeah, I'm scared to death." They have a reason to be. I mean, it's not a death sentence, but in general, people who get Parkinson's, they live maybe 20, 30 years with Parkinson's, or it can go really quickly. You just don't know.

Again, the medications are much better. The medications are better. There's lots of other meds besides the one I'm taking. The one I'm taking just is the base one you start on. If that doesn't work, they can give you other meds on top of it, or interestingly enough, the meds stop working typically after... I think Sinemet, they say, in general, stops working maybe every about five years with that. You have to find something else.

Jennifer Ghahari:  Yeah. I think, as you said, it's almost the fear of the unknown. That's the biggest drive of anxiety for people, and so I think things like this where you're helping disseminate information and just experiences is a really huge help for people.

Larry Rosen:  And one of the things that I would recommend is... The Parkinson's Association of San Diego has done a really nice service for people, and what they've done is they've had professionals record very short videos, we know our attention span is way too short these days, eight, 10-min videos on different symptoms and different kind of things that happen. It's just pasd.org, I think. They're free. You can go look at the videos. There's probably 30 or 40 of them, maybe even more.

Jennifer Ghahari:  Wow.

Larry Rosen:  The PA for my doctor does a few, and other people who know what they're doing do a few. Then my doctor, my neurologist is involved in lots of research too along with it. So I get to kind of eavesdrop and hear what she's finding. She talks on there about her research. People talk about the REM behavioral disorder and what it means. People talk about how to know when your medication's not working. So they're just little blurbs. I encourage people... I think it's a really great idea to just go there and harvest what we can.

Now, having said that, when I was diagnosed, I did no reading. In retrospect, I was scared to death and I didn't want to know. Everybody else read for me. My kids reported. My wife reported. Everybody read for me. Then at some point after about six months, I found that I was able to dive in and see what's there. Also, I mean, I encourage people to not be afraid to say, "I'm afraid."

Jennifer Ghahari:  Wow. Thank you. So psychologist, who's an expert in technology, someone who's battling Parkinson's, do you have any parting words of advice or anything else that you'd like to share with our listeners?

Larry Rosen:  Well, on both sides, I can share a lot about the technologist stuff, but I think keep track of what you're feeling. If you need to, take a diary. Keep track of it in a diary. Mark down when something odd happens, something weird happens. It may be Parkinson's. It may be not. At least, it's noted.

Don't spend a lot of time reading research because it's in its infancy. We're talking about really the last 10 years maybe that there's been this new emphasis on Parkinson's, even though Michael J. Fox had his foundation for quite a while, but it's pretty much a new phenomenon. When you say to somebody, "Oh, I have Parkinson's," say, "Oh, my uncle had Parkinson's, and my mother's sister had Parkinson's." Everybody knows somebody that had Parkinson's.

And to just realize it's not a death sentence, but you also need to kind of be aware of your body and your mind because you can just go on gleefully unaware, and then the symptoms will definitely get worse left untreated. What you want to do is try to get the best treatment possible and really trust that...

You're not doing this through your family doctor or your internist. You're doing this through a neurologist who knows Parkinson's, whether it takes... Even if you have some of these symptoms, and you try to get an appointment and you can't get an appointment for four months, don't worry about it. Nothing's going to much change in four months maybe.

Keep track of your symptoms. Keep track of everything. Don't study the research on it. Go look at how you can diagnose Parkinson's. There's lots of things that talk about how you walk or do this. (Moves his hands) My right is faster than my left.

Jennifer Ghahari:  Oh.

Larry Rosen:  Typing, my right is better than my left. I can't type anymore. I mean, I can type. It's just I make lots of mistakes. Keep track of your symptoms. Keep track of them, and write them down. Make sure that you are being as dispassionate as you can, but yet accept the support of other people. Don't ever let somebody tell you you're going to die of Parkinson's because they will. They'll say, "Oh, my uncle had it for 20 years and then died."

Jennifer Ghahari:  Right. Well, thank you so much. If anybody wants to read more about Dr. Rosen's research or read more about his blog, you can do so at www.drlarryrosen.com, and we'll have that link on our site.

Larry Rosen:  And the doctor is just D-R. Mention that maybe.

Jennifer Ghahari:  Oh, perfect. Thank you. Yeah.

Larry Rosen:  Please feel free to message me too. I mean, I enjoy talking to people about this because I think I can maybe not... Don't I'm a great helper, but I'm a pretty good listener.

