EP 2.9 - Immediacy in Therapy: Breaking the Fourth Wall with Dr. K Hixson

I'm Reba Stout and you're listening to Atherapist Can't Say That, the podcast where we talk about the things that it feels like Atherapist can't say. I'm changing up my format a little bit today because today's episode features a conversation between me and my dear friend and colleague Dr. K. Hickson about immediacy, which is in my opinion the primary tool of magic in the therapeutic relationship. And this conversation is me and Dr. Hickson in the thick of our relational magic, which is substantial. And I don't want to give away the goods with a long introduction here. What I will say is, if you're not sure you want to listen to this episode because you think immediacy is a stale topic, let me assure you that Dr. Hickson and I are about to revive it for you. immediacy is risky. immediacy is counter-cultural. immediacy is a disruption to our people pleasing tendencies. immediacy challenges us to stretch our tolerance for uncertainty. immediacy is a key to unlocking difficult clients. immediacy invites us to do therapy by taking off the therapist mask and being seen. immediacy is the mediator of the therapeutic intimacy that can change lives. And on my next episode, I'm going to be diving into more about that relationship between immediacy and intimacy and how the kind of intimacy we cultivate through this kind of relational dance with our clients invites us as therapists into greater personal growth and differentiation. So please make sure you're following the show so you can catch that one and I know you'll enjoy this conversation you're about to hear with Dr. Hickson. Welcome Dr. Hickson, the sunshine of my life. You're so kind. You actually are though. I make one visitor to the podcast. I want to just express my appreciation to you for the last episode that you gave us. Go on. And I think it's going to lend beautifully to today's conversation that we're going to have. And I just think that concept you mentioned about the collapsing paradoxes in this work is just kind of stuck with me quite a bit. And it's something I've been thinking about as I'm supervising people and it's just sort of like once like a nice salient crisp concept like that comes into your consciousness, you can kind of see it everywhere. Yes. So thank you for the vulnerability and the like the good thinking you did in that episode and it made me emotional, which you know, like that's a good thing. Well you're welcome. And thank you. I do think it's a good segue because you know, I talked a lot about intimacy in that episode and about not trying away from intimacy and all the things that are part and parcel of intimacy in our client relationships in that episode. Obviously and immediacy is, you know, as I see it, it's one of the primary mediators of intimacy in any relationship, not just the therapeutic relationship, but in any relationship. And so I think it's a good, it's a good segue. Yeah. Into what we're going to be talking about today. All right. Where are we going to start? I mean, let's talk about what it is. Okay. First. All right. Do you want to talk about? Yeah. I want you to chime in and just add on to this, but I think the definition of it as well as the other things that's called are quite important to talk about for after therapists theoretically because immediacy has called a lot of things like metacommunication, here and now kind of interventions, interpersonal process or any kind of like process commentary. So like depending on what your like orientation is, people call it different things, but essentially I think about it as like bringing the present moment, specifically aspects of the therapeutic relationship or the interpersonal dynamic that's coming up in therapy into the light, like bringing it out into the open. And obviously, you know, immediacy interventions can be focused on a lot of things, but they are designed essentially to enhance the therapeutic work that's happening to move things along, to illuminate things, to play hunches, you know, like all kinds of things we might do with immediacy and process commentary. To disrupt therapeutic enactments, which is a thing I'm very deep diving into right now, it's interesting because I think like, I don't think the impression that people have is that this is like a very spicy topic. I think it almost feels like dated in a way like it's not very cutting edge. We're not talking about the fucking vagus nerve and all that stuff that people are so excited about right now. But to me, I actually think it's such a spicy topic because immediacy is so risky and it's so it can like the intimacy that it creates can be super intense and complex. And I think the very fact to me that it's like not trendy right now makes it almost like spicier because my impression is that people are not being well trained in this aspect of the therapeutic toolbox. What's your impression in general around that? Like my impression is that I mean, I want to tell you the history of how I learned about this please. That's thing in a minute. But to speak to what you just shared, I think that it's somehow gotten collapsed in or folded into something and it's just not poking out as an important piece of training. And all of this other shit has taken precedence in the last 10 to 15 years. Like evidence-based practice, protocols, neuroscience, attachment, like of course, and you know, immediacy can relate to some of those concepts of course. But it just does feel like it's kind of like not getting its fair share of time. And I would say that that's evidence by how much I have to support associates in learning how to use immediacy when I'm supervising them. And they're super receptive and interested, but they never really learned that level of like nuanced intervention in their graduate programs. So for me, I was trained before this sort of movement. And I was trained at the University of Puget Sound in, you know, 1999 to 2002. And I have these amazing mentors and professors there, Betsy Gast and Grace Kirschner, who had like really sweet little program. They were running their counseling program. Wasn't K. K. Krep accredited yet. And like I learned about this intervention because we had one of those group therapy courses where you learn didactically about yellow and you know, all of herbs kind of steps for doing groups like a therapy. And then you experientially practice it with your peers. And it was a complete revelation for me to kind of have a group formed by my very experienced amazing professor who taught us how to sit in that group with our peers. And get real about like what was happening or was not happening in that room. And it was the most powerful and important work that I learned in graduate school. And group work became a formative part of my career because of that experience, you know. And then I was able to teach group counseling with that same paradigm. The Betsy Gast used for us. And it was an amazing moment of like sharing that with others. And you know, we're used to thinking about counseling as solving problems that happen outside of the therapy room. Right. Right. So this is kind of where it begins is sort of