Episodi
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Everyone who has a foot in the world of psychiatric diagnosis seems to agree that our diagnostic system could, at the very least, use some updating, if not burning it down and starting over.
So how do we approach developing constructs of psychiatric diagnoses that are more complex, more accurate, more flexible, and more context-specific than what weâve been taught or what exists in the DSM-V?
Today, Iâm excited to share my conversation with Dr. Miri Forbes, an expert in psychopathology and one of the authors of the paper, âReconstructing Psychopathology: A Data-Driven Reorganization of the Symptoms in the Diagnostic and Statistical Manual of Mental Disorders.â
Dr. Forbes and her colleagues are doing innovative research on creating more empirically-supported diagnostic constructs.
This approach to symptoms, categorization, and how we think about and use diagnostic constructs is one that I hope will help us get out of the habit of taking our current diagnostic constructs too literally.
Dr. Forbes, an Associate Professor at Macquarie University's School of Psychological Sciences, is focused on improving our understanding of the empirical structure of psychopathology based on the specific patterns in which symptoms of mental disorders tend to co-occur.
She is an Associate Editor of The Journal of Psychopathology and Clinical Science,and serves on the Editorial Boards of Clinical Psychological Science and The Journal of Emotion and Psychopathology. Additionally, Dr. Forbes is a member of the Executive Board of the international Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium.
Listen to the full episode to hear:
How a dimensional model can potentially help decrease stigmatizing and pathologizing of individual human experiencesHow the regrouping of symptoms creates potential for more fruitful research into how and why symptoms cluster and how best to treat themWhy reliance on current categorization and diagnostic criteria can cause clinicians to miss or lose vital information about clientsReckoning with the utility of existing diagnoses like BPD that may lack statistical supportLearn more about Dr. Miri Forbes:
WebsiteTwitter: @MiriForbesLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
Reconstructing Psychopathology: A data-driven reorganization of the symptoms in the Diagnostic and Statistical Manual of Mental Disorders -
In my last episode, Dr. Awais Aftab and I explored the controversial nature of Borderline Personality Disorder as a diagnosis.
One of the reasons I wanted to discuss BPD is that it opens the door for digging into psychiatric diagnosis itself, and thatâs part of what I want to discuss more today.
What is our purpose in using diagnosis? How does it benefit us as clinicians and the clients who receive that label?
Getting more clear about the constellation of things we may be referring to when we talk about diagnosis, in general, is a crucial prerequisite for using specific diagnoses wisely, especially for using highly controversial and stigmatized diagnoses like BPD.
Even if you never use diagnosis, the language and concepts of psychiatric diagnoses are out there. It shapes our professional discourse, past and present, and increasingly impacts our clientsâ thinking when they arrive in our offices. Diagnosis is complex, multifactorial, and profoundly impacted by context, and we must contend with it.
Listen to the full episode to hear:
Why it is vital that we understand diagnoses and their valueâor lack thereofâas constructs and constructs as toolsHow holding diagnosis as a lens, not a label, allows for more flexibility and curiosityThe heavy lifting we expect from diagnostic constructs applied across multiple contextsWhy itâs not always necessary to share how youâre applying a diagnostic construct to your therapeutic relationship with a clientWhy we have to learn to uncouple âdifficultâ from âbadâ with our clientsLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
Management of Countertransference with Borderline Patients, Glen Gabbard
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Episodi mancanti?
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Suppose you polled therapists and asked them what the most controversial diagnosis is in the current version of the DSM. Many of us would likely say Borderline Personality Disorder, and it would certainly be in almost everybody's top three.
Iâve been wanting to do an episode on BPD for a bit because there is something about this controversial diagnosis that allows us to explore the challenging and consequential nature of psychiatric diagnosis itself.
To guide us in this exploration, I've had the privilege of inviting Dr. Awais Aftab, a leading authority in the field. His extensive work on philosophical, ethical, and scientific issues related to diagnosis makes him the perfect person to delve into this complex topic with.