Jennifer Ghahari:  Aw.

Larry Rosen:  And I think that's important.

Jennifer Ghahari:  It does make all the difference, definitely.

Larry Rosen:  Yeah.

Jennifer Ghahari:  Thank you so much, Dr. Rosen, and we wish you all the best.

Larry Rosen:  Thanks. Thanks for having me on.

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.

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 Amanda Ann Gregory on Trauma & Roe v. Wade

An Interview with Therapist Amanda Ann Gregory

Amanda Ann Gregory, LCPC is a psychotherapist, national speaker, and author. She holds licenses in the states of Illinois, Texas, and Missouri, and has EMDR certification. She specializes in working with trauma survivors.

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 today with us the trauma psychotherapist, Amanda Ann Gregory. Amanda is a trauma psychotherapist, national speaker, and author. She holds licenses in the states of Illinois, Texas, and Missouri, as well as an EMDR (Eye Movement, Desensitization, and Reprocessing) certification and a National Counselor certification. Amanda has provided individual, group, and family therapy for more than a dozen years in outpatient and residential settings, and is currently in private practice in Chicago.

Her work has appeared in Psychology Today, Psychotherapy Networker, Happiful Magazine, Addiction Professional, and other magazines. Amanda has also served as a presenter for clinical conferences, employee trainings, and community events and has spoken for the American Counseling Association, the National Alliance on Mental Illness, the Missouri Department of Mental Health, the Missouri School Counselor Association, Prevent Child Abuse Illinois, and the Missouri Association of Marriage and Family Therapy.

Before we get started, could you please tell us a little bit more about yourself and how you came to work as a trauma psychotherapist?

Amanda Ann Gregory:  Yes. How I came to work in trauma was actually by accident. My very first job out of graduate school was at a very specialized residential treatment center for teenagers, which specialized in treating developmental trauma, which especially at that time really wasn't well known and it’s trauma that basically occurs in childhood over a period of pivotal development. And when I was there, I absolutely loved it. I loved working with trauma survivors, and I didn't want to leave it. And so I took those skills into the outpatient world in community mental health centers. Now, I'm in a group practice. And so this is a population that I just fell in love working with. And later, honestly, realizing that I'm also a developmental trauma survivor, and so, really feeling that I'm connected to this population. I was able to do my own work, my own trauma treatment, which is a big part of being a trauma clinician. And so really it's twofold. It's a wonderful population to work with, and also I consider them my people, my tribe, so to speak. Yeah. And I just always feel grateful to be able to do this work.

Anna Kiesewetter:  That's really beautiful. Thank you for sharing that with us. What does this therapy generally look like for you?

Amanda Ann Gregory:  And can you say that again?

Anna Kiesewetter:  Yeah. What does therapy generally look like for you as a trauma therapist?

Amanda Ann Gregory:  Right. Dealing with trauma, it's a little bit different sometimes from other types of therapies. When we think of therapy, sometimes we automatically think of talk therapy, which is typically cognitive behavioral therapy, but with trauma work, it's a bit different because you have to bring in other interventions to address those earlier developing parts of the brain. And so therapy for me really depends upon the trauma survivor, what they've already been exposed to, what work maybe they've already done, or is this their very first time participating in treatment? I tend to combine a lot of methods, so I'm attachment based. There's a big focus on the relationship with the client and creating that safety to start. And I bring in a lot of interventions to help the brain such as EMDR, somatic experiencing, maybe even at times play therapy, animal assisted therapy, internal family systems. It's really eclectic depending upon what the client needs, but it does look a little bit different at times from what people may think of as that talk on the couch type of therapy.

Anna Kiesewetter:  That's really interesting. Could you tell us a little bit more about how it differs from the talk therapy practice... It sounds like it's a little bit more hands on for the things that you do. Is that right?

Amanda Ann Gregory:  Yes. It could definitely be more hands on and a bit more interactive. Here's an example. Let's say I'm working with a client about, let's just say one experience that they've had that they've really kept with them. It's really blocked them in areas of their life. And we would call that trauma. Some people, if they're working with a client, they may want to talk through it. They may want them maybe to create a narrative of their experience, which can be wonderful. My type of therapy is bringing more things, for example, the body. When you recall that memory, what do you notice in your body? Connecting with that sensation, helping that sensation to process.

