Therapy is not a monolith!

Psychotherapy is everywhere: on tv shows, in movies, reality TV, and on social media. However, we don't really talk about what therapy actually is. In this episode, Dr. Alex Iantaffi explores the diversity of therapeutic approaches, clarifies distinctions between related fields, and emphasizes the importance of informed choices in therapy for both clients and practitioners.

Key  topics

Diversity of therapeutic approaches
Distinction between psychology and therapy
Impact of theoretical frameworks on practice
Decolonizing therapy and recognizing lineage
The role of critical thinking 
Myths in therapy
Therapeutic joining as evidence-based
Ethics beyond basic boundaries
Role of diagnosis and diagnostic models
Things educators can do
Things therapists can do
Questions clients can ask therapists

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Transcript

0:01

Hello and welcome to another live episode of Warm Take Wednesdays with Dr. Alex. That is me. I'm an independent scholar, author, licensed therapist and clinical supervisor, as well as the host of the podcast, Gender Stories, and this YouTube series, Warm Take Wednesdays with Dr. Alex. Today, what I really want to talk about is therapy. Therapy really seems to be everywhere. It's on social media. It's on TV, in TV series, in movies, and yet I think that can really be confusing because therapy is not a monolith. We talk about therapy as it's just one thing and that's not just the general public. think that therapists do this too online. And so I really kind of want to get into it because when we talk about therapy as just one thing, it can not only be confusing, but at its worst, it can also be harmful. And the reality is that there are several approaches to therapy and the theory on which different therapeutic approaches are kind of founded and rooted really dictate kind of how we as therapists show up for our clients, but also how we think about people, how we conceptualize the human condition and mental health challenges, whether we take, for example, a more pathologizing framework, a more individualistic framework, a more systemic framework, and so on and so forth. I'm not gonna break down all the different main theories in the therapeutic world. There are so many, and maybe if people are interested, I might do some more episodes on kind of specific approaches, if you like. What I'm really interested in in this episode is challenging this idea that therapy is just one thing and that there is just one way of doing therapy. The other issue that I see is that we really conflate kind of therapy with psychology. And there are actually two distinct fields. Psychology is his own field, right? And therapy is very much his own field. Now, psychologists also provide therapy if they're clinical psychologists. Not all psychologists, of course, are clinical psychologists. Some psychiatrists who are medical doctors also provide therapy. But the reality is that therapy is its own field. And we really need to be able to make those distinctions, right? So psychiatrists are medical doctors that can also prescribe some Some nurse practitioners also specialize in mental health and they might provide therapeutic services as well as prescribing services. Psychologists are again their own field. Usually the folks who are psychologists and do therapy are clinical psychologists who are licensed. And then there is the field of therapy where you might have licensed professional counselor, licensed mental health counselor, licensed marriage and family therapist like myself. So I really want to start from these distinctions that maybe seem simple to you, but I think they can be really confusing. and of course this lies in social workers too. And some of them are clinical social workers. And so if they're clinical social workers, that would also provide therapy. My apologies to my social work colleagues. Didn't mean to leave you out. And social work in its way is its own field too, because social workers don't only go into therapy, they might go into kind of more macro policy work, for example, or case management and so on. So it's really important to understand that the field is really vast and it contains many disciplines, which means it contains different ways of thinking about humanity, of thinking about mental health, thinking about change, and thinking about how all of this relates to the system which we're part of. So our families, the places we live in, where we're located geographically, where we're located in time, and so on and so forth. And the other thing that I see happen is that therapists and many therapy approaches are really seeking or have sought to legitimize, legitimization, such a hard word to say, so much easier to write it down. And, you know, for being recognized as being part of the healthcare system, which is great. However, sometimes that can create a little bit of a dissonance because For example, as a systemic therapist, I really view mental health issues as the symptoms of something being dissonant or not working well or having challenges within a system, whether the system is a family. And of course, we cannot look at families outside of the context of language, culture, sociopolitical context, historical context, and so on and so forth. And so we really need to kind of to understand um how different therapists might approach the field. We really need to understand what are the theoretical foundations that they're standing on. And are they trying to operate within the medical industrial complex or adjacent to the medical industrial complex? Because of course we are healthcare providers. So I don't believe we can fully be outside of the medical industrial complex, but we can either be fully in it. For example, some of us work, might work for agencies or larger hospitals. And there are different demands for those therapists compared to therapists, for example, who operate in private practice. And even within private practice in the so-called United States, for example, people might be accepting insurance, which kind of locates us closer within the medical industrial complex, or not accept insurance, which puts us a little bit more adjacent to the medical industrial complex. But we're always adjacent to the medical industrial complex because, for example, sometimes we need to provide documentation to our clients for FMLA, family and medical leave, know, or for requests for disabilities and so on and so forth. And this is not even to speak about the geographical differences. For example, I am qualified and trained to be a psychotherapist who can operate in the so-called United States. I was also able to operate in the United Kingdom where I trained as a systemic therapist, but where I had to move to my country of which is Italy, I could not operate as a psychotherapist because my first degree is not in psychology or medicine. And so every country also has its own rules about who can be a psychotherapist and who cannot be a psychotherapist. So if this seems really complicated, it's because maybe it is. But why do I want to talk about it? I've said a little bit about this at the beginning, but