Learning to Do Research

This past spring, I had the chance to complete a graduate-level course in Qualitative Research Methods at UMBC. I’d always wanted to learn how to do qualitative research, but had not had the chance to devote my attention to it. (My dad is a retired research biologist, and I’ve always admired the act of creating new knowledge.) Overall, I was really impressed with UMBC, my fellow students, and our professor, Sarah Chard.

Designing and executing my research - recruiting respondents, interviewing them, transcribing the interviews, analyzing the data and writing it all up - was an awesome experience. I learned a ton. Ultimately, I had the chance to shorten my final paper and get it published in The EFT Community News - a newsletter for therapists that practice Emotionally Focused Therapy.

Check it out here (scroll down to page 12):

Are Parts Real?

I’ve had the title of this blog post in my head since January of this year, when I completed the first level of training in Internal Family Systems (IFS) therapy. IFS is a systemic experiential style of therapy, which means that it works at the level of the individual’s psychological system and focuses less on cognition/insight than on lived experience (of which cognition is merely one element).

Essentially, the model proposes that each of us has an internal system that is composed of parts, and that each part has a unique identity with its own desires, fears, interests and motivations. For instance, you may feel like one part of you wants to go out to meet someone, while a different part, which is feeling anxious, wants to stay home and bake cookies. Parts may show you memories, generate emotions, pass down intergenerational trauma, and will often manifest in the body. (IFS didn’t come up with these ideas - more like assembled them from various lineages.)

The theory goes on to say that in addition to Parts, there is You-who-is-not-a-Part, also known as the Self. In my tradition (Judaism), the Self could perhaps be described as shkhina - the “divine spark,” the godliness that’s within each person. The universal essence. IFS proposes that this form of energy has the power to heal wounded Parts - and that Parts’ unhealed wounds are what often create imbalance in our lives. Within IFS, the therapist does not do the healing, but rather helps the client harness the flow of internal Self energy in order to heal.

As you can already tell, this style of therapy is way more spiritual than cognitive. Very different from every other style I had ever studied or received as a client (EFT, ACT, CBT, EMDR, psychodynamic). After some friends turned me onto IFS in 2020, I began to read and try out some basic techniques. The results were compelling, so I sought out supervision from a certified IFS practitioner. After one meeting, I asked her to be my therapist instead.

The two years I spent in therapy with that provider were deeply impactful for me. It was a level of honesty within myself I’d never experienced. It was compassionate, it felt safe, and I grew as a result. As I embraced the model, my skepticism decreased, and I grew even more. Completing the “official” Level 1 training - learning to do this therapy with other therapists, practicing the model on ourselves and one another - changed me as a person. I have learned to trust the model - which can be quite powerful - and am learning to trust myself to deploy it in a way that is safe.

Trust is the key concept in IFS. According to the theory, one of the therapist’s primary goals is to increase the trust between Self and Parts. Having trusting relationships with Parts means you can negotiate with them. For instance, in the baking at home Vs. meeting up scenario, what if the meeting is a crucial opportunity that you shouldn’t miss? Rather than attempting to banish the socially anxious part (e.g., by drinking), ideally, you could connect with it and ask it to give you enough space for you to take the meeting. If the Part trusts you, it is more likely to honor that request and let you go out and be brave. If the Part’s anxiety is connected to a traumatic/overwhelming experience, building a strong relationship may take time. That relationship-building is the work of therapy.

There is a whole discourse that flows from these ideas; there is a lot more I could say. But I’ll offer this reflection: if you can trust that Parts are real, and that Self is real, and IFS is real - then this is a model that can offer deep healing. There’s room for skepticism, which is understood to be a welcome form of wisdom.

I like IFS because, even though it’s a doctrine with certain underpinning beliefs and certain methods to accomplish its goals, it’s still a “big tent.” (In this way, it reminds me again of Judaism.) There’s room for creativity, individuality, humor, flexibility and generosity. I also like IFS because it’s synergistic with the use of psychedelic medicines. When we use psilocybin, MDMA, cannabis (etc.) for self-healing, it is common to encounter Parts of us directly and interact with them in ways that are not available to us within ordinary states of consciousness. IFS can help us prepare for psychedelic experiences beforehand, as well as integrate and make use of the wisdom revealed to us by the medicine afterward.

A visit to Chicago

Recently I had the chance to go to Chicago to speak at an international conference hosted by MINT, the Motivational Interviewing Network of Trainers. This is the global body responsible for the dissemination of wisdom about the therapeutic modality known as Motivational Interviewing.

