The five "don'ts" we are taught in therapy training: self-disclosure

Wrapping up a week of exploring therapy norms versus what may be effective cross-cultural therapy, I want to touch on the last of the five "don'ts" identified by Dr. Derald Wing Sue, self-disclosure.

I have heard of a Practicum site that has a "no self-disclosure" rule. I am at a loss to understand how they enforce it since, by walking into a room, we self-disclose: skin color, gender presentation, possible social class based on what we might be wearing, ethnicity based on accent, among other tells. I think what they mean is "Don't talk about yourself."

In the analytic tradition, as I understand it, the therapist was to be a blank slate. I did Jungian Analysis for a decade and, after a year of face-to-face, I finally lay on the couch with my analyst sitting quietly behind me. I became intimately aware of the paintings next to the couch. I also did not know anything about my analyst other than his work at the Jung Institute which was public knowledge and that we had had our children close to the same age.

Many cultures value the personal connection. I am reminded of the scene in one the Matrix movies where Sereph, the guardian of the Oracle, spars with Neo, the protagonist seeking out the Oracle, saying, in apology, "You don't know someone until you fight them." Likewise, it is important for some clients to know you somewhat as a person before they can trust you to hear their stories.

As a clinician who has gone through their own gender identity journey and who often works with others doing the same, some clients want to hear specifically about my experience. Likewise, other demographics that I work with may want to hear first-hand experience. In these cases, I often do self-disclose as long as it is in service to the client.

I have another practice, though, that I use often and teach to students: "stealth disclosure." This is when I have had an experience or know of an experience in my circle that may benefit the client though does not need to be about me. This could be an interaction with my parter or children or an experience with my own depression or therapy. In these cases, I will share the experience, framing it as, "I heard a story . . ." or "Someone I know . . ." or something similar. This way, my experience can benefit the client without it centering on me.

On the whole, I probably self-disclose more than the average therapist and I talk openly to my students that they will need to find their style. I recommend that, earlier on, is likely better to self-disclose less until you get the sense of what is appropriate. I find with my clients that they appreciate knowing a little about me and that it benefits the therapeutic alliance.

Thank you for reading this week. I met with my two new sections of Cross Cultural Aspects of Psychology this week and I am excited to embark on another journey to help promote cultural competence and cultural humility with them.

First posted on LinkedIn

The five "don'ts" we are taught in therapy training: dual relationships

Understanding the complexity of engaging in dual relationships, especially in non-US cultures, is crucial in the field of therapy. Dr. Derald Wing Sue's fourth "don't" highlights this issue. It is important to avoid obvious dual relationships like counseling friends, family, students, supervisees, or intimate partners. In addition, less apparent scenarios such as working and doing Practicum at the same location should be approached with caution to maintain professional boundaries.

Bartering in therapy presents unique challenges due to potential power imbalances. While culturally appropriate in some situations, ensuring parity in the exchange is essential to mitigate risks. The CAMFT Code of Ethics recognizes that dual relationships may sometimes be unavoidable, stressing the need to prioritize the client's well-being in such cases.

Transparency is key when working and socializing in overlapping communities. Being two degrees of separation from clients can be common, with many referrals coming from friends or colleagues. Clear communication during informed consent discussions about community memberships and potential relationships is vital to establishing trust and boundaries.

Navigating dual relationships, such as seeing an individual both individually and in a group setting, requires careful consideration. While the general advice is to avoid such situations, open conversations with all parties involved can lead to beneficial therapeutic outcomes.

In conclusion, rigid "all or nothing" restrictions may not always serve clients well, especially those from diverse cultural backgrounds. Balancing ethical considerations with the unique needs of clients is essential in providing effective and culturally sensitive therapy.

First posted on LinkedIn

The five "don'ts" we are taught in therapy training: making eye contact

As we continue to strive for cultural competence in mental health, it's important to recognize the potential clashes between therapeutic practices and cultural norms. In his lectures, Dr. Derald Wing Sue identifies five "don'ts" in therapy, the third of which is making eye contact.

