Dear friends and colleagues,

Things have been quiet here for awhile, but recently my ethical compass got spun around by the update to the privacy policy of the EHR platform I was using (if you haven’t heard yet, it rhymes with Dimple Cactus). I was particularly concerned about the privacy updates that stated a few different things:

First: they were saying that they owned my user data and claimed that they had a “non-exclusive right to repurpose it in perpetuity.” Ugh.

9.2 License to User Data.  By uploading or submitting any User Data to or through the Services, and permitting other Users (including, without limitation, Clients) to upload any User Data into the Services, You hereby automatically at such time grant SimplePractice (and its affiliates) a non-exclusive, worldwide, royalty-free, fully paid-up, perpetual, irrevocable, sublicensable (through multiple tiers), and transferable license to use, reproduce, distribute, prepare derivative works of, perform and display such User Data (including User Data that is created, collected or generated by the Services or SimplePractice using the User Data Users submit), for the purposes of providing you the Services and further developing, improving, and marketing SimplePractice’s products and services (including the Services), it being understood that the results generated from use for purposes other than providing the Services are not identifiable with the Organization or any natural person. The foregoing rights and licenses will be exercised in accordance with the SimplePractice Privacy Policies referenced in Section 10 below. You agree that the license includes the right to copy, analyze and use any User Data as SimplePractice may deem necessary or desirable for purposes of debugging, testing, or providing support or development services in connection with the Services and future improvements to the Services. The license granted in this Section is referred to as the “Service Data License.” You also acknowledge that the Service Data License granted to SimplePractice with respect to User Data will survive the expiration or termination of Your Account. Notwithstanding the foregoing license, the license granted to SimplePractice to use User Data that includes content that You provide for purposes of Your Professional Website is set forth in Section 17.2 (Professional Website Service) below. You further irrevocably waive any “moral rights” or other rights with respect to attribution of authorship or integrity of materials regarding User Data that You may have under any applicable law under any legal theory.

I am NOT an attorney, so some of this was mumbo jumbo to me, but as a person who creates and sells my own intellectual property (as practice forms), I did not like the idea that the EHR I was paying to use would claim ownership of my own copyrighted intake forms and policies. What do you mean I am “irrevocably waiving,” my rights to attribution or authorship of things I put in your system?? And why in the world would I agree to such a thing?

But that was just the self-interested part of me.

What was especially concerning was the part that informed me that psychotherapy clients are included in such User Data! I mean, how can I be on board with using any healthcare platform that has plans to copy and claim ownership of health data of my clients for the purposes of developing new products?

I wasn’t the only person who was concerned. There was a big discussion of this on a national APA listserv, and I was really hoping that my professional organization would advocate on behalf of mental health professionals and our clients and push back on these policies, but they determined that there is currently nothing of concern here.

But… they also have an existing affiliate relationship with this EHR, which according to their own ethics codes seems to be an existing conflict of interest.

3.06 Conflict of Interest

Psychologists refrain from taking on a professional role when personal, scientific, professional, legal, financial, or other interests or relationships could reasonably be expected to (1) impair their objectivity, competence, or effectiveness in performing their functions as psychologists or (2) expose the person or organization with whom the professional relationship exists to harm or exploitation.

Huh.

There was a fantastic webinar put on by Person-Centered Tech (oh, how I miss my dear Roy Huggins) and Zynnyme on this topic in which Eric Ström, attorney and LMHC weighed in on the legal challenges and SP’s seeming misunderstanding of how patient initials are part of PHI. I highly suggest watching this replay if you can. One thing that Eric said, however, was interesting to me: He noted that your Informed Consent shouldn’t say which EHR platform you use. I believe his point was that you might be boxing yourself into the platform if this was the treatment contract you created with clients.

This intrigued me because my practice has always been one that values transparency. I have also given clients the option to NOT use electronic records because I recognize that there are many reasonable objections a person might have in this day and age to having their data stored in the cloud. Since I moved to using an EHR in 2016, I have continued to honor all of my clients’ requests to stay on paper (about 20% of my practice).