Awais Aftab, MD, is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He led the interview series "Conversations in Critical Psychiatry" for Psychiatric Times, which explores critical and philosophical perspectives in psychiatry, with a book adaptation forthcoming from Oxford University Press. He is a senior editor for Philosophy, Psychiatry, & Psychology and has been actively involved in initiatives to educate psychiatrists and trainees on conceptual and critical issues. He blogs at Psychiatry at the Margins.
In the conversation, we dig into whether Borderline Personality Disorder is ârealâ and what that means, how it relates to the philosophical concept of epistemic injustice, how context influences the utility of a diagnosis, and more.
Listen to the full episode to hear:
How treatment of people diagnosed with Borderline Personality Disorder frequently illustrates aspects of epistemic injustice/justiceThe ways that clinical setting and context influence the use, or misuse, of BPD as a diagnostic label and how that impacts patientsHow quantitative psychology is influencing how we conceptualize personality disordersWhy a BPD diagnosis can be intensely valuable for some clients, and how it helps guide cliniciansWhy we canât chalk up all psychopathology to traumaHow calls for testimonial justice from psychiatric patients should serve as a corrective force to excessive skepticism of patient narrativesLearn more about Dr. Awais Aftab:
Psychiatry at the MarginsX: @awaisaftabLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
Borderline Personality and Self-Understanding of PsychopathologyEpistemic injusticeThe epistemic injustice of borderline personality disorder, Jay Watts, BJPsych InternationalA Metaphysics of Psychopathology, Peter ZacharPeter Fonagy -
Imagine yourself saying, âI am angry at my client.â
If you immediately need to add a whole bunch of context and caveats to make that statement feel okay, youâre not alone.
Admitting that we get angry with clients is uncomfortable. Itâs uncomfortable with colleagues and supervisors, and itâs definitely uncomfortable with clients.
Itâs even uncomfortable to admit just to ourselves.
But anger is powerful, and it makes itself important, whether we want it to or not. Even the most mild-mannered, even-tempered person can experience anger towards a client at some point. It's okay, and it's a normal part of the therapeutic process.
When anger presents itself, we have two options. We can repress and avoid something important, or we can choose to confront it and deal with it. As I so often tell my clients, before we reliably know what to do with a feeling, we have to actually feel it to get to know it.
Expanding on last episodeâs conversation with Dr. K Hixson about conflict with clients, I want to explore some of the reasons why we might get angry with clientsâsome situational, some due to the very nature of the therapeutic dyadâand where we go from there, even if it gets messy or uncomfortable.
Listen to the full episode to hear:
Why client relationships might, by their nature, be more frequent sites of anger than average interpersonal relationshipsHow guilt and shame compound our discomfort with anger and get in the way of the curiosity and possibility that come with sitting with itWhy itâs worth learning to understand our anger as a source of information about ourselves, our clients, our client relationships, or all threeHow anger is like fire or waterâdangerous but capable of being handled with skill and purposeThe social and cultural forces that make us even more reluctant to admit to anger at clientsWhy we owe clients and potential clients a view of our humanity within the workLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythat
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Be honest. When you think about overt conflict with a client, is your first thought that itâs a site of exciting progress, full of potential for movement?
No, of course not. I donât either.
If youâre like me, and Iâm guessing a lot of you are, your first reaction to actual, or even hypothetical, conflict with a client is somewhere on a spectrum from deeply uncomfortable to scared. It's a shared experience, and it's okay.
Itâs okay to feel uncomfortable, challenged, and even scared. But these are the moments when we have the potential to do the most transformative work for ourselves and our clients. So, let's embrace these opportunities for growth.
Dr. K Hixson returns to the podcast to dive into how we can handle overt conflict with clients, including how avoiding conflict damages the therapeutic relationship, common sites of conflict, the importance of not rushing a resolution, and much more.