what are we there to do. So I think, I think, Yalom, Yalom, you know, however you pronounce it, or you know, there's debate there, right? That book changed my life, particularly chapter six, which is the therapist working in the here and now. So that chapter of that book, whether it's on the fifth or sixth edition by now, that chapter is still a formidable kind of theoretical orientation for me on this work. And it was game changing for me to like read that text on group psychotherapy from that old school perspective that, you know, now all of our groups are fucking psychoed only. Totally. Right. Yeah, it's, it's absolutely. And there's still those process groups out there, but there's so much harder to find. And they're also the ones that I consistently hear from clients are the ones that they stick with and are life changing. I, so I think when I was trained is right along, I think being like an older millennial, And that, the general. generational shift, that kind of gen X to millennial shift is when is also like the same generational like professional generation shift. So when I was in grad school, I think that I was just on the cusp of this move towards You know, and no one can see my huge scare quotes right now, but evidence-based practice and this shift towards you know really modality focused Reputed practice and so I think I kind of got the last vestiges a little bit like in you know 2011 2012 Whatever when I was in school of some of this more Old school like interpersonal process based therapy But we weren't It was not heavily emphasized and my program was so you know for better or worse was so focused on like you're developing your own You know, you're your personal theoretical orientation and how you work and whatever that wasn't imposed on us and so We weren't really inculcated into a specific modality which was good, but also You know a lot of things left out I'm gonna talk about my experience with like my introduction to a mediacy because I think like your experience with it like as Not as it being taught to you, but as someone involved in it is what really shapes you right? So and like you were in that group and my introduction to it was in the first time I went to therapy as an adult so When I was like around God I was probably 27. I knew I wanted to be a therapist. I Was like okay if I'm gonna be a therapist I need to actually go and do my own therapy and really Whatever the fantasy I had that at that time about resolving Resolving my issues and then I was gonna go on to be a therapist But I did have the sense like I need to go work on my shit later found out that is not many of Like compatriots did not Think that was also a requirement of going into this field which is interesting to have learned But so I was like okay. I'm gonna apply to grad school at some point. Whatever. I'm gonna go Be in therapy and this was like around the time that like those shows like intervention and hoarders were popular and So and there was one that was about OCD and I was a very captivated by these shows And so I was watching the show about OCD And it was very like sensationalized where they were doing exposure and response prevention, but it was like super dramatized and they'd be like video you know the guy who's like has OCD around dogs and as afraid of dogs and they'd be doing a show Show showing his like exposure with the puppies crawling on him and he's crying and whatever that was like my Idea of what therapy was was like CBT because I'd been watching these shows So I had I like went in having no idea what to expect. I went to this therapist and I remember Reading his like professional disclosure statement where he said he had this section that was like our relationship And he was like our relationship is an important part of your therapy You know sort of explaining a little bit about immediacy and that he might ask or comment about that topic, right? And I just remember being like what the fuck are you talking about our relationship like we're what like Okay, so I didn't have any idea what that meant It was helpful that that was in his pds because I was like Set up for like this thing that I was confused by but you know had that to refer back to and I remember I don't think I remember Like the specific first time he asked me a question about like, you know like how does it feel to hear that from me right now that kind of thing But I do remember the emotional experience of like how strange it felt It's so interesting to me to reflect on that therapeutic experience because I've been to a number of therapists since then You know a variety of experiences, but that Was the absolutely the most life-changing impactful therapy experience I had was with him even though he made many mistakes He was not perfect by any means, you know our relationship kind of ended in a strange way but the Focus he had on our relationship was like Even though sometimes it made me uncomfortable and it was still confusing and it was still like And I didn't love every minute of it and sometimes it was like excruciatingly intimate and vulnerable and I wanted to never come back I feel like because of all that in in many ways like He was the first person I probably ever really let in you know that I ever really felt like I fully let in Not like to every single thought or feeling I ever had but like who's like in the intimacy of that relationship like he actually like I let him like touch me and That was life-changing and so I think when I Think about immediacy That's the potential even though there's it was not perfect That's the potential that I think of it having is like Yeah, is that it can create that kind of experience? I think I want to pick up on a couple threads before we talk about the risks or the deeper intimacy But I want to talk about why is this even novel at all and it's based on what you just shared number one He had really awesome informed consent policies go there. It's good. I know Cool and that's the second thing is that like we don't typically talk this way in our culture Meaning we leave a lot unsaid in our culture It's our social norms to sort of not make those comments on like this is how you're making me feel right now Or this is what this is bringing up for me some of us who are involved in activists or queer culture have more experience with that Kind of like communication, but it's still not the norm in our society. So in its sense When you start to do this kind of work as a client with your therapist or as a therapist You're sort of like breaking the the fourth wall or something like yes Yes That's that's why it's so unique in a way and it feels weird sometimes to clients because They aren't used to talking about what's actually happening inside of them vis-a-vis you in any particular moment and so it is like think a unique skill and a unique perspective But I think it's so like in your description like potent and I think that it It is sometimes annoying for clients and clinicians to learn to do this Or to like sit with a discomfort that you mentioned because totally because it's so like It's so like real talk, you know, and we're not used to it Yes, absolutely well, and it is it was I remember like