Therapy on the Cutting Edge

In this episode, Oona discusses how she went through her own divorce a number of years ago and found that there were not that many resources for women. After moving through her own divorce and becoming resettled, she started running groups for women going through divorce and has run numerous groups over the years. She shared that through working with many women, she began to find patterns and themes and wrote a book for women to help them as they make this transition in their life. She explained that the Kubler-Ross model of grief was helpful, but wasn’t quite capturing the nuances of divorce. She described what she calls the five phases of divorce, which are Heartbreak, Roller Coaster, Mending, Letting Go and Moving On. In the Heartbreak phase, she explained that whether the person initiated the divorce or not, there is a great deal of pain and heartbreak and its a time for the therapist to be fully present with their client. The Roller Coaster phase features a mix of emotions with sadness, anger, fear, shame, and other emotions, and can be confusing since there may be conflicting emotions. For example, someone might feel a great deal of anger and maybe hate, but at the same time sadness and love. Helping clients to understand that this is a phase of the process of moving through divorce can help clients to understand that this will not last forever and to be patient with themselves, rather than rushing into another relationship or self medicating. The Mending phase is a time to turn toward the self instead of spending so much energy on the ex or the divorce. Mending includes a process of renegotiating boundaries, not only with the ex around what their interactions will be like or how they will coparent, but also their friends, family, and in laws. She explained that it’s a time for reevaluation and many people also begin to reevaluate their boundaries with others in their life. The fourth phase is Letting Go and is an important component of healing. When people divorce, they not only let go of their spouse, but also their identity of being a married person, as well as their identity of being part of an intact family. Lastly, in the Moving On phase, she explains that the person is shifting their focus away from the divorce and towards the future, whether that be in another relationship, their work, their children or a new venture. She explained that sometimes people can get stuck in a phase like the Roller Coaster phase, and it can be helpful to work with them in becoming unstuck. The process of the therapist figuring out whether this is part of the natural process or whether the client is stuck can be difficult to differentiate. We discuss getting legal consultation and Oona recommends against therapists referring to a specific lawyer because all divorces are different, but instead encouraging clients to do a lot of research to find what is the right fit for them. We also talked about co-parenting counseling and how it’s different than therapy where you’re not working on the relationship between the couple, but helping them work together for the best interest of the child. Oona shares how valuable the groups have been for her clients. Her book, Unhitched: The Essential Divorce Guide for Women just came out the week before the interview and is reflective of so many women’s journeys through the process. She also said she is providing trainings for therapists to learn how to run the divorce support groups for women and is leading a two day long Institute at the American Group Psychotherapy Association Conference in NY in March for therapists experiencing divorce.

Oona Metz, LICSW is a Licensed Independent Clinical Social Worker, a Certified Group Psychotherapist, and a Fellow of the American Group Psychotherapy Association. She has 30 years of experience working with individuals, families, and groups. Her private practice offices are located in Brookline and Arlington, Massachusetts. She is active on numerous committees and boards related to group therapy and prioritizes ongoing learning in diversity, equity, and inclusion. Her practice is focused on treating the emotional aspects of divorce and group therapy, and she leads three weekly divorce support groups. She is the author of Unhitched: The Essential Divorce Guide for Women. You can learn more about her at her website oonametz.com

In this episode, Alicia discusses her work with Dialectical Behavior Therapy and Radically Open DBT. She explains that she was first exposed to DBT in her predoctoral internship at Marin General Hospital, where part of the rotation was to run a DBT group and fell in love with its practicality and giving people real tools they could take away. She explained that it was great to see clients using the tools and finding success, so she got went and got trained with Marsha Linehan, Ph.D. and Behavioral Tech and made DBT her focus. She explained that DBT is especially helpful for clients who describe themselves as emotionally sensitive or struggle to “ride the wave” of emotions that feel overwhelming. Alicia discusses the five modules of DBT that she works from, including mindfulness, distress tolerance, affect regulation, interpersonal skills, and “walking the middle path,” (which is related to validation and reinforcement in family emotional dynamics). Alicia goes on to explain the use of the modules in working towards emotional awareness, getting through emotional crises, and radical acceptance of emotions. We also discuss coping skills and exposure therapy and how there are tools to expand one’s window of tolerance as well as self-soothing skills utilized to sit with one’s emotions. We speak on what dialectics in DBT refer to: holding two truths at a time, as opposed to relying on rigid, black-and-white thinking, which can exacerbate feelings of distress and overwhelm. Alicia discusses Radical DBT, or Radically Open DBT, and how it is different from regular DBT as it expands radical openness, self-inquiry, and accepting imperfection in oneself in treating emotional OC (overcontrol) disorders such as Anorexia Nervosa, OCPD, and chronic depression. We discuss how RO DBT benefits clients who experience rigidity in their overcontrol as well as shame, anxiety, and hypervigilance in their daily life. Alicia discusses her website, Therahive, which provides DBT skills online for clients as well as training for therapists to make DBT accessible throughout the world. We discuss how important having a supportive community is for clinicians who are providing DBT and how DBT’s model includes a therapist consultation group. Lastly, we discuss phone coaching with clients and how it is utilized with clients who are struggling with self-harm and other behaviors and how therapists navigate personal boundaries around time with family and time off, while also being available for clients in need.