The MINTies, as they call themselves, were interested in my coauthored article “Macro MI: Using Motivational Interviewing to Address Socially-Engineered Trauma”. Being invited to share my ideas in this space was absolutely a career highlight - as was getting to meet Bill Miller, a founder of MI and one of the most famous living therapists.

I’m incredibly grateful to MINT for the opportunity to contribute to their essential work. It’s not too much of an overstatement to say that Motivational Interviewing forms the bedrock of contemporary ethical human services direct practice. To be taken seriously be these folks felt validating on a deep level.

Feel free to check out my talk:

On being an EFT guy

Last week, I accomplished a goal that I set for myself back in 2018: to achieve full certification in the practice of Emotionally Focused Therapy for couples, or EFT. This is the only form of couples therapy with a significant base of clinical research proving its effectiveness, which is why I chose it. It also plays to my strengths as a therapist - it’s a fit for my personality and temperament. The certification process was a real schlep, and I’m eternally grateful for the guidance of my clinical supervisor, Neil Weissman, as well as to the couples who allowed me to videotape our sessions so that the EFT honchos up in Ottawa could see my work in action.

When I first started off in private practice, I figured that working with couples was the same thing as working with individuals. I learned rapidly that this was not the case. EFT gave me a way in - a lens for making sense of how and why couples argue. I’ve always felt that understanding why things unfold as they do can reduce suffering and provide a foundation for creating change. Over and over, I’ve seen EFT offer couples a needed off-ramp from cycles of emotional disconnection.

Something I’m always hearing myself say during therapy is, “Being a person is hard.” What I mean is, there’s a lot of pain and suffering in this world, and most of it is beyond our control. It may even have happened before we were born, and gotten passed down to us through our genetic code. Similarly, the desire for relief from suffering is universal - it’s organismic. For me, one of the main functions of a successful romantic relationship is that it offers a safe haven from the pain and suffering of being a person in the world.

This is certainly true of my own experience as a person with depression. Being able to turn to my partner to care for me when I’m feeling blue has been an essential part of feeling okay in adulthood. I mean, obviously I’d prefer to not be depressed, and I definitely do lots of stuff to manage my symptoms of depression even as I dig at the roots of it in my individual therapy. But I also choose to leave room for the possibility that the depression will always be there, perhaps in part because it’s interegenerational and is connected to ancestral experiences of pain, loss and oppression. Where the romantic relationship comes into play is connected to my desire to feel okay even though there’s also suffering present.

In EFT, we call this “facing the dragon, together.” In other words, there are some experiences that cause pain but which are beyond our control as individuals - racism, inequality, trauma that occurred before you showed up to therapy (to name a few). What we know from science is, pain that is felt alone is felt more intensely; pain that can be shared is mitigated. Personally, I feel committed to participating in broader social projects to eliminate racism and other forms of inequality, and to prevent trauma from occurring to children and other vulnerable individuals. In my day-to-day work, however, I choose to focus on helping individuals share their burdens with one another, so that whatever it is they’re going through, they don’t have to go through it alone. For many of us, that’s the best that can be hoped for in the short term. In the medium-to-long term, being securely emotionally connected to a trusted other also can give us strength to participate in fighting the bigger battles for social justice. In this way, the micro and macro are intertwined.

As a group, therapists tend toward cultishness and sometimes subscribe fervently to a particular way of seeing the world. Personally, I remain agnostic on the question of whether EFT is a fit for every couple. In the years I’ve been practicing EFT, I’ve noticed that a history of childhood trauma often (but not always) increases the complexity of couples therapy. For adults who emerged from a childhood situation where nobody cared about their emotional experiences, and/or where they weren’t allowed to express their emotions openly, EFT can feel daunting. As my level of skill and experience with this modality has increased, I’ve become better at making EFT accessible to survivors of childhood trauma.

That said, EFT is (in the words of my supervisor) an “open” form of therapy; often, adults who were emotionally abused or neglected as kids received a thorough education in how to survive while being “closed.” This is, I think, one of the cruelest ironies of trauma: having been abused or neglected makes it harder to get access to the thing that would help the most, i.e., secure, reliable, intimate emotional connection with a trusted other.

(It’s also worth noting that our society trains people assigned the gender “male” to hide and disregard their emotions; compared to women, cisgender men tend to be less attuned to their internal experiences of emotion and their external expression of it. This is connected to how misogyny and homophobia operate in society: by teaching men that emotions are “gay” or “for girls,” it diminishes guys’ abilities to participate fully in pair-bonding activities, causing them to miss out on crucial experiences for connection and healing. Fortunately, unlearning that crap is often fairly straightforward and a matter of practice. All humans are hard-wired for deep emotional connection with other humans - this is the basis of attachment theory.)