Listen to the full episode to hear:
The many factors that cause therapists to be conflict avoidant, from cultural milieu to liability fearsHow the âgood therapistâ myth and taboos in the field impact common sites of conflict between therapist and clientWhy we have to disentangle fear of doing harm from fear of hurt or conflictWhy we need to learn not to take responsibility for things that arenât oursHow denying a clientâs bids for conflict and not calling them on their shit can damage the relationshipHow clients benefit from our modeling, that conflict does not have to be dangerous or suppressedLearn more about Dr. K Hixson:
WebsiteLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
The Analyst's Vulnerability: Impact on Theory and Practice, Dr. Karen Maroda -
How can we stop treating our clients like our parents?
As therapists, we often share the experience of having been a parentified child, and this shared background fundamentally shapes the way we practice therapy, creating a unique bond and understanding among us.
The relational patterns we developed as children, regardless of our current relationship with our parents, deeply influence how we manage our relationships with our clients. Recognizing and addressing these patterns is crucial, as repeating them without awareness can lead to disengagement, burnout, and even leaving the field entirely.
So, how can we shift our approach from treating our clients as we would our parents to treating them as independent adults?
Our journey towards treating our clients as independent adults begins with acknowledging our childhood patterns and the wounds we still carry. This self-awareness is not only a path to personal growth but also a key to improving our professional practice.
Listen to the full episode to hear:
How the relational programming we received in childhood can keep us and our clients stuckHow successful therapy actually replicates the foundational grief of the parentified childWhy your relationships with both your favorite and your most challenging clients might be where these relational patterns lurk the mostWhy we have to accept reciprocity and mutual gratification beyond collecting your fee in client relationshipsWhy you have to stop coddling your clients and treat them like the capable, strong adults they areWhy repressing your own emotional reactions to your clients isnât helping them or youLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
The Analyst's Vulnerability: Impact on Theory and Practice, Dr. Karen MarodaSeason 3 Ep 5: From Childhood Wounds to Therapeutic Wisdom with Dr. Karen MarodaSeason 2 Ep 9: Immediacy in Therapy: Breaking the Fourth Wall with Dr. K Hixson -
Iâve said it before, and Iâll say it again: as a group, therapists tend to have some pretty similar formative childhood experiences.
Our shared experiences as parentified children not only draw us to this field, but according to todayâs guest, they fundamentally influence and shape how we practice once we become therapists. This understanding can foster a sense of connection and empathy among us, enhancing our ability to relate to our clients.
From the modalities and techniques we employ to the all-too-common fear of hurting our clientsâ feelings, Dr. Karen Maroda asserts that how we approach our profession is deeply tied to how we were parentified. By acknowledging and examining these impacts, we can take control of our practice, helping our clients grow and ensuring a sustainable career in the field.
Dr. Marodaâs work is not just theoretical. It's a call to action, urging us to embrace clinical and personal courage. It's a roadmap, guiding us on how to navigate our roles as therapists in light of our formative childhood experiences.
Karen J. Maroda, PhD, ABPP, is a psychologist/psychoanalyst in private practice in Milwaukee, Wisconsin, and Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin. She is the author of several books, including The Analyst's Vulnerability: Impact on Theory and Practice, and has published numerous journal articles, book chapters, and book reviews. She lectures nationally and internationally on the therapeutic process, including the place of affect, self-disclosure, countertransference, legitimate authority, and the need for clinical guidelines.
Listen to the full episode to hear:
How our parentification as children can be an indicator of our potential empathic strengthsHow parentification often sets us up to be conflict-avoidant and self-sacrificing, to the detriment of ourselves and our clientsHow treating our clients as excessively fragile or infantile hinders their ability to get betterThe real antidote to feeling frustrated and disengaged with a client whoâs not making progressThe relationship between our outsized fear of harming clients and our fear of our anger and frustration that was forged in childhoodLearn more about Dr. Karen Maroda:
The Analyst's Vulnerability: Impact on Theory and PracticeLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
Season 2 Ep 10: Client Relationships in the Trenches: The Role of Self-Validated IntimacyA Curious Calling: Unconscious Motivations for Practicing Psychotherapy, Michael B. Sussman -
As humans, we tend to like answers a lot more than we like questions. When we believe we have found answers, re-examining what we think of as truth is inherently destabilizing.