While eye contact is generally encouraged in Western cultures, it may be seen as disrespectful in others, particularly when interacting with elders or authority figures.

As mental health clinicians, it's crucial to understand that non-verbal communication carries significant weight in many cultures. Lack of eye contact does not necessarily indicate avoidance or disinterest or timidness. Rather than making assumptions, it's important to seek consent and inquire about the meaning of eye contact in the client's culture. This can be a delicate conversation, but taking the time to educate ourselves and approach with sensitivity can greatly benefit the therapeutic relationship.

In my work, I practice and teach consent for conversation. We often think about consent for touch or activities, though consent for conversation can be overlooked. Sometimes people can just unload on us without checking to see if we are ready, willing, and able to listen. Likewise, as clinician, we can sometimes ask questions that may seem intrusive if the client is not prepared.

I might approach this situation something like: "As we are talking, I am noticing something about our interactions, and I would like to explore that with you." Provided I get a yes, I might say, "I am noticing that you don't make eye contact often and I want to check in with you about it. I understand a little about your culture though I also know that a little knowledge can be a dangerous thing so I don't want to assumptions. Can we talk about that a little?"

Asking for consent for conversation gives the client some agency in saying yes or no and can help remove what may seem like a requirement or obligation from an authority figure, the therapist.

Let's continue to prioritize cultural competence in mental health and strive to provide inclusive and respectful care for all.

First posted on LinkedIn

The five "don'ts" we are taught in therapy training: receiving gifts

Building on yesterday's exploration of giving advice, I want to touch upon the second "don't" on the list of five “don’ts,” as identified by Dr. Derald Wing Sue in his lectures, that of receiving gifts.

While conventional wisdom discourages therapists from accepting gifts due to the potential impacts on the therapeutic relationship, I've encountered nuanced situations in my nearly two decades of practice where it was appropriate. In specific instances, the significance and appropriateness of the gift were paramount, aligning with cultural norms of respect and gratitude.

Understanding the cultural context of gift-giving is essential. For some, it symbolizes respect, and declining a gift could be perceived as disrespectful. I prioritize discerning the intent behind each gesture, ensuring that it enhances rather than disrupts the therapeutic alliance.

Touch, another delicate aspect of therapy, has its complexities, too. While professional guidelines advise against physical contact, there have been rare instances where a client-initiated hug or a culturally significant gesture has strengthened the therapeutic bond significantly.

A great example of the latter was a client where I noticed that the therapeutic alliance seemed to have weakened. When I inquired with the client, who had grown up in a culture of overt demonstrations of respect, they replied that I never used their name in session and I never offered to shake their hand at the end of the session. With some discussion, these seemed like reasonable requests that I implement to good effect on our work.

Recognizing the cultural nuances in gift-giving and touch is vital for mental health clinicians. While certain professions embrace gifts as tokens of appreciation, mental health practitioners must navigate these interactions mindfully, considering the cultural implications and significance behind each gesture. Refusal, when necessary, should be coupled with respectful explanations to uphold the integrity of the therapeutic process.

First posted on LinkedIn

The Five "don'ts" we are taught in therapy training: giving advice

As I embark on another trimester of teaching Cross Cultural Aspects of Psychology at Golden Gate University, I want to touch upon five “don’ts” we are taught in providing therapy that may clash with cultural norms, as identified by Dr. Derald Wing Sue in his lectures. The first "don't" on the list is giving advice.

In Counseling Psychology, we are often taught not to give advice due to the possibility of removing agency from the client or making them dependent on the clinician as a source of answers. However, many cultures have an expectation that the clinician is the expert and may seek advice as a part of therapy. As a clinician, it is important to strike a balance between the two.

To combat the possibility of giving "stealth advice," I remain transparent with my clients. I help them understand how therapy works and identify options from which they can choose. I also help separate the signal from the noise, which is where my expertise comes in handy.

I might say something like, "When we are taught therapy, they tell us not to give advice. However, I know that it can sometimes be hard to see your options. As I am listening to your story, I see some of those options. Can I share them with you?"

In the end, I don't get a vote--and I often say just that to clients--but part of what I do is help clients simplify an issue to make better decisions. I try to key off what the client identifies as options and help them move forward on their journey.

