Therapy on the Cutting Edge

In this episode, I speak with Shafia about her path to becoming a health and sex educator. She discussed how she had worked in case management and social work with kids who were experiencing dual and triple diagnosis, and a common theme was having a history of being harmed. She decided she wanted to try to help increase the prevention of such harm, and was fortunate enough to work at a great school, Marin Academy, where they allowed her the resources to create an in depth class where she could help the kids process the foundational concepts related to relationships, being respect, dignity, safety and pleasure. After 25 years of teaching in many schools, Shafia wrote a book: ​Sex, Teens, and Everything in Between. We discussed her book, which is written to help parents and teens have conversations about consent, sex, their rights, and many other topics. We discussed her use of Emily Nagoski’s metaphor of the garden and deciding what to leave, what to take out, and who we’re going to let in to our sexual guardian, and the beliefs and feelings we have about sexuality and how we connect with others. She also shared a conversation she has with the students about how they would feel if the sat down with some French fries and everyone started grabbing them. This leads into conversations about consent, power, respect, and a whole host of other concepts. She also shared that it is very important for parents, as well as therapists, to think of their own relationship to sexuality, body image, relationships, gender, sexual orientation because these will influence how we respond in guiding teens. Shafia Zaloom is a health educator, parent, consultant and author whose work centers on human development, community building, ethics, and social justice. Her approach involves creating opportunities for students and teachers to discuss the complexities of teen culture and decision-making with straight-forward, open and honest dialogue. Shafia has worked with thousands of children and their families in her role as teacher, coach, administrator, board member, and outdoor educator. She has contributed articles to The New York Times, The Washington Post, and numerous parenting blogs. Shafia’s book, Sex, Teens and Everything in Between has been reviewed as “the ultimate relationship guide for teens of all orientations and identities.” It is one that “every teen, and every parent and educator - and every other adult who interacts with teens - should read.” Shafia is currently the health teacher at the Urban School in San Francisco, and develops curricula and trainings for schools across the country. She was honored by the San Francisco Giants Foundation in 2018 for her work with Aim High, a program that expands opportunities for students and their teachers through tuition-free summer learning enrichment, and was recently granted CAHPERD’s Health Teacher of the Year Award for 2021. Her work has been featured by many media outlets including, The New York Times, USA Today, NPR, KQED, and PBS.

In this episode, Terry discusses his experience initially being trained psychodynamically and psychoanalytically, but finding that it did not seem to be a good fit for the population whom he was working with, which were families in Chinatown in San Francisco, many of which were immigrants. He discussed how a training at the Mental Research Institute (MRI) had a profound impact on him when he heard the person teaching saying that people are not sick, they are stuck. The therapist's job is to help them get unstuck. Terry discusses the four elements that he feels are important to working with clients and families, which are related to the relationship, being humanistic in approach, understanding the client’s cultural context, activating the clients’ strengths, and the placebo effect, which is the client’s belief that positive change is possible. We discussed the differences between the Brief Strategic MRI model and Jay Haley’s Strategic Family Therapy model, and the 180 degree shift in solution. This is based on the idea that the attempted solution has become the problem. We discussed one example of a session Terry had written about, and how both the cultural competency and the MRI model came into play. The case involved a Vietnamese woman who was encouraged by her previous therapists to stop taking care of her sick father and instead individuate and take care of herself. She flatly rejected this idea. Terry understood the importance of certain roles in collectivists cultures. Instead of encouraging her to take care of herself more, he helped her to become more effective in caring for the father. He used different metaphors to step into the clients’ worldview and shifted the system, which worked within the client’s cultural context. The intervention was a success and the father and the client experienced great improvement. Terry discussed his approach called, Strength Based Culturally Informed Integrated Model, and how the two most important parts are adaptability and flexibility, and collaborating with your clients on creative interventions to disrupt the stuck cycle and generate new more effective solutions. Terry Soo-Hoo, PhD is currently professor at the California State University East Bay in the Marriage and Family Therapy Program, and was the Clinical Director of MRI in Palo Alto. He completed his Ph.D. in clinical psychology at the University of California, Berkeley and is Board Certified in Family and Couples Psychology (ABPP). Prior to university teaching he devoted over twenty years as a psychologist in Community Mental Health Services in San Francisco working with a diverse range of people with many different psychological problems. Terry's publications include topics on multi-cultural issues in psychotherapy and consultation, brief therapy and couples therapy. He has special interests in the area of innovative culturally relevant approaches to psychotherapy. He has also provided extensive presentations, training, supervision and consultation on these topics to agencies and other professionals in many countries around the world.