When I understood that SP was not only forcing therapists into agreement with these policies in order to access our accounts in mid-August (they since retracted that and gave us until September 6th), I knew I had to get off the platform. It didn’t feel good to be forced to accept an agreement that was not in my own best interests, and which I could barely comprehend. I could not imagine what it would feel like to be a psychotherapy client and be similarly forced into accepting such an agreement to “ownership” of my health data simply to access a therapy session or get my Superbill.

So I fled for a platform in which I had more certainty about the commitment to patient privacy, as well as little interest in making big tech bucks. But let me tell you, it wasn’t fun. Moving seven years worth of clinical data that is only exported as single PDF’s is quite an undertaking. I feel great about my new system’s ethical commitments, but it is clunky and much more cumbersome than the one I was using. Things that took one click in my former platform sometimes take five to complete, and my wrists are aching! I also heard from many colleagues with group practices (that also run therapy groups) that it was just too overwhelming to change platforms, and they have my empathy and understanding.

What I Did

When this started going down, I first revoked my consent in Simple Practice. Then I sent all my clients an email letting them know that I had concerns about the EHR I was using and that to avoid them being forced into accepting any new terms of service, please use my HIPAA compliant Zoom link to access our upcoming sessions.

I also discouraged them from logging in to obtain their superbills and I told them I would email them their August Superbills encrypted from hushmail. I moved their payments over to IVY pay. This is one of the few times where my not using one platform for everything actually helped. My clients who do not want their information stored in the cloud had already been meeting me on Zoom or were using IVY pay. Bear in mind that HIPAA compliant Zoom with a Business Associate Agreement does not have the AI features enabled.

And then, I completely updated my Informed Consent, explaining the details of the new platform I am using, and updated my electronic consent policy so that people could opt-out of electronic records again if they had changed their minds.

What Ethical Standards Apply Here?

So we know that there are legal issues here, in terms of possible HIPAA issues down the line, but what are the ethical considerations?

I went to my APA Ethics Code to look at what is relevant to this situation. Let’s begin by thinking about Informed Consent. For psychologists, this is would be Standard 10.01, Informed Consent to Therapy:

10.01 Informed Consent to Therapy

(a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent , psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers.

Look at your own ethics code and see what it says about Informed Consent, but generally, ethicists point out that Informed Consent is an ongoing process that evolves over time. When we implement fee increases, or change any office policies, or need to remind people of cancellation policies, etc. we are continually reviewing and providing informed consent.

Now, I believe that “involvement of third parties,” absolutely extends to the use of payment systems, electronic health records, telehealth platforms, and so on. In the past, I have emphasized that “involvement of third parties,” could also mean your use of search engines if you engage in searches on your patients as part of your practice.

So if these relationships are changing, or if the platform itself is going to require psychotherapy patients to agree to new terms and give up ownership of their data in order to access their therapy sessions, I simply do not see how we can fail to discuss this with our clients.

But let’s also go back to Standard 3.10:

3.10 Informed Consent

(a) When psychologists conduct research or provide assessment, therapy, counseling, or consulting services in person or via electronic transmission or other forms of communication, they obtain the informed consent of the individual or individuals using language that is reasonably understandable to that person or persons except when conducting such activities without consent is mandated by law or governmental regulation or as otherwise provided in this Ethics Code…..

And let’s skip to section d, below:

(d) Psychologists appropriately document written or oral consent, permission, and assent…

So our Ethics Code tells us that when we are providing services via electronic transmission we obtain informed consent in language that is reasonably understandable. I would say as one of the “Users,” of the platform I was using, I was not able to fully understand what I was agreeing to. I would guess that many of my clients who aren’t in the legal profession might also be unable to understand it as well. Furthermore, it seems to me that we would need to also document permission to continue with an EHR platform that is changing its terms on our patients.

I tried to liken this to some colleagues as what happened when I moved from a quiet little office in the Castro to a big professional building in downtown SF. When I moved, my clients had to check in with a security guard who asked for their names and identification when they entered the building after 5pm. I talked to the building management to protect client confidentiality and ask them to please let people simply say they were coming to see me without having to provide any name or identification. It worked out fine. But I also discussed it with my clients and let them know they did not have to give their name and identify themselves. This was a change in procedures that impacted their privacy. It is the only comparable example I can give now that we are so digitally enmeshed. Because, obviously, my office building wasn’t going to take photos or names and claim to own them.

