51 Jessica Borushok, The ACT Therapist, PsyD

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[00:00:54] You need help like this guy, call your own doctor. What if the problem isn't your anxiety, but rather your relationship to it? Today, we're joined by Dr. Jessica Borishat, known as the ACT therapist, a clinical psychologist and ACT trainer who's helping reshape how we understand anxiety, rumination, and psychological rigidity.

[00:01:20] Her work centers on building psychological flexibility, teaching patients and clinicians how to step out of an unhelpful cognitive pattern and move towards values-driven behaviors, even in the presence of distress. This is a conversation about shifting from symptom control to actually living well. And for Renegade Psych listeners, watchers, we have become increasingly familiar with ACT over the years.

[00:01:48] I don't know if I could do my job without it. So, without further ado, welcome, Jessica. It's very nice to have you on the podcast. Thanks so much. I'm excited to be here. Tell us, I guess, a little bit about just your background, where you're from, and how you got introduced to ACT therapy. I'm originally from South Florida. I got my master's and then my PhD in clinical psychology from Bowling Green State University in Ohio.

[00:02:16] And I feel like I was very lucky. A lot of people stumble upon ACT after they've already been out in the world practicing for a while, whether they do a continuing education credit or something like that. I was introduced to ACT in my first year of grad school. One of my professors, Dr. Bill O'Brien, introduced, you know, he likes to sneak in ACT into all of the classes that he does. And I just became absolutely hooked. I did more trainings.

[00:02:44] I got involved in ACBS, the Association for Contextual Behavioral Science. That's kind of like the intellectual home of ACT and have been actively involved with them. And now today, my main job is private practice. This is, you know, my home office where I do telehealth with clients all over the country.

[00:03:04] And then I also train other therapists how to use ACT in the work that they do and then have my own YouTube channel where I share a little bit more about ACT sporadically. I've referred a couple of patients to your YouTube channel and I've watched several of the videos. They're great because they're really short form and they dive into one particular niche within ACT and explain what it is and how to utilize it.

[00:03:31] My experience was I went through all of my medical training. I got into my residency. In my second year, we start doing half a day a week of therapy. So four hours of therapy once a week. Got a lot of CBT training, but we kind of just get thrown to the wolves and they're like, all right, go do therapy. And it's like, what the fuck? What do you mean? We've had this little module on it. You know how to help people go out into the world. I don't know how to do therapy.

[00:04:00] And so my introduction to ACT was just through desperation and trying to find a way to connect with patients that didn't feel. I don't want to knock on CBT because there's a lot of concepts within ACT that are born or bred out of CBT, but it just seemed too algorithmic or not individualized enough. So I'm a little bit curious.

[00:04:27] Again, no formal training in ACT in my residency, but you said that Bill O'Brien, you said he had to sneak in ACT. Was that part of your curriculum or was it something that you just happened to be in the right place in the right time with the right professor or mentor? A little bit of both. So I will say it was a research methods class. So not really somewhere that you would be talking about theoretical orientation, but he always found a way to bring it in.

[00:04:55] So some of our clinical supervisors, a director of our clinic, as well as a couple of our supervisors, ACT was their main therapy modality. And so if you happen to be matched with them as supervisors, you would learn about ACT through that process. My advisor, for example, in the research lab I worked in, which was a lot about obesity, diabetes prevention, more kind of health psych focused, was pure CBT based.

[00:05:21] So kind of similar to you, that was the foundation I had gotten introduced to in kind of my everyday work. But ACT really spoke to me as a person in terms of understanding my experience, understanding how my mind interacted with the world. I am a huge, like, I love ACT, but I'm a huge functional contextualist at heart of really just ACT, not looking at it as good or bad or right or wrong, but why something works in a given situation.

[00:05:51] And like understanding why someone might behave in a way that doesn't maybe like logically make sense on paper. But if you look at it behaviorally, you're like, oh, yeah, like alcohol, great way to not think about things. Might have some long term consequences if you're drinking an excessive amount, but in the short term, it makes sense. And it felt very kind of like non-judgmental.

[00:06:17] It was an approach to understanding humans that felt very empathetic and kind of not as prescriptive as some of the other therapies that I learned. I've heard other ACT practitioners talk about the click, that moment where everything kind of conceptually falls into place. For me, it was based on the underpinnings within relational frame theory and contextual behavioral sciences.

[00:06:45] I remember I was trying to understand it better. And I'm listening to a podcast that Stephen Hayes is on, and I've told him this, so he won't feel attacked or anything by this. But I was listening to a podcast, and he's 10 minutes into an explanation of what RFT is within the context of ACT. And I'm sitting there thinking, what the fuck is this guy trying to sell me? Like, what is he talking about? And it wasn't but a couple of minutes later.

[00:07:13] And I don't remember exactly what he said, but it clicked. I could let go of this automatic internal monologue. And that doesn't mean escape from it. That I can't do.

[00:07:28] But I could let go of trying to escape from it and let go of that internal monologue, which to me is just this prism of every experience I've ever had that my automatic part of my brain or my mind, as we like to colloquially call it, is seeing my current experience through. Yeah. That was so freeing for me personally.

[00:07:53] Can you expand upon that and how RFT is maybe fundamentally different as a precursor to ACT than some of the other therapies you've been exposed to? Yeah. Yeah. So when we're talking about RFT, I think one of the things that can be hard for especially adults to understand is how symbolic our language is and how much we are inferring things that aren't like natural connection.

[00:08:21] So for example, like, you know, if I had a dollar bill here, everyone's like, oh, yeah, that's money. And it's like, OK, but this means nothing. It literally means like a barter system makes sense because you're assigning a value based on its use. But we use symbolism in our language so frequently that we don't really recognize it unless maybe we've spent a lot of time around young children or people who are trying to learn a new language of understanding how that gets built up.

[00:08:50] And being able to really take a step back and say, oh, our mind tries so hard to fill in the gaps to understand and create these networks or relational frames for understanding our experience. And so when people talk about being cute or being triggered by something, you're not just bringing in that one word or that one object or that one phrase. You're bringing in everything that it's connected to.

[00:09:20] And it explains really perfectly why people who've experienced trauma might have an aversion to something that is objectively neutral. But because it is within that framework, it pulls in all of the emotions and the traumas and the memories and experiences with it.