In a relatively young field like neuroscience, paradigm shifts, misconceptions, corrections, retractions, and foundational remodels are inevitable. We already have more questions than answers, and each answer spawns a thousand more questions.
That ever-unfolding feedback loop of curiosity, seeking, and finding is beautiful. However, it also causes problems when the paradigms weâve adopted as true turn out to be mistaken.
Do we throw out therapeutic interventions that work because the neuroscientific explanation becomes irrelevant or outdated? Or do we twist the evidence to make it fit to keep using these interventions? The former seems wasteful, the latter disingenuous.
So what do we do?
It's a daunting task, but acknowledging the vastness of what we donât know or understand with certainty is a crucial step. This honesty and humility might just be the key to becoming better therapists.
Listen to the full episode to hear:
The high stakes of re-examining accepted paradigms for ourselves and our clientsWhy the therapy fieldâs longing for legitimacy makes us so prone to cling to neuroscientific conceptsWhy even rock-solid science probably still wonât erase therapyâs âweirdâ reputationWhy itâs worth asking ourselves how we would explain what we do if we couldnât rely on our favored neuroscientific explanationHow over-adherence to neuroscientific explanations is fueling the toxic intraprofessional culture of therapistsWhy approaching neuroscientific concepts with humility and a grain of salt and maintaining a healthy skepticism with your clients isnât going to kill your credibilityLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythat -
If youâre a therapist in 2024, odds are you have given a client a neuroscientific explanation for a symptom theyâre experiencing or an intervention youâre using. Youâve probably done it sometime in the last week. So have I. Neuroscience-based language is the lingua franca of our field nowadays.
As a field, we have largely abandoned the languages of behaviorism or psychoanalysis, though there are still therapists who use those frameworks. But if you asked most therapists right now why they think what they do works, you would get an answer about the brain and nervous system.
This would be fine, except that at this moment, as our scientific knowledge rapidly grows, so do our claims about what that knowledge means, sometimes outpacing real understanding of the emerging research and its practical implications.
So when I encountered an article in The Washington Post titled âThe Body Keeps the Score offers uncertain science in the name of self-help. Itâs not aloneâ by writer and cultural critic Kristen Martin, I was intrigued by the way she shed light on some of the neuroscience that we increasingly use to justify what we do as therapists.
I invited Kristen to join me to unpack some of the all-too-common misrepresentations and over-interpretations and the wide-ranging implications for our field and the people we treat.
Kristen Martin is a writer and cultural critic. Her debut narrative nonfiction book, The Sun Wonât Come Out Tomorrow, will be published in winter 2025.
Listen to the full episode to hear:
Why we are so compelled to seek out neurobiological explanations for human experiencesThe significant limitations of the research that routinely gets cited to justify neuroscientific models of mental illness and traumaHow poor communication, low science literacy, and social media exacerbate the spread of âfolk neuroscience.âHow neuroscientific explanations for mental health struggles are being co-opted and exploited by bad-faith actors and systemsHow biologically-based explanations for mental health issues can increase stigmaHow neurobiological models let us bypass our collective responsibilities to mitigate systemic issues associated with traumaLearn more about Kristen Martin:
WebsiteTwitter: @kwistentLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
âThe Body Keeps the Scoreâ offers uncertain science in the name of self-help. Itâs not alone.Scanning Dead Salmon in fMRI Machine Highlights Risk of Red Herrings | WIREDCaitlin Shure, PhD Fundamental challenges and likely refutations of the five basic premises of the polyvagal theory, Paul GrossmanHow Emotions Are Made: The Secret Life of the Brain, Lisa Feldman Barrett
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Since the last episodeâs conversation with hannah baer about the Jewishness of therapy, Iâve been thinking a lot about lineage.
When I first decided to do an episode on the topic, I was primarily motivated by wanting a deep sense of admiration for the Jewish pioneers of the field. Their contributions, which, like any minority group, tend to get erased as they are absorbed into the dominant culture, are invaluable and deserve explicit recognition.
But our conversation and hannahâs original article also helped me connect to something more than claiming therapyâs Jewish roots and contributions to global culture.