I want to say a little bit more about that. After I sip some water, if you watched other episodes, you know I sip a lot of water when I talk. So the reason why I want to talk about it is because there can be really harmful beliefs that are perpetuated if we are not informed as clients, but also if we're not informed as therapists. I'm also a clinical supervisor and I know that the issue is not just the general public not having information. I think it's also people who enter the field and even therapists within the field not always having access to all the information. And I think that when we have more information, people who are entering the field can make better choices in terms of what kind of therapy they want to really get into. Clients can make more informed choices about what kind of therapist they're looking for. And at the end of the episode, I also have some suggestions for therapists, for educators and clients. And of course, some of us are all of those things. I'm an educator, I'm a therapist and clinical supervisor, and I'm also a consumer of therapy. I have my own therapist. I really believe that good therapists have therapists. I'm sorry, that is a hill I will die on as people say nowadays on social media. So I think that kind of talking about how therapy is not a monolith, it kind of helps all of us, right? And for therapists, excuse me, being better informed, about all the different kinds of therapeutic approaches that are out there. It can really reduce cognitive dissonance, confusion, stress. And we know that there's already quite a lot of stress to be frank, that therapists are holding nowadays. This is not an easy moment. We're seeing global rise of fascism, ongoing climate crisis, ongoing genocides, due to the ongoing silo colonial projects globally. It's not an easy time to be a And some therapists who are operating now and have been trained in the past few years have also come into the field right at the beginning or in the middle of the ongoing COVID pandemic. So none of this is particularly easy, right? And so when you have this stress of then cognitive dissonance or trying to understand how to reconcile your own values with the field, that can be even more challenging. And finally, I really want us to move away from kind of binary thinking that many of us have about therapy. This is the right way to do therapy and this is the wrong way to do therapy. I would say there is an ethical way to do therapy, therapy that's in integrity with our code of ethics and our statutes, and we'll look at that in a moment, and therapy that is not. But to say that this is the right way to do therapy and this is the wrong way to do therapy really kind of shifts the way the issue from ethics and integrity with our values and puts it in this very white supremacist colonial way of thinking in dichotomies, in binary of good and bad and right and wrong. And there is a lot of this on social media. I'm sorry, I love social media. I'm an early adopter of technology, social media. I'm in my mid fifties, but I love tech and I love social media platforms and I'm active on some of them. But I do believe that sometimes we can perpetuate this kind of stereotypes of what makes good therapy in air quotes, and what makes bad therapy. And I would really love to shift the conversation into what makes ethical therapy, effective therapy and therapy that's in integrity with our values, beliefs, and the way we look at the world, ourselves, and each other. And so I want to start from talking about how I see a real tension in our field. uh I talked about this recently at the Psychotherapy Networkers Symposium as well in Washington, DC. I think there is a tension in our field. On one hand, people are really specializing very early. I've worked with graduate students who are still doing their masters in kind of mental health counseling or professional counseling or marriage and family. therapy, social work and so on and they're already thinking about what should they specialize in and they're being encouraged sometimes by the educators in their graduate program to start thinking about their specialization. Now to me that is really dissonant when you're still in your master's program or in your doctoral program if you're in SID or a clinical psychology PhD program this is the time to learn to be a therapist. This is the perfect time to be um just a generical therapist. Like do we even know how to sit with people when they're suffering? Do we know how to listen? Do we know how to hold a nervous system that can really... accept whatever the client or clients are bringing to us with unconditional positive regard and giving a sense of unconditional sense of belonging to humanity. And often we don't have this very kind of foundational basic skills, even though we know from research evidence that regardless of therapeutic approach used, most reliable predictor of therapeutic effectiveness is the relationship and the fit. between therapist and client or clients. And I say clients plural because for example as a family therapist sometimes I work with couples, polycules or family systems or other relational systems and so it's not always individuals in therapy. And so you know on one hand we have this kind of push to specialize early, know what kind of approach you want to use, know what kind of population you want to work with and so on and so forth. And on the other end, there's this real desire that I see in the field that's very clear from the books that are getting published. um from social media, know, shout out to Dr. Jennifer Mullen and decolonizing therapy, there's a real desire for decolonizing the field. But there are also a lot of challenges of going from this desire and maybe even the learning and relearning that people are doing to the application. What does it look like in practice, right? How can we relate to these ideas such as decolonization in actual clinical practice with our clients, right? So there's a lot to talk about and probably more than I can fit into one episode But those are kind of some of the reasons why I wanted to talk about What is therapy and the therapy is not a monolith and so you will see in our field people They're much more kind of embedded in the medical industrial complex who do um Believe in a more positive stick kind of approach to the human condition and come from the more psychological framework, let's say, which is usually a more pathologizing framework, honestly, historically. And then you will also have, you know, practitioners that come from a more uh integrative and even decolonized perspective and of course everything in between, right? And some of us might even move kind of between those poles and that can be really confusing, both for the general public, for clients, for students, and honestly sometimes for therapists themselves. And so one of the things that I, one of the reasons why I think this is happening is because while we talk about being evidence-based, In all of graduate programs, we don't even teach the skills that would help us really be evidence-based. Like I said, one of the strongest, kind of most consistent pieces of research evidence