What do you think about this approach? Share your thoughts in the comments!

First posted on LinkedIn

Recognition

On Friday, June 2, 2023, I received the Ted Mitchell Distinguished Adjunct Professor award from Golden Gate University. In 2022, I also received the Outstanding Adjunct Professor recognition from the university. Both awards reflect my commitment to the learning of my Counseling Psychology students including guiding them in the self examination that is vital to becoming an effective clinician. While it might seem obvious to thank the university, the true thanks goes to these students who do heroic work and show up in ways that make my work both more easy and more fulfilling.

Return to In-Person Sessions!

This month, I saw my first in-person client in three years at my new office on Mission Street between 24th and 25th Streets. It was great to settle into the new office and to recall how it feels to be face to face with a client without screens in between. (It was weird to have the same furniture in a mirror image setup in a different place!) While I believe I am successful both as a therapist and a teacher through Zoom, returning to the office and to the classroom reminds me how important the live human connection can be for this work.

How am I managing safety? I am up to date with my vaccinations. I have a well-rated HEPA air cleaner, masks on hand, and hand sanitizer. I am also considering spacing out in-person and telehealth clients so there is less overlap.

C’mon in and have a seat, let’s talk about what’s going on in your life!

CAMFT Annual Conference

This past weekend I attended the CAMFT Annual Conference in Garden Grove, California, two blocks away from Disneyland. I have attended this conference twice before, once in San Francisco and once in Los Angeles (it alternates between Norcal and Socal) and I have had mixed experiences. Of the three I have attended, this, by virtue of my selection of and/or the presenters of the sessions, was the best quality of the three.

The program was book-ended by two wonderful speakers talking about addiction. Dr. Gabor Mate framed addiction as one response to trauma and pain. The addiction is the coping or defense mechanism, not the primary problem. Dr. Adi Jaffe used his own experience with and journey to transcend addiction as a framework to talk about compassionate treatment that is accessible, affordable, and addresses the issue of abstinence. His data, his experience, and his approach present a form of treatment that addresses the barriers to treatment while taking into account that the addiction, as Dr. Mate describes, is the--dysfunctional--attempt at a solution rather than a primary problem.

Dr. Steven Sultanoff explored the use of humor in psychotherapy and how humor, when used appropriately, can be a powerful tool in the therapist's toolbox. He noted, though, that it must be intentional and directed toward the client to be useful. 

Dr. Johanna Olson-Kennedy and her husband Aydin Olson-Kennedy LCSW presented a two pronged exploration of health issues with trans youth. Johanna, the Medical Director at The Center for Transyouth Health and Development at Los Angeles Children's Hospital, dove deep into the medical issues of youth in transition while  Aydin, Executive Director of the Los Angeles Gender Center, presented on the mental health side of the issues. Together, they explored the impacts of the medical interventions such as hormone suppression and hormones augmentation as well as the psychosocial issues faced by trans youth. Of particular interest was  Aydin's--himself a transman--reframe of Gender Dysphoria from a disorder to Gender Dysphoria Noise as an experience than many transfolk have every day before, during, and after transition. He used a powerful exercise to help the audience understand some of the things that lead to transfolk not succeeding in school, being called out, and being hyper-vigilant for danger both real and perceived. 

All day Friday, David Jansen, JD, a staff attorney at CAMFT, did a great job of making the potentially dry 6 hours of required hours of Law and Ethics appealing. The framing of the topic was the Standard of Care and David used songs from three recording artist as samples for the audience to practice suicide assessments. He has a way of engaging audiences with the right amount of humor and meaningful metaphors that help me remember the material.

Saturday morning, Dr. Gary Small, Director of Geriatric Psychiatry at the UCLA Longevity Center, spoke about how habits and healthy living can help prevent and mitigate the issues of aging brains. Much of the talk was seen through the lens of dealing with patients suffering from Alzheimer's Dementia and what people can do for themselves and their clients to help prevent the onset and progression of AD. Again, the right amount of humor and engagement made this an entertaining and informative session.

