Therapy on the Cutting Edge

• The Qualities of Effective Psychotherapists and Using Motivational Interviewing to Partner with Clients in Creating Change

  In this episode, I speak with Bill Miller about his road to developing Motivational Interviewing. Bill explained that he started off heading into pastoral ministry but instead chose to be trained as a clinical psychologist. His behavioral PhD program required a two-semester course on how to work with clients before engaging in behavior therapy, and that's where he was introduced to Carl Rogers and a person-centered approach, which significantly influenced his career. He mentioned watching Gerald Patterson doing behavior therapy with families and seeing how he was with clients: warm, engaging, empathic, and funny, which was not covered in published descriptions of the method. On a sabbatical leave in Norway, Bill was asked to demonstrate his own therapeutic approach through role plays in which the clinicians would stop him and ask good questions: "What are you thinking just now? "Why did you ask that particular question?" "How did you decide what tor reflect from all that the client said?" These interactions helped him reflect on what he was doing and why he was doing it, and he wrote down a description that became the first description of motivational interviewing. Seven years later, on sabbatical leave in Australia, he found himself officed next to Stephan Rollnick who would become his career-long co-author. Rollnick had already been teaching motivational interviewing based on Bill's first article and they decided to write together the first book about motivational interviewing that was published in 1991. When they began teaching the method they noticed that some trainees seemed to be using MI techniques “on” rather than “with” clients. What had they left out? They began writing and teaching about the underlying spirit or attitude with which MI is to be practiced. Therapists also shared with them that this way of practicing seems to prevent burnout. In a later book with Theresa Moyers, Bill discussed eight clinical skills that characterize more effective therapists, which are: accurate empathy, genuineness, positive regard, acceptance, hope, evocation, giving advice, and having shared goals or direction. Bill and I explored the term “resistance” and how it is something that happens between people yet is often attributed to client pathology. In yet another book he argued that ambivalence is natural human nature and even a virtue, as it means the person is weighing the options. He and Rollnick reformulated "resistance" as sustain talk (a natural part of ambivalence) and/or discord in the therapeutic relationship. We discussed how in motivational interviewing the therapist is a guide rather than an expert-director. Lastly, he touched on his work on quantum change, which is transformational change that that can occur within a matter of moments or hours and tends to be both permanent and benevolent. Dr. William R. (Bill) Miller, Emeritus Distinguished Professor of Psychology and Psychiatry at the University of New Mexico. He is the author of 67 books including four editions of Motivational Interviewing, Effective Psychotherapists: Clinical Skills That Improve Client Outcomes, Listening Well: The Art of Empathic Understanding , and On Second Thought: How Ambivalence Shapes Your Life. He has been teaching the skill of accurate empathy for over 50 years.

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  56:38
• Working with Adult Children and Families Using Core Focused Family Therapy

  In this episode, Judye discusses growing up in a family where her father was a psychoanalyst and became interested in the field. In graduate school, she became interested in family therapy, and worked at a youth guidance center in Massachusetts, but didn’t find working with children and play to be a way she really wanted to work. Her supervisor had trained at the Ackerman Institute in New York City and had her start working with families, which really fit well for her and her work. She explained she moved to California and worked at Xanthos, now Alameda Family Services, and studied with Alan Leviton, one of the founders of the Association of Family Therapists of Northern California. Additionally, she started teaching at California Institute for Integral Studies in San Francisco, where she taught family therapy by having the students bring in their families to have a family therapy session, or role play if the family was unable to come in. She discussed her work and how she ended up writing a book about her approach called Core Focused Family Therapy. She discussed one of her strategies in the beginning of a family session was to do some dyadic work with two members of the system who were not the central focus, which seemed to help open up conversation and soften stuck systems, and then moving on to the focus on the areas the system might be struggling. Judye explained that one of the reviewers of her book wrote that her approach is love and truth, using a warm, but direct approach. She explained another strategy is to move the focus off of the identified patient, and look at how the whole system is involved with the difficulties that are happening, so they can make a systemic change, which she calls increasing the surface area of the problem. She discussed connecting with he vulnerabilities behind the defenses, and in helping the dyad that seems most open, the rest of the system then usually also become more open to vulnerabilities. She talked about using this model to make significant changes in the family system in a short period of time. She discussed how she focuses on working with families with adult children, and the variety of clients who reach out to her, with family cut offs being a common issue clients are seeking help in repairing their family. Judye Hess, PhD, has worked with families since 1974 when she began her family therapy career at Worcester Child Guidance Center in Worcester, Mass. In 1977, Judye moved to the west coast and found a home at Xanthos, a family counseling center in Alameda, CA, where she worked for the next three years. In 1984, she began teaching at the California Institute of Integral Studies, where she was on the core faculty and taught family dynamics, couples counseling and group process until 2015. She is the author of Core Focused Family Therapy: Moving From Chaos to Clarity and she is now Professor Emerita from CIIS, and since then has maintained a private practice, seeing couples and families of adult children exclusively.