Hence, I feel optimistic about the possibility of combining EFT with the regulated use of MDMA, which works by boosting production of oxytocin (the “bonding” hormone) in the short-term, decreasing guardedness, and increasing motivation for connection as well as openness to both praise and feedback. My hope is that the Biden administration reschedules this medicine in the near future to become available by prescription, to assist individuals who need and deserve access to the healing power of secure attachment. Feel free to contact your federal elected officials (Senators and U.S. Representatives) to lobby them in favor of this policy change.

All in all, I feel glad to have achieved full certification in the practice of EFT. It puts me in the company of some of the therapists I most respect. Whatever’s going on, feeling alone makes it worse; to me, EFT offers a path forward for those who are partnered but still feel alone in some ways - but don’t want to any more.

My second academic publication.

I’m pleased to announce that my second-ever academic journal article, another collaboration with my friend and thought partner Wendy Shaia, was just published in the Journal of Progressive Human Services. In this paper, we explore using the time-tested tools of Motivational Interviewing to engage clients in conversations about power, oppression, inequality and trauma. In our view, the health of the individual and the health of the broader society are reciprocal and intertwined. I feel lucky to be a part of contemporary conversations about how individual psychotherapy can be responsive to structural issues.

The writing of this article was a labor of love that began right before Covid. Working on it each day during the bleakest periods of quarantine helped to give me a sense of purpose. Writing has always done that for me - though there are some days when I wish I preferred a less taxing form of self-expression…!

MDMA and Me

Cool news - I am enrolled in the official certification/training program to learn how to do MDMA-assisted psychotherapy. This training is sponsored by the Multidisciplinary Association for Psychedelic Studies (MAPS) and begins in the Fall.

Even as our knowledge base for understanding trauma and PTSD has grown exponentially in recent decades, thanks to the work of scholars like Judith Herman and Bessel Van Der Kolk, treating trauma remains a stubborn business. In my career I have always been focused on the study and treatment of trauma. Probably it’s because the existence of trauma - the fact that the world is, for some people, a dark and dangerous place - represents a reality that Jewish people have always had to coexist with. Much of our ethics and philosophy concerns itself with making sense of this dialectic: that this life is simultaneously amazing and terrible, full of possibilities for both transcendent enlightenment and abject suffering.

According to the available data, MDMA appears to represent the possibility of a breakthrough in the treatment of PTSD, compared to current available treatments. There is much hope within the psychedelics community that the FDA will reschedule this medicine in 2022, making it available by prescription.

I look forward to partnering with MAPS to bring the use of MDMA back into the mainstream of PTSD treatment. Ultimately, my goal is to use MDMA in couples therapy - where it enjoyed a strong reputation before it was made illegal in 1985 - in order to help individuals with a history of trauma exposure gain access to the healing power of secure romantic attachment.

Oldie/Goodie

Writing letters to the editor is one of my weird hobbies. A couple years back I wrote to the New Yorker in response to a long-form piece they’d published about the opioid crisis in West Virginia, and they published my response. (Scroll to the fourth letter for mine.)

Following the publication of this letter, for a short period of time I received unsolicited emails from left-wing amateur economists in various parts of the country, who’d taken the time to google me in order to dig up my contact information. I’m grateful to them for being as weird as me.

StoryCorps: Me & Mr. Riddle

Back in 2016, when I was a therapist at Health Care for the Homeless, I got an opportunity to participate in StoryCorps, which you may know as the NPR segment that makes you cry on your drive to work. This conversation between me and my former client, Mr. Thomas Riddle, is preserved in the Library of Congress. That is cool.

This interview is special to me because it is a snapshot of a relationship that meant something to both of us. The picture of me & Mr. Riddle also makes me smile. I got to work with so many incredible people over the four years I spent at HCH. It was a formative experience in my life.

An Op-Ed I Contributed To

Back in July I was able to work with some colleagues on this op-ed for the Baltimore Sun, titled, “Police Shouldn’t Be Handling Mental Health Crises.”

It is obvious that the police should not be the ones responsible for dealing with mental health crises, because they are not equipped to do so. They lack both training and skills, which increases risk of harm to people in crisis - especially People of Color.