[00:09:43] And so, again, I think ACT and everything that is its foundation does a really good job of helping people just understand, why is my brain doing this? Why do I get nervous every time I see this specific exit sign? And it's like, oh, well, I was on the phone when I got broken up with. And every time I see this, my body just goes right back into that state. Like, why does that happen?

[00:10:08] So being able to kind of understand how our mind makes connections between things that are seemingly arbitrary and how all of those are all kind of connected into a network can be really helpful as a foundation in the same way as like thoughts are just kind of content that your mind makes up. For knowing then, OK, well, that is a thing that exists. Now let's learn how to interact with it. How do we notice it and how do we interact with it?

[00:10:38] It also sets a really good foundation for metaphors, which ACT absolutely loves. Metaphors are my favorite because they just they cut through trying to communicate directly and allow for a little bit more subjective interpretation of the message. The low hanging fruit example I like to use is, you know, if you're bit by a snake when you're young.

[00:11:04] Well, it's pretty straightforward and obvious to most people that you may be afraid of snakes as you get older. What's not as obvious is you may have a pang of fear pop up when you see something slithering across the ground because we associate slithering with snake. If you get bit by a dog with sharp teeth, you may be afraid of not only dogs with sharp teeth or dogs or sharp teeth.

[00:11:32] You may experience a human being who's baring their teeth at you one day and that triggers some sort of response in you. I always tell people there's no way for us to intellectually sort out every current experience and be able to track it back to some previous experience. Maybe I do too much of trying to explain this. How do you incorporate this concept of RFT into your work with your patients or clients?

[00:11:59] I'd say really in helping them understand how these things are really connected. So I don't do like a, you know, deep dive. If someone's like getting really excited about the nerdy parts of it, I will refer them to a book. You've done a good job of not using the term arbitrarily associated or relational. Derived relational responding. Yeah, exactly. All of that kind of stuff. So my brain is always going back to the function of something. It is not necessary or necessarily helpful to go into the weeds on all of these things.

[00:12:27] If someone's interested and they want to learn more, I can direct them to outside of session to learning more as an educational pursuit. But that's not relevant to the work that we're doing in session. And so really helping them understand why, you know, they got mugs in a parking lot and now they get nervous when there's a lot of cars around. Like why that makes sense.

[00:12:50] And in terms of just introducing metaphors and helping them build some of these kind of arbitrary ways of interpreting the world, kind of these shortcuts to be helpful. But there can be a fine line between, you know, I tend to work with a lot of folks who are highly anxious. The avoidance behaviors are very much mental avoidance behaviors. So rumination, planning, analyzing, all of that kind of stuff.

[00:13:16] And I want to be careful of not getting sucked into this avoidance behavior of trying to understand instead of trying to feel or experience or exist in the present moment with something. So it is really kind of taking a step back and exploring those frameworks that come up in relation to certain things. And that might come up through like doing a functional analysis with them of, you know, okay, this thought pops into your head.

[00:13:45] You don't have control over that thought popping up. What else comes up with it? And helping to draw their attention to their experience in the present moment and what kind of network might have been activated. But outside of that, I am not going into the weeds of, you know, pulling out Nicholas Turnecke's relational frame theory. Phenomenal book. But we're not diving deep into that.

[00:14:11] What I think is so relevant to today's world is this massive amount of information that we're exposed to, or maybe better in the context of this conversation, that our minds are exposed to. This unconscious part of us that is automatically logging all of our experiences, which nowadays are not just your firsthand experiences with the 15 to 20 other people that would live in your cave with you.

[00:14:39] Where you have a very clear idea of what your strengths are, what your weaknesses are, how you fit into the group. And also there's limits to your awareness of really what I categorize as the two main aspects to our minds survival pursuit, which are things that I need to avoid to survive. And things that I should be doing that I'm not doing currently that would promote my survival.

[00:15:08] Are we fighting a losing battle with the massive amounts of first and now secondhand or even thirdhand experience where you may see a video and tell me about that video. And that's now embedded into my awareness and generates more outputs that I need to look out for things I should be doing than I'm not.

[00:15:32] Yeah, I mean, it's no surprise that our environment and how we are designed is kind of mismatched. Whether you talk about like access to foods, the availability of different things, the amount of information that we're taking in, what is considered a community these days. So going from kind of like small towns, small groups to an entire city with half a million people in it and how to like understand how to navigate who's safe and who's not safe.

[00:15:59] I will often talk to clients about, you know, our mind was designed as a threat detection system. But back in the day when our brain was, you know, being designed and developed through evolution, the things that we encountered that were threats were very often things that happened in the moment that we could decide yes or no. We heard a limb break. Is that a lion or is that my, you know, my friend who was just going to grab berries and we can make a decision.

[00:16:26] And usually we find out pretty quickly whether that was a good decision or a dead decision. And people who were a little bit maybe more cautious oftentimes lived to tell another day and tell the story. The problem now is for most people in kind of a modern day world, obviously not the case for everyone. The threats that we are encountering now are not necessarily immediate.

[00:16:54] It's not, oh, like, is that person safe or not? It's, oh, I wonder what will happen if I get fired. Or what if I had only done, you know, coulda, woulda, shoulda in this situation. And that is the way our brain is designed and our environment is kind of a mismatch in that if there's nothing threatening going on in the present moment, our brains kind of designed to go find potential threats.

[00:17:18] And it does that by either jumping to the future and looking at all the what if scenarios or jumping to the past and reviewing everything you've ever done and identifying all the ways it could have gone horribly wrong to learn from it. And then as you were saying, we also are learning from other people's experiences as well. We don't have to stick our hand in the fire to get burned in order to know like, hey, we shouldn't do that because someone else already told us that that's hot.

[00:17:43] We don't have to stick our hand in the fire to get burned in order to get burned in the fire to get burned in the fire. It's default.

[00:18:12] Its default is to go find problems. That might be incompatible with us living a meaningful life, right? It's kind of the difference between surviving versus thriving. Surviving is going to be constantly deciding like, oh, do these people hate me? Am I going to be kicked out of the group? Is this safe? Is this not safe? What if this happens? Thriving is being able to be in the present moment a little bit more. Because that's where you can make changes in your life.

