A Therapist Can't Say That

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.

Learn more about The Kiln:

• Website

Learn more about Dr. Kae Hixson:

• Website

Learn more about Riva Stoudt, MA, LPC:

• Into the Woods Counseling
• Instagram

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.

Listen to the full episode to hear:

• How MBNET builds on existing research and frameworks to create a novel approach designed explicitly for interpersonal trauma
• Why complex interpersonal trauma needs an approach that addresses incidents across the lifespan
• How MBNET provides tools to intervene in client avoidance of traumatic memories
• How the concept of traumatic mind mapping explains and addresses the depth and severity of interpersonal trauma
• Why we believe in the transformative power of clients’ stories in processing their trauma 
• How the structure and flexibility built into MBNET make it easier to meet clients where they are

Learn more about The Kiln:

• Website

Learn more about Dr. Kae Hixson:

• Website

Learn more about Riva Stoudt:

• Into the Woods Counseling
• Instagram

Resources:

• Season 1 Ep 10: Leave No Stone Unturned: The Healing Opportunity of Exposure Therapy With Allison Aosved
• Season 1 Ep 14: Growing Into the Light: In Memory of David Schnarch
• Brain Talk: How Mind Mapping Brain Science Can Change Your Life & Everyone In It, David Schnarch
• Season 3 Ep 5: From Childhood Wounds to Therapeutic Wisdom with Dr. Karen Maroda
• Season 3 Ep 3: Unraveling Popular Ideas: Challenging Neuroscientific Narratives in Therapy with Kristen Martin

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.

Listen to the full episode to hear:

• How even using suffering as a metric for a problematic trait  is often complicated by context
• Why we cannot discount the sociocultural context for an individual’s expression of traits
• Why pathologizing states as problematic across the board falls apart in real life
• How the medical model of optimal human functioning fails to translate to psychopathology
• Why we have to stay open to uncertainty in viewing our clients’ suffering and how we can help ease it

Learn more about Riva Stoudt:

• Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat

Resources:

• Season 3 Ep 9: Epistemic Justice in Diagnosis: Exploring Borderline Personality Disorder with Dr. Awais Aftab
• Season 3 Ep 10: What We Talk About When We Talk About Diagnosis
• Season 3 Ep 11: Redefining Psychiatric Constructs with Dr. Miri Forbes
• Effective Reaction to Danger: Attachment Insecurities Predict Behavioral Reactions to an Experimentally Induced Threat Above and Beyond General Personality Traits, Tsachi Ein-Dor, Mario Mikulincer, and Phillip R. Shaver

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.

Listen to the full episode to hear:

• How a dimensional model can potentially help decrease stigmatizing and pathologizing of individual human experiences
• How the regrouping of symptoms creates potential for more fruitful research into how and why symptoms cluster and how best to treat them
• Why reliance on current categorization and diagnostic criteria can cause clinicians to miss or lose vital information about clients
• Reckoning with the utility of existing diagnoses like BPD that may lack statistical support

Learn more about Dr. Miri Forbes:

• Website
• Twitter: @MiriForbes

Learn more about Riva Stoudt:

• Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat
  
  

Resources:

• Reconstructing Psychopathology: A data-driven reorganization of the symptoms in the Diagnostic and Statistical Manual of Mental Disorders

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.

Listen to the full episode to hear:

• Why it is vital that we understand diagnoses and their value–or lack thereof–as constructs and constructs as tools
• How holding diagnosis as a lens, not a label, allows for more flexibility and curiosity
• The heavy lifting we expect from diagnostic constructs applied across multiple contexts
• Why it’s not always necessary to share how you’re applying a diagnostic construct to your therapeutic relationship with a client
• Why we have to learn to uncouple “difficult” from “bad” with our clients

Learn more about Riva Stoudt:

• 
  Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat
  
  

Resources:

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.