around the effectiveness of therapy is about the fit between therapy and client. And yet, so very little time in most graduate programs is spent teaching students how to be present with their clients and how to join, for example, in family therapy, systemic therapy, we call it joining, right? It's like the ability to uh join with the system in the therapeutic room so that we can build some degree of relationality, some trust, and so that we can do this work together. Or how to be holding and demonstrating unconditional positive regard, or how to show up with curiosity. And sometimes there's even words that are very specific in the context of some therapeutic approaches that taken out of context don't make a lot of sense. So for example, the concept of neutrality in family therapy, it's a very specific concept. It doesn't mean neutrality the way we use it in kind of everyday parlance, let's just say, right? The concept of neutrality in family therapy is what enables us to have multiple people in a room, for example, if I'm working with a family where I might have five or six different clients in the room, what the concept of neutrality is inviting me to do is to not get sucked into just one part of the system and listen only to one story, but rather to hold curiosity towards all parts of the system. Now, that doesn't mean that just because I know how to hold neutrality as a family therapist, that I'm not political in my stance towards therapy, or that I don't have moral judgments, or that I'm staying neutral in the more kind of mainstream sense of the word. I actually do think that therapy is political. Not every therapist thinks that, but many therapists do. Many feminist therapists do. Many systemic therapists do. um And that, you know, the person will he's inherently political and that would include therapy. And so we talk about evidence-based and yet we do not teach those skills that therapists need in order to be effective with clients. And it's not surprising that that even while they're still in school, many students are seeking more certification, more specializations, more tools and interventions because they're thinking about what do I do when I'm with a client rather than how do I show up when I'm with a client. And you know, I really encourage supervisees when I work with them and they're at the beginning of their professional identity development journey to think about how do I show up when I'm with a client. Anyway, I digress. So let me get another sip of water and get back on topic. So like I said, the reason why I want to talk about all of this is because I think it's important to have kind of more nuanced conversations about what therapy is. And also that the last thing that I want to mention before going into some more issues and one another reason why I want to talk about this is that part of kind of decolonizing therapy, and like I said, there's also a strong desire to decolonize our field. And that's really exciting to see many conversations that once upon a time used to be pretty fringe and on the margins to be honest, really takes center stage nowadays and that's fantastic. And I think we owe a lot of that to black, brown and indigenous practitioners in particular, as well as trans and queer folks within our field. So, so excited to see this conversation about decolonization being mainstream. And I think that part of that decolonization is knowing our lineage. And so when we treat therapy as a monolith, we are not honoring our lineage. And our lineages can be multiple, right? But one of those lineages is our theoretical lineages. Where do we come from? Whose shoulders are we standing on? Who are our ancestors in terms of therapeutic approach and so on? Where do our ideas come from? When were they developed? By whom were they developed? Who disseminated them and how? How did they connect to the time and place when they were developed? The historical moment, the cultural context in which they marriage. I don't think it's... eh Coincidence that several therapeutic approaches, for example, come up around the same time, you know, through the 60s, 70s, and 80s. There's a real kind of pushback to that more pathologizing approach to therapy and a real desire to recognize systems. This is also a time where we see globally more more movements for civil rights emergence. So it makes sense to me that that is kind of reflected in the field of therapy, right? as in therapy is also knowing where what you think and do comes from as a therapist and as a client having a therapist who can speak to that. a therapist who can say for example you know I'll use myself as an example I'm a systemic therapist I also practice and I'm trained in narrative therapy and somatic experiencing and I'm also trained in dance and movement therapy and I can say more to clients if they want to know more about my background or less, because not everybody wants to know a lot. And I also have some questions toward the end of this episode that clients can ask therapists when they're shopping around for a therapist. And if you are looking for a therapist, I really do encourage you to shop around and find somebody who's a good fit, because we already talked about how important it is in terms of effectiveness. And so I've already said that kind of talking about therapy as a monolith can create confusion and it and cognitive dissonance between our values and how we do therapy, but it can also create confusions for clients around roles and expectations. For example. You know, if you're a client, you must ask yourself things like, is my therapist just supposed to listen and just accept everything I say without questioning? Or can they give advice? Can they tell me what to do or not? Right? Sometimes clients want us to tell them what to do. And how do we hold that as therapists? Are we clear with our clients about what our stance is and who we are, what our job is and what they can reasonably expect in session and in between session from us, right? How to communicate, what the boundaries are, all of those things, really important. And because there is so much information about therapy out there on social media, it can be really confusing. At one point, all over various social media platforms, there was this whole conversation around... Are therapists allowed to drink or eat in sessions or not? To eat or not to eat? To drink or not to drink? Now, I drink a lot of water. I also sometimes drink tea or coffee in session. I try not to eat during session, but it does happen occasionally if I have to kind of cram into a crisis session during lunch, for example. But that is just me and it's not that there is a right or wrong way like I was saying earlier, it's more thinking about ethically. However, I always have when I do in-person therapy, which has been a while now because I've been doing telehealth really. I have snacks, I tea and coffee, and I really encourage clients to eat in session if they need to, to take care of themselves. But as a therapist, I want to really keep my focus on the client. So if I can avoid, I don't eat in session, but it doesn't mean that eating in session is wrong, and I have