[00:18:41] We can plan for the future. We could review things in the past, but we literally can't do anything about it until we're in that moment. It's less about like us being doomed or like succumbing to just information overload, but more of a not understanding, hey, our mind is getting caught in a default that's no longer useful to us. So we need to be a little bit more intentional about, hey, when is this useful and when is this not useful and developing different skills?

[00:19:10] I heard a philosopher talking the other day saying, you know, time is a construct. It's not a reality. It's something that our minds create to help to explain what we see in front of us. When have you ever been to the past? And when have you ever been to the future? And it's a huge, I think, important.

[00:19:32] Well, it's an important aspect of my personal life to literally take a few minutes every now and then and remind myself I'm right here and I'm right now and I'm okay. Yeah. That's such an important point. What I find myself doing and my patients doing, whether it's internal or external, is, for lack of a better word, complaining about the problem that I see in front of me.

[00:20:02] And when we complain, it's a conscious thing and it feeds back to our minds that there is a problem that needs to be addressed, leading to a cortisol response, leading to inflammation. I thought that was such an interesting way to intervene, to catch yourself complaining and defuse it.

[00:20:24] Point out what you're doing and point out that you don't need to be doing that and maybe even adding a little bit of gratitude as a replacement. I know you work a lot with rumination. Can you speak to the role of conscious complaining and how that can feed that loop or pave over that same track deeper and deeper and deeper over time? Yeah.

[00:20:50] So I like to differentiate in our mind, like mental processes that are automatic, that we don't have any control over and like cognitive behaviors, which sometimes don't feel like we have any control over them, but we can choose whether to engage in them or not. So that like automatic thought that we don't have a control over, like some people call them hooks, those things that, you know, if we bite them, they kind of just yank us off down a mental rabbit hole.

[00:21:18] So let's say we're having the thought there's been a big layoff at your work and you're wondering like, oh, what am I going to do if I get laid off? That's a problem that maybe has a high likelihood of coming to fruition. It's not an active problem you're dealing with right now. We don't have control whether that thought pops into your head or not. And in fact, the things that are going to be most distressing to us are usually the thoughts that are going to automatically pop up because they're tied to our values, right?

[00:21:44] If we care about, you know, our work, our family, our loved ones, our health, those are the things our mind's going to go, hey, do you think this is a problem? Now that's there. What happens is we reach out, we grab that thought, and then we start doing things with it. And that's when we get into cognitive behaviors, which oftentimes are avoidance behaviors.

[00:22:07] That's when we get into the planning, the analyzing, the what if-ing, the strategizing, the rumination. Those are behaviors that might happen as a default, but those are things we can choose to engage with or not. And so oftentimes I will have a conversation with clients and I'll maybe use like hooks and biting hooks kind of metaphor. So the hook is that like, oh, what if I get laid off thoughts?

[00:22:32] And what happens when you bite the hook is thinking about, you know, do I need to update my resume? And all this other stuff that your brain is going through. First, just noticing. Because a lot of times we can't interrupt patterns that we don't know are happening. So if we can notice, hey, okay, this thought's coming up. That makes sense. What is my mind doing next? And you might think like, okay, well, I feel miserable after I'm ruminating. Like there's no way that that has a function. But it does.

[00:23:02] If you have a problem that you can't do anything about right now because it doesn't exist in the present moment, thinking about it and worrying about it and coming up with a plan for if it does happen feels good in the short term. There is a certain amount of immediate relief we get of like, okay, this would be bad, but we know what we're going to do in this scenario. And that could be a, we do this with things that are likely to happen. Like what happens if something embarrassing happens on a first date?

[00:23:32] And with things that like, you know, what happens if aliens land tomorrow or, you know, whatever it is. It's all the same. But being able to pause and recognize, okay, my mind finds comfort in trying to solve the problem. And I often will talk to clients about like your mental default is problem solving. The problem is that's not always what we want our minds to be doing. And so if we can kind of notice, okay, that's happening.

[00:24:01] The next time it pops up is pausing and kind of asking yourself, hey, is this useful right now? Is this what I want to be spending my time on? And that might be the question of like, is this a real problem? It might be like, what are my values? What's important to me? I am in this moment here now. What do I want to be connecting with?

[00:24:22] And the metaphor I often use with clients who struggle because sometimes it is useful to ruminate on things is, you know, imagine you have a lemon. The first time or two that you squeeze that lemon, you're going to get juice out of it. Third, fourth, fifth, thirteenth time, no matter how hard you squeeze, there's just like nothing else to get out of that lemon.

[00:24:44] And what that does is it helps clients differentiate between like a functional response to planning and analyzing and when it starts shifting over into, hey, this isn't helping me anymore. And that's also helpful because sometimes when it comes to these mental behaviors, it can be very tricky to figure out when is it useful to me and when is it not useful. And so using that idea of a lemon is like, hey, are you getting anything more out of this? Or are you just now rehearsing the same thing over and over again?

[00:25:12] Or are you getting something out of it? But maybe 3 a.m. is not the time that it's super useful to be doing that. Maybe we want to do that in the afternoon instead of in the middle of the night when we're trying to sleep. So often in my life and I think in my patients' lives, the value that reemerges is balance. And you described that perfectly when it comes to some of our automatic thought processes. We cannot get into these habits of escaping all of them or ignoring them.

[00:25:42] They're a shadow that will follow us around for the rest of our lives. It's not that they are good or bad. They're meant to be interpreted here. Yeah. So is this helpful right now or not? Right. Because I have a lot of clients who keep themselves distracted all day long and then their head hits the pillow and they're like, my mind has decided this is the time to problem solve. And I'm like, cool, have you decided that this is the time to problem solve?

[00:26:07] Because if not, let's find a different time to work on these problems and actually slow down and be present in your life during the day and then practice some diffusion skills in the evening so you're not getting hooked by this desire to solve world hunger at 1 a.m. I love the lemon metaphor. I may use that, but it may be an orange instead. Yeah. Or, yeah. Or orange is real, real acidic, you know?

[00:26:35] This concept that you're talking about has fundamentally altered my perception and treatment of addiction. I cast such a wider net around what I consider to be addictive behavior now and kind of fundamentally just label addictive behavior as things we do that only serve the purpose of getting us away from what's uncomfortable.