times where it would be like he'd say something that like impacted me and like I'd feel like we were like having a moment and I just wanted to like experience the moment He'd be like how does it feel to hear that and I'd just be like oh god like shut up Could we just have this have this moment and what I like about that though is like I Okay, right now I think there's these two These two directions I see in terms of our field like there's the one that really de-emphasizes the therapeutic relationship Right, it's modalities in its evidence-based practice and so whatever then there's the there's this other thread where it's emphasizing because of course We know the research says the relationship is a crucial component, right? And it's saying yes do the relationship Whatever but it almost is like Make the client happy. I feel like as an undertone of a lot of like a good relationship is one of which the client is pleased with you and I Was so often not pleased with this therapist, right? And he and and that intervention that I'm advocating for and doing an episode on right now Often irritated me or like felt weird and uncomfortable And still like that was the one that was the thing that made the difference for me and it wasn't about Whether it made me happier in that moment and when or whether it felt great or whether I He did it perfectly It still had this disproportionate impact compared to like everything else that we did in that therapy and I think like given that we're a profession full of people pleasers in various stages of recovery I think it's really worth paying attention to The difference between doing an intervention that's helpful to the client And an intervention that makes the client happy with you in that moment or pleases them in that moment And I think that that is a huge impediment for a lot of people when it comes to being willing to do immediacy because There's always a risk that you're gonna make the client upset That's like that's a major risk of this kind of therapeutic intervention Totally and I think I want to speak to a couple things you said there one is the pleasing clients component I feel like kind of concerned that therapy has become a little bit more synonymous with like a customer service mentality Yes I think that's kind of concerning and I think that this work is a real gritty and it's real challenging and and we we aren't going to make our clients happy and It has to have there has to be room in all of the work for rupture and repair which is important skill set for us because Sometimes your meta communication or your process commentary or your immediacy, whatever you're calling it is going to, like you said, piss a client off. They may feel misunderstood. They may, they may feel projected upon and true to the pond because they have their own interpersonal template that you are pushing on when you do this shit. And so their stuff comes up if they distrust people, if they are fearful of manipulation, if they are fearful of being misunderstood, there are so many ways criticized. I think people take that, like, especially because like what you said in our culture, we don't do this. I think often when we do give feedback, it is critique. And so it's very hard often for people not to hear it as critique. Right. And when we're sitting in therapy and saying, Hey, as I sit here and listen to you talk with me, I feel like you're leaving something out of the conversation. Like, that might be something I would say that's pretty basic. That's a sort of here and now immediacy comment, but it kind of can feel like a critique, but it's really like an offering of like whatever that thing is, whatever you're not saying, bring it. Like I want to hear it. And, and there's a lot of different ways it comes up, but it can be risky. And I actually think this is wild, but I'll tell you that a supervisee needed to talk last night because they had a rupture due to immediacy with a client and the client fired them. And it's just such a hard one for early group folks to take risks and then to feel like, well, that did not land. And I think that it does take a bit of time, experience, practice and like knowledge to kind of even try to do it effectively. And even no matter how much you have, you could still like muck it up because like we're human first and foremost. And I just have so much compassion and empathy when we do mess up and clients do get pissed because I think that's just normal. That's the work. Like I don't think it's messing up. I don't think it's messing up that they get pissed. Your client having a negative response to your your immediacy based comments is not a sign that you did something wrong. You might have done something wrong, but you might as easily have done something wrong. If you said something that they liked, you know, it's like there's times that I've said things that have made my clients happy. We're like later on, I'm like, oh, we were actually like we're stroking each other's egos there. And it's not really that therapeutic, you know, whatever it is. So it's like your clients like emotional response to what you say positive or negative is not the defining factor into whether an intervention was successful or not. And that I think is another differentiating that as a high level skill. And it requires like a lot of discernment and it's challenging and complex. I think to like that discernment that you just spoke of, I wanted to pick up on that thread because one of the things I'm often doing in consultation or supervision, whether I'm getting consultation and supervision or I'm providing it is I'm helping people discern the formulation of an immediacy intervention because you do have to sink through like what are the different doors I could go in to make this intervention that I know I need to make. And there is some way that if you do get a chance to talk in consultation or supervision about a tough case, you will clean up some of the edges of your counter transferential reaction that could be hinged in your intervention that can make it like spicy and a not good way, even if it's not a mistake. Like I find that process so rewarding as an educator and a trainer and a supervisor, like helping people formulate these interventions based on what they're experiencing in the therapeutic relationship. And yeah, you don't have to be perfect and you're right. You can, I mean repair, rupture and repair can strengthen the therapeutic relationships significantly because we don't deal with repair very well in our society. We don't deal with conflict very well. We don't deal with feedback very well. So I like the use of that word discernment as we're doing this work. So I think, you know, I'm imagining as people, you know, I shared something about like obviously with my experience with my therapist, but it was, you know, I think it was pretty general. You know, I'm just imagining people listening to this and thinking like when I think that this is is how people think about this topic often. It's like, well, if I'm risking pissing the client off or if I'm risking us having a shitty time, I'm if I'm risking them leaving, which they might, if I'm risking all of this stuff, right? What's