In this episode, Mary Jo discussed her background in community psychology, which lead her to start her career working with child abuse, leading to a lifelong career working with interpersonal violence, family therapy, and community interventions. Mary Jo discusses her Collaborative Change Model (CCM), which is a meta-model, being concept driven , as opposed to intervention based. The two main concepts are how to collaborate and integrate the therapist, clients resources and timing. In timing, she discusses both the timing of what you’re doing session to session, but also the timing in the session, based on whether we need to expand or contract following a rhythm to stay attuned and connected to our clients. She discussed how transparent she is with her clients, discussing the model and direction, and teaching the neuroscience they’re using in the session. She discussed working with clients with domestic violence and incest in a family therapy model, given that most would not do sessions with the offender(s). She discussed how the first phase is creating context, and assessing and establishing safety, then the second phase is challenging patterns and expanding realities, and finally the third phase is consolidation. Mary Jo shared the awareness of the 5 Essential Ingredients for Successful Treatment. We discussed her work with cut-offs between adults and their family members and her specific work with those dynamics, and finally discussed her current project working with gang involved individuals and families on the South Side of Chicago. Mary Jo Barrett, MSW is the author of Incest: A Multiple Systems Perspective and Treating Complex Trauma: A Relational Blueprint for Collaboration and Change (Psychosocial Stress Series). She is also the Executive Director and co-founder of The Center for Contextual Change, Ltd. and in the past on the faculties of University of Chicago, School of Social Service Administration, The Chicago Center For Family Health, and the Family Institute of Northwestern University. Mary Jo was the Director of Midwest Family Resource and has been working in the field of family violence since 1974. She focuses on the teaching of the Collaborative Stage Model, systemic and feminist treatment of women, adult survivors of sexual abuse and trauma, eating disorders, couple therapy, Post Traumatic Stress Disorder, and Compassion Fatigue.

In this interview, Dick discusses how his work with families lead to him learning from clients about their parts. He discusses how his clients talked about their parts, and at first he and his client tried to argue against that part and try to get rid of it or for it to not be doing what it was doing. When this wasn’t working, he and his clients began to have compassion for those parts, and learn about what they needed, and how they were trying to protect the client. He explained he conceptualizes parts as natural and universal, rather than something only born out of trauma and being indicative of pathology. He explained how he conceptualizes a Self, which is the part that is the leader, essential, wise part, and how other parts exist from the beginning of our lives, but sometimes, just like in families, they take on roles to protect the system. He talked about how these parts reminded him of children in the families who he worked with that were trying to help the family system by taking on roles. Using this conceptualization, he worked with the parts as children in the family who were trying to stabilize the system, and instead helping the Self to connect with these parts, and relieve them of their need to try to protect. He explained that the goal of IFS is not to integrate, as that would suggest that the goal is to not have the parts, but more for the parts to feel safe, and coexist in a healthy system, just like a healthy family. During the interview, Dick demonstrates the technique of unblending with Keith, the interviewer, and uses this demonstration to further explain the aspects of IFS including the Protectors, the FireFighters, and the Exiled Parts. He discusses working with complex trauma with IFS, using IFS with couples and families, and his next chapter in his career, making IFS more accessible to the public through books or apps or other ways that people in the public can use it, not just only in therapy. Richard C. Schwartz, Ph.D., is the founder of The IFS Institute, originally named The Center for Self Leadership. He began his career as a systemic family therapist and an academic. Grounded in systems thinking, Dr. Schwartz developed Internal Family Systems (IFS) in response to clients’ descriptions of various parts within themselves. He focused on the relationships among these parts and noticed that there were systemic patterns to the way they were organized across clients. He also found that when the clients’ parts felt safe and were allowed to relax, the clients would experience spontaneously the qualities of confidence, openness, and compassion that Dr. Schwartz came to call the Self. He found that when in that state of Self, clients would know how to heal their parts. A featured speaker for national professional organizations, Dr. Schwartz has published many books and over fifty articles about IFS.

