Therapy on the Cutting Edge

In this episode, Alecia explores the critical intersection of women's mental health, ADHD, and reproductive psychiatry—an area where science is only beginning to catch up with women's lived experiences. Alecia's journey into psychiatry began in Sacramento, California, where she witnessed profound disparities in healthcare access across diverse communities. After seeing loved ones struggle with both physical and mental illness, she pursued medicine with a mission. During medical school, she gravitated toward geriatric psychiatry, drawn to the complexity of caring for older adults. But during residency, her focus began to shift as she became fascinated by something even more fundamental: the intricate dialogue between mind and body. This growing interest led her to consultation-liaison psychiatry, formerly known as psychosomatic medicine, where she served as chief resident. The field gave her a lens to understand how physical illness shapes mental health and vice versa—a perspective that would profoundly inform her later work. She went on to complete a consultation-liaison psychiatry fellowship at the University of Chicago, followed by specialized training in reproductive psychiatry. Alecia’s attention to health disparities guided her toward women's and minority mental health, populations that remain vastly underfunded and underresearched. In her clinical work, she began noticing a troubling pattern: many patients struggling financially, physically, and emotionally actually met criteria for ADHD, yet had never been properly identified or treated. These missed diagnoses often compounded existing challenges, leaving people to navigate life with an invisible burden they didn't understand. In our conversation, Alecia illuminates why girls with ADHD are so often overlooked. While boys typically display hyperactive, disruptive symptoms that demand attention, girls more commonly present with inattentiveness—daydreaming, losing track of conversations, internal restlessness—symptoms easily misattributed to anxiety or depression. This diagnostic blind spot means girls are less likely to receive appropriate medication and more likely to struggle silently through years of self-blame. Alecia then guides us through the remarkable role hormones play in ADHD across the female lifespan. She explains how estrogen acts as a neuroprotective force, supporting the neurotransmitter systems that govern focus and impulse control. During the menstrual cycle, as estrogen and progesterone fluctuate, women with ADHD experience predictable shifts: heightened impulsivity and hyperactivity when estrogen dips after ovulation, and increased inattention, depression, and anxiety when both hormones plummet before menstruation. Strikingly, about sixty percent of women with ADHD also meet criteria for Premenstrual Dysphoric Disorder, underscoring just how intertwined hormones and mental health truly are. The postpartum period presents another vulnerable window. When estrogen declines after delivery, previously manageable or even unrecognized ADHD symptoms can suddenly intensify, leading to new diagnoses during what is already a demanding transition. Alecia thoughtfully discusses navigating stimulant medication during pregnancy, emphasizing that treatment decisions must honor each woman's unique circumstances while weighing risks and benefits for both mother and baby. As women approach perimenopause and menopause, declining and erratic estrogen levels can trigger cognitive changes, mood shifts, and worsening ADHD symptoms—yet clinical guidelines for diagnosis and treatment in this population remain virtually nonexistent. Alecia addresses the ongoing debates around hormone replacement therapy, noting that timing matters: estrogen therapy initiated earlier may offer benefits with fewer risks than when started later in life. She also discusses how certain SSRIs may help manage perimenopausal symptoms by supporting neurotransmitter function. What emerges most powerfully from this conversation is Alecia's compassion and her insistence on one fundamental principle: believe women. Listen to their experiences. Include their families in care. The science, she acknowledges, still has considerable catching up to do—but in the meantime, women deserve to be heard, validated, and treated with the individualized, evidence-informed care that respects the full complexity of their lives. Alecia Greenlee, MD, MPH is a board-certified psychiatrist who brings both rigorous training and deep humanity to her work with women navigating ADHD and co-occurring mental health conditions. After earning her medical degree from UC San Francisco, she completed her psychiatric residency at Harvard Medical School/Cambridge Health Alliance, where she served as chief resident in consultation-liaison psychiatry and developed expertise in collaborative care and mental health services for vulnerable populations. She went on to fellowship training at the University of Chicago, first in consultation-liaison psychiatry and then in reproductive psychiatry, gaining specialized knowledge in how the body and mind interact throughout women's lives. Allecia specializes in comprehensive psychiatric evaluation and evidence-based treatment for adults, with particular expertise in how hormonal changes throughout the female lifespan—from menstrual cycles to pregnancy to perimenopause—influence ADHD symptoms and overall mental health. Her commitment to health equity drew her to focus on women's and minority mental health, populations often underserved by research and clinical resources. She approaches each patient with cultural attunement and warmth, creating collaborative, safe spaces where people from all backgrounds feel genuinely heard. Her practice reflects a commitment to whole-person care that considers not just psychiatric symptoms, but the complex interplay of biology, identity, life circumstances, and medical conditions that shape each individual's treatment needs.