In the afternoon, Dr. Yamonte Cooper LPCC spoke about Racial Battle Fatigue. This session was challenging not because of the content but because of the sheer volume of information. This could easily have been an all-day 6 hour presentation and it would have barely scratched the surface. I appreciated Dr. Cooper starting with a grounding exercise to help everyone be present in the room and with the material. As someone outside of the direct experience of People of Color and in particular African American men, I think it is important to do my best to understand their experience in order to be a better clinician. This session was a jumping off point to dig deeper into this topic. 

On Sunday morning, Suzanne Hughes, Executive Director of the One Life Counseling Center, spoke about tele-health including legal and ethical issues as well as her views on how to create a successful tele-health business. She highlight the pros and cons of both face to face and tele-health sessions. I appreciated her opening the discussion up to the audience to make sure we covered the topics that were most important. Copious amounts of audience input made this an informative and collaborative effort to help better understand tele-health. 

Throughout the weekend Heather Brewer LMFT and I, along with other attendees and members of the CAMFT staff, live-tweeted the event using the hashtag #CAMFTLIVE. Check it out to get a sense of an event that included not only great sessions and chances to network, but also a Petting Palace featuring dogs and a pony you could pet! I look forward to next year's conference in Burlingame and to connecting with new and old friends.  

End of the Year Updates

As we move through the holiday season, I am reflecting on some of the activities I engaged in this year.

As a part of Bay Area Open Minds, I organized our participation in the SF Trans March, I worked our booth at Folsom Street Fair, and I organized a lunch for our clinicians at Dark Odyssey: Surrender. DO was a great conference and I was excited to be out and about in the community, meet new people, and reconnect with friends.

I taught didactics on Open Relationships, Gender, BDSM/Kink Relationships, and Using Culture in Psychotherapy at Haight Ashbury Psychological Services and I guest taught in the Couples Therapy class at Notre Dame de Namur. I am working on the Human Sexuality course I will teach this spring at Golden Gate University.

I continue to work as an EAP counselor for Concern EAP at Google in San Francisco and I gave a well-received presentation on Gender in Psychotherapy to the Concern EAP offsite clinicians. I also continue to see private practice clients in my San Francisco office.

In the coming year, I plan to do more teaching, to work on my book about attachment and open relationships, and to continue seeing clients at both locations. A new clinical interest has been working with gender as a spectrum. By this I mean working with people that find themselves somewhere between cisgender and transgender. This is something that grew out of my own experience with gender as well as out of who has been coming through my door and what I have been asked to speak about. I look forward to more exploration of this topic as well as nurturing myself as a therapist in general.

Last but not least, this year saw me make a change in my appearance by dying my hair first teal and then blue. This change has been interesting in terms of how and with whom I connect and it has given me food for thought in terms of working with clients that make significant, visible changes in their appearance and their lives.

Some updates

Last month, I began working once a week for Concern Employee Assistance Program as an onsite counselor located at Google in San Francisco. It has been exciting so far and I look forward helping the employees with their challenges. I continue to see clients in my private practice on Mon, Tue, and Thu.

Next month, I will be attending Dark Odyssey: Surrender. Fellow therapists, let's get together! Clients, know that I will keep your confidentiality and if we do run into each other, I won't reach out to you. If you want to reach out to me, that is fine, though I won't engage with you extensively.

Earlier this month, I did a training on Gender in Psychotherapy at Haight Ashbury Psychological Services and I will be doing a similar training for my fellow Concern EAP onsite counselors next month. Next year, I will be teaching Human Sexuality in the Golden Gate University graduate school program.

Finding a Therapist / Making Friends with Your Discomfort

There are a number of "Finding a Therapist" sites that I recommend for people seeking an affirming therapist. They are listed on my resources page and I want to highlight a few here:

I am on the Board of Bay Area Open Minds whose mission is best stated on our website:

"We are a group of San Francisco Bay Area psychotherapists and psychotherapy students who affirm that sexual and gender diversity are natural expressions of the human experience. We provide a safe haven for mental health clinicians to gather, network, support, and consult."