[00:27:01] That kind of branches out way beyond drugs and alcohol into things like our phones or even things that have a lot of positive consequences like diving into work, productivity, you know, things that kind of satiate our minds. And I could imagine somebody who grew up or had bread into them that they were not good enough and whatever they did was not good enough.

[00:27:26] And when they are really productive, that allows them to escape that uncomfortable feeling of ineptitude. But it's temporary and they come back around to it. Yeah, it's all avoidance behaviors, right? So the thing I really love about ACT is there's nothing that's like good or bad or right or wrong. It's looking at how something works in a context. So like work is hard because it's one of those ones you get a lot of external praise for.

[00:27:53] So it just, you're internally reinforcing it and externally reinforcing it. But if I'm struggling with like perfectionism or imposter syndrome or whatever it is, and I'm feeling very insecure constantly and I'm like working harder in response to it, or like a student who thinks they're going to fail their exam. And so they're studying like wild hours every night to do well.

[00:28:17] And then they do well, it becomes this kind of self-fulfilling prophecy where they feel like, oh, well, I only did well because I did X, Y, and Z. I only got my promotion, not because I'm smart or good at my work, because I just work harder than everyone else. And oftentimes that's not true. And it's not a great feeling to have to just be constantly working to escape something as opposed to be like moving towards something.

[00:28:47] Yeah, I'll put a graphic up over top of this of that ACT matrix. It's such a powerful thing when you can take the same intrusive thought that led to your escaping behavior. And like you said, decipher meaning out of it, which absolutely. Actually, there's a neuroscience mechanism behind this with addictions where if you give me a plate of French fries, which are delicious.

[00:29:14] I mean, I cannot stop eating French fries because they're so good. I had some for lunch. But I know that they're really not very good for me, right? But if you bring me a plate of French fries every day, there's going to be a transmission from this mind or my limbic system towards my frontal lobe, kind of asking permission initially. Hey, should we eat these? And my frontal lobe will say, well, let's weigh the pros and cons.

[00:29:41] They're delicious, but they're not as nutritious as I would hope they would be. And I may get heart disease and cancer and whatever. I might have bad outcomes down the road. I know that as a medical professional. But let's say that I eat them and then you bring them back the next day. That signal that transmits to my frontal lobe gets a little bit weaker because my brain is trying to conserve energy.

[00:30:06] And so with our addictions, each time we go back, that stimulus of asking the conscious question, should I do this, gets weaker and weaker and weaker until eventually it bypasses that system altogether. And it turns into an automatic behavior, which is why that first step of conscious acknowledgement and diffusion.

[00:30:31] This is a process that's happening up here automatically is so, so important. And then being able to use that to take a fucked up thought like I'm a bad dad and use that to figure out what I really care about. Right. And so it's straightforward to say, well, if I'm interpreting that thought, it probably means I care about being a good dad.

[00:30:58] And my mind probably sees anything less than perfection is bad. Yeah. And at that point, you have a general, my thought means I want to be a good dad. How do you take that step from being a good dad to really connecting people? How would you connect me to my parental fatherly values in that situation?

[00:31:24] Yeah. Well, I mean, what we're talking about not to get too RFT nerdy is transformation of stimulus function, right? That you have this thought, I'm a bad dad. Your automatic response is to avoid, to, you know, maybe not spend time with your kids, not do this because you're like, oh, they're better off without me. You kind of, you know, hide and escape. Being able to pause and go like, OK, I'm noticing this thought, I'm a bad dad. The flip side of that pain is something that's important to me. OK, well, what kind of dad do I want to be?

[00:31:52] Let's take the true or false, right or wrong of like whether you're a bad dad off the table. Is being a dad an important role to you? What is important to you about that? If I were to like ask your kids to describe dad, like what would you want them to say? Is it that, you know, he's always there for me? Is it that he's like fun and silly and playful? Like what are you might get different answers across the age spectrum there? But what is important?

[00:32:18] And then the question is, OK, well, it doesn't matter whether I'm a good dad or not. What matters is that this is the kind of dad that I want to be. So what is one tiny step that I can take in this moment towards that? So now instead of I'm a bad dad being a stimulus for avoidance, it becomes one for connecting with your behavior and moving forward.

[00:32:43] And that's why that connection to present moment is so important because it's pausing and going like, OK, we're getting up in the weeds here about like whether I'm a good dad or not. We can debate that all we want. It actually doesn't matter. Because what time do you live in? Yeah, right now, like in this moment, what kind of dad do you want to be? And then like, what is the smallest step you can take forward in that direction?

[00:33:08] And it just might literally be like listening or physically keeping your body in the same room. A lot of times we think of committed action as these like grand gestures of like quitting your job or getting a divorce or, you know. You know, sometimes they're just screaming and yelling and they're doing their own thing. And I know that they are not trying to make me feel any certain way.

[00:33:35] But yeah, that might be the one step is like, OK, I'm going to take a really deep breath. And I'm going to remind myself of those things that I just told Jessica. They don't know. And they're not there's nothing personal there. Maybe I feel it personally. Maybe there's something in my background that that kind of presses on that automatic button that generates a feeling that comes out of that.

[00:34:00] Maybe you're just exhausted and it's hard in that moment to acknowledge like, no, a three year old's not doing that on purpose. They're just doing it. But it feels personal. And just being able to kind of pause and taking that breath, thinking like, what is some small thing that I can do? And sometimes a thing that you can do to be a good dad is what someone might categorize as an avoidance behavior.

[00:34:26] It might be removing yourself for a moment and then coming back. It doesn't have to be like, oh, I'm going to stay and I'm going to get on the floor with them and we're going to wrestle and all this kind of stuff. It can be I'm going to say tag your it and I'm going to go make them lunch. I like that. Because I'm physically incapable of they're safe right now. There's another, you know, maybe another parent's around or, you know, they're amusing themselves.

[00:34:51] I am physically not capable of engaging in the way that I want to right now, but I can do something else loving towards them in this moment. You mean act is not about rigidly forcing behaviors that you're not feeling at the time? Exactly. Exactly. Act is so applicable even to somebody who has maybe objectively done some really bad things or in that example, been a really bad dad because of that time context.