In this episode, I speak with psychologist Kenneth Perlmutter about his work with wounded family systems and how his background shaped his therapeutic approach. Kenneth shared that he originally planned to go to medical school but switched to journalism, then worked in advertising in San Francisco in the 1980s. During that time, he worked with a therapist who made a profound impact on him, which ultimately inspired him to pursue graduate training and become a therapist himself. In 1989 he joined Boyer House as an intern, later becoming the Clinical Milieu Director, and it was there that he was placed on the Family Therapy team and found he really enjoyed working with family dynamics. Kenneth explained that his work is heavily informed by psychodynamic and psychoanalytic thinking, especially the ways people relate to others across different parts of their lives. He shared that his current clinic functions as a full-service mental health center with significant expertise in substance abuse, addiction recovery, and trauma-related disorders, and that many of their referrals involve college-age and young adult clients whose families are struggling to support them. We discussed how he uses a psychoanalytically informed systemic approach, paying close attention to attachment patterns, the family’s stage of development, and even reflections on his own family system. He talked about how wounded family systems often fall into patterns of dependency, such as exaggerated dependency, hostile dependency, or chronic dependency, and how parents may unknowingly reinforce these dynamics. He explained that he looks closely at what he calls the ‘S’ actions,” which include serving, soothing, saving, smoothing, solving, sacrificing, and sobbing, and how these actions often keep families stuck in their roles. He shared that when parents begin to shift their focus toward their own needs and adjust their responses, children often change their behaviors in positive ways. Kenneth also discussed how families tolerate hostility and how interventions often start by looking at the behaviors that enable it. He explained that part of the work is helping families understand how their system functions, what they want more or less of, and what keeps them locked in certain roles. He postulates on what can be considered “right” or “wrong” actions as a result of these pressures and gives the example of sending an adult child money time and time again under tenuous circumstances. He claims that what would be “wrong” in fact, would be not to reflect at all on how the parent’s actions are affecting the child’s behaviors. Kenneth calls these narratives “the lies that bind”, explaining that the most common belief is that whatever ‘S’ behavior is at play is what is keeping this family member alive and well. This distorted narrative keeps a tight grip on current dynamics and gives the parent a false sense of control. Being locked in this “if only” mindset is either aspirational or regretful. We ended the conversation by talking about his Model of Stress-Induced Impaired Coping. Kenneth explained that every family develops its own stress-driven roles and that members often fall into patterns such as escaping, distracting, blaming, or fixing. He described how he helps families understand what holds them in these roles, what reinforces them, and how these patterns originally developed, so they can move toward more flexibility and healthier ways of relating. Kenneth Perlmutter, PhD, is the founder of the Family Recovery Institute and a licensed psychologist specializing in Family Systems. He has 35 years of experience working with complex psychological and behavioral health disorders. In 2008, he founded The Family Recovery Institute to provide multi-disciplinary treatment for individuals and families including dynamic therapy, family systems work, group therapies, healing workshops and clinician training. He has pioneered and validated a theory of family system woundedness with a corresponding recovery model he calls Stress-Induced Impaired Coping. He wrote the book Freedom from Family Dysfunction: A Guide for Families Battling Addiction or Mental Illness specifically for family members who love someone battling addiction or mental illness but “want to break the cycles of codependency and relapse plaguing their dysfunctional systems.” He has overseen the design and installation of the family treatment program for Bayside Marin, Morningside Recovery, Safe Harbor Treatment Center for Women, Casa Capri/Windward Way and other national-level programs. In addition, he conducts a twice-monthly therapy group for parents of troubled teens and stuck young adults and has historically conducted several healing workshop for families of the White Mountain Apache Reservation in Whiteriver, AZ. As a professional educator, he has served on the graduate faculty for San Francisco State University’s Counseling Department and as Associate Professor of Chemical Dependency Studies at Cal State East Bay.