Here is our "Find a Therapist" page.

Also valuable in the Bay Area, I recommend Gaylesta, an educational resource and therapist directory that identifies as "the Psychotherapist Association for Gender & Sexual Diversity."

Farther afield, the National Coalition for Sexual Freedom has a national and international Kink Aware Professionals directory that I find valuable even for those not in the kink or BDSM communities.

An up and coming "Find a Therapist" site is Therapy Den which hopes to build off of a successful experience in Portland, Oregon, by providing a "progressive mental health directory and resource - made with love for the Bay Area.". From their site:

"Our mission is to make finding the right therapist or counselor as painless as possible, raise mental health awareness, support causes we believe in and challenge all systems of oppression."

My first post on Therapy Den is oriented toward therapists though I hope it is a beneficial read for all. Let me know what you think of making friends with your discomfort.

Fluid Bonding

People sometimes ask me, "What is the difference between working with open relationships and working with relationships in general?" The answer is often "Not all that much, but the small differences are quite significant." One area where this is the case involves types of commitments. 

In the myriad types of open relationships commitment can take many forms. This came to mind because of an essay about the concept of fluid bonding and what the term means to the writer and readers of the essay. One challenge is that here isn't a simple definition of fluid bonding. For some, it is Penis-In-Vagina (PIV) sex without a barrier. For others, it is no exchange of fluids including kissing except with a particular partner or partners. Another challenge is whether or not fluid bonding reflects a different type or level of commitment. Fluid bonding may also be both or neither of these.

Since there is no one definition of fluid bonding (much like there is no one definition of making love) people use it in different ways. Some use it to indicate that they have stopped using barriers with one or more partners. Others use it to mean that their relationship has moved to a new level.

In some monogamous relationships, regardless of the composition of the relationship, the commitment can be somewhat simpler than in an open relationship. While each monogamous relationship is unique, most center on some kind of one to one partnership between two people. Many partnering ceremonies--a more inclusive term than marriage for my purposes--have language to this end. The concept of fluid bonding may even be built into the relationship structure and may reflect a deepening of the relationship.

In some open relationships, the discussion of fluid bonding can be the similar, though it can also involve pregnancy mitigation, sexually transmitted disease mitigation, and other concepts. Some people chose to have "closed open relationships" meaning that their relationship is more than two people, a triad or a quad for example, and there is exclusivity within that structure. This relationship is "open" in the sense that it does not look like a monogamous relationship but otherwise it may be more like a monogamous relationship than what people think of as an open relationship. In other open relationships, the discussion of fluid bonding may come up more often because there are usually more people to consider in the decision making.

There are many opinions for, against, and neutral regarding the use of the term fluid bonding and whether or not it reflects a type or level of commitment. I am curious about how people think and feel about the concept of fluid bonding. Do you use the term? If so, how do you use it? If you don't, do you have any judgments either way. Feel free to comment below.

TED talk relationship toolbox

When Esther Perel says (or in this case tweets) something, I pay attention. Recently, she pointed to these TED Talks that just might save your relationship featuring two of hers and one from Brené Brown that together comprise an excellent relationship toolbox. Topics covered include infidelity, vulnerability, daring to conflict, getting heard when you speak, and long term desire in relationships. They are all worth a watch.

Poly.Land and Mono / Poly as a Spectrum

I recently discovered the blog Poly Land written by Page Turner. Here is link to her Facebook page, too.

The post that caught my eye is about seeing monogamy and polyamory a spectrums rather than as a binary construct. In a time when more and more things are seen as spectrums, I think that this topic is an important addition to the conversation. The post was inspired by the reaction to two other posts titled 9 Things Monogamists Can Learn from Polyamory and 9 Things Polyamorists Can Learn from Monogamy. Both posts have great insights on different aspects of the different types of relationships and the 18 items taken together are great things to consider in any relationship.

Finding a Therapist

My friend and colleague Michel Fitos shared an informative article from last year about finding a therapist. Though focused on marginalized communities, it is good advice for all. 