[00:35:21] My mind lives in the past and that's one of the things that may burden me automatically is it remembers all the things that I've done and it remembers all the things that have been done to me. But what I love about it is you live right now. This moment matters. Can we move in this moment right now towards something that is really important and meaningful and fulfilling to you? Yeah.

[00:35:47] And it's the process because a lot of times and this shows up like with addiction, with parents, things like that, where maybe like they were very abusive or, you know, did some awful things when they were deep in addiction and struggling or they were experiencing chronic pain and misusing prescription drugs, for example, or things like that. That is a lot of people want to do actions for a specific outcome, right? They're very outcome based of like, oh, well, if I'm nice now, then these people must forgive me and that can alleviate my guilt.

[00:36:16] It's still very avoidance based. It's I'm doing this so I don't have to feel this way anymore. But act is very process based, even though it's hard, even though that person might never forgive me and that person might always think I'm a bad person and that's allowed to exist. But I'm choosing now that I'm going to show up and be the kind of person that I've always wanted to be because that's important to me.

[00:36:39] And that means creating space for and acknowledging these different memories that I've had, these different behaviors that I've engaged in, creating space for them while also having this kind of flexible view of myself that I can change how I move forward, but it might not change how other people view me.

[00:36:56] It's really hard to be nonjudgmental and curious with yourself about those things, to take accountability without demonizing yourself for your behavior. Because I mean, I have always felt this way since I was a young kid that everybody has a story. And when you really understand people's story in depth, it explains a lot of why they behave the way that they do.

[00:37:24] It's so interesting to me, the little overlap here with quantum physics and the double slit experiment where photons are shot through a barrier with two slits and they create an interference pattern on a screen behind the two slits. But when we position a camera behind the barrier to try to see what the photons are doing, it changes their behavior.

[00:37:53] Observation of the outcome changes the outcome. And I think that's so fascinating in terms of what we're talking about, that we tend to get closer to our desired outcome when we just focus on the process.

[00:38:13] When you're playing golf and you're just thinking about your process of hitting a ball and how you want to do it, as opposed to, I want to make a birdie on this hole. I don't know if you've ever dove into the double slit experiment or any of that stuff. This is the first time I've heard of it, but it does bring up an interesting concept of perceived control and actual control.

[00:38:38] A lot of the time, avoidance strategies are trying to gain perceived control over a situation at the expense of actual control over the things that are within your control. So kind of like what your body's doing, what your mouth is saying in the here and now. So take the golf example.

[00:38:56] If I'm focused on getting a birdie, there are a lot of things, wind, the composition of the ball, you know, how my hands are feeling in the club, some guy that's going to yell out when he's not supposed to. There are a lot of things that are just out of my control that I can't. This comes up a lot with clients who have panic attacks. I'm like, I can't tell you if you'll ever have a panic attack again or not. That's not within either of our control.

[00:39:24] But what I can do is help you notice what are the things that have led to it and equip you with some skills so that when it does, if it does show up, you can create space for it and move through it to get to the other side. And oftentimes you'll find as you go through treatment that like clients who have, let's say like nightmares or flashbacks or panic attacks, it becomes less distressing to them. It still is intense, but they're like, all right, but like I know how to move through it now.

[00:39:53] I have some ownership of what my body is doing in that moment. And so I think about that idea of control. If I'm focused on what are the things that I actually can control, if I'm focused on how I show up as a dad, I can't always control how my kids are going to interpret it. What are the lessons they're going to hold on to? What are the memories of me they're going to have?

[00:40:15] And often the more you try to like force this, like I'm the best dad persona, the probably worse outcomes you're going to have. But instead focusing on, okay, well, what are the things I can control in this moment that helped bring me towards the type of person, the type of life that I want to have, what's important to me. And the hope is that that takes you closer to the outcome that you want, but that's not really your decision.

[00:40:43] I received a phone call from another provider that was talking to me about this patient with a really long, intense, severe history of opiate addiction. And as they're talking to me, I don't know how long it went on, but eventually I noticed that my mind was going on this track of this is going to be such a difficult patient.

[00:41:07] I don't know how I'm going to help them. And I don't. And in that moment, I realized because I was allowing myself to go towards that desired outcome or the lack of it, I was totally missing what they were telling me. Yeah. Which the focusing on that information may have been more helpful to get them to their desired outcome. Yeah. And if you have this idea of like, oh, well, this is how I help all of my clients who are really struggling.

[00:41:34] And then that doesn't work. That's where we bring in kind of psychological like inflexibility, right? We're so rigid to this is how I do things or this is what works instead of, oh, hey, I tried this thing. It didn't work. Let's pause. Let's pivot and figure out how I can get traction with this person instead of like against this person. You reminded me of Steve Hayes doing that.

[00:41:59] What's an example of a time where as a practitioner, you felt really stuck or all the time? OK, love it. Love it. OK, so it's normal, right? Normally, when I'm feeling really stuck, it's because I have gotten very caught up in an outcome that I want. And usually it's well-intentioned. It's like, I mean, my clients are absolute wonderful people.

[00:42:25] I want the absolute best for themselves. Some of them just been handed like a shit-handed life. Or like things have happened to them that just are objectively horrible and not their fault. And I just, I want so much for them. And it's when I get really caught up in like, I want them to realize how amazing they are. I want them to like, you know, oh, if they just go after this thing, right?

[00:42:54] And I all of a sudden become, I don't know, like God who's preordained. Like if you just follow this path, your life will be better, which is utter nonsense. Those are the moments I kind of have to pause and go, OK, what is driving this? And usually it's on the one hand, my values of like, I really want to help people. I think I have, you know, skills and knowledge to be able to pair with their life experience to help them move in the direction that they want to.

[00:43:21] I care deeply for them, all of that kind of stuff. And some of it is this discomfort with the fact that they're wonderful people and life is hard. And I like, I want that feeling to go away. I think it's very, you know, normal and human of me. It's why I think that if you are going to use ACT in your work, you really have to walk the walk and talk the talk of having those moments where you pause.

[00:43:49] Like whenever I'm starting to get really frustrated in session and clients won't notice it, but I'll just notice I'm getting really caught in my head and less present. Of really just pausing and going like, OK, what am I getting hooked by? What thoughts are really grabbing me and I'm getting really stuck on? What future outcome am I becoming very rigid around? What am I not seeing across from me? Like, what am I not being present to?