why bother? Like why do this? So what's your, what's your thoughts about why do this? If it's that risky. Oh my gosh, it's like the most important part of the deal for me. Like one of the things that's tricky about therapy is that you can spend a lot of your time talking about the problems that exist outside the clients, outside in the client's life, right? That's kind of the then and their part of therapy. Like we're in here together talking about what's going on out there. I just find that to be not that dynamic. If you're not including the sort of interpersonal realm of how we're working with it into the conversation or the work, even if you're not constantly commenting on it, right? Like it's it's a potent force that's there. And I think it's, it's the most like important part of how therapy works to me. And again, theoretically, people are going to have different values and ideas about what you and I are saying. But I think that it's the most, it's like the potent force that brings in this sort of energy that makes therapy unique to me. It makes it different than talking to your neighbor about a problem. You know, like we're talking to your best friend about a problem. It's the fact that I am in like trained or thinking about or constantly learning about these ways to intervene with my clients and supervise these that name things that can advance therapy must much quicker. So there's high so much to say about the answer to your question, but that's like an immediate thought I have about it. In my opinion, it's the only truly effective way to engage difficult clients. And I include myself among that in that category. Like when I look back on that therapy experience that I was talking about, I was a difficult client. I was a pain in the ass. I was difficult to engage. He tried a million things. I was very unresponsive to many of them. And the immediacy was the key to getting me engaged. The times that I have had therapy where a therapist was unable to engage me, many times the reason that they have not been able to engage me is because they were not doing that. And they were not willing to take the risk of doing that. We're in a, I think, a weird place right now culturally is a profession in talking about difficult clients because of the fear of acknowledging that there are clients who are more difficult than others that it's stigmatizing. And I don't I think it can be and I don't think it has to be and I don't think not talking about it makes people not get stigmatized. So I think that part of I'm just thinking about myself as a client and that about the clients that I have found to be difficult and that some of which I've had success within some of which I haven't over the years. I think that the clients people fear giving direct feedback immediacy based feedback to the most are the clients that need it the most. And I think I'm intimidating to therapists. And so I'm thinking about what it would be like to sit with me in the room as a client. And I know that many therapists would be afraid to, um, afraid to give me direct feedback. And I think about the clients that, you know, years ago before I, you know, at some point I made a decision to work on immediacy specifically. And I'm thinking about clients that I had a long ago before I made that decision and that I didn't have success with. And I think about how those were clients I was afraid of. And if I had been willing to take this kind of risk with them of saying like, this is my experience of you, this is what's happening in our relationship, I think there's a much higher likelihood that I would have been able to successfully engage them. Like if they came along now versus back then before I was willing to do that. There is nuance in what you're saying because some clients who have a really intense interpersonal trauma background or who are like I mentioned, maybe less trusting or fearful of being manipulated or criticized, some clients can get really reactive at this as a defense, right? They're like, why are we using my therapy time to talk about our relationship? Why are we processing this relationship in our therapeutic time? Your first therapist really heathed that off pass with that informed you did. Now I love that because I think it's something I do try to tell my clients is that we will talk about how this is going with us and I will talk about things that are kind of hard to talk about or I will reveal my own insecurity with what's happening at times. Like I can't say that. I can think of a time recently where I used a media see where I was, you know, I recently got off insurance panels as you know, and, you know, I'm charging cash for therapy. And that brings up its own shit, right, for us, especially as like political people. And I was starting to feel anxious and I wasn't giving this client enough, okay? We're like, uh-huh, uh-huh. We're like eight sessions in. I'm like, where are we going? What are we doing? And I was able to say, you know, something to the client, to the effect of like, hey, I'm just like wondering if you're getting what you need out of our time. Um, I'm aware that you're bringing out a lot of information. We haven't quite made sense of it yet. And um, the client was like, you know, experienced therapy clients. It was like, oh, we're good. You're responding to me and exactly the way I need you to right now. We'll figure it out. And I was like, that was fascinating because that was the client calming me down. Yes. Like my own kind of bid for some stuff back for like, yeah, where are you at with this? Um, and I know I have factors on why that was coming up for me. And, uh, but it's, but it's fascinating because it can like break tension and put you back in the present moment and back in the game with your clients too. When you're scheduling with something or you're trying to clarify something, you know? Yes, totally. I mean, I, that thing about people getting reactive though. And I do agree that what my therapist did was ideal. And I'm trying to, you know, I know we've been talking lately about that like idea of informed consent as a more dynamic idea, um, and trying to prep people for things more and all of that. Um, but to me, like the, those clients who have the most difficulty trusting and have the most interpersonal trauma and fear of being manipulated and criticized, I think those are the, I think those are the most important clients to do it with. The ones who are most likely to be reactive. Um, and I think that that question of like, why are we using my therapy time to do this? As so to me, that's an easy to answer, which is that like, you're never going to have a client like that, right? Who doesn't struggle with relationships in some way. Um, and to me, it's like, well, we're having a relationship. And if you struggle with relationships, you might as well work on the one you have with me because I'm what you've got, you know? And you're paying me to try to help you with that topic most likely. You know, most of the people, I don't think I've ever had somebody come in with a significant interpersonal trauma history, right? Who says that they don't struggle with relationships with it somewhere in somewhere