Alicia Smart, PsyD is a licensed clinical psychologist in California with over 20 years of clinical experience providing evidence-based mental health care to children, adolescents, adults, and families. She began seeing clients during graduate training and has worked across community mental health, medical, and private practice settings throughout her career. Alicia earned her B.A. in Psychology and Chemistry from New York University and her Doctorate in Clinical Psychology (PsyD) from the California Institute of Integral Studies. She is a DBT-Linehan Certified Clinician and has extensive experience treating mood and personality disorders, trauma, anxiety, grief, ADHD, autism-spectrum presentations, and chronic emotion dysregulation. Her work frequently integrates DBT into suicide risk management, neurodivergent-affirming care, and complex relational systems. She is the Founder and Clinical Director of Guidepost DBT in Corte Madera, California, where she oversees a team of therapists providing comprehensive Dialectical Behavior Therapy (DBT) and evidence-based care. In addition to clinical leadership, Alicia provides training, supervision, and consultation to clinicians seeking advanced education in DBT and related approaches. Alicia is also a co-founder of TheraHive, an innovative online DBT skills and learning platform designed to make high-quality DBT education more accessible to individuals and clinicians worldwide.

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

Alecia Greenlee, MD, MPH is a board-certified psychiatrist who brings both rigorous training and deep humanity to her work with women navigating ADHD and co-occurring mental health conditions. After earning her medical degree from UC San Francisco, she completed her psychiatric residency at Harvard Medical School/Cambridge Health Alliance, where she served as chief resident in consultation-liaison psychiatry and developed expertise in collaborative care and mental health services for vulnerable populations. She went on to fellowship training at the University of Chicago, first in consultation-liaison psychiatry and then in reproductive psychiatry, gaining specialized knowledge in how the body and mind interact throughout women's lives. Allecia specializes in comprehensive psychiatric evaluation and evidence-based treatment for adults, with particular expertise in how hormonal changes throughout the female lifespan—from menstrual cycles to pregnancy to perimenopause—influence ADHD symptoms and overall mental health. Her commitment to health equity drew her to focus on women's and minority mental health, populations often underserved by research and clinical resources. She approaches each patient with cultural attunement and warmth, creating collaborative, safe spaces where people from all backgrounds feel genuinely heard. Her practice reflects a commitment to whole-person care that considers not just psychiatric symptoms, but the complex interplay of biology, identity, life circumstances, and medical conditions that shape each individual's treatment needs.

In this episode, I speak with psychologist Kenneth Perlmutter about his work with wounded family systems and how his background shaped his therapeutic approach. Kenneth shared that he originally planned to go to medical school but switched to journalism, then worked in advertising in San Francisco in the 1980s. During that time, he worked with a therapist who made a profound impact on him, which ultimately inspired him to pursue graduate training and become a therapist himself. In 1989 he joined Boyer House as an intern, later becoming the Clinical Milieu Director, and it was there that he was placed on the Family Therapy team and found he really enjoyed working with family dynamics. Kenneth explained that his work is heavily informed by psychodynamic and psychoanalytic thinking, especially the ways people relate to others across different parts of their lives. He shared that his current clinic functions as a full-service mental health center with significant expertise in substance abuse, addiction recovery, and trauma-related disorders, and that many of their referrals involve college-age and young adult clients whose families are struggling to support them. We discussed how he uses a psychoanalytically informed systemic approach, paying close attention to attachment patterns, the family’s stage of development, and even reflections on his own family system. He talked about how wounded family systems often fall into patterns of dependency, such as exaggerated dependency, hostile dependency, or chronic dependency, and how parents may unknowingly reinforce these dynamics. He explained that he looks closely at what he calls the ‘S’ actions,” which include serving, soothing, saving, smoothing, solving, sacrificing, and sobbing, and how these actions often keep families stuck in their roles. He shared that when parents begin to shift their focus toward their own needs and adjust their responses, children often change their behaviors in positive ways. Kenneth also discussed how families tolerate hostility and how interventions often start by looking at the behaviors that enable it. He explained that part of the work is helping families understand how their system functions, what they want more or less of, and what keeps them locked in certain roles. He postulates on what can be considered “right” or “wrong” actions as a result of these pressures and gives the example of sending an adult child money time and time again under tenuous circumstances. He claims that what would be “wrong” in fact, would be not to reflect at all on how the parent’s actions are affecting the child’s behaviors. Kenneth calls these narratives “the lies that bind”, explaining that the most common belief is that whatever ‘S’ behavior is at play is what is keeping this family member alive and well. This distorted narrative keeps a tight grip on current dynamics and gives the parent a false sense of control. Being locked in this “if only” mindset is either aspirational or regretful. We ended the conversation by talking about his Model of Stress-Induced Impaired Coping. Kenneth explained that every family develops its own stress-driven roles and that members often fall into patterns such as escaping, distracting, blaming, or fixing. He described how he helps families understand what holds them in these roles, what reinforces them, and how these patterns originally developed, so they can move toward more flexibility and healthier ways of relating.