In this interview, Michael discusses his work with patients with bipolar disorder, and his own background as an entrepreneur, and how this has lead him into research and treatment of entrepreneurs with bipolar disorder. Michael explains what bipolar disorder is, and how to accurately diagnose Bipolar Disorder I, Bipolar Disorder II, hypomania, and mania and how they are different than Major Depression, ADHD, and/or complex trauma. He discusses the importance of assessing for a genetic history, as bipolar disorder his highly hereditable. He talks about how individuals raised by a bipolar parent may have some of the qualities of bipolar disorder (e.g., creativity, drive, high energy), but not bipolar disorder itself and some of the theories on the benefits of heredity of part of the genetics for bipolar disorder. He explains how important medication is to the treatment of bipolar disorder, and how any treatment should build upon that, rather than focusing on therapy first, then adding medication. Michael discusses the evidence based therapies for bipolar disorder including Interpersonal Therapy (IPT), Cognitive Behavioral Therapy (CBT), Psychoeducation, Family Focus Therapy (FFT), and Social Rhythm Therapy (SRT). He discusses the elements being related to self care (e.g., light therapy, time anchors) and a plan for addressing prodromal signs that an episode is coming, as well as examine the effect bipolar disorder has on relationship with partners and family members in order to strengthen those relationships. He explains that many folks with bipolar disorder go into the fields of art, science, and entrepreneurship, and how the symptoms can be harnessed to aid in success, while simultaneously managing the symptoms to prevent the deleterious effects of the disorder. Michael Freeman, M.D. is a psychiatrist, psychologist, consultant and former CEO who serves on the faculty of the Department of Psychiatry at the University of California, San Francisco School of Medicine. His clinical practice is focused on the treatment of people with mood, anxiety and attention disorders, and his consulting practice is focused on entrepreneurship and performance enhancement coaching. Michael’s research addresses the strengths, vulnerabilities, and mental health issues faced by entrepreneurs. He has held CEO and C-level leadership positions in several public and private sector health care organizations. Michael brings medical, psychological, prevention/self-care and executive competencies to his clinical and consulting practice.

In this interview, Dave discusses his career in researching suicide and how Marsha Lineman encouraged him to go beyond his assessment work to create an intervention for therapists working with clients who are suicidal. He discusses how many therapists struggle to know how to effectively assess suicide risk and intervene in a manner that can build the therapeutic relationship as well as keep clients safe. He explains that due to lack of training, knowledge of evidence-based interventions, and fear, therapists often jump to hospitalizing their clients, when it may not be necessary, and he challenges the overall utility and effectiveness of hospitalization altogether. Dave discusses his clinical tool and intervention, the Suicide Status Form (SSF-4) and his Collaborative Assessment and Management of Suicidality (CAMS), which have been found to decrease suicidal risk in patients through randomized controlled trials. He explains that therapists can effectively treat suicidality through collaboration, being clear and transparent on the limits of confidentiality and what may lead to a hospitalization. His intervention helps reduce access to lethal means as well as the value of identifying and treating patient-defined "drivers" for suicide, which research shows leads to decreasing hopelessness while increasing hope. The topics of suicidal ideation vs. suicidal intent are discussed and how ideation in itself is sometimes a form of coping. He speaks to the most feared situations where the therapist is not sure if the client can be sufficiently stable for outpatient care, and he addresses cases in which clients who take their life despite all clinical best efforts. Dave encourages therapists to become more competent in suicide assessment and treatment, because even though clinicians may screen for suicide when accepting patients, it is inevitable that they will have clients who are suicidal. He argues that suicide risk being "not something I work with,” is a problematic stance as it reflects an unwillingness to work with the one fatality of mental health. David A. Jobes, Ph.D., ABPP, is a Professor of Psychology, Director of the Suicide Prevention Laboratory, and Associate Director of Clinical Training at The Catholic University of America. Dave is also an Adjunct Professor of Psychiatry, School of Medicine, at Uniformed Services University. He has published six books and numerous peer-reviewed journal articles. Dave is a past President of the American Association of Suicidology (AAS) and he is the recipient of various awards for his scientific work including the 1995 AAS “Shneidman Award” (early career contribution to suicidology), the 2012 AAS “Dublin Award” (for career contributions in suicidology), and the 2016 AAS “Linehan Award” (for suicide treatment research). He has been a consultant to the Centers for Disease Control and Prevention, the Institute of Medicine of the National Academy of Sciences, the National Institute of Mental Health, the Federal Bureau of Investigation, the Department of Defense, Veterans Affairs, and he now serves as a “Highly Qualified Expert” to the U.S. Army’s Intelligence and Security Command. Dave is a Board Member of the American Foundation for Suicide Prevention (AFSP) and serves on AFSP’s Scientific Council and the Public Policy Council. He is a Fellow of the American Psychological Association and is Board certified in clinical psychology (American Board of Professional Psychology). Dave maintains a private clinical and consulting practice in Washington DC; clinicians can get trained in the CAMS evidence-based treatment at https://cams-care.com/.