In this episode, I speak with Peter about his work on narcissism and its place within the broader spectrum of personality disorders. He shares that when he was in graduate school for literature, he was required to participate in a course of psychotherapy—an experience that sparked his interest in the field and eventually led him to pursue clinical training. Peter explains that he became increasingly interested in personality disorders, especially after having his own personal encounter with someone exhibiting narcissistic traits. This experience helped shape his focus in this area of study. He notes that the field of psychotherapy often views narcissism through the lens of “hurt people hurt people”—the idea that harmful behavior stems from unresolved trauma. While that framework can sometimes be useful, Peter believes it may also lead people to remain in harmful dynamics for too long because they extend too much empathy and assume the behavior is unintentional. He discusses meta-analytic research on twins showing that roughly 50% of psychological traits are heritable; in some studies, narcissistic traits have been found to be up to 79% heritable. Peter emphasizes the importance of clinicians and clients understanding that, in many cases, narcissistic individuals do know their behavior is harmful and continue it because it benefits them. This runs counter to the prevailing idea that such behavior is purely unconscious or trauma-driven. He acknowledges that this perspective is controversial and that he has received criticism for challenging long-standing therapeutic assumptions. When working with clients, Peter helps them navigate the cognitive dissonance between their painful or abusive experiences and their belief that the narcissistic individual “didn’t mean it” or was simply reacting from trauma. The belief that someone is merely “wounded” and reacting can keep people in unhealthy relationships far beyond what is safe or reasonable. We also discussed the differences between narcissism and antisocial personality disorder. Peter explains that one way to determine whether a person is workable is to assess their collaborative capacity—and, importantly, for therapists not to assume there is mutual agreement on collaboration or shared responsibility. He underscores the importance of validating victims of these relational dynamics, reminding them that no matter how much self-work they do, they may not be able to improve the relationship because the problem may not be about them at all. Part of his work involves helping clients reconnect with their sense of self, especially when an invalidating environment has led them to doubt their own perceptions, question their reality, or even wonder whether they are a “good” person. Peter Salerno, PsyD, is a Doctor of Psychology, retired licensed psychotherapist, and nationally recognized expert on personality disorders and pathological relationships. Over the course of his career, he has specialized in personality disorders, family trauma, complex trauma, and pathological abuse. He was trained and qualified to administer the Hare Psychopathy Checklist–Revised (PCL-R), the gold standard for identifying psychopathy in clinical and forensic settings. He was also a featured expert in the docuseries Ted Bundy: Dialogue with the Devil, streaming on Hulu and Disney+. His work has always been driven by a passion for understanding the human mind and helping people make sense of some of its most challenging and misunderstood conditions. Today, he uses that expertise to help people around the world understand painful, confusing, and often manipulative relationship dynamics. While he no longer practices traditional therapy, he offers remote consultations focused on clarity, insight, and practical decision-making—not treatment.