Kenneth Perlmutter, PhD, is the founder of the Family Recovery Institute and a licensed psychologist specializing in Family Systems. He has 35 years of experience working with complex psychological and behavioral health disorders. In 2008, he founded The Family Recovery Institute to provide multi-disciplinary treatment for individuals and families including dynamic therapy, family systems work, group therapies, healing workshops and clinician training. He has pioneered and validated a theory of family system woundedness with a corresponding recovery model he calls Stress-Induced Impaired Coping. He wrote the book Freedom from Family Dysfunction: A Guide for Families Battling Addiction or Mental Illness specifically for family members who love someone battling addiction or mental illness but “want to break the cycles of codependency and relapse plaguing their dysfunctional systems.” He has overseen the design and installation of the family treatment program for Bayside Marin, Morningside Recovery, Safe Harbor Treatment Center for Women, Casa Capri/Windward Way and other national-level programs. In addition, he conducts a twice-monthly therapy group for parents of troubled teens and stuck young adults and has historically conducted several healing workshop for families of the White Mountain Apache Reservation in Whiteriver, AZ. As a professional educator, he has served on the graduate faculty for San Francisco State University’s Counseling Department and as Associate Professor of Chemical Dependency Studies at Cal State East Bay.

In this episode, I speak with Peter about his work on narcissism and its place within the broader spectrum of personality disorders. He shares that when he was in graduate school for literature, he was required to participate in a course of psychotherapy—an experience that sparked his interest in the field and eventually led him to pursue clinical training. Peter explains that he became increasingly interested in personality disorders, especially after having his own personal encounter with someone exhibiting narcissistic traits. This experience helped shape his focus in this area of study. He notes that the field of psychotherapy often views narcissism through the lens of “hurt people hurt people”—the idea that harmful behavior stems from unresolved trauma. While that framework can sometimes be useful, Peter believes it may also lead people to remain in harmful dynamics for too long because they extend too much empathy and assume the behavior is unintentional. He discusses meta-analytic research on twins showing that roughly 50% of psychological traits are heritable; in some studies, narcissistic traits have been found to be up to 79% heritable. Peter emphasizes the importance of clinicians and clients understanding that, in many cases, narcissistic individuals do know their behavior is harmful and continue it because it benefits them. This runs counter to the prevailing idea that such behavior is purely unconscious or trauma-driven. He acknowledges that this perspective is controversial and that he has received criticism for challenging long-standing therapeutic assumptions. When working with clients, Peter helps them navigate the cognitive dissonance between their painful or abusive experiences and their belief that the narcissistic individual “didn’t mean it” or was simply reacting from trauma. The belief that someone is merely “wounded” and reacting can keep people in unhealthy relationships far beyond what is safe or reasonable. We also discussed the differences between narcissism and antisocial personality disorder. Peter explains that one way to determine whether a person is workable is to assess their collaborative capacity—and, importantly, for therapists not to assume there is mutual agreement on collaboration or shared responsibility. He underscores the importance of validating victims of these relational dynamics, reminding them that no matter how much self-work they do, they may not be able to improve the relationship because the problem may not be about them at all. Part of his work involves helping clients reconnect with their sense of self, especially when an invalidating environment has led them to doubt their own perceptions, question their reality, or even wonder whether they are a “good” person.

Peter Salerno, PsyD, is a Doctor of Psychology, retired licensed psychotherapist, and nationally recognized expert on personality disorders and pathological relationships. Over the course of his career, he has specialized in personality disorders, family trauma, complex trauma, and pathological abuse. He was trained and qualified to administer the Hare Psychopathy Checklist–Revised (PCL-R), the gold standard for identifying psychopathy in clinical and forensic settings. He was also a featured expert in the docuseries Ted Bundy: Dialogue with the Devil, streaming on Hulu and Disney+. His work has always been driven by a passion for understanding the human mind and helping people make sense of some of its most challenging and misunderstood conditions. Today, he uses that expertise to help people around the world understand painful, confusing, and often manipulative relationship dynamics. While he no longer practices traditional therapy, he offers remote consultations focused on clarity, insight, and practical decision-making—not treatment.