Mental health crisis response is a key example of a community safety & support role that we currently do not handle properly in American society. Rather than relying on police, we need to invest in community-based, peer-led, grassroots infrastructure. What that means is, funding and supporting agencies rooted in the community that can use culturally appropriate techniques rooted in deescalation and harm reduction.

Unfortunately, we’re pretty far away from that at this time. One way to consider a transition toward grassroots/peer-led/community-based intervention is to prioritize a shift away from policing and toward the use of social workers in crisis response. Of course, social workers have their own problems with bias and abuse of power, but they don’t have guns. This step, while incremental, represents a form of harm reduction.

One question is how to recruit and train social workers to staff these positions, which involve overnight shifts, on-call work, etc.. In recent decades, as a way to reduce the harm caused by the lack of professionalism and training within our public child welfare apparatus, the federal government created a funding stream, known as Title IV-E, to incentivize social work students to pursue careers in child welfare. This strategy worked, and child welfare outcomes improved as the workforce professionalized. A similar program should be used to train mental health crisis response workers, to cultivate a trained pool of professionals at scale who are equipped to take over certain functions currently handled by police.

My first academic publication.

This post is significantly belated as this article was published last December. Nevertheless, it’s a collaboration I’m proud of. We’re actually in the process of planning a regional (DMV) social work conference based on its ideas. As of now the social work schools within the University of Maryland, Howard University and Catholic University have signed on. This article poses a critique of contemporary social work theory and practice, and articulates a new path forward for our profession.

A Feminist Approach to Sex Therapy

Feminism means different things to different people. I call myself a feminist psychotherapist because certain key tenets of feminist theory - in particular, examining the the distribution of power in society and in relationships - can be powerful tools in my work with clients. This is true when it comes to treating sexual problems as experienced by an individual or couple.

How does it work? First, we look at the status quo and ask what’s missing. Contemporary discussions of sexual problems privilege a biomedical perspective. For example, two of the most common reasons people seek sex therapy - erectile dysfunction and lack of sexual desire - are often viewed as exclusively medical problems, with expensive pharmacotherapies being prescribed for both conditions. While for some clients medication brings relief, the biomedical approach alone ignores other potential causes and solutions.

Traditional sex therapy examines a sexual problem from three different angles: biomedical, psychological, and relational. Often, more than one angle is in play. For example, a biomedical reason for erectile dysfunction could be hypertension, a psychological factor could be depression, and a relational factor could be a feeling of emotional distance from one’s partner. By jumping straight to medication, we ignore important - and treatable - problems underlying the sexual complaint. One possible consequence of ignoring other causes: if a client manages his ED by taking a prescription medication without treating an underlying depression, he may lack the motivation to remain adherent to the medicine. Research on the drug Viagra, for example, has documented that up to 50% of patients who are prescribed the drug will quit taking it within a few years; a significant minority never fill the prescription to begin with.

Feminist sex therapy introduces a fourth angle for examining a sexual problem: the political. It seeks to understand sexual functioning in the context of society’s expectations of women and men, as well as how we are taught to think about our bodies and sex. For example, female hypoactive sexual desire disorder (HSDD; “hypoactive” means underactive) is thought to occur in up to one third of all women in the United States. A feminist analysis would ask: is this the product of social conditions? For example, research has documented that in heterosexual relationships in which both partners work full time outside the home, a disproportionate share of housework and childcare continues to fall on women. This can create resentment and discord within a relationship. Conversely, other data has shown a positive correlation between marital satisfaction and sexual desire. A feminist psychotherapist would be curious whether the division of labor in the home is related to the female partner’s experience of sexual desire.

Sexuality is inherently complex. In my experience as a therapist, examining a problem from multiple angles and gathering as much data as possible, rather than being limited to a single model, can lead to new opportunities for improved functioning both for the individual and the couple.
 

Sources:

• Female hypoactive sexual desire disorder: epidemiology, diagnosis and treatment. Warnock JJ. CNS Drugs. 2002;16(11):745-53.
• Women in the Workplace Survey 2015, LeanIn.org & McKinsey
• How long do patients with erectile dysfunction continue to use sildenafil citrate? Dropout rate from treatment course as outcome in real life. Sato et. al. Int’l Journal of Urology, April 2007
• The F.A.S.T. Model. Teresa L. Young. Journal of Feminist Family Therapy, 2007; 19:2
• Sexual desire and relationship functioning: the effects of marital satisfaction and power. Brezsnyak M & Whisman MA. Journal of Sex and Marital Therapy. 2004 May-Jun; 30(3):199-217.