The American myth of being self-made or self-determined tends to alienate us from our lineages, but we are part of them whether we consciously engage with them or not. The history and context of our field matter, even when those histories are messy, ugly, and problematic. Contending with therapyâs history opens a dialogue between ourselves and our forebears in ways that move the profession forward and bring us together in solidarity and kinship. And that is a project worth taking on.
Listen to the full episode to hear:
How the American fantasy of being self-made teaches us to ignore the lineages of our practiceThe importance of pushing back against ahistoricism and divorcing concepts from their contextHow we are in relationship with our lineages, whether we are conscious of it or notWhy critiquing and rejecting what you donât like about the fieldâs lineage isnât enoughHow acknowledging our lineage opens the door to deeper camaraderie and kinshipLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythat -
Raise your hand if this sounds familiar: In a group of leftie social justice therapists, someone says that therapy is a profession founded by white men. Everyone else in the room nods along and acknowledges the white male hegemonic roots of the profession, then moves on to discuss other things.
The problem with saying that white men founded therapy and is part of a white hegemonic legacy is that it just isnât true.
If you go down a list of the founders and early theorists of therapy as theory, discipline, and practice, youâll find that many of them were Jews. Even now, many of our theory heroes and celebrity therapists are Jewish.
And thatâs not incidental or coincidental; it is consequential. Therapy is foundationally and elementally Jewish.
To dig into therapyâs Jewish roots, I invited writer and therapist hannah baer to join me. We also talk about therapyâs relationship to Jewish mysticism and esotericism and delve into the ways in which therapy follows the Jewish tradition of marking and understanding the past.
hannah baer is a writer and therapist based in New York. She is the author of the memoir trans girl suicide museum.
Listen to the full episode to hear:
The conflation of survival and accumulation of privilege that has happened in many Jewish families as they have been assimilated into whitenessHow the rejection of psychoanalytic therapy is tied to the drive for assimilation into white culture and the rejection of mysticismWhy it should be okay for therapists to accept that the magic that happens in the room canât always be explained by science or reduced to an insurance noteThe Jewishness of verbalizing and analyzing trauma, and reinterpreting historic theoryThe radical promise of therapy to help people metabolize and contextualize their trauma so they donât repeat it on othersThe American insistence on focusing on the now or the future at the expense of grappling with and understanding the pastThe impact of consumerism on how patients approach mental health treatmentLearn more about hannah baer:
trans girl suicide museumInstagram: @malefragilityLearn more about Riva Stoudt:
Into the Woods CounselingThe Kiln SchoolInstagram: @atherapistcantsaythatResources:
Wikipedia: Who Is a Jew?Therapy Was Never SecularThe Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients, Irvin YalomThe Case for God, Karen ArmstrongHannah ArendtBuilding a Life Worth Living, Marsha M. LinehanStanding Together -
Co-conspirator and friend of the podcast, Dr. K Hixson, returns to share some exciting news about a true labor of love.
Weâve joined up to create The Kiln, a comprehensive supervision and training program for pre-licensed therapists in Oregon. The Kiln will also offer continuing education to practicing clinicians.
This venture was born out of our mutual frustrations and concerns with the direction, trends, and tendencies in the current state of our field, and our deep dedication and commitment to our work.
Today, weâre going to get into why we are bringing an apprenticeship lens to postgraduate supervision, pushing back on current paradigms in trauma treatment, and how you can join our trainings or become part of our very first cohort.
Listen to the full episode to hear:
Why many grad schools and supervision programs fail to train great therapistsThe two fundamental philosophies that define our approach with The Kiln Why we teach exposure-based trauma therapies and push back on anti-exposure biasWhy therapists need to be able and willing to confront themselvesTrauma processing modalities that we are excited about working with and teachingLearn more about The Kiln:
WebsiteLearn more about Dr. K Hixson:
WebsiteLearn more about Riva Stoudt:
Into the Woods CounselingInstagramResources:
Trauma and Recovery: The Aftermath of Violence--From Domestic Abuse to Political Terror, Judith Lewis HermanBrain Talk: How Mind Mapping Brain Science Can Change Your Life & Everyone In It, David Schnarch -
To wrap up season two of A Therapist Canât Say That, Iâm continuing my reflections on my ten years as a therapist.