or another? Um, so the connection there seems pretty clear, you know, not not necessarily to them, but from where I sit to be able to access that and explain, explain my thinking. I think, you know, there's another, you know, the self disclosure piece. Yes. I think I want to, yeah, let's thank you. Let's thank you to that because I think to me, that's, um, I think that's, um, I think that's the most important part of the, if you're trying to disarm someone's fear of being manipulated, um, you have to use self disclosure and especially in this, in the media. You have to include yourself in the immediacy or in the process commentary. Yes. Yes, yes, yes. Especially when it's a very relevant part of your formulation that you're trying to bring, that is so vital. I wrote like self disclosure down as something I hope we talk about today. So I'm so glad you reminded us of it because there is a revealing of your inner world as the therapist that must take place as part of this kind of intervention. And it's not always the self disclosure that's being critiqued in our field, right? Like it's not the self disclosure. Yes. Like I'm telling you everything about me and my life. I have three dogs and I divorced. Yeah, exactly. The self disclosure is that vulnerable inner world of the therapist that is so potent in terms of like you have so much possible data on what's happening. It's not always correct when you're playing a hunch at times. So you are self disclosing how you're experiencing the person in this moment or how you're experiencing your dynamic and that can feel weird. Totally. I think it feels very weird. It feels incredibly vulnerable. It can be revealing of your personal shit, you know, in a way that feels scary and sorting through, you know, that's part of sorting through the counter transfer and some ass that you were talking about of like, okay, like, you know, I can't, I'm not going to put a percentage of it on it, but how much is my shit and how much is there shit and how much does it need to be addressed and how much doesn't it, whatever. But I think that the self disclosure piece, I think it keeps it honest for one thing. I think sometimes therapists make the mistake of they're taking their experience with the client, right? And then they're trying to, they're trying to leave themselves out of it and they put it on. They're like, Oh, I think you're what if your boyfriend experiences you this way, you know what I mean? And then you get really in the muck and that does feel manipulative. And I think it's a lot more honest to say, I'm experiencing you this way. I'm afraid of pissing you off, right? Like, whatever the thing is, in my experience, it creates trust, even if they don't like hearing it. And from the perspective I look through, which is mentalization, clients, especially clients who are like, interpersonally hyper vigilant, who have a lot of interpersonal trauma, they're picking up on how you feel about them. They're watching you, they're watching you closely for that, scanning you, scrutinizing you for how you feel about them. So if you don't make it explicit, that creates a sense of unease. If you do make it explicit, even if it's not what they want and wish you felt, and you do it, you know, with some elegance, you know, to the best, I'm not the most elegant person in the world, but with to the best of our ability. It creates trust because what you're saying is congruent with what they're feeling from you. And I think that's really important. I'm going to use an anecdote that I used in, you know, the training I did in the winter that I think was really, is really important around that kind of self disclosure, because this was a client initiated immediacy, so which like get ready, because even if you don't think you're going to use immediacy, like someone's going to bring it up to you and you're going to be in it. So this client and I had been doing trauma work, and they were also having some, you know, issues with their relationship, their primary relationship. And at some point, the client said, I think you want me to break up with my partner and that this would be that me like leaving them would be this great capstone to like all the trauma work that we've been doing. I was totally clocked. That is how I felt. And I, if I had said to that client, no, I don't feel that way. Like that would have wrecked the trust that I had built with that client. Like because obviously they knew they picked it up. So I, so I wasn't just like, yeah, that's how I feel full stop. We had a great conversation where I was like, you know, if I was your friend and like, you'd been telling me all this and like, on a peer to peer level, you know, sometimes that is how I feel, right? And also on the level of your therapist, I don't want to make decisions for you and I can't tell you like I truly feel in my heart, I don't want to be the arbiter of whether somebody breaks up with their partner or not. I don't want that on me. And I want that autonomy for you. And you know, we were able to pack through it complex it like with all the complexity, you know, on all like in the, in the episode I just had all those layers of the therapeutic relationship, we were able to unpack it on those different layers. And that created trust, even though it was very uncomfortable and like, I don't want to be broadcasting that kind of stuff to my clients like where they know so much more than we think that we're putting off. Because I thought I had done a pretty good job hiding that and I clearly know I had not busted. You're like busted, totally busted, right? Like exactly. And I think that's where transparency and honesty and authenticity are quite important in working through all of the complexities we're talking about because this isn't just like an open-ended question intervention. There's so much like you're saying complicated contacts that can come into the conversation. And I just think that when we are like at least bringing it out into the open ourselves or our clients are, in that client's case, we are like reading ourselves of this idea that the therapist is just supposed to know what to do. Uh-huh. Yes. Why would I know what to do in all of these situations that I'm, that I'm faced with? Because I have information that might lead us to understanding where to go together in a collaborative sense. And I might be playing a hunch about that or like kind of taking a risk to name something that's like unnamed. But like, why would we be able to just bypass the experiential component of grappling with these things with our clients in the moment? Like we're not meant to sense, man. Like totally. Yes. We can't like just do our like just pressure behind the scenes and like rearrange things and just be like, here's the answer, here's the worksheet, here's the thing. We are grappling together and part of the immediacy and process commentary is designed to bring a lot more of that into the light so that it can be useful to you and the client in moving forward. And again, none of the shit we're talking about is easy. And but some of it is not as. hard as we're talking about either. It just happens naturally also during the course of