Listen to the full episode to hear:

• How treatment of people diagnosed with Borderline Personality Disorder frequently illustrates aspects of epistemic injustice/justice
• The ways that clinical setting and context influence the use, or misuse, of BPD as a diagnostic label and how that impacts patients
• How quantitative psychology is influencing how we conceptualize personality disorders
• Why a BPD diagnosis can be intensely valuable for some clients, and how it helps guide clinicians
• Why we can’t chalk up all psychopathology to trauma
• How calls for testimonial justice from psychiatric patients should serve as a corrective force to excessive skepticism of patient narratives

Learn more about Dr. Awais Aftab:

• Psychiatry at the Margins
• X: @awaisaftab

Learn more about Riva Stoudt:

• Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat

Resources:

• Borderline Personality and Self-Understanding of Psychopathology
• Epistemic injustice
• The epistemic injustice of borderline personality disorder,  Jay Watts, BJPsych International
• A Metaphysics of Psychopathology, Peter Zachar
• Peter Fonagy

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.

Listen to the full episode to hear:

• Why client relationships might, by their nature, be more frequent sites of anger than average interpersonal relationships
• How guilt and shame compound our discomfort with anger and get in the way of the curiosity and possibility that come with sitting with it
• Why it’s worth learning to understand our anger as a source of information about ourselves, our clients, our client relationships, or all three
• How anger is like fire or water–dangerous but capable of being handled with skill and purpose
• The social and cultural forces that make us even more reluctant to admit to anger at clients
• Why we owe clients and potential clients a view of our humanity within the work

Learn more about Riva Stoudt:

• 
  Into the Woods Counseling
• The Kiln School

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.

Listen to the full episode to hear:

• The many factors that cause therapists to be conflict avoidant, from cultural milieu to liability fears
• How the “good therapist” myth and taboos in the field impact common sites of conflict between therapist and client
• Why we have to disentangle fear of doing harm from fear of hurt or conflict
• Why we need to learn not to take responsibility for things that aren’t ours
• How denying a client’s bids for conflict and not calling them on their shit can damage the relationship
• How clients benefit from our modeling, that conflict does not have to be dangerous or suppressed

Learn more about Dr. K Hixson:

• Website

Learn more about Riva Stoudt:

• Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat
  
  

Resources:

• The Analyst's Vulnerability: Impact on Theory and Practice, Dr. Karen Maroda

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. 

Listen to the full episode to hear:

• How the relational programming we received in childhood can keep us and our clients stuck
• How successful therapy actually replicates the foundational grief of the parentified child
• Why your relationships with both your favorite and your most challenging clients might be where these relational patterns lurk the most
• Why we have to accept reciprocity and mutual gratification beyond collecting your fee in client relationships
• Why you have to stop coddling your clients and treat them like the capable, strong adults they are
• Why repressing your own emotional reactions to your clients isn’t helping them or you

Learn more about Riva Stoudt:

• Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat
  
  

Resources:

• The Analyst's Vulnerability: Impact on Theory and Practice, Dr. Karen Maroda
• Season 3 Ep 5: From Childhood Wounds to Therapeutic Wisdom with Dr. Karen Maroda
• Season 2 Ep 9: Immediacy in Therapy: Breaking the Fourth Wall with Dr. K Hixson

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. 

Listen to the full episode to hear:

• How our parentification as children can be an indicator of our potential empathic strengths
• How parentification often sets us up to be conflict-avoidant and self-sacrificing, to the detriment of ourselves and our clients
• How treating our clients as excessively fragile or infantile hinders their ability to get better
• The real antidote to feeling frustrated and disengaged with a client who’s not making progress
• The relationship between our outsized fear of harming clients and our fear of our anger and frustration that was forged in childhood 

Learn more about Dr. Karen Maroda:

• The Analyst's Vulnerability: Impact on Theory and Practice

Learn more about Riva Stoudt:

• 
  Into the Woods Counseling
• The Kiln School
• Instagram: @atherapistcantsaythat
  
  

Resources:

• Season 2 Ep 10: Client Relationships in the Trenches: The Role of Self-Validated Intimacy
• A Curious Calling: Unconscious Motivations for Practicing Psychotherapy, Michael B. Sussman