occasionally done it. It's more thinking about what is the impact that this is going to have on the client. Going back to this idea that I don't want us to think about what's good or bad. I want us to think about what's ethical, what's integrity with my values. What is a good fit for this specific relationship that I have with my client? Right? If I'm working with somebody on disordered eating, that might not be the ideal client to eat in front of for lots of different reasons. Or they might be the perfect client to eat in front of, depending on what we're working on together. This really highlights the idea that there is not one right or one wrong way of doing things, but there is an intentional way. an ethical way, thoughtful way of doing things. And when we reduce the ethics, the integrity, the intentionality to good or bad or right or wrong, we're really doing a disservice to our clients if we're therapists and to each other also as therapists because we're really eliminating all nuance and we're also eliminating context and relationality. Why supremacy is so good at doing that? Why supremacy is really great, I think, at eliminating context and relationality. And so part of decolonizing therapy is also being very aware, actually, of context and relationality, I would say. And the other thing that really frustrates me is also that um sometimes as therapists, we talk about theories or diagnostic models as if they were objective reality that cannot be controlled. tested. For example, if it's in the DSM, which is the Diagnostic and Statistical that Exit Manual, or the ICD, the International Classification of Diseases we treat that as if it is some sort of sacred text that tells us the unquestionable truth. And the reality is that neither of those documents uh give us the truth, whatever that means, and they absolutely can be questioned. In fact, many things have changed over the years and over the decades in both of those. At this point, we are at version 5 of the DSM and version 11 of the ICD, for example, right? But when we treat those things as if they were objective reality that cannot be questioned, we're really doing a disservice to our clients and to ourselves because than if they see a different perspective, that can be really confusing, right? And I know graduate programs have a lot to answer for on this one. I'm sorry if you're an educator or you work at the higher educational institutions, but I do think that there is a lot to be said for how we train therapists to be in the field. And so when we treat those things as kind of ultimate truth, we are really not engaging our critical thinking. And we're also not giving appropriate context for people to understand where things like diagnosis come from and how they're negotiated. Because really diagnostic labels are a negotiation in the field, in the committees that come up with those diagnostic labels. They weigh in clinical experience as well as available research evidence as well as theoretical frameworks, which is why I said it's so important, I think, for us to know. what kind of theoretical framework we're standing on as therapists. And people don't always know that, to be completely honest. And so... I really want us to be aware that things like theories and diagnostic models and diagnostic labels like the ones that we find in the DSM and the ICD are not the ultimate truth. They're just tools. They're just one way of looking at the world. Now, that doesn't mean, for example, that just because they're one way of looking at the world, that if we look at the world in a different way, things look completely different. What do I mean by that? For example, recently, was in a big conversation about personality disorders online. And personally, I don't subscribe to the idea of personality disorders for various reasons. I find them to be a pathologizing framework. I find them to be based on questionable research evidence. They're often really weaponized against minoritized folks. They have been used, you know, really against sexual and gender minorities, for example, disabled folks, neurodivergent folks who often end up misdiagnosed with a person. disorder. Now that doesn't mean that for some clients to be diagnosed with a personality disorder is not meaningful. It might be incredibly meaningful for somebody to find the framework that explains what they have been experiencing. It also doesn't mean that there isn't a configuration of cognitive patterns, so the way we think, behavioral patterns, the way we act, and relational patterns, the way we are with one another as well as in relation with ourselves. that fall under those umbrella. Those patterns exist, but they don't need to be labeled the way they're labeled, for example. The way we label them very much depends on the theoretical lens that we are applying. That's what I meant by the theoretical lens we use really determines the way we conceptualize ourselves and each other as human and the way we think about mental health. So having awareness of kind of those theoretical foundations becomes really important. Otherwise, we perpetuate ideas that uh something is so common that applies across all therapists, right? So for example, I've been told that my license should be taken away because I don't uh support the idea of personality disorders, you know, and that I shouldn't practice according to my opinions. In this historical moment, it's also very interesting that some people are coming at me with that idea, given how much science has been questioned. But I have to say, this is not an uninformed opinion. This is an opinion that's backed up by theoretical support and research data. Here are some peer-reviewed sources, for example, that I've cited. None of them were from me, by the way. So it's not like uh there's no circular citation. when I'm making this argument, this is an argument that's been made by many people, people before me, and I'm sure will be made by people after me until we find a better way of kind of uh using the idea of diagnosis, for example. And I'll put that in their quotes because again, even the diagnostic framework comes from a very specific theoretical uh understanding. Right? And so that's why I think it's important to talk about this because otherwise the general public, clients, and sometimes therapists themselves. don't really know that those things can be approached critically. That just because something exists, we don't have to work in that specific paradigm. Another example is the way that a lot of people talk about transference and counter-transference, right? Those are terms that a lot of therapists talk about. A lot of therapy terms have made it into everyday speech, which I think it's great, by and large, for people to have access to more information. Information is power and is great. But one of the drawbacks is that sometimes people talk about transference and counter-transference as if that is universal in therapy. In therapy, there is transference and counter-transference. I've literally heard people make the statement. And I'm not talking about just clients or the general public. therapist make those statements. University professors who