therapy. And some of it isn't very like, it isn't very intense at all. It's just part of the jam. So, but I think it's so important to kind of play with this idea of what am I not saying, or what am I not naming that could illuminate something? And a lot of times where this comes up with clinicians is in impasses with clients. They're not helping the client, they're not able to help the client. They don't feel like they're helping the client. And so there's some dynamic that they've been tracking that gives them a clue as to why things aren't moving forward. And then you have to figure out how to put that into a formulation that the client can receive and that, you know, you're making sense so that you can try to move there beforeward. And I think like that, and you have to do it imperfectly. I think that that to me like is the, I want to hammer that message because I think, you know, when I think about therapists says like people please, there's in various stages of recovery. There's another element to that, right? Where we're all people who, for some reason or another, whatever that is decided that figuring people out and figuring out how to say the exact right thing was a good way to manage other people. That, like you would not get into this work if you did not have like a propensity for that, you know? And to some degree, we have a responsibility to do that to the best of our ability in these client relationships. And I also think we can get really straight jacketed by the need to do it perfectly or the need to do it right. And I think that that is why people have such an attachment to protocols and doing the protocol as, you know, as it's written or whatever and people get so scared of changing and being flexible around protocols because like protocols create, they indulge the fantasy that we have in this field that there's like a right way to do therapy that's reliable, which is bullshit, fantasy, complete scam. None of those protocols have any, I've been banging the strum a lot lately, but there is no indication that doing any form of therapy according to a protocol is better than doing it not according to a protocol. That's, we're not there yet. - Don't you think though, Riva, like as we're like conversating here, this is maybe not your traditional interview? Like don't you think that's our, like part of our fields fundamental wish, so Philman is that we could collapse, we could collapse the paradox and have this right way to do it. - Yes, totally, exactly, it is, it is, and it's a, yes, and I could, you know, I mean, maybe I've just been so immersed in object relations theory, but like to me, that's like a wish fulfillment, that's the wish fulfillment of the parentified child, right? You figure it out and you do it right, and then your parental figure is available to you. Like that's the whole, that's the, what our field is defined by. So, but where I was going is like, I think what immediacy asks us to do is to take a risk without knowing what the payoff is gonna be, without having a one right way, without really allowing it to be imperfect and trusting that you are crafting a relationship with your client that's resilient enough to handle your imperfections, and to be able to handle whatever your best effort is. When it comes to those impasses, you know, what I can tell people who might be hearing this, who find the idea of like confronting an impasse with immediacy, terrifying, is to not confront it is actually riskier, actually it's not riskier, it's more guaranteed you will lose that client. That's probably what will happen. - I agree and Riva, you were constant banging the drum of messiness in this work is a real value ad for all of us to be reminded of that because when I am thinking about immediacy with a client in the moment, of course I can't figure it out perfectly, I'm like having meta thoughts while I'm sitting with someone trying to be present, and this is even more illuminated when I'm sitting with the supervisor or colleague, and like we're trying to formulate an intervention, and there's like four, five or six doors. Basically I end up saying, well, there's this possible direction, what do you think about that based on what you know about your client? You sit with them, I don't. There's lots of ways in, and it's gonna be like an in the moment kind of like experience to kind of choose a pathway, and I think that it's important to think about the messiness and the imperfection, and you know, as a teacher, I end up creating a structure that looks like it could be the right way, but it's really not like the right way, it's just a way to kind of get yourself there, and then you have to experience it yourself, let it be messy, and that's why one of my theoretical influences to this work, Safran and Morayan wrote a manual called the therapeutic, negotiating the therapeutic alliance, and Safran Morayan knew that if you're gonna do this relational work, you have to figure out rupture and repair, because they're intimately connected, and so their model for repairing ruptures is really valuable, and it's really involves the therapist too, because if we've ruptured with a client, we're part of that rupture, meaning we participated in some weird something that we can take responsibility for, not in a like shameful, I fucked up sort of way, but in a like, yeah, you know, the way I said that might have been sharper than necessary, I hear you, you know, and I think that that's why it goes back to the intimacy and the risk that you were talking about earlier too, and the imperfection and the messiness, and we're not here to prevent ruptures, right? We're here to be able to effectively repair, and that has a sort of very much of a meta message of like that needs to happen on much larger scales in our site. - Mm-hmm. - I would say a couple of other of my theoretical influences on this. I think relational cultural theory has been one for me too, which has this component of being able to transform disconnection with clients by being able to name when a lack of connection is occurring and trying to formulate an understanding of why that might be happening, or at least be curious about it. And I also think like, taper and McClure's interpersonal process work has also been an influence. And so I sort of take all of these different like theoretical threads, you know, and kind of take pieces from them to try and help me think about how to do this work with my clients and how to help supervise these, develop these skills, and how to help my colleagues resolve impasses in their cases. And I think that there's obviously so many more theoretical influences to this, and the gestalts have their own way of doing it. And the, you know, the whomever's have their own way of formulating these kinds of interventions or what they say about them. And so there's so much learning to be had in our field on like what do different theoretical schools or orientations think about how to do a media see. And I think there's a lot of value in thinking really widely about them and thinking about what might work for you, because I personally couldn't tolerate some forms of a media see personally in my own therapy that like for