Iâll be back in April with interviews on some juicy topics, but for now, here are lessons six through ten that Iâve learned over the last decade of doing this work.
Listen to the full episode to hear:
Why being overly passive for fear of screwing up might be the biggest mistake of allHow courage is the true gatekeeper of all my clinical skillsWhat it really means to take responsibility for what happens in the therapeutic spaceWhat Iâve come to deeply appreciate about the siblinghood of being a therapist, cardigans includedLearn more about Riva Stoudt:
Into the Woods CounselingInstagram -
Every therapist remembers their first client.
Many look back and cringe at what a bad job they think they did. But for me, I look back and remember the magic I felt in the room with my very first client.
Which isnât to say Iâve never done a bad job with clients. I have, just like we all have.
But after ten years of being a therapist, when the work I do has become part of the mundane fabric of my day, I still remember so clearly the magic of being so in it with my first client.
So today, Iâm reflecting on ten years of being in this field.
Listen to the full episode to hear:
Why I believe that empathy is crucial to our relationships with our clientsHow making a new therapy with every client is about more than what tools we useLearning to have faith in the emergent process of doing therapy while confronting the unfixableThe realities of balancing the amount of relational energy I have between clients and loved onesLearn more about Riva Stoudt:
Into the Woods CounselingInstagramResources:
Slapstick, Kurt VonnegutSeason 2 Ep 9: Immediacy in Therapy: Breaking the Fourth Wall with Dr. K HixsonStanding by Words, Wendell Berry -
In the last episode with Dr. K Hixson, I said that our field is defined by the wish fulfillment fantasy of the parentified child. The parentified child wants nothing more than to get it right, manage the relationship, and have the parental figure be healed and available to you
If you are a therapist and you think that you were not, in some way, a parentified child, youâre probably wrong or in denial, or youâre one of the very, very few exceptions to this trend.
I stand by what I said that grown up, parentified children make up the bulk of this field, which means that knowing someone is a therapist means knowing something pretty significant about a dynamic that shaped them.
But when we name it, there can be a sense of residual shame that comes up.
Today, Iâm digging into where that shame comes from, why so many parentified children end up in this field, and how the drives of the parentified child help and hinder us in this work.
Listen to the full episode to hear:
How being a therapist can actually be an impediment to personal healingThe fine line between interpersonal hypervigilance and interpersonal hyperattunementHow this work can reinforce patterns of relational perfectionism and imbalanced caretaking roles so common to parentified childrenHow using immediacy with our clients can actually help us heal these patterns and tendenciesThe difference between self-validated intimacy and other-validated intimacy and how it applies to immediacy and self-disclosureLearn more about Riva Stoudt:
Into the Woods CounselingInstagramResources:
Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy, David Schnarch -
Immediacy may seem like a stale topic, but I truly believe that it has the capacity to be the primary tool of magic in the therapeutic relationship.
Immediacy is risky. Immediacy is counter-cultural. Immediacy is a disruption to our people-pleasing tendencies. Immediacy challenges us to stretch our tolerance for uncertainty. Immediacy is a key to unlocking difficult clients.
Immediacy invites us to do therapy by taking off the therapist mask and being seen. Immediacy is the mediator of therapeutic intimacy that can change lives.
Itâs not trendy, influencers arenât posting about it, but it is incredibly powerful and effective.
Today, my dear friend and colleague K Hixson returns for a conversation about immediacy and why we believe that it is such a potent tool.