teach therapy students make those statements. but. Transference and counter-transference are concepts that are rooted in psychodynamic theory. And psychodynamic theory is very specific. It's kind of the type of theory that originates from Freud and those folks. So psychodynamic theory has this idea that therapist needs to be a blank slate, right? On which the client can kind of uh project uh anything that they might or might not need. And also so that we don't influence the client, right? And so the idea of transference and counter transference is those things that, you know, the client might project onto the therapist and the therapist then might project onto the client. But when you take away those theoretical foundation, The concept of transference and counter-transference doesn't always hold. For example, I don't use that concept. Now people sometimes ask me, usually supervisees, like, well, if you don't use transference and counter-transference, what do you use? Because the reality is that sometimes our clients will react to us because of their past experiences. And we will react to our clients because of our own histories, positionalities, and past experiences, just like they do. But the way I look at it, it's not through this lens because personally I'm not a psychodynamic theorist, psychodynamic therapist. Now there is nothing wrong with being a psychodynamic therapist. What I challenge is the idea that then that framework gets applied to all therapists. So as a systemic therapist, the way I tend to think about this phenomena is through the lens of communication theory. Actually, the way I was taught in my own training was heavily reliant on the idea of core coordinated management of meaning, for example. And given that my first degree is in linguistics, that really appealed. And the reason why that appeals to me is because when we're communicating with somebody else, we're always carrying all of our positionalities, our past experience, our history with us, right? And so are they. And so when we're communicating, that communication is not happening in a vacuum. That communication is happening within a story. cultural, political context, right? And that's the way I tend to look at it. And of course, history includes our personal history, right? And so the way we relate to each other in everyday life means that we bring everything we are with us and other people bring everything they are with them. And that's when communication happens. And it can get challenging and that's a whole other conversation. But that also of course happens within the therapy room. And so we can absolutely look at what psychodynamic therapists call transference and counter-transference. But the way I look at it is through these lenses of linguistics and systems. What is it that you are carrying that is here between us? And what is it that I'm carrying that is here between us? And how do we negotiate it together in a way that feels supportive, ethical, therapeutic and dare I say healing because there's a whole other debate about healing and I'm not even gonna get into that because you know I'm saying way more than I expected to say on this topic. Anyway so one of the Other reasons why it's so important to talk about all the differences that there are between therapeutic approaches is because uh not all of those things are universal. They're specific to kind of a theoretical outlook. So another example is that when we kind of do away with this idea that therapy is not one thing, We also kind of perpetuate myths that almost become their own facts, which is very concerning. So for example, I have seen in the last few years a trend. I'm not trying to be shady, but I've seen a trend amongst a lot of therapists, um especially in their early professional identity development, but even some seasoned therapists talk about narrative therapy as if it's just talking, it's just stories. Now, narrative therapy, is its own framework. um It's a type of kind of postmodern therapy. It's a systemic therapy. It's kind of under the umbrella of systemic therapy. It has its own kind of uh grounding. It has its own principles. um And yet, the way it's used is just... with the meaning of the word in kind of the general context. So a lot of people are using narrative therapy to mean just talking. But narrative therapy is not just talking. Narrative therapy, you know, developed by Michael White and other colleagues like David Epstein, you know, is about externalizing so that we separate the person from the problem. For example. It's about encouraging our clients to kind of... um thicken stories if they're thin when they present them to us, so kind of make them kind of richer and bigger and larger. You know, it's about encouraging clients to discern between the relationship with the stories that they are immersed in and stories that people say about them and find out their own preferred story. It's about helping the client recognize agency over their own story, but also how their own story is influenced. by all the social, cultural, political, familial, historical relationships that they're immersed in. So it's not just talking. Just like the idea of neutrality in family therapy, it's not the general kind of everyday discourse around neutrality, like I said earlier. And so we're losing a lot of this nuance when we approach therapy as a monolith. There's also a lot of other things that I have seen perpetuated as myths amongst therapists, for example. I've been told by some colleagues, uh even licensed colleagues, not always pre-licensure, oh we cannot diagnose things like autism or a DHT and I was like what? Why not? I mean if you're in a state where your licensure doesn't, or a country where your licensure doesn't allow you to diagnose, absolutely that's one thing, but then usually you can't diagnose anything or maybe there are specific things that you cannot diagnose. But um if you're in a state, like the state of Minnesota, for example, where as a licensed marriage and family therapist, I can diagnose, there is not a limit to what mental health uh issues I can diagnose or not. I can diagnose a DHT or autism, but I cannot do a neuropsychological assessment unless I'm trained to do a neuropsychological assessment. That is the difference, right? And so when we treat therapy as just one thing, we kind of keep perpetuating those myths, those misconceptions, and honestly, we kind of keep perpetuating ignorance, which is not super helpful. And I'm not really faulting the therapists who have those ideas or beliefs because that is what they've often been taught and have had passed down from educators or from colleagues who are more senior than them, even supervisors sometimes. Another idea is that uh licensed therapist, if they don't have specialist training, cannot do letter of supports for gender affirming care. Any licensed therapist can do letter of support for gender affirming care as long as they're following all of the steps that they need to follow. They might need to consult, they might need support if they've never done one before, but there's nothing stopping them from doing this. But when we kind of... are not really