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  58:50
• The New Paradigm of Online Therapy and a Career as an Analytic Relational Group Therapist

  In this episode, Haim discusses his extensive experience providing group and being an early adopter of group therapy in 2006, which lead to his work on the effectiveness of telehealth. He discussed how in 1995 he started an internet forum called GP Listserv which now consists of 400 group therapists from all over the world who join together to discuss group therapy. Haim talked about his group analytic relational approach to therapy and discusses the difference between psychodynamic and relational approaches. He talked about how the research has found clinicians experience four obstacles to online therapy, and discusses the various ways one can address them. He explained that these obstacles include (1) Setting (2) Disembodied Environment (3) Presence and (4) Ignoring the Background in Online Settings. He discusses the body of research surrounding online therapy which is very promising and explains how a meta-analysis concluded that for individual therapy, there is no difference in the results for online vs in person therapy. According to research, the best predictor of success in individual therapy is the therapeutic alliance and goes on to list the three components of the therapeutic alliance which are agreeing on goals, agreeing on tasks, and bonding. While online group therapy is less researched, Haim’s experience suggests that it is very effective. He explained how in group therapy, the factor that is most predictive of success is the cohesion of the group, rather than the therapeutic alliance. He goes on to discuss how the preference of modality –such as having an auditory or visual preference– influences one’s ability to effectively do online therapy. He talked about how in groups, time, space, and attention are always shared, which can create turmoil for group members. He also discussed how keeping attention can be difficult online because there are more distractions and people may feel more unnoticed, which can promote disengagement in an online group setting. He recommends that small group therapy should consist of group sizes between six and ten people and for people who are not as skilled or experienced, groups should not exceed eight people. In 2018, Haim created an online training process group for therapists, and these groups consist of therapists from all over the world where they discuss their experiences with group therapy and learn how to improve their practice, but also use them to work on their personal issues, thus providing professional and personal growth. Dr. Haim Weinberg is a licensed psychologist in California (PSY 23243) & Israel and has a private practice in Sacramento, California, with more than 40 years of experience. He is also a group analyst and Certified Group Psychotherapist. He is past President of the Israeli Association of Group Psychotherapy and of the Northern California Group Psychotherapy Society, and list-owner of the group psychotherapy professional online discussion forum. Haim was the Academic Vice-President of the Professional School of Psychology in which he created and coordinates an online doctoral program in group psychotherapy and marital therapy. He published books on Internet groups and about Fairy Tales and the Social Unconscious, and co-edited a book about the large group and a series of books about the social unconscious. He is on the clinical faculty of Psychiatry at UC Davis Medical Center and Fellow of the American Group Psychotherapy Association and of the International Group Psychotherapy Association, as well as a Distinguished Fellow of the Israeli Group Psychotherapy Association. He has received several awards including the Harold Bernard Group Psychotherapy Training Award and the Ann Alonso Award for Excellence in Psychodynamic Group Therapy. He also co-edited the books: 1. Theory and Practice of Online Therapy: Internet-delievered Interventions for Individuals, Groups, Families, and Organizations. 2. Advances in Online Therapy: Emergence of a New Paradigm. 3. The Virtual Group Therapy Circle: Advances in Online Group Theory and Practice with Arnon Rolnick and Adam Leighton.

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  57:18
• Utilizing Intrapsychic and Larger Systemic Systems to Create and Support Resiliency in Individuals, Families and Communities

  In this episode, Michael discusses his work in therapy, resilience research, and helping people find diverse systems to support their well-being. Michael explains how he became interested in predictions of psychopathology and pathways to adolescent well-being through resilience and advocacy. Throughout his early career, he noticed how there had been greater efforts to suppress disorders, but these efforts did not create a sustainable, clinical outcome for people. He explores how intrapsychic systems and larger, systemic environments are important for supporting and maintaining resilience. Michael defines resilience as 1) a navigation to the resources you need and 2) a negotiation for these resources in culturally relevant ways. He states that stimulating optimism for teenagers doesn't just come from internal self-affirmation, but also from living in predictable environments. He also emphasizes the importance of caregivers and social networks in an adolescent's life. These relationships support a positive identity in adolescents, allowing them to have control and self-efficacy. We discuss how both stimulating a social network and giving young people a sense of identity are vital to promoting resilience. Michael then moves on to explain how there are differences between positive psychology and the study of resilience. The study of resilience is about matching the right protective factor to a particular risk profile. He explains that through his research, he has identified a core list of 52 potential resilience predictors. He developed a program, R2, where he takes the list of 52 predictors and identifies which factors are most relevant to the population in a specific region. Through this process, Michael and his team have been able to provide a more tailored approach to promoting resilience. For example, he mentions how in certain cities, transportation systems and housing are the key factors for promoting resilience in people. We then go on to discuss how changes in even just one of these systems can result in virtuous or negative cycles in someone’s well-being. Changes in transportation and housing may have a cascading effect on co-occurring systems of a person’s life, which may then affect their overall well-being. We emphasize how in therapy with an individual, it is important to work in the context of their external systems, such as their school or their workplace, instead of simply focusing on the individual’s depression. Though it may seem like social work, he believes it is vital to not delineate between what psychologists do and what social workers do. Michael finds that expanding various aspects of one’s identity and engaging their social networks in therapy can cultivate better mental health and resilience for a person. Finally, he touches upon the idea of wear and tear on adolescents. There is a toll that resilience and stress take on adolescents: They may seem successful in some ways, but then may crash later in life. Michael states that resilience is a constant dance between helping people navigate and negotiate for their needs, but never assuming that the journey for healing is complete. Michael Ungar, Ph.D. is the founder and Director of the Resilience Research Centre at Dalhousie University where he holds the Canada Research Chair in Child, Family and Community Resilience. In 2022, Michael was ranked the number one Social Work scholar in the world in recognition of his ground-breaking work as a family therapist and resilience researcher. That work has influenced the way human development and organizational processes are understood and studied globally, with much of Dr. Ungar’s clinical work and scholarship focused on the resilience of marginalized children and families, and adult populations experiencing mental health challenges at home and in the workplace. In addition to providing consultation to international NGOs like the Red Cross and Save the Children, government agencies in more than a dozen low, middle, and high income countries, and educational institutions at all levels of study, Dr. Ungar’s research has also influenced the HR and corporate social responsibility initiatives of Fortune 500 companies like Unilever, DHL and Cigna. Michael’s work emphasizes how to use the theory of resilience to increase both individual and institutional agility during crises, with numerous organizations having adopted his concept of resilience as a negotiated process that enhances wellbeing and social responsibility. He is the author of over 250 peer reviewed articles and book chapters and 17 books. His blog, Nurturing Resilience, can be read on Psychology Today’s website.