In this episode Rachel discusses her career in treatment and research of schizophrenia, and particularly, her research at the University of California, San Francisco, studying the prodromal phase of schizophrenia, which refers to early signs and symptoms, in an effort to detect and prevent the development of a full blown disorder. She explains the differences between prodromal symptoms and the Clinical High Risk Syndrome (CHR), and how there are three main aspects: the presence of delusions and hallucinations, the level of the individual's conviction that the delusions or hallucinations are real, and the level of distress or impairment. She points out that only 25% of people develop psychotic disorders within 2.5 years after diagnosis of the CHR syndrome. She discusses the Coordinated Specialty Care Model that involves medication, Cognitive Behavioral Therapy for psychosis, family support and psychoeducation, case management, and supports to keep the individual on track with school or work. She talks about the advancements in psychiatric medication and discussed elements of CBT for psychosis. She talks about the role of the family and supporting the family through this process, and how the concept of Expressed Emotion and past theories about families with schizophrenia (e.g., refrigerator mother), have done damage in the conceptualization of working with families. She discussed the need for psychoeducation, as well as understanding the interactional patterns that happen between family members as there is a great deal of fear, helplessness, and shame. She discussed how clinicians in practice who are unfamiliar with psychosis should manage their own reactions of fear or overwhelm, as expressing these reactions may lead their client to shut down or avoid seeking support for their symptoms. She reassured that working with psychotic symptoms is very similar to working with other issues in therapy. We discussed validating the client, being curious about their experience, and getting consultation, as many clinicians are unfamiliar with psychosis, or only received training in intensive situations like hospital settings, so have a fatalistic view of these diagnoses. What the clinicians don’t see is that generally, 1/3 of clients recover on their own, for 1/3 medication works, and its only 1/3 that struggle with severe, chronic psychosis. Many people may live with symptoms their whole life, but be happy, healthy and functioning, so the reduction of symptoms may not be the main goal of treatment. Rachel Loewy, PhD, is a clinical psychologist currently working as a Professor of Psychiatry at the University of California, San Francisco. Along with teaching, Rachel has developed clinical programs to diagnose and treat early psychosis, and has led many research studies, primarily focused on early identification and intervention in schizophrenia. Currently, she is a co-investigator on a research project dedicated to building a California early psychosis network that would input thousands of patients' data into one network hoping to create a better system that allows for improved intervention effort. Alongside her research, Rachel has many publications regarding her work that have all been compiled at https://profiles.ucsf.edu/rachel.loewy. These publications focus on various studies regarding schizophrenia and psychosis, such as evidence-based practices for early intervention in psychosis particularly in community settings.

In this episode, Keith talks about his unique experience of being deployed in Iraq with his wife, and after a roadside bomb (IED) attack, she struggled with PTSD. He discussed how after she received treatment through the military mental health system, which was retraumatizing, he started taking classes in Psychology and learned all he could about trauma, and together they worked through her PTSD. This lead him to go on to obtain a doctorate in psychology, and work with veterans and their families specializing in combat trauma and military sexual trauma. He explained that soldiers are trained to turn all of their vulnerable emotions into aggression, because that is what is needed to survive in battle, and this makes it difficult for soldiers to transition back into their family system and larger society. Additionally, in the military, they form strong bonds with their fellow soldiers, and between conditioning, the group think, and the experiences that the soldiers go through together, it makes some feel that no one else understands their struggle which leads to suffering alone. This creates a dual family systems paradigm, the differences between the military system’s culture and the family’s system’s culture, leaving veteran's feeling disconnected from both families. He discussed the importance of connecting with the individual, being with their experience, and how this can be very hard for clinicians as working with veterans with trauma session after session can lead to vicarious trauma and compassion fatigue. He discussed his work with The Hume Center, with the chronically homeless population and working with severe mental illness, and how there is a great deal of intersectionality between homelessness and veterans. He discussed the importance of meeting the client where they are, and then finding what approaches might fit best for them, rather than using a top down approach such as trying to fit them into an evidence based scripted protocol. We discussed a rather successful program for Veterans in Oakland at the Oakland Vet Center, where staff had been working there for many years, as opposed to other programs where there is high turnover both in clients and in clinicians. One of the aspects that seemed to make it successful was the connections built through the community of clients. He discussed how clients who had been doing group work there would come to his PTSD 101 workshops just to see their friends. We discussed how engagement, whether with the clinician, or the community of clients was so significant in engagement for mental health services. ​Keith Bonnes, Psy.D. is a clinical psychologist and an Air Force (deployed Army) blue to green veteran of the Iraq war. Keith has worked extensively with veterans and their families and now works at The Hume Center in the San Francisco Bay Area East Bay https://www.humecenter.org, which as a Non-profit provides a range of community based treatments including full service partnership with homeless individuals, outpatient services and partial hospitalization programs and many other community based services and programs. He is also a trainer with The Hume Center working to help develop the clinical skills of early career clinical trainees and provide an exceptional training experience as a behavioral training center. He works from a humanistic, client centered, phenomenological approach, meeting the client where they are, and connecting with their experience, and then integrating modalities of treatment and interventions to fit for the clients perspective of the world. Keith uses Maslow’s Hierarchy of Needs as a building principal along with cultural humility in his work with clients to ensure a holistic approach to the clients experience is considered.