engaging our critical thinking when we are not um going into the nuances and complexities of what therapy is. This is when we get to run into this uh kind of... uh not well-informed takes and kind of those obstacles. And sometimes it's also other things they have seen around treating therapy as a monolith is kind of bypassing the issue altogether. What do I mean by that? Like I said earlier, there's a strong desire of decolonizing in the field and I love it. So happy about it. And one phenomenon that I saw, which seems to have kind of come down, but at one point it seemed like everybody was divesting from licensure and the licensure was seen as this kind of representation of the Western medical industrial complex. Now I'm not saying that it's not, but I'm saying that decolonizing therapy is much more complicated than just giving up your license. And also when we give up our license, what happens in community? Because we do not yet have systems where we can hold each other accountable and where clients can hold us accountable. And not saying that licensure is the perfect system, far from it. Licensure has a lot of issues. There's a lot of ableism. There's a lot of sainism. There's a lot to address when it comes to licensure, believe me. And I also understand how problematic it is to have state oversight, right? And at the same time, when we divest from licensure, then where's the community that holds us accountable and that protects the client? Because in theory, and I say in theory because it's complicated, but... Theoretically licensing boards are there to protect our clients. Also, this is another misconception because I've heard a lot of therapists say things like, well the licensing board doesn't do anything for us or doesn't protect us. And I'm like, the licensing board is not there to protect us and is not there to do anything for us. That's professional associations. Professional associations are there to represent us, protect us, you know, and offer us support. Licensing boards are there to provide oversight, quality control, and like I said, hopefully to protect clients, right? And so when we, I'm trying to think of a more diplomatic way of saying this, but I'm just gonna say it, because if you listen to my stuff and you know me, I'm pretty direct. When we bypass critical thinking and engagement with the field in this deeper way, we take shortcuts that I don't think take us where we wanna go. So I've been talking about this for a while and I'm trying to keep those episodes of Wormtake Wednesdays to between 35 minutes and an hour tops. So I'm going to go on to the last part of kind of the notes that the very rough notes have made for this episode, which is what can we do? You know, given all of that, given that often therapy is talked about as a monolith, given that talking about therapy as a monolith has a lot of consequences, many of them not great for therapists and clients alike. And of course, some of us, like I said, are both. What can we do? Well, if we're educators, I think that one of the things that we can do is be very clear on the theories and models that we use and which ideas cut across them and which do not. So for example, transference and counter-transference belongs to psychodynamic theory. I'm not sure why it's being taught to systemic therapists. Sure, you can mention there is this idea you will come across in the field this is where it comes from. And here is a different systemic way of looking at this. Or hey, here is a individualized diagnosis that very much pathologizes the individual, know, that, and this theory called personality disorder. And here is a systemic way of looking at it, which is different because when we look at systems, we're really seeing what the individual is experiencing as a symptom and a product of what they've experienced due to the various systems that we're all immersed in. So when we're clear on theories and models as educators, as clinical supervisors, that helps the therapists that we're training and also helps the clients that are going to be served by those therapists. And I think it's also important to do that on social media if we are kind of educating either therapists and or the general public as kind of social with our social media presence as therapists, for example. Also, we can be clear about how those kind of theories and different ways of kind of conceptualizing humanity, mental health and healing, there I say, are connected to scope of practice. There are a lot of therapists that are not really clear what their scope of practice are. For example, marriage and family therapists have different training and licensure requirements in most states to become licensed marriage and family therapists in the so-called United States, in other places. em might be called systemic psychotherapy. I was first a licensed systemic psychotherapist in the UK and that transferred as an LMFT in the so-called US. But we have specialist training in working with more than one client in the room, working with children and adolescents, and often our licensure requires a specific number of hours to be done with couples, polycules, families, um or residential groups, for example, to meet those requirements. That is different than the requirements for a licensed professional counselor or licensed social worker or... licensed psychologists. And so there are very specific skills that people need to work with relational systems. And we also need to educate, you know, students if we're educators or if we're educating people online for platforms like YouTube, for example, or a podcast. Let's educate both the general public and our students and our supervisees about the differences between professional association and licensing boards, which is what I've mentioned before and how we have both code of ethics and statutes. You'd be surprised how many therapists I've talked to that often, and again, I do not fault the individuals I've talked to, I fault the system. This is a symptom of the system, right? But how many therapists do not understand that we have a code of ethics that's usually linked to our profession. So family therapy has its own code of ethics. know, social work has its own code of ethics. American Counseling Association has its own code of ethics. right? em American profession is American Psychological Association, its own code of ethics. So each licensure, each profession has its own code of ethics. But then we also have um and the licensure, which might be national or state bound in the so-called United States is mostly state bound. But that is different than the statutes that we also have to answer to in the state or the number of states that we're licensed to. For example, I'm licensed in both Minnesota and Wisconsin, and there are governmental statutes that as a licensed provider, I need to be accountable to. For example, as a licensed marriage family therapist in the state of Minnesota, I have to diagnose my client. It doesn't matter if I take insurance or not, I have to diagnose. I also have to keep notes. In the state of Wisconsin, if I remember correctly, my notes have to be done and ready within a period of two