[00:44:16] And that really, like coming back to the present moment always, like really helps me just reset. And sometimes I'll just sit there while someone's talking and listen to them and just try to notice what their face is doing and hear them a bit more so that I can reset and show up for them in the moment.

[00:44:34] I used to try to memorize so much information and that's an inevitable aspect of being in school for so long, but I'm trying to just be as present as possible for receiving information. That actually makes me less capable in terms of the direct rote memorization. But in terms of integrating an entire person in their treatment plan, I find that I'm way better.

[00:44:59] And if you needed to look up a drug interaction or something like you have access to the Internet, it's not like you're not allowed to look up things like you don't actually have to hold all that information in your brain. Thank you. I needed that. So let me ask you this. If a patient or maybe even a psychiatrist who's working with his own ACT therapist tells you something like, I understand ACT intellectually or RFT intellectually, but I'm still stuck.

[00:45:28] Maybe this therapist may have told this psychiatrist that you need to be able to feel more and not intellectualize everything. How would you approach that kind of patient who's understands what you're talking about, but gosh, they're so resistant to feeling it?

[00:45:48] People who tend to be high intellectualizers struggle, and I'm making broad stroke generalizations here, but tend to struggle at times with identifying what is a feeling, especially when it's very subtle. We know when we're feeling very frustrated or very angry or absolutely elated and joyous, but just emotions on a day-to-day basis can be very hard. They're so intangible, it's very hard to contextualize.

[00:46:16] Instead, I kind of skip trying to be in touch with our feelings and jump right into present moment and physical sensations. Physical sensations, unless you're in a coma, are the easiest present moment experience to come in contact with. Everything else is a little bit more intangible. Memories, feelings, thoughts.

[00:46:42] We can do leaves on a stream or different exercises to kind of pay attention to them, but it's oftentimes taking us out of our bodies. And if we want to be present, one of the first steps is kind of being in our bodies. And so I will do some very basic, whether it's mindful breathing exercises with clients.

[00:47:01] One I really like, and I don't know where I got this from, I just started doing it one day, but I will have clients tap each finger to their thumb and try to see how gently you can tap and still feel the sensation. And sometimes people will mention, like my fingertips get a little itchy when I do that, but really trying to slow down and feel the sensation. Because people want to like go like this and they want to run through it really quickly.

[00:47:31] And it's something that just helps ground people into sensation. And then the other thing is getting into noticing. So intellectualizing, right? I like, I understand the concepts of it is being able to describe it, being able to apply it to a scenario, all of that kind of stuff. But what it doesn't help you do is just notice stuff that's actively happening.

[00:47:57] So I might send a client out into the world and say, okay, I want you to notice when your hooks show up and what happens when you bite them. I don't want you to do anything else. I don't want you to try to not bite the hooks. You might not even notice it happens until after the fact. And that's totally fine. And then come back to me and let's use those experiences and kind of describe them.

[00:48:19] And usually what happens is clients will go out and they'll come back and they'll be like, okay, wow, I like am constantly getting hooked. Or I forgot to practice. And then we'll like talk about that. But it's getting into the doing of the work. And highly analytical people love talking about the work. Instead of actually reading books about the work. Instead of actually paying attention. So for example, I would probably tell you, you're not allowed to read another ACT book.

[00:48:49] Until you go out into the world and just pay attention to what you're doing and how you're interacting in the world. And like maybe your kids are a great way to start because I imagine you probably have like regular opportunities to practice noticing you getting kind of hooked by things. You know, little kids are delightful and chaos goblins at the same time. Absolutely.

[00:49:12] I'm curious to hear your perspective as somebody who doesn't prescribe psychiatric medication. What do you make of just the massive amounts and numbers of diagnoses and medication treatments? And do you feel like any of that interferes, whether it's the labeling or the effects of medication themselves?

[00:49:38] Which a lot of antidepressants, a lot of patients tell me that they feel a little bit more numb on them. Yeah. Or completely numb. What's your perspective on that? Yeah. So I'm going to sound a little like a broken record here and go back to function. But I've had many conversations with clients who are either deciding whether they want to start medication or on medication and are feeling like it's doing something, but it's not necessarily doing what they want it to do. Like it's having a numbing effect. I think of medication as another tool.

[00:50:08] Its purpose is supposed to be to help people be able to engage in their life a little bit easier in the way that they want. So oftentimes I'll talk to clients. Let's say someone's very anxious or depressed. I'll be like, you know, in theory, the purpose behind medication is to take like 20% off the top so that you have a little bit of wiggle room to then engage with therapy, to then go out into the world and practice behaviors that are going to help move you forward.

[00:50:37] And sometimes people need to be on that for a short period of time. And sometimes people need to be on that for a very long period of time. And there's no right or wrong or good or bad thing there, but it's how it's functioning. If you're taking medication and it's just numbing you to everything, maybe it stopped you from killing yourself, but I think we can do a little bit better than that. And so that might be trialing different medications. The goal is not to remove what you're feeling.

[00:51:04] The goal is to make it a little bit easier to come in contact with what you're feeling. So I know some people are like very anti-medication and some people are very like totally pro-medication. And I really think about it as it just depends on how it's working for someone. Classic act answer. Yeah, I know. It's like a very wishy-washy, but it's what I believe. It depends.

[00:51:24] In terms of diagnosis, I think diagnosis is a huge barrier to getting access to adequate health care, at least in the U.S., because of how insurance companies operate and needing a diagnosis. It leads to a lot of unnecessary diagnosing, diagnosing too quickly. Not being able to get life insurance. Yeah. No, I mean, it's problematic. It also allows some people to get access to resources, to state-run programs that they wouldn't otherwise have access to.

[00:51:53] So it sometimes feels a little bit like golden handcuffs in that necessary evil, whatever it is. What I will say is there are times when having a diagnostic label can be very limiting. I had a client once who had major depressive disorder and had come back after a session. It was like, I noticed the weirdest thing that happened. I was hanging out with friends. We were watching a movie. It was like a comedy or something. And I started laughing.

[00:52:22] And I had this thought, oh, I'm not allowed to laugh. I'm depressed. And so this kind of gets into more like self-as-content kind of work. But when that label becomes very limiting for how we're able to go through the world, right? Like, oh, no, I'm a depressed person. I'm a this. I'm a this. And therefore, I can't do these things in my life. That's when it becomes very, I think, problematic and very limiting for people.