In this episode, I speak with Matt about his work with veterans, PTSD and his research on AI's ability to diagnose mental health disorders. Matt explained that he got into the field of psychotherapy after being a patient, working through his own issues after being in the Marines. He found the process very helpful and went on to become a therapist and initially worked with unhoused populations, psychosis and gang young, but wanted to go into working with veterans and first responders, treating PTSD. He shared that he never intended to go into research, but after doing his dissertation, he thought he might as well publish it, and then was invited to be part of a research group. Matt shared that most of the treatment for veterans is provided by the Veteran’s Administration, although they did not hire clinicians with his licensure. He explained that he was fortunate to get connected with an organization called the Head Strong Project that provides services to active duty military and veterans addressing PTSD and suicide prevention. He said that many of his clients often have a history of trauma, in addition to their experience in the military, as well as around 50% of his clients also have comorbid ADHD. Matt discusses the three major evidence based approaches to treating trauma: Prolonged Exposure (PE), Cognitive Processing Therapy, & Eye Movement Desensitization Reprocessing. He shares how the dropout rate for PE is 40% and EMDR is not always successful, which might be due to the eye movements and that not being as effective with those in the military, although he doesn’t know any research backing that up. Matt explained that he uses CPT and in the approach, the focus is on beliefs or what they refer to as “stuck points”. There may be assimilated “stuck points" that the person has taken from the traumatic experience and over accommodated "stuck points”< which are things that the person now believes and has adjusted their thinking patters as a result of the trauma. He explains the treatment starts off with psycheducation and teaching coping skills, then addressing the “stuck points”. He explained that they help the clients break down thinking patterns from events, then usechallenging questions, identify cognitive distortions, use cognitive reframing, and put this all together into a challenging questions worksheet. He shared that once you have that framework in place, then you follow up on five themes which include: Safety, Trust, Power & Control, Esteem, and Intimacy, then work through stuck points in each of those areas. Finally, you work through the traumatic narrative and what you believed before and what you believe now. We discussed the five themes and how particularly discussed an intervention called the Trust Star, where the person picks aspects of someone’s personality, and rates how that leads them to be more trusting of them or less. The breaks out of the all or none thinking around trust. Lastly, we discuss Matt’s research into linguistic patterns in different DMS disorders throughout the various editions of the DSM. He also discusses his work group’s research into having AI review vignettes and try to arrive at a diagnosis. He reported that Chat GPT did worse than chance, Claude was about as good as chance, and Gemini had a 97% rate of accuracy. We discuss AI and its use related to therapy. Matt Rensi, Ph.D., LPCC, is a licensed counselor in California, Oregon, and Idaho. He holds a Ph.D. in counselor education and supervision, often teaching at various universities. He currently works primarily with law enforcement, veterans, firefighters, and active duty military personnel. His primary focuses are PTSD, substance use, ADHD, marital or couples issues, and anything that may be associated with that cluster of struggles. Matt conducts research on various topics as part of an independent research team. He is a clinical partner with The Headstrong Project and the SOF Network. Matt is also a clinician at the Institute for the Advancement of Psychotherapy and its specialty center, the Bay Area Center for ADHD.

In this discussion, Fred Luskin—psychologist and director of the Stanford Forgiveness Projects—dives into the power of forgiveness. He shares his journey from personal struggles with forgiveness to groundbreaking research. Fred advocates for a secular approach to make forgiveness accessible, emphasizing that it benefits the injured party, not the perpetrator. He critiques the misuse of 'trauma' labels that can hinder healing and promotes mindfulness as a tool for present moment awareness. Ultimately, he presents forgiveness as an essential practice for fostering love and joy in our lives.

Jeff Greenwald, a licensed marriage and family therapist and world champion tennis player, dives into the synergy of sports psychology and clinical therapy. He discusses how anxiety permeates both athletics and family dynamics, emphasizing the need for tailored therapeutic approaches. Greenwald introduces practical frameworks like the four dimensions of focus and the concept of 'permission to miss,' highlighting how these tools help young athletes navigate pressure and performance. He also addresses the influence of family dynamics on athletic development and the shift from outcome to mastery mindsets.

In a captivating discussion, psychotherapist Michelle Ferris shares her journey from a dysfunctional upbringing to becoming a codependency expert. She defines codependency as over-functioning for external validation and emphasizes the importance of boundaries. Michelle highlights the dual nature of hypervigilance—it can be a gift but also lead to anxiety. Through befriending oneself and setting limits, she encourages healing and self-connection, while addressing the role of shame in recovery. Michelle’s insights are both practical and empowering.