weeks. I haven't looked at those statues in a minute, so if I'm wrong, please forgive me. But what I mean here is that we have multiple bodies that we are accountable to. And often therapists don't realize this and often clients don't realize this but also if we don't realize that as therapists how are we going to communicate that effectively to clients as well? and those are just a couple of ideas there's so much more that could be said in terms of what educators can do but you know I want to go on to what can we do as therapists right? First of all I would say know what ground you're rooted in right? What is your the theoretical ground that you're rooted in and what are the seeds you're nurturing with your work? What are the theoretical approaches that you use? uh How do you view the world, right? Do you view the world from this kind of systemic lens, through a psychodynamic lens, through a cognitive behavioral lens? If you're viewing it through a trauma-informed lens, there are lots of different ways of looking at trauma. Trauma, it's not in itself a theoretical model. There are lots of different theoretical ways of looking at trauma. And so just saying trauma-informed doesn't tell me a lot. And so know what the ground that you're rooted in is and know what you're watering and nurturing with your continuing education as well. Because I find that often we can get so preoccupied with the doing and the wanting more more interventions, more and more tools in our toolbox, that we forget to kind of go back to basics and really think about, in a minute, what are my values and are the theoretical approaches and the interventions I'm using in integrity with those values. And another thing that I encourage to ask yourself if you're a therapist is know what your role is. It seems really simple, but you'd be surprised how many kind of early career therapists or therapy students I have talked to who have never been asked that question. What is the job of a therapist? And we need to be able to articulate that to our clients. And our clients have every right to ask us, how do you view your job? What do you think your job is as a therapist? That means really looking critically at our own positionalities, our own beliefs about change and relationship to systems of power, privilege and oppression, amongst many other things, right? But as therapists, we should be able to answer the question, what is your job? And if I say, well, my job is to be a therapist, Well, what does that mean? Right? What does that mean to you to be a therapist? That's that because we can as therapists we can be more in alignment with the system so more in alignment with policing containing and control for example and carceral logic or we might be more in alignment with kind of more liberatory Decolonizing relational approaches and we need to understand how we are approaching this uh in order to be consistent and coherent in our work um and when we're consistent and coherent that benefits clients too. Because then we can be really honest and clear and authentic when we communicate what can you expect, what can you not expect, what approach do I use and what are the expectations you can have of me, but also what are the expectations that as a therapist I have of you as a client. For example, one of the things I often say to clients is that change doesn't happen in therapy. Change happens in between therapy sessions. In the therapy session, in the way I work, plant the seeds, we might even water them, we might even put a little fence around them to kind of protect the little seedlings. But then the work of change happens in between sessions because it's when as clients we go out of the therapy session and we do things differently and we experiment with doing things differently, that's when change occur, right? But we need to be clear about who are and what our job is to be able to have those kinds of conversations with clients. And we also as therapists and as clients and as a field, we really need to broaden out our idea of ethics. I feel like ethics only get talked about when it comes to therapists in the context of how much do we charge or don't sleep with your clients, which absolutely, please, for the love of all that is good, do not ever sleep with your client, do business with them, or have dual relationship, which by the way doesn't mean just knowing somebody. relationship as very much its own definition in the field of therapy which is you know not to engage in friendship, business relationships or romantic relationships with your clients or your clients immediate family members. And so that, fine, absolutely, that is about ethics, but ethics is so much more than that. So for example, personally, if you work with minors, so people who are still dependent on their caregivers for legal decision, I think it's unethical not to involve those caregivers in the care of that young person. And yet I've talked to a lot of therapists and again, nothing about the individual therapist per se. I think it's a symptom of the system to say, I love working with young people, I just don't work with their families. And why you cannot work with young people and not with their family. I you can, guess, if those young people are emancipated and they're not dependent on any caregivers. But most young people, most minors are still dependent on their parents, their caregivers for decision making, especially medical decision making. And so when we exclude the caregivers from the care, um we are doing a disservice because we often end up having issues or not being very effective in our approach. And I don't think that's ethical. So we really need to think about ethics as a much broader lens, way beyond just, you know, don't engage in sexual romantic business or friendship relationships with your clients. But it's actually how do we show up when I disclose something personally to my client? Am I doing it just because it just came out of my mouth without even thinking or because I think it helps build relationship or what is my goal and is it centering the client's needs or my need? Those are ethical decisions. Again, there is no one right or wrong way of doing things but there are ethical, intentional and in integrity ways of doing things. And finally... I think we need to be really clear about how do we translate the values we hold into clinical practice, because that's not always clear to ourselves even or to our clients. And so if I say that I'm an abolitionist therapist, how do I then hold also my duty by... uh according to the state as a mandated reporter. How do I negotiate that? Do I know how to talk about that with clients? Because for me to act in a more abolitionist manner, I need to have strong enough joining with the client in a conversation around being able to be authentic and honest, being able not to just, you know, make throwaway remarks that might indicate that they're in danger or somebody else might be in danger and then not engage in a subsequent conversation. it's the process. You know, I can say whatever words I want in a way in terms of what my values are, but what does that look like in practice, right? If I say I'm a