Dr. Kae Hixson and I started a new podcast! I wanted to give you a peek into what we’re up to.
Welcome to The Kiln, where postgraduate education meets brave, bold, and imperfect therapy.
We’re here to shake up professional culture—to make it braver and to help therapists rediscover their excitement for this work.
At The Kiln, it’s okay to be imperfect. We’re building a learning community where practicing trauma therapy with courage is just as important as doing it with competence.
On this podcast, we’ll share what we’re creating at The Kiln and why it matters.
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Over the course of three seasons, we have talked plenty about trauma. And yet, somehow, I have never explicitly described or discussed the modality I use with clients, Mentalization-Based Narrative Exposure Therapy (MBNET).
MBNET is a methodology that Dr. Kae Hixson and I synthesized from two different approaches that we were independently trained in, and it’s what we teach at The Kiln.
On today’s bonus episode, Dr. Hixson joins me to get into how we arrived at this blended model for treating patients struggling with complex interpersonal trauma.
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As I’ve been trying to wrap up this season of the podcast, I’ve been reflecting, in particular on my conversations about psychiatric diagnosis with Dr. Awais Aftab and Dr. Miri Forbes.
I keep coming back to this question: How do we decide what human traits, behaviors, and subjective experiences to pathologize? What makes something about a person a problem that we try to fix?
It’s a deeply complicated question, with few, if any, absolute answers. Yet I still think we have to wander that hall of mirrors, and I believe that how we conceptualize and approach the question is actually more important than any conclusions we might make.
Because when we are able to articulate the various factors that influence what we pathologize and when, we actually increase our ability to apply those factors across contexts without needing to have an ultimate conclusion that is true for all people, in all contexts, at all times.
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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 we’ve been taught or what exists in the DSM-V?
Today, I’m excited to share my conversation with Dr. Miri Forbes, an expert in psychopathology and one of the authors of the paper, “Reconstructing Psychopathology: A Data-Driven Reorganization of the Symptoms in the Diagnostic and Statistical Manual of Mental Disorders.”
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.
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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 that’s 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 clients’ thinking when they arrive in our offices. Diagnosis is complex, multifactorial, and profoundly impacted by context, and we must contend with it.
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Management of Countertransference with Borderline Patients, Glen Gabbard
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.
I’ve 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 “real” and what that means, how it relates to the philosophical concept of epistemic injustice, how context influences the utility of a diagnosis, and more.
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Imagine yourself saying, “I am angry at my client.”
If you immediately need to add a whole bunch of context and caveats to make that statement feel okay, you’re not alone.
Admitting that we get angry with clients is uncomfortable. It’s uncomfortable with colleagues and supervisors, and it’s definitely uncomfortable with clients.
It’s 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 episode’s conversation with Dr. K Hixson about conflict with clients, I want to explore some of the reasons why we might get angry with clients–some situational, some due to the very nature of the therapeutic dyad–and where we go from there, even if it gets messy or uncomfortable.
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Instagram: @atherapistcantsaythat
Be honest. When you think about overt conflict with a client, is your first thought that it’s a site of exciting progress, full of potential for movement?
No, of course not. I don’t either.
If you’re like me, and I’m 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.
It’s 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.
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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.
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I’ve said it before, and I’ll 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 today’s 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 clients’ 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. Maroda’s 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.
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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 we’ve 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 don’t know or understand with certainty is a crucial step. This honesty and humility might just be the key to becoming better therapists.
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If you’re a therapist in 2024, odds are you have given a client a neuroscientific explanation for a symptom they’re experiencing or an intervention you’re using. You’ve 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 “The Body Keeps the Score offers uncertain science in the name of self-help. It’s not alone” 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 Won’t Come Out Tomorrow, will be published in winter 2025.
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How Emotions Are Made: The Secret Life of the Brain, Lisa Feldman Barrett
Since the last episode’s conversation with hannah baer about the Jewishness of therapy, I’ve 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 hannah’s original article also helped me connect to something more than claiming therapy’s 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 therapy’s 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.
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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 isn’t true.
If you go down a list of the founders and early theorists of therapy as theory, discipline, and practice, you’ll find that many of them were Jews. Even now, many of our theory heroes and celebrity therapists are Jewish.
And that’s not incidental or coincidental; it is consequential. Therapy is foundationally and elementally Jewish.
To dig into therapy’s Jewish roots, I invited writer and therapist hannah baer to join me. We also talk about therapy’s 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.
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Co-conspirator and friend of the podcast, Dr. K Hixson, returns to share some exciting news about a true labor of love.
We’ve 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, we’re 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.
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To wrap up season two of A Therapist Can’t Say That, I’m continuing my reflections on my ten years as a therapist.
I’ll be back in April with interviews on some juicy topics, but for now, here are lessons six through ten that I’ve learned over the last decade of doing this work.
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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 isn’t to say I’ve 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, I’m reflecting on ten years of being in this field.
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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, you’re probably wrong or in denial, or you’re 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, I’m 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.
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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.
It’s not trendy, influencers aren’t 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.
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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 “multiple irreducible levels of reality in the therapeutic relationship.”
None of those multiple realities is more or less real than the others and it’s essential that we, as clinicians, maintain our awareness of them. Yes, it’s hard. These multiple realities evoke a whole range of relationships and power structures that often contradict each other. Of course it’s hard.
But when we try to collapse these realities, that’s 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.
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