With EMDR, we do a lot of that bilateral stimulation to desensitize the actual impacts of those experience and reprocess adaptable core beliefs. Instead of the client telling me what happened and going through the story of it, I might move their eyes back and forth, back and forth. I may have them hold onto these vibrating tactiles that go back and forth, back and forth in their hands. And that's what's helping them process and I'm going to help them along. I'm going to be right there. It's definitely not hands off, but it does tend to be a bit more experiential in nature.

Anna Kiesewetter:  I see, yeah. Thank you for explaining that. Awesome. Okay, now that we've gotten to know a little bit about you and the therapy work that you do, today, I'd like to address a topic on a lot of our minds. On June 24th, 2022, the Supreme Court overturned its Roe v. Wade decision in the US, ruling that the right to an abortion is not protected under federal law and delegating jurisdiction over abortions to the states. Following that ruling, abortion has become or will become illegal in over a dozen states whose legislatures had passed automatic trigger bans, as reported by the New York Times. In a recent article that you wrote, you write that this ruling is particularly harmful to trauma survivors. I'm wondering, what are the implications of this ruling on survivor's physical and mental health?

Amanda Ann Gregory:  Yes. The issue about this ruling that tends to threaten, sorry, trauma survivors is it really does threaten that sense of safety. And if we can just use that as a foundation: just safety. And if we look at trauma, trauma is usually created by an experience or a bunch of experiences where that safety wasn't there, or perhaps that agency or autonomy wasn't there and that's created this response. If we take these folks who've had those experiences and then we have something like this happen, which does strip people of that agency and that autonomy, that does not feel safe. And so basically what we're asking now is trauma survivors to try to heal, try to recover, try to not offend others because of their trauma, which at times has happened. We want them to do this work, but we're not going to provide that safety.

It's kind of like you get healed, you do your best, but we're going to take some of that safety away. And in trauma treatment, any trauma therapist knows that doesn't work. There has to be maybe not 100% safety, but some foundation of safety for trauma survivors to be able to work on this and to be able to really move past surviving to thriving. And this ruling makes that so much more difficult, because it really does strip that safety and really specifying that, and I'll just use the word agency, taking away that agency, that bodily agency, that relational agency, which directly has a negative impact on mental health.

Anna Kiesewetter:  Right. Yeah. Thank you for that. And here at Seattle Anxiety, we focus a lot on anxiety disorders. I'm wondering with the implications of this ruling on trauma survivors, how this impacts anxiety disorders or any anxiety symptoms in survivors?

Amanda Ann Gregory:  Sure. If we look at anxiety, we just take trauma out of it for a second, trauma is anxiety. They're very much mixed up, but if someone, let's say, has a generalized anxiety disorder, and they're in this world, this is definitely going to create some anxiety because it's, well, now my choices are restricted. Now I may have to worry about this and that. And even if you feel like it doesn't apply to you, for example, if you are someone capable of giving birth, you don't want to do that at all. Don't want to even be involved in that. Knowing that somebody else is restricted in some capacity in their choices could make you really feel unsafe and it could lead to a lot of additional worrying. Folks who experience anxiety tend to struggle with racing thoughts, worrying, issues like that. And this could really infiltrate that and actually make that significantly worse.

Anna Kiesewetter:  That makes sense. And then on the physical health aspect, I know you write also a little bit about how there is a continuation of trauma and often being more exposed to the source of the trauma if you are put in a place where you're forced to carry a pregnancy to term. Could you talk a little bit more about that and the continuation of that trauma?

Amanda Ann Gregory:  Right. If we go back to safety and look at that agency being stripped, it's like you're suspecting to be back in that situation again, or you already feel like you're back in it. And so actually, I believe the United Nations actually believes that forcing a woman to carry a pregnancy is a crime against humanity. And so I think that's interesting that they have that set and then yet we have that overturned here. And if you just think about the restriction of that, and if we look at relational trauma. Okay. If somebody has a relationship, it could be with a parent, it could be with a romantic partner, it could even be with a friend or a community member, and that relationship is not safe. Let's say it's toxic. Let's say there's abuse involved. What do we tell these people as a society? We say, “Get out.” Right? “End the relationship, have some boundaries, get out.”