[00:52:50] Especially if someone's had a diagnosis for a really long time, it can become a very big part of their identity. In the same way that something like I'm a victim can be very empowering for someone to acknowledge the hurt that they've experienced. But I've also worked with a number of trauma survivors who have talked about this fear that, like, if I get better, does that mean that what I experienced wasn't that bad?

[00:53:17] Like, I'm a walking scar for what I went through to highlight, like, how horrible it was and what this person did. On the other hand, there are times when getting labels can be very empowering. It can be a huge relief to help someone understand what they've been going through.

[00:53:35] If the diagnostic label is simply, hey, here's a shorthand for understanding your experience that you can go out and relate to other people, learn how to navigate in the world that helps you learn skills that people have found to be really helpful for folks who struggle similarly to you. But I think it can be absolutely wonderful. Like, I've had clients who have felt such immense relief getting a diagnosis. Help them not feel as alone. Help them not feel crazy.

[00:54:03] I'm sure, you know, I work with a number of folks with chronic medical conditions. And so, like, I've had a number of clients who are young women who it took them, like, a decade to get diagnosed with MS or endometriosis or something like that. And getting a label, even if it doesn't offer any, like, real treatment option forward, is just validating. So, again, my answer is going to be it depends. Yeah.

[00:54:28] To summarize that point, it's seeing something as your identity versus an aspect of your identity. Yeah. Or one little I in the big bubble letter I, right? Yeah. That represents all of you. I am a father, but I'm also a husband. I'm a psychiatrist. I'm a patient. I'm, you know, you're all of these things.

[00:54:52] And each one of those things provides a little bit different context for what you care about in that realm of your life. They're not limiting you. They're helping you get more clarity around what matters to you. How, when, why did you start your YouTube channel? Yeah. So, I started my YouTube channel 2021 or 2022. I was going through some, like, really bad health stuff. I was having a lot of issues with my heart.

[00:55:22] I had two cardiac ablations. I've had some AFib stuff. And I wasn't working full time. And I, like, I love YouTube as a source of information and entertainment. Just kind of personally, I find, like, the long form content very interesting. And I had looked online and there were some mental health channels out there that really just, like, gave information about, like, what does this diagnosis mean? And it was kind of like something I could have Googled, but just in a video format.

[00:55:51] And then there were people sharing their personal experiences, which I thought was really cool. There were also people out there who had no qualifications. And I think we're using their personal experience not to say, like, hey, this helps me. This might help you. But almost as, like, a this is the way that you should do things, which felt very dangerous to me.

[00:56:10] And I think this is something that the mental health field gets into a lot is we are often not the ones who are translators and disseminators of our own education and research. It's, like, other people who might not be as nuanced, who might just make more, like, broad sweeping generalizations that could be dangerous. Or who have sweeping ulterior motives. Exactly. They're trying to, like, sell something or, you know, whatever it is.

[00:56:38] And I'm not, again, not saying that, like, everyone is like that. But I kind of think of it like the coaching field. There are some mental health coaches who are, you know, phenomenal. They do good work. They fill in, like, really great gaps. And then there are also people who are just absolute charlatans. Not to say that that doesn't also happen in the mental health field. It does. We're just a little bit more regulated. But there's also, you know, bad apples and that kind of thing.

[00:57:04] And so I had been doing trainings for ACT practitioners. And I'd gotten a lot of feedback that I do a really good job of taking kind of higher level terms and breaking it down into kind of things that are easily digestible without being, like, overly jargony. I've also gotten some criticism for that. But, you know, back and forth. Either good or bad. Yeah, yeah. It's just, like, it just is. Like, it fits a certain niche. So it's like, oh, like, I would love to make a YouTube channel.

[00:57:34] It's a platform that I really find interesting to help share ACT. Because there are so many people who, you know, at least in the U.S., like, can't access mental health services. You know, I have a lot of clients with ADHD who, like, you know, they might find a lot of benefit from the happiness trap. But they're not going to read it. That's just not going to happen. There are people who there's a lot of stigma about seeking help or a lot of limitations to access to care.

[00:58:02] And I was like, this isn't going to replace therapy. But maybe it can give someone a different way of thinking about it or some kind of insight so that it helps a little bit or is a stepping stone towards accessing mental health care. Now, it is definitely a passion project, which means there's been, like, you know, a whole year or two that have gone by where I haven't posted a video. Or I'll post a couple of videos and then not for months at a time.

[00:58:28] But I think not that we are required to, but I felt a certain amount of responsibility that I have the time and the access and the means. And it's fun for me to share what I know with people who I might never see doing one-on-one therapy.

[00:58:47] I really appreciate it because we just have to have, I think, more content available produced by professionals that don't have these major ulterior motives. And don't get me wrong, like, I've had my podcast for going on, like, three years now. And I would like to make money from it. That would be a nice thing.

[00:59:13] Like, I have an on-demand course called, like, Anxious Adults Academy that, like, I never talk about or promote. And I think it's good and it's helpful for some people. I don't feel bad making money off of it because I've spent a lot of hours putting it together. I don't think that's inherently evil or bad. It's just it should also be alongside a good faith effort to help people.

[00:59:35] And I think part of that good faith effort is not doing all the clickbaity stuff that could very easily expand the viewership or listenership. But it wouldn't be genuine. I love the ACT community because I've never, ever paid for an ACT resource. The only thing I've ever paid for was ACT boot camp, which was long overdue last year.

[01:00:01] You get, like, continuing education credits and things like that that you need for your licensure. Like, that's worthy of paying for. Absolutely. But people who not just practice ACT with their patients that do it themselves think we are driven by what we value as important and meaningful. Much more so than happiness. Hence the title of that book. Yeah. The Happiness Trap.

[01:00:27] It's all about, again, how do I want others professionally to talk about me in the most ideal way one day? And how can I put things in place right now in this moment that will make that more likely? That at least conceptually, I am moving towards being available or being informative. The kind of professional that you want to be. And it's not going to be for everyone.