liberatory therapist, what does that look like? If I say I'm collaborative, what does that look like in practice? And as clients, like we're coming to the end of this episode, don't worry, I will not talk forever even though I have a lot to say on this topic, turns out. As clients, we also have the right to understand those things. from our therapists, right? And like I said, I'm both a therapist but I'm also a consumer of therapy. You know, I have an individual therapist, have a couples therapist, a family therapist, it's good to have therapists. They have different scopes of practice and different remits, right? So as a client, I want us to be well equipped to ask questions. So I want people to know that there are different therapeutic approaches and things that we could ask potential therapists. for example, are what are your theoretical foundations? What is kind of the ground that you're rooted in? What can I expect a session to look like? um Do you work longer term or shorter term, for example? How do you relate to diagnosis? And by the way, you should know what your diagnosis is if you work with a therapist in a place where therapists can diagnose. You might not remember, I've had plenty of clients where I know I shared the diagnosis. the beginning and then they didn't remember it and that's totally okay. But you should know and you have every right to ask what diagnosis um your therapist is using and also how do they relate to them. For example, I often say to my clients that I see diagnostic labels as a portal. They give us a way through an entrance to um work that we can do together, services that they might need and so on and so forth. do not see as who they are, right? For example. We are so much more than any diagnostic label can encompass any of us, regardless, I think, of what theoretical approach we use. And hopefully that's not too controversial to say. Other things that we can ask potential therapists is how long have they been in practice as an independently licensed clinical provider? And I don't want to be elitist, but I think it matters. I think it matters if you are operating under somebody else's license and supervision, or if you're operating independently. why it matters is also because especially if you work within an agency or a group practice, but honestly in any setting, if you are a pre-licensure therapist who's working towards licensure, as a client I might also be interested in knowing who your therapist is and what is their theoretical uh approach to the work, because that's also going to influence the way we're going to work together and that's why I think it's important to ask that piece about independent clinical licensure or not. And like I said, it's also important for therapists to know what is our job. And so as clients, we can ask, how do you see your job as a therapist? What is your role as a therapist? How do you approach it? How do you understand it? As clients, we have the right to ask those questions. And if a therapist is a little surprised or doesn't know how to answer that question, of course, they might never have thought about it, so they might need a minute. Absolutely. I want us to be human and compassionate. therapist a moment if they never thought about things that way, you know, or the potential therapist. But I think that as clients we have the right to ask like how do you hold your own job as therapist? How do you see your role? How do you relate to it? How do you understand and approach it? And a couple more questions before we kind of wrap up for today. Other things that we might ask is to a potential therapist is what is your relationship to your own positionality to systems of power, privilege and oppression? bet clients ask me, what work have you done around whiteness? How do you understand your immigrant experience? How do you relate to disability justice or the concept of sainism? Right. Those are all legitimate questions, I think, from clients who are interviewing us as potential therapist or when we interview somebody as a potential therapist. And finally, you may even want to ask what is it that you enjoy about your work and what is it that you find challenging if you want to better understand how your therapist kind of relates to their jobs. And don't be afraid if you're looking for a therapist, whether you're therapist yourself or not, to shop around. Like I said at the beginning, like one of the most consistent pieces of evidence from research, one of the most evidence based, we could say, approaches to therapy is that the fit between therapist and client is the most important predictor of effectiveness. And so I always say to clients, like, I would never take it personally if you decide we're not a good fit. And in fact, sometimes it's like I would be a bad therapist if I didn't bring up that maybe we're not a good fit. And I have somebody that I can refer you to who is a better fit because not every therapist is going to be a good fit for every client. and that's okay. And, you know, finally, like, ask yourself as a client also why you're sick in therapy and why you're sick in therapy right now. Of course, your therapist might also ask you that. But the reason why I ask is because there's also this kind of spirit of the time at the moment, this zeitgeist where people just go to therapy because they're supposed to, in air quotes, to go to therapy. Like, I don't know. I mean, it seems like a good idea. Everybody should be in therapy, right? Or people have told me to come to therapy. Take a little bit of time to ask yourself a few more questions. And I would say that, you know, know that kind of, regardless of the approach used, generally, does require effort on our part as clients, you know, the willingness to do things differently, which is incredibly uncomfortable. As humans, we like to do things the same way over and over, even when sometimes that's not the best way. Or we like what is familiar, even when what is familiar might not be the most helpful. for us. And be clear, are you looking for insight, are you looking for change, or are you looking for both? Do you prefer just like somebody holding space for your process or are you very focused on outcome and very goal-driven? However you feel and whatever you're looking for is legitimate, but the clearer you are on why you're looking for therapy and what you're looking for in therapy, the more helpful it can be when it comes to choosing a therapist. Ultimately, I think that this episode is really all about better understanding and knowledge in the therapeutic field so that we don't approach therapy as a monolith. And when we have more understanding, more knowledge, I think that increases our agency in our decision making. It gives us more power and it also honors lineage. It honors context and it honors relationality, which I think it's really important. So thank you so much for joining me for this episode. you join me live or whether you're watching this afterwards or listening to it wherever you listen to podcasts. This was Wormtake Wednesdays with Dr. Alex Iantaffi and until we meet again take care of yourselves and each other. Ciao e alla prossima!