Okay. But what if certain decisions made by other people are forcing you to stay in that relationship in some capacity? There are states that a rapist can sue for parental rights of a child. And that means that you will need to have a relationship with this person in some capacity going forward. And so you can't just get out. You can't just have these boundaries because that's very much restricted. And so let's just take rape out of it for a second. Let's say you're in a relationship and it is abusive and you get pregnant. Would you be required to carry that child to term? And is that going to hold you to that other person for at least 18, 19, 20 years, maybe the rest of your life, honestly? Is that going to help you or is that going to traumatize you or is that actually going to feed more of those trauma responses? And it will. The thing about trauma is it compacts upon itself. It's very rare just to have this one event.

Now, some people do have one traumatic event that I need to address, but when it comes to developmental trauma or complex trauma, it compacts. It's a series of these progressive experiences. And what we sometimes see with trauma survivors is their old coping mechanisms, what they needed to do to survive, they keep doing it into adulthood. They just keep doing it. And so this can create situations for folks to continue to have that trauma compacted upon itself.

Anna Kiesewetter:  Right. Yeah. That's very important. You also write about the implications of this ruling on the messaging it would send to children about consent and bodily autonomy. Would you be able to tell us a little bit more about how this ruling affects childhood development?

Amanda Ann Gregory:  Sure. A couple of ways, one, I'll talk about the children being around the adults and then just the children. And so when adults don't feel safe, when adults don't feel like they have a sense of agency, children pick up on that. They do. And we try to keep that from them. We try to protect them, but we have to understand that we're actually putting that off in all this nonverbal communication all the time and children constantly pick up on that. When a child is with an adult who, let's say, is their primary attachment figure and the adult is struggling, then the child's going to pick up on that in some capacity. And so now we have parents who may not feel as safe as they did before this was overturned. And we have those children in the home who are going to also pick up on that.

And if you think of it from a child's point of view, I'm requiring, I'm really relying on this adult or this set of adults or maybe multiple adults to keep me safe. But if they're struggling, if they don't feel safe, how are they going to keep me safe? And these aren't words that are spoken. It's very nonverbal. That's one thing that may negatively impact children. Second is as some cultures, we tend to struggle at times with teaching children about bodily agency and consent. Sometimes we will do these things of “Give me a hug, give me a kiss, go hug grandma, go do it.” We send those messages, which isn't great, because it doesn't really line up with what we say and “Hey, if anybody touches you, you need to tell us. These are the places that they can't touch.” We have to provide that education, but then somebody in your family or somebody that your parents trust can just do whatever they want and you have to consent to that. We do tend to send some mixed messages to children, I think.

And there is a movement in child psychology to really encourage parents to request children to provide physical intimacy if they would like. For example, “Would you like to hug grandma? Is that something you would like to do?” Or asking a child, “Can I give you a kiss?” Things like that could actually build up more of that sense of teaching a child, “This is your body - yes, within reason, some adults may be making some medical decisions or things like that for you, but I'm going to expose you to the fact that this is your body. You get to decide what you do with your body. You get to decide who touches it, who doesn't touch your body.” And those messages can be pretty mixed. And now we're in this society with this Roe versus Wade being overturned, which well now, what are we telling children? Are we telling children that only the boys have controls over their body? Where is that line there between, we're trying to teach them to be safe, but then we're not providing this global safety or this national safety for them. For children, very, very confusing.

Anna Kiesewetter:  Right. That makes a lot of sense. Still on the topic of children, you've written another piece on how to talk to children about the experience of growing up in the era of school shootings, in light of the mass shooting in Uvalde, Texas. I was wondering if we could relate this a little bit to this question and think about how you would approach conversations with children about abortion rights.

Amanda Ann Gregory:  Right. When it comes to these big national events, it could be very intimidating for us to talk to children about that and to know what to do, whether it's a school shooting or a decision being overturned that really impacts us and them. I always tell parents, start with curiosity. Don't assume a thing. Sometimes we come to children and we assume they know nothing. And then we get all this information about things they've heard. And of course in our digital age, it's just one click away for them to find all of this information. Even very small children know how to do that. We don't know what information they've already been exposed to. The first thing I tell parents is, just be curious. Approach the conversation with calmness, just very gentle, and just be curious, "Hey, what have you heard about this?”