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  57:57
• Effecting Third Order Change in Therapy Using Socioculturally Attuned Family Therapy to Address Power and Create More Loving and Equitable Relationships

  In this episode, Carmen discusses her work in family therapy and her Socioculturally Attuned Family Therapy. Carmen shared that she entered the field when there were feminist critiques of family therapy and a focus on power in the therapeutic relationship. She explained that she went to Loma Linda University to direct the family therapy doctoral program, and worked with Douglas Huenerardt, Ph.D. doing cotherapy. They invited students to observe, and their goal was to be able to articulate the work they were doing, and later finalized it into a research study. She explained that the model that evolved out of that work was named Socioemotional Relationship Therapy. Later, she moved to Oregon to teach at Lewis and Clark College, and worked with Teresa McDowell, EdD, LMFT, and wrote the textbook, Socioculturally Attuned Family Therapy, with Teresa and Maria Bermudez, Ph.D., LMFT. We discussed how Carmen’s background in sociology led her to always be thinking about sociocultural aspects and how they play out in relationships. She explained that Teresa introduced the idea of Third Order Thinking or Third Order Change to her, which goes beyond the Systemic concept of Second Order change, to bring awareness to the therapist and client of how the sociocultural system the relationships are embedded in and influence their experiences. She also discussed how this helps therapists be aware of how they are accountable for possibly unknowingly reinforcing and repeating larger societal patterns. Carmen discussed the Socio-Emotional Relationship Therapy Model and how it is influenced by experiential, structural therapy, and social constructionist theory and technique, while centering sociocultural awareness. She discussed how emotions are the window into the larger context by helping us see the thinking that is happening and how that thinking may be a product of social-cultural influences. She also discusses the role of power in the model, and being aware of how that determines what is important, what is valued and the meaning of things, and seeing how power plays out in the couple or family dynamics. She explained that they operationalize relational equity as the Circle of Care, which consists of four parts: 1) Mutual Vulnerability - openness and willingness to admit mistakes, safe to express one’s sensitivities, 2) Mutual Attunement - that each person is aware of the other person and their needs, as often the person with more power is less attuned, 3) Mutual Influence - whose interests are organizing the relationship and whether there is a willingness to be influenced, and 4) Shared Relational Responsibility - where both are taking responsibility for the wellbeing of the relationship. Carmen discusses how when these are balanced, there is a more equitable relationship, and by the therapist’s awareness of power, they can support the changes in the relationship to be more equitable and mutually supportive. Carmen Knudson-Martin, Ph.D., LMFT is a professor emerita in the Marriage, Couple, and Family Therapy program at Lewis and Clark College. Her scholarship focuses on how the larger social context influences health and well-being and how therapists can address the inequities that result. Carmen especially loves working with couples and is widely recognized for her work regarding gender, marital equality, and relational health. She is a founder of Socio-Emotional Relationship Therapy, an approach that attends to the ways couple interaction, emotion, and socio-cultural context come together in clinical process. Carmen’s teaching and practice are based on her conviction that how therapists conceptualize client concerns is an ethical issue and that clinical practices have consequences that are never neutral. Carmen is an AAMFT approved supervisor and licensed MFT. She served as an associate editor of the Journal of Marital and Family Therapy, vice-president of the Family Process Institute, board member of the American Family Therapy Academy (AFTA), and president of the California Division of the American Association for Marital and Family Therapy (AAMFT-CA). She is currently editor of the AFTA Springer Series in Family Therapy. Prior to coming to Lewis and Clark, she directed family therapy programs at Loma Linda University in Southern California, Montana State University, and Valdosta State University in Georgia.

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  58:49

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