Three quick takeaways regarding finding a therapist:

1. Shop! You can see more than one before you decide.
2. Advocate! You have no obligation to stay with any therapist let alone one who marginalizes you.
3. Refer! If you find a good therapist, tell other people so that they can benefit, too, and seek referrals from friends.

 

New York Times Magazine open relationship video

The New York Times Magazine seems to be the major news outlet talking about open relationships lately. In addition to the article published a few weeks ago, they posted a video with five people talking about their overlapping relationships. The participants talk about how they got to where they are and about some of the dynamics that they experience. I think it is a great video that speaks to the ups and downs of open relationships.

Some Thoughts on the Sexology Podcast

Having gotten feedback from therapists and non-therapists and from people in and out of the kink community about my episode on fetishes on Dr. Nazanin Moali's Sexology podcast, there are two themes that seem to resonate:

  • Normalizing fetishes with examples can help people put aside the biases and pre-conceived notions that they have about fetishes and better understand how they operate.
  • It is important to recognize that fetishes can be normalized and that many people can have them to varying degrees however it is equally important to realize that fetishes can become disordered.

These two themes are two of the most common themes in my work: normalizing and recognizing whether or not something is disordered.

The normalizing comes up in my work in alternative lifestyles communities because there can be a stigma about how people live their lives and how people practice their intimacy. This stigma can lead to shame and shame can lead to a number of things including not living a fulfilling life, to hiding wants and needs, and to acting on wants and needs without consent creating breaches of trust. I often use examples from outside of the alternative lifestyles communities that resonate with examples from within the communities to demonstrate that the various kinds of relationships are not all that different.

The normalizing also comes up with my work in general. It is reasonable to be anxious when you are going on a job interview or meeting someone new. It is reasonable to be depressed if your pet dies or you don't get that job you wanted. For whatever reason, mental health states and moods can be stigmatized. It may be socially acceptable for me to have high cholesterol or high blood pressure though please don't let anyone know that I can be anxious or depressed! It is this stigma that can lead to people not seeking the help they want or need. Sometimes citing an example outside of the client's experience can help demonstrate the things in common that their situation has with others.

The recognizing whether something is disordered is an important part of my work. Whether it is depression, anxiety, or stress; whether it is relationship choices; whether it is communication or lack thereof, I believe it is important to understand whether what is happening is a reasonable reaction to a situation or if it is a disordered reaction.

Though I use normalizing above, I use reasonable in my elaboration on reactions because I don't know that there is an objective standard of normal. I use disordered because I believe that something can be out of sorts without being a diagnosable disorder. Having disordered eating is different that having an eating disorder. 

As I spoke about with fetishes in the podcast, one of the key things when examining an issue that a client presents is the impact that the issue is having on their lives. I have had a couple come in because they were concerned about some disagreements and arguing that they were having, and we determined that these things were reasonable and, in fact, were a part of adjusting to the new situation of living together. I have had individual clients bring up the shame they felt for having the sexual desires they had. When we looked into the desires and the shame, we determined that the desires were objectively fine. The initial impact can seem serious though when examined more closely, the reaction is reasonable. Disordered versions of these include some kinds of acting out with the couple that makes it difficult for them to function or the individual acting out their desire without consent.

I am happy with my Sexology episode because it spoke not only to a specific topic--sexual fetishes--but also spoke to some important concepts in therapy in general.

On Being and the Lack of a Cure

[This post appeared on my previous web site and this is an updated version.]

Recently, I again picked up Psychotherapy Grounded in the Feminine Principle by Barbara Stevens Sullivan. As I have said previously, this was one of the more influential books that I read while at Pacifica Graduate Institute about doing therapy, though in light of Sullivan’s message of embracing the practice of being noted below, saying so (“doing therapy”) is perhaps ironic. In addition to a wealth of other ideas, Stevens explores using the feminine-oriented (more receptive) practice of being with clients rather than the more masculine-oriented (more active) practice doing things with or to clients.

Along with being with clients, using a responsive and inviting approach, comes the idea that the role of the therapist is not to cure the client. The medical model that is the basis of a lot of therapy eduction is often focused on curing the patient. 

For more thoughts on this topic click here.