“What have you know about this? What are their friends saying?” Just be very curious and to listen first. We want to jump in. We want to give insights and advice. And sometimes, especially if a child reports not feeling safe, we want to fix it. We'd be like, "You're safe. I'm going to keep you safe. It's not going to happen to you." Well, hold on. Let's listen first. Do they have any concerns? Do they not feel safe? Do they have any questions? And then really validating what are they going through? If a child is confused about this, validate that. Absolutely it's confusing. This is a really tough thing to understand. If a child doesn't feel safe, validate that. If a child doesn't care, they're just like, "Ah, I don't really care about that." Okay. Validate that and acknowledge that. And notice that there's so many steps before we get to actually implementing or speaking. We're being curious. We're listening. We're validating.

Then I think if we need to, we can move into problem solving. We can move into providing them maybe some education or some information, but not before we go through all those steps, because that really opens up the line of communication and it keeps it open. Because things like this, whether it's a school shooting or Roe versus Wade, it's not going to go away. These things are going to keep happening. They're going to keep developing. With kids, we really want to keep that line of communication open. We want them to know it's safe to come to me. It's safe to talk about this.

Anna Kiesewetter:  Yeah. Thank you for that. I think that's going to be really helpful for parent listeners. I'm also wondering: what do you think that the mental health community and psychotherapy can do to help survivors post-Roe?

Amanda Ann Gregory:  Yes, there's a couple of things. First off, when it comes to mental health providers, and I'm sure they're already facing this, it's so important to allow clients, members of your family, people in the community, really a safe space to process this. And that's really exploring their thoughts and feelings related to this. Sometimes we want to shut that down. We want to move people over here, over here, but what if we just step back and we just allowed them to process. There were quite a few clients the next day and this week in my sessions with them that they needed that time. They needed that space. And as a clinician, it may be tempting to say, "Whoa, hold on. This isn't what we're working on. We're working on your trauma or we're working on this or that. Let's focus on that."

No, you can't. You have to address what's happening in their lives here and now to not only support the relationship you have with them, but free them up, get these wheels going, get that processing going. And when it comes to trauma survivors, we can't pick and choose. We can't say, "Okay, well this is something going on now, but let's focus on your past." It's interwoven. It all comes together. I think it's really important to give the people in our lives the time and the space to really explore this. And that can be really difficult. And again, when putting this to members of the community, it's the same thing. We're all going through this together. And it's regardless of if you agree with the decision or if you don't agree with the decision. I think this is really stressful for everybody. And I think when we provide those safe places for people to explore that, it's one of the best things that we can do.

Anna Kiesewetter:  Yeah. Thank you. I think that's very important. With that, do you have any final thoughts or insights that you'd like to impart to our audience, on the Roe v. Wade decision or about children or school shootings? Anything that you'd like to talk about?

Amanda Ann Gregory:  Yeah, I do have one more point. This might be a little controversial, but this isn't political. If you really take a step back and look at it, whether if it's Roe v. Wade, whether if it's the war in Ukraine, whether if it's a school shooting, it's not political. And I think we sometimes use that as a mask or a band-aid to hide these things. And as a clinician, I had people reach out to me and say, "Thank you so much for just talking about, for just writing about this because we don't really see this from a whole lot of clinicians." And that shocked me.

And I saw just online and in social media, there was this movement to try to get counselors therapists, social workers, to stop talking about this. People were saying, "This is political. You need to just treat people. You need to keep this out of the conversation," but that doesn't work so well. We don't live in a vacuum and if we are devoting our lives to treating these folks and helping them, then it's very difficult to stay quiet when things happen that we know is going to have a direct negative impact upon them and could very easily sabotage treatment and make it so much more difficult. And so I did hesitate before writing that article that you read or even doing this interview.

There were some people that said, "Oh, you're not going to get certain clients" or this and that. I was like, "I get that. That's a risk. But I can't pretend that it doesn't impact the same people that I'm trying to help." And so I guess I would say that if something is going on that impacts your clients, think about that. Do I want to say something? Do I want to advocate? Does that feel right for me? And if not, simply allowing your clients or the people in your life that space to process that and process that with you might be another good option, but when it comes to these events that cause trauma in folks, that really perpetuates trauma, it's not political not anymore.

Anna Kiesewetter:  Right. Thank you. I think that's so important. And thank you so much for everything that you've talked with us today about. I think you have a very powerful message and it's really important at this time to have that. We wish you the best and hope to have you back for another interview in the future; thank you again for coming. And that'll conclude this installment of The Seattle Psychiatrist Interview Series. Thank you all so much for listening and we hope that you'll tune in next time.

To read more about Amanda Ann Gregory, click here.

To access our PTSD Self-Care page, click 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 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.