Listen to the full episode to hear:
How immediacy lays the groundwork for intimacy and trust in the therapeutic relationshipHow weâve confused therapy with customer service, and how immediacy breaks down our people-pleasing tendenciesHow immediacy can teach us to repair ruptures in a way that strengthens the relationshipWhy immediacy is so effective with clients with interpersonal trauma historiesThe role of self-disclosure in using immediacyWhy over-attachment to protocols is really just wish fulfillmentWhy itâs vital to broaden our understanding of the history of the field and not just chase the latest trendsLearn more about Dr. K Hixson:
WebsiteLearn more about Riva Stoudt:
Into the Woods CounselingInstagramResources:
The Theory and Practice of Group Psychotherapy, Irvin YalomNegotiating the Therapeutic Alliance: A Relational Treatment Guide, Jeremy Safran, J. Christopher Muran -
Inspired by my conversation in the last episode with Dr. Andrea Celenza, today I want to talk about tolerating paradoxes and about love in the context of therapy.
In our conversation and in her book, Sexual Boundary Violations, Dr. Celenza discusses the concept of the âmultiple irreducible levels of reality in the therapeutic relationship.â
None of those multiple realities is more or less real than the others and itâs essential that we, as clinicians, maintain our awareness of them. Yes, itâs hard. These multiple realities evoke a whole range of relationships and power structures that often contradict each other. Of course itâs hard.
But when we try to collapse these realities, thatâs where we get into trouble. I want to unpack what that means for us in our therapist-client relationships, and how it requires us to hold and tolerate those multiple realities.
Listen to the full episode to hear:
Three essential layers in the therapeutic relationshipHow the relationship dynamics that arise out of transference and countertransference are both real and useful, even when they contradict each otherThe paradoxical axes of power in the therapist-client relationship How multiplicity and power bump up against each other and why we have to tolerate the tensionHow collapsing the paradox of multiple realities in the dyad creates problems with intimacyâbeing either exploitative or superficialWhy too little intimacy in the therapist-client relationship is a significant problemHow love and grief show up in therapeutic relationshipsLearn more about Riva Stoudt:
Into the Woods CounselingInstagramResources:
Season 2 Ep 07: Let's Talk About Sex: A Humane Approach to Sexual Boundary Violations with Dr. Andrea CelenzaLynda BarrySeason 2 Ep 4: What Happens When Our Clients Encounter Our Humanity?Sexual Boundary Violations: Therapeutic, Supervisory, and Academic Contexts, Andrea Celenza -
Sex with clients.
Itâs an interesting topic because itâs both very taboo and not at all polarizing. Many taboo topics are just that because discussion of them invites conflict. Sexual boundary transgressions arenât like that. We can pretty much all agree that theyâre wrong and bad.
So then why is it so hard to talk about?
I would argue that in this case, itâs because of fear of being in any way associated with a transgression of that magnitude, and the vicarious shame of being part of a group whose members sometimes commit these transgressions.
But we have to talk about it and hereâs why: a 2017 paper reviewed multiple studies and found that as many as 7 to 12% of therapists surveyed in those studies admitted to having sexual contact with a client. And thatâs in self-reported surveys. The consensus among people who study and write about this topic is that the actual numbers are probably much higher.
Obviously, just agreeing that we shouldn't do that and then moving on isn't working.
We need to be having conversations that go beyond, âitâs wrong,â and âhereâs some tips for holding boundaries,â especially if you are a supervisor or therapist of therapists. At some point, you will have a supervisee or client who comes to you about sexual attraction to a client and how you respond can make or break whether they go on to act on it.
To guide us in wrestling with this very fraught subject in a deeper, broader, and more generative way, I am so excited to bring you my conversation with psychologist and author Dr. Andrea Celenza.
Andrea Celenza, Ph.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute and Assistant Clinical Professor at Harvard Medical School. She is also Adjunct Faculty at the NYU Post-Doctoral Program in Psychoanalysis and The Florida Psychoanalytic Center. She has written numerous papers on love, sexuality and psychoanalysis. Her third book, entitled, Transference, Love, and Being: Essential Essays from the Field, was published in 2022 by Routledge. Dr. Celenza is in private practice in Lexington, Massachusetts, USA.