In this episode, I speak with Rachel about using Energy Psychology (EP) and Sound Healing (SH) in her psychotherapy work. Rachel describes how she was originally trained psychodynamically and had been in psychodynamic therapy herself. After Rachel learned about EP from her acupuncturist she pursued training in the approach, and found it was very effective with clients. She also worked with an EP psychotherapist and experienced a significant shift. Rachel explains that EP facilitates changes in subtle energy resulting in shifts in behaviors, emotions, physical symptoms, anxiety, PTSD, performance and other issues. Rachel discussed the most well-known EP approach, Emotional Freedom Technique (EFT). Many people have learned it as a technique to help regulate the nervous system. With more in depth training, EFT can be used for a variety of issues one might bring to a therapist. Rachel discusses how she integrates SH into other EP techniques. She has found that it often increases the speed and ease of change. Rachel discussed the significant research support for EP, including numerous double blind, randomized and controlled research studies. Lastly, Rachel shared practical strategies listeners can use to calm their nervous system and also demonstrated the sound produced by her various SH instruments. Rachel Michaelson, LCSW is a licensed clinical social worker in the state of California with over 35 years of clinical experience. Along with providing individual and group psychotherapy, Rachel is a clinical supervisor and consultant, who specializes in energy psychology and sound healing. She is a certified Diplomate in Comprehensive Energy Psychology (D-CEP) and has training in several energy-based therapeutic modalities including Emotional Freedom Technique (EFT), Havening Techniques, Advanced Integrative Therapy (AIT), Tapas Acupuncture Technique (TAT,) Psych-K, Trauma Tapping Technique and other energy medicine techniques. Rachel has developed an Energy Psychology protocol called Release Issues Past and Present which she uses with individuals and in groups and teaches to other mental health providers. When working with clients, Rachel often integrates sound healing by utilizing calibrated tuning forks and chimes to facilitate change. For over 25 years Rachel has been providing training to mental health professionals on a variety of topics including Energy Psychology, Sound Healing, trauma informed care, clinical supervision, law and ethics, telehealth, diagnoses, time and paperwork management, and suicide. Rachel is a past chair of the Association for Comprehensive Energy Psychology’s Humanitarian Committee.

In this episode, I speak with Nigel about his work with Integrative Attachment Therapy (IAT). He discusses how his studies with Dan Siegel, M.D. and his meditation training in the Tibet Bon Dzongchen, led him to be very interested in what is a “mind”, how it works, what its about, and how ti develops. He discussed how attachment is the basis for the development of the mind, which we create "bottom up in our relation to others. He explained that the key developmental processes for the mind include attachment, care and nurturance, social rank, sexual identify and safety. He said that the novel part of the work that Daniel Brown, Ph.D., the coauthor of Attachment Disturbances in Adults: Treatment for Comprehensive Repair, was using an ideal parental figure to repair what had or had not been established in development. Nigel talks about the three pillars of IAT, where the therapist and client are collaborating on the work they’re doing together at the beginning of the session, doing the imaginal intervention of the ideal attachment figure, and then using metallization to process the experience and gain new awareness. He explained that they are helping a client to connect with the felt experience of feeling safe, seen, being able to trust and other elements of experiencing a secure attachment with this imagined parental figure. He shared that the conditions for a secure attachment include embodied trust, felt safety, being good enough, that its ok to explore, being able to down regulate the nervous system, and knowing your a good person. He spoke about how transference is encouraged to be shared directly with the therapist, and discussed using metallization, rather than using the therapist to provoke transference and letting it build up and then be worked through. We also discussed his work with psychedelics and its ability to help clients to integrate experiences in a different interpretive map. Nigel Denning, M.Psych, MA is a Counselling Psychologist and Director of Integrative Psychology and Medicine in Melbourne, Australia. Nigel is Research Fellow at Australian National University. Nigel has been involved in developing the Three Pillars of Attachment Repair and Integrative Attachment Therapy with David Elliott and Traill Dowie and developing the IAT Training Program. Nigel is a nationally recognized expert in family violence, institutional abuse, trauma and attachment-focused practice. Nigel is also clinical lead in several psychedelic medicine trials and a trainer in psychedelics and holotropic breathwork, having studied under Stanislav Grof. In addition, Nigel is a long-term meditation practitioner and teacher in the Tibet Bon Dzogchen tradition. Nigel has a profound understanding of how Eastern practices affect the mind and their subsequent connection to psychotherapy. Nigel is a jovial and kind person who is passionate about improving the world one mind at a time.

In this engaging discussion, Peter Fraenkel, an Associate Professor of Psychology and expert in last-chance couples therapy, shares insights from his extensive experience working with couples on the brink of separation. He delves into the Creative Relational Movement approach that breaks cycles of conflict by fostering vulnerability and addressing gender dynamics. Peter outlines key principles for effective therapy, suggests actionable strategies for couples, and explores common scenarios they face. His expertise shines as he offers hope for transformative change in strained relationships.