example, like in the somatic domain. I'm like, like, no, like, no, stay out of my business. And so that tells you a lot about me. And like, and like how I like wanna receive therapy, which is in this verbal relational way that does happen media see, but is not like really intruding upon my body, for example. - Yeah. - Yeah, yeah, yeah. Lots to be said about the different schools of thought, but there's a lot of stuff out there in our field to dig through about this that is really phenomenal and can really help us continue our learning, especially if we didn't get a lot of it in grad school. - I'm just thinking about the way, I know we already talked about this, just the way this modality kind of focused, protocol focused, era that we're in. I just have so many like genuine concerns about like the direction that's taking our field. - Well, your concerns are valid. And I think you should keep contextualizing those based on whatever, you know, things you're thinking about, whatever guests you have on, because we are at a very interesting point where we could lose the plot here, I think. And so your alarm is very warranted to me as someone who's been in the field for over 21 years, thinking like what is the direction in the field is heading? Are we gonna go in the completely medicalized, completely evidence based, completely like protocolly, completely like matching therapies to diagnosis direction? Or are we gonna like deal with the human, messy, complex, existential, relational part of the work? And just because we, you know, medical necessity isn't embedded in that, like what does that mean? Right? I think, you know, you might feel like you're lamenting that issue or like grinding it down, but like it's worthy of like mentioning a lot. And I don't pretend to know what's happening full-- what's happening, but I do feel uncomfortable with the direction of our field. And I think that's why these conversations you're having on a therapist can't say that are so important. - What do you think it is? I'm just thinking about like, there's the insurance company kind of like thing of promoting this idea of evidence-based practice and the things you can supposedly measure and all that. I get that, but what I don't understand right now about this field exactly is even outside of that, there's this push. You know, like the things that are like emerging in popularity right now, like internal family systems, right? For example, which I'm trained in and use. I hear, I would say increasingly about IFS trained therapists who are very removed won't do any relational stuff and really hide behind the modality and the theory of the parts and all that and won't make emotional contact, right? With their clients, relational contact. I same deal with EMDR, have heard so many stories about EMDR therapists who are not there, they're not in it. And it can be challenging to talk about sometimes because I don't, I actually don't, it's not about criticizing those modalities. I don't have a beef against any particular, you know, overall, I'm sure there's some pringy shit that I would disagree with. But overall, I don't have a beef with any particular modality. I really don't. It's the way that I am seeing therapists hide behind their modalities to stay out of contact with their clients. I have such grave concerns about that. It's not because it's just happening on that personal level with that individual therapist and that individual therapist. It's because of the way that we're using this fantasy of neuroscience and, you know, the pretence that we have this like incredible understanding of neuroscience enough to say like this modality, that modality, work for trauma, whatever, to excuse what I think is a, really an abdication of the central component of our role as therapists, which is to be in a relationship with the client. Not we're not doing something to, we're in a relationship with. And the immediacy is part of that. But I also, you know, it feeds into this broader concern I have about like, why are we trying to get out of that? That's what this job is. Why are we trying to get out of that? Is a really good like question? And I'm not going to pretend that I have all the answers there. But I think about it in terms of systems of influence versus the individual clinicians. And I think the systems of the influence are many. And I think it's quite complicated why we are where we are right now in terms of a lot of the comments you've made. But I think the reality is all of these systems and bureaucracies that are up in our business, like they don't fundamentally believe that the relationship is healing despite all the evidence we have of such. And I fundamentally think that there's a lot of service rationing going on in terms of how these systems infiltrate our work. And I think that we want to have the solution for everything with some of these modalities, right? That's why they're all becoming very transdiagnostic. Is that want to say that like, DBT can do all these things. IFS can do all of these things EMDR for everything. And it's like, that's interesting to me too. Because I think that's like a fundamental collapsing of the paradox in terms of just how hard this work is. And just how many things we have to know about or supposed to know about or need to know about, like this job is wild if you think about it. If you look at the diagnostic and statistical manual, you're basically saying, if you are a clinician, you should know some about most of this stuff. And that's very challenging for us to sit with. And it's not possible for a two to three-year graduate program to train us in much of what we need to know. And so when you think about the influences that are pushing us in these directions, a lot of it is sort of how does accreditation work, right? How does licensure work, how does insurance companies work, how does Medicaid work, how are they going to claw back money to maintain profits? And even if clinicians are doing self pay, and they are touting these methods as the only methods that work, I mean, that's kind of wild, right? Like that's not true. And it might be what they like to do. And that's totally fine. Like they like to do it. It feels good to them. And we know from the research that if you like the modality you're using, it's going to be more effective just because you believe in it. And you're in it. You're more involved if you like what you're doing. Yeah. Yeah. Yeah. Yeah. You're ongoing learning about it. You're investigating it. You're researching it. You're examining your practice. But like we're just, we just like love to collapse all these paradoxes, I think, in our field. And we want to just, we want to just be like, this is what works. And this is what doesn't work. And we want you to get that done. And I just think fundamentally there's a lot of forces that play in your question of why are we like this right now? Yeah. Yeah. But why are we like this? Right. And I think that it's a complex question. And I think that we just have to at least keep trying to like name it so that we don't get stuck in either side. Because I do believe there's a lot of value in some of the modalities. And I use plenty of