Content note: This episode contains brief, non-graphic mentions of sexual assault, incest, and suicidality
Listen to the full episode to hear:
Why we need to reframe sexual boundary violations as something we are all potentially vulnerable toRisk factors and precursors for boundary transgressors and how they overlap with non-transgressorsHow the therapeutic relationship can mimic common problematic childhood dynamics for therapistsThe impact of negative transference on the potential for boundary transgressionsWhy we have to be aware of and positively leverage the power imbalances inherent in the therapist-client relationshipWhy we have to learn to capture and tolerate multiplicity in ourselves and our patientsLearn more about Dr. Andrea Celenza:
WebsiteLearn more about Riva Stoudt:
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Sexual boundary violations: A century of violations and a time to analyze.Confronting Our Stories: Recentering Narrative Work In Trauma Therapy -
Being in therapy as a therapist, and being a therapist for therapists, is a bit like magicians trying to entertain each other. Weâve studied the tricks and techniques. Weâve seen behind the curtain and we canât pretend otherwise.
There is enormous pressure for each of us to do our own work in therapy in order to be good clinicians for our clients, but therapists are truly a special population. We carry the weight of other peopleâs stuff, and weâre much more likely to need to unload about our work in session. And yet, knowing what we know, it can be difficult to let goâabout work or whatever weâre trying to parse throughâwithout fear of being judged as bad therapists.
On the clinician side, we know, or at least sense, that therapists need something a bit more from us, but thereâs no specific training in just what that is or how to give it.
So what do we do? How do we approach being in therapy as a therapist and providing therapy to therapists?
Iâve been mulling over those questions since my conversation with Dr. Elene Herrera in the last episode, and today Iâm digging into where I think we can go from here.
Listen to the full episode to hear:
How therapistsâ inside knowledge of the therapeutic process and of being a therapist impacts our experience of therapyWhat needs to change on the macro level of our professional culture to better provide treatment for therapist clientsWhy we have got to stop being so quick to harshly judge each other if we want to be better clinicians to each otherWhy we need to accept and invite human messiness into our sessions with therapists as clientsWhat we can do in session to break through barriers to get our therapist clients to be vulnerable with usLearn more about Riva Stoudt:
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Behind the Scenes: When Therapists Become Clients with Dr. Elena Herrera -
Why is it so hard to be in therapy as a therapist?
Why is it so hard sometimes to be a therapist for other therapists?
What happens when we sit down and try to play this game we play with each other?
Iâve been wanting to do an episode on therapists as clients since I conceived of this show, so Iâm excited to share my conversation with Dr. Elena Herrera today.
Dr. Herrera specializes in working with therapists as clients, and shares some unique insights about challenges and patterns she has noticed in her work, as well as frequent themes of shame and embarrassment and fear of judgment that come up when therapists seek therapy.
We also dug into the broader issues of therapists feeling that they need to have achieved âwell-adjustednessâ in order to be good therapists, what it is that makes seeking therapy as a therapist feel so very vulnerable, and what happens when our work comes with us into the room.
Dr. Elena Herrera is a bilingual (English/Spanish) speaking psychologist with over 15 years of experience treating adults, youth, and families. She has worked in college counseling centers, children's crisis clinics, and community mental health clinics helping clients from various ethnic, cultural, and economic backgrounds. She has experience working with a range of populations, from people facing extreme emotional crises, to college students adjusting to life away from home, and engineers and techies experiencing burn out and fatigue. Dr. Herrera is also a clinical supervisor, training and mentoring future psychologists. Currently, her practice focuses on treating men and women in tech and engineering, couples, and other therapists.
Listen to the full episode to hear:
The challenges of maintaining professional boundaries and distance when working with someone whose experiences may be so similar to your ownWhy seeking therapy evokes so much shame for therapistsThe layered fear of judgment, personally and professionally, that often comes up for therapists in therapyWhy letting go of the therapist identity feels so vulnerableWhat happens when therapists bring their work with them into therapyWhy itâs vital for therapists to put aside rigid rules and listen when a client reveals boundary or ethical violationsLearn more about Dr. Elena Herrera:
Herrera Psychological Serviceshttps://www.linkedin.com/in/elena-herrera-psy-d-9737024/Facebook: @DrElenitaLearn more about Riva Stoudt:
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