[01:00:53] And that's why, as you said, like, having a lot of voices is really great because, you know, I get some very funny comments on my videos sometimes about, like, well, she certainly talked a lot. You know, and then I get another one that's like, oh, my God, I, like, finally understand what you're talking about. Thank you so much. And I love both of those because the way I describe something might not be for everyone. And someone else, there could be a different channel out there that someone really resonates with. And I want all of those options to be available.

[01:01:23] And it's just freeing. It's just freeing to do things that are important and meaningful to you and to consciously defuse the outcome of your efforts. And just, no, I'm just doing this because it's important. And that one comment by somebody who said, oh, thank you so much, that makes me feel good. Yeah. Like, there's a selfish component to it, too. Absolutely. There's nothing wrong with that. It makes me feel like my life is important and meaningful.

[01:01:49] What's one thing you believed about diagnosis or treatment or therapy five years ago that you don't believe now? I don't think I could do five years ago. I mean, maybe 10 years. Ooh, that's a good question.

[01:02:04] I think, and this is maybe going back to kind of grad school days, that like my understanding of mental health was very siloed into these very like clean cause and effect type of things. Like either it was like, oh, something like neurochemically was in balance or like, oh, you had this event and it led to this experience.

[01:02:28] And one of the things I've learned is, one, how many different ways people can respond to the exact same thing. And they are all correct and valid and make sense. And it's helped me understand people and help people so much more to know that things aren't always as like simple and clear cut as they seem.

[01:02:57] But that, yeah, like we really are as complex as we like to think we are. Yeah, I would second all of that. It sounds like you were taught in the way that I was taught is very different than the complex reality of clinical situations that I find myself in. Every now and there, there's something very, very straightforward. But for the most part, there's complexities. You get past one problem and you realize there's an even larger problem kind of hiding behind it. Absolutely.

[01:03:26] Just, you know, get your annual blood work because sometimes someone's vitamin D levels are very, very low and that can be a really helpful solution. Oh, yeah. Do you know somebody like that? I just it's like if ever any time I have someone with like onset depression that is more apathetic and like lethargic and not triggered by anything specific. And I was like, when was the last time you've done like an annual physical with your doctor or gotten, you know, any kind of blood work done?

[01:03:56] It usually doesn't solve all the problems, but I've had some women with like vitamin D and vitamin B12 deficiencies. That's it's one of the worst practices that's happening widespread across psychiatry right now is not the number one thing you do is rule out that there is something medical or obviously manipulatable going on. Yeah, like low hanging fruit. It's also just helpful for people to be connected with their primary care doctors anyway.

[01:04:24] So I had a nice gentleman who was in my office a while back who never been to see a psychiatrist, was very reserved, didn't say a whole lot. Something just didn't feel right. He started talking to me about not enjoying things he usually enjoyed. But this is a mid-50s gentleman who, again, had never experienced that. And his example was that he really would like to wash his car with his nine or 10-year-old son.

[01:04:53] And it was something that they enjoyed doing. He's like, I'm not even enjoying that. And so, you know, I have him put his hand out and there's just the slightest little tremor there. And I said, hey, I think you should go see the neurologist before we try to treat you with some psychiatric medication. Go see the neurologist. He comes back and he says, yeah, they said they don't think that I have Parkinson's or anything. And I'm like, okay, well, but they're going to do a follow-up.

[01:05:20] So we initiated treatment for him with something that I thought would kind of mimic a Parkinson's agent. And he goes back and they do the official what's called a DAT scan in the brain to look at dopamine transmission. And sure enough, he comes back the next time and he's like, yeah, so they think it's Parkinson's. Yeah. And haven't seen him since. Yeah. You know, it's like, I mean, these are just, oh, it makes my blood boil sometimes that people don't get the workup that they should.

[01:05:50] And some of that's driven by insurance and payment. Absolutely. But a lot of it is also driven by people in my position or primary care who either don't have the time, energy, or effort to investigate a little bit further. So. Yeah. Last question. Get your annual blood work done and get your teeth cleaned. There you go. Those two ones that can lead to longer term problems. All right. Last question. It's just very straightforward. There's no right answer. It's philosophical.

[01:06:20] What percent of all that we know represents everything that there is to know? And we could say within our field of psychology. So what percent or the field of medicine, what percent. That's known. That is known. What does that represent over everything that there is to know? I'm going to say something very small because we have no idea how like the brain works at all. I'm going to say like seven to 13%.

[01:06:49] I love it. I love it. I've gotten the answers from less than 1% to 75%. But I would tend to agree with you. I think we are at a very low percentage. Yeah. It was what we know of everything there is to know in the world is like less than 1%. But collectively what we know as a scientific academic kind of community around the world versus what there is to know. Yeah.

[01:07:19] I mean we're just starting to get into understanding like gut microbiome and how those things influence mood and even just understanding. I mean I imagine in psychiatry like there's a lot of medications that work that you don't really understand. Like you understand the pathways that they operate on but you don't understand like why those pathways do the things that they do. Which is just fascinating to me.

[01:07:41] So the oldest and most effective medication in all of psychiatry that you don't have to use high doses for outside of somebody with confirmed bipolarity is lithium. And it's got such widespread actions. I mean there's effects on every single organ system. Yeah. We don't know why. And we don't know.

[01:08:04] The most I feel like the most that we know about bipolar disorder comes from reverse engineering the most effective medication for it in lithium. So yeah it's an interesting question. But what a time to be alive. Right. Absolutely. Well thank you so much for coming on and I appreciate your time and appreciate what you're doing. Appreciate it. Yeah. So nice talking to you. If you saw a tail in the background that was just my dog pacing back and forth waiting for us to be done.

[01:08:34] And it was wonderful chatting with you. Thanks again for watching and or listening. If you're passionate about the subjects I discuss on the channel do me a favor. Hit that like button. Comment. Subscribe. Share. Sign up for membership. Join me in this fight. There are a lot of powerful well-funded entities that don't want you to hear my message.

[01:08:57] So do whatever you can to make our voices heard by as many as possible and let it be known that these are problems that we're demanding be addressed in our society. And if you have any questions comments concerns or challenges to the information I've presented here I want to hear it. Feel free to reach out on social media or email me at renegadesych at gmail.com.

[01:09:24] If you know of expert guests or allies with critiques of the broken overpriced American health care system that could help promote and grow the channel please connect us. Thanks again for listening.