In this interview, Scott discusses how he came to his work focusing on Feedback Informed Treatment and deliberate practice. He discussed how when working with the Solution Focused Therapy founders, independent research found that the approach was effective, but not so significantly more effective than other approaches. He explained how this was surprising to him, and when he looked into it more, he found this finding was true when applied to all theories and techniques. He discussed his drive to improve as a clinician himself and his work with Michael Lambert and Lynn Johnson in looking at the common factors related to outcome and using client feedback to improve alliance and thus outcome. We discussed how continuing education is often focus on theory and technique, and how if a clinician would like to improve their effectiveness with clients, they need to focus on improving their relationships with clients. He discussed learning about Anders Ericsson's research related to deliberate practice, and how clinicians can use this to improve their work with clients. We discussed how research is often focused on symptoms, but it is actually the individual's functioning that is more important as functioning is often what brings clients into treatment, rather than symptoms. He explained that when working in drug and alcohol treatment, he often wondered why the clients had not sought treatment earlier, and it was often an effect on their functioning (e.g., losing their partner, losing their job) that propelled them into treatment. Scott discusses how often when people consult with him, he always returns to why the client is in therapy and what they want out of it, which many therapists forget about as they turn their attention towards the symptoms. Scott D. Miller, Ph.D. is the founder of the International Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Scott conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of "invited faculty" whose work, thinking, and research is featured at the prestigious "Evolution of Psychotherapy Conference." His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery. He is the author of numerous articles and co-author of ​Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy, and ​Feedback Informed Treatment in Clinical Practice: Reaching for Excellence.

In this episode, Jane discusses her own experience of growing up in a privileged white community and the subsequent development of her career in social justice. That was the beginning of her journey working with different organizations concerning the effects of wide-spread oppression particularly in education in the United States and in Israel at the Hebrew University of Jerusalem. When she became a psychotherapist years later, she realized that her training did not specifically cover the effect of the “isms,” and their relationship to the life experience of clients and their mental health, even though family therapists were trained in systemic thinking and the importance of context. After becoming a Visions consultant, she became more aware of her own privilege and the historic and present oppression others continually experienced. Intersectionality became very important as well because each person usually has some places where they have privilege and some where they are oppressed. How each of us behaves in those different places becomes an important area of exploration, both for therapist and client. Briefly, she discussed three important characteristics that therapists hopefully bring to their work. One is cultural humility, another is authenticity, and the third is a constant awareness of context and privilege and how it intersects with individual and relational mental health. She discussed how the role of therapist itself brings power into the room, and even if there is intersectionality, where there is shared race, gender, sexual orientation or a number of other characteristics, the therapist continues to hold power. She shared her experience in Kosovo dealing with grieving and traumatized families just after 9/11 occurred. She used the term “open listening”, which is a valuable way to be completely present, stay with the person’s experience empathically, while at the same time not losing oneself. Jane Ariel, PhD, LMFT is a psychologist in Oakland, California, and works with individuals, couples, and families. She has been an adjunct professor at the Wright Institute in Berkeley and has worked also with the Women’s Therapy Center and other institutions in the Bay Area. She is an active member of the American Family Therapy Academy, and works with Visions, a national organization dealing with issues of equity, inclusion, and multiculturalism.