them. But I don't think they can take the place of this relational work that we're talking about. Or this sort of immediacy work or this focus on the therapeutic alliance that is so vital. And again, therapeutic alliance isn't about our clients liking us. Right. That's not how happy we're making them in any given moment. Yes. No, it's a much more complicated concept than that. And I still think we all have to round ourselves in all of the common factors research to really kind of ground our theoretical orientation. And I feel worried, like I think underneath your snarky comments or your drum beating is a fear that we're losing. A fundamental aspect about what makes this work potent, what makes matter, what makes other people feel like they matter, as our clients. And I think there's a really solid fear. And I also feel like one more thing I'll say is that the history of this field isn't very much taught in graduate school. Yes, Freud, you learn about those things. They exist and they did psychoanalysis. Right. And I'm talking about what's happening in this field in the last 50 years. What's been happening in the last 20 years? What were your local clinicians facing 20 years ago when they were trying to practice in this community? What were they facing when they were dealing with OHP or not actually dealing with OHP or insurance companies? There's just like a history that kind of gets lost about how this field has evolved. And what I think is something I've been thinking about lately. And I think that contributes to-- I mean, and I think that's an American tendency in general, right, as to everything's the present moment. And whatever came in the past is not as good and exciting as what's happening right now. And right now, I have like-- I mean, I've been doing the reason I've been doing this fucking deep dive into object relations theory, which is from the '40s. And Melanie Klein was an amazing genius to get no credit. The reason that I'm getting into that stuff is because it's helping me now in a way that none of the shit that's popular now is helping me with some of my tough cases. Full stop. It's such a loss. Full stop. Full stop. Like, yes. What you said, like, we are-- when I would show videos in teaching, if those videos were more than 10 years old, students would lose their minds. Like, because we're like, this is old shit, yo. I'm like, if you don't want to see Yolam doing inpatient, like here and now, group psychotherapy, because we're not allowed to do that anymore, then that's we're losing something, right? And so the latest research, the latest trends, we've-- you know, I've been around long enough to see us all jump on those. But the reality is, is there is some deep knowledge in this field that is older than 20 years old, that's older than 50 years old. And it's overwhelming, though. It's overwhelming for us. It is. Explanations, because there is so much to learn. There's so much work we can do. This work is so-- Who called? Yes. And I think, like, I-- you know, and I've spent my time-- I've put in my time, as you well know, like, really honing and developing my modalities and, you know, really, like, diving into the kind of trauma processing stuff that I do, and that was not time wasted by any means. It's really been in the last, I would say, probably, a year-ish and much to do with your influence that I've been really working on building my, like, relational skills and my immediacy skills with my clients, really seeing a lot of payoff as messy as it often is. And realizing, like, in a really deep way, that we work on our alliance building skills forever. And I was not taught that. Yeah. In grad school. I was told in grad school, that I was good at building alliances and I am. I can build an alliance with a client very quickly. And that caused me to rest on my laurels around my alliance building. And I didn't understand that was a lifelong practice of getting better at building an alliance. It's not the salts that you sprinkle on at the end of the dish, you know, and you know how to put the right amount of salt and then you're good. Like it's an ingredient that is so crucial and so complex and that's just really, I've really internalized that. Recently that I, that that's not something I get good at and then lose track of. It's something I continue to work on forever as long as I'm doing this work. And to me that's, if I had heard that, right? 10 years ago, I would have felt demoralized, frankly, because that sounds intimidating and scary. But I can say from this vantage point that to embrace that knowledge makes the work so much richer. And I think if I had understood that sooner, if I had not, if I had been scaffolded more instead of being told that I was good already and didn't need help, which is essentially, 'cause sometimes the messaging I was taught in early in my career or the messaging I was given early in my career. I think it would have contextualized a lot of my early career confusion and struggles. - What if someone had sent to you, you are naturally gifted at connecting with people and you have a natural skill for this beyond your intergenerational demands to do it. But you are going to, and you're gonna benefit from learning so much more across the lifespan on how to hone this natural gift you have. What if that was the message? Like, you figured that out yourself, thank goodness. And that, to me, is goes back to conversations about excellence is like, the excellence is not like a static kind of consumption of knowledge. It is a constant looking at reviewing, letting go of, adding to kind of critiquing your own practice and thinking about it. And I think it is too overwhelming at first. Maybe for a lot of people and our graduate programs certainly don't wanna say that we've only taught you a tiny bit of what you need to know. - No, they don't. - But what is, that's the truth. - Yeah. And I think that it's important to like, to be gentle with ourselves in terms of, yes, this is overwhelming. And if you have to sit around and think about how hard it is and how much you don't know and how much you've already learned, but still don't know, it is overwhelming. And I think that we wanna protect ourselves from a lot of aspects of this work that are overwhelming. - Well, we've been going for an hour. - Thank you for being here. You're brilliant, as always, consistently, every time I talk to you. - Thanks for chatting with me and wanting to chat about all of these nerdy things that are coming up for us and on your podcast. You can find Dr. Hicksons' work at DrHickson.com. If you're enjoying a therapist, can't say that, please rate, review and follow the show wherever you listen to podcasts. And please don't forget to share the show with the therapist friend who you know really wants to join us in talking about the things it feels like a therapist can't say. As always, you can find me, revost out at IntoTheWoodsPortland.com. I love hearing your thoughts, feedback, critiques, complaints, compliments, suggestions, and of course, your therapist can't say that moments. Feel free to reach out to me via email or sending me a voice note to riva@ IntoTheWoodsPortland.com. Talk to you next time.