Moving on, I believe strongly in the General Principles of my Ethics Code and I also believe a number of them apply:

Principle A: Beneficence and Nonmaleficence

Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm…

Well, I definitely think that moving to a more privacy minded platform and talking to my patients about this is in service of safeguarding their welfare and rights and minimizing harm.

While many clinicians may have reasonable arguments for continuing on this or any platform, it seems that a conversation about what it means to stay on there would be another easy way to minimize harm. And what about those who might feel forced to accept an agreement that isn’t in their best interests just to continue care with a therapist they want to continue seeing?

Wouldn’t a discussion about this be important?

Principle B: Fidelity and Responsibility

Psychologists establish relationships of trust with those with whom they work. They are aware of their professional and scientific responsibilities to society and to the specific communities in which they work. Psychologists uphold professional standards of conduct, clarify their professional roles and obligations, accept appropriate responsibility for their behavior, and seek to manage conflicts of interest that could lead to exploitation or harm….

I absolutely believe that what this EHR is doing is a form of exploitation of both the clinicians and the therapy clients using it. So I think Principle B applies here too. Continuing to establish a relationship of trust and managing conflicts of interest was at heart when I talked to my clients about it.

Principle C: Integrity

Psychologists seek to promote accuracy, honesty, and truthfulness in the science, teaching, and practice of psychology. In these activities psychologists do not steal, cheat or engage in fraud, subterfuge, or intentional misrepresentation of fact. Psychologists strive to keep their promises and to avoid unwise or unclear commitments. In situations in which deception may be ethically justifiable to maximize benefits and minimize harm, psychologists have a serious obligation to consider the need for, the possible consequences of, and their responsibility to correct any resulting mistrust or other harmful effects that arise from the use of such techniques.

If we are acting with integrity and promoting accuracy, honesty, and truthfulness in our practices, why would we NOT discuss what’s happening on our EHR platforms and chat openly about this with the people we are seeing clinically? I think most of them would care about this quite a bit.

Principle E: Respect for People’s Rights and Dignity

Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination….

My primary concerns about these privacy changes were initially about peoples’ right to privacy and confidentiality. But self-determination speaks to a person’s right to to make decisions for themselves.

Ultimately, this is one of the most relevant and critical ethical considerations to me in terms of what is happening with this EHR (and what may happen to other big tech EHR’s).

I want my clients to feel free to decide what happens with their health data and not have it decided for them by me or by a service I willingly choose to use. So this brings it back to why it felt imperative to me to talk about this openly with my clients and give them the option to move to the new platform with me or go back to paper charts.

Are there Clinical Considerations? 

Why what a great question. I’m so glad you asked!

At some point in the near future, when psychotherapy clients start trying to attend therapy  on Dimple Cactus and they are met with a pop-up  forcing them to accept new terms of service that some of their therapists have discussed with them (and some have not),I think it’s going to get…interesting.

Maybe some clients will feel like they have to say yes to this in order to continue seeing their therapist. Some may have already talked about it with their therapist and they have already decided they are okay with it. Some psychotherapy clients may wonder why their therapist didn’t talk this through with them at all? And I wonder if perhaps some will look for therapists who use different systems.

Will people feel comfortable raising the issue at all if they are upset with their therapist for not moving or not mentioning it?

I am so very curious about all of these scenarios. So aside from legal, ethical, and risk management, I think this has the potential to become a big clinical issue and I am very interested in hearing from any of you who wind up having clients respond to the forced opt-in, whenever that gets rolled out.

As for my own clinical feedback: despite the headache, hassel, and repetitive strain issues of the last weeks as I drag and click away into eternity as I move charts to the new system…most of my clients have thanked me for caring about their privacy and getting off that platform that wanted to own their data.

It’s still unclear to me what will happen with the records of terminated clients who will never have the opportunity to have a vote in this. I would guess that their records would be outside of the license to use, reproduce, distribute…blah blah blah. But I lost trust in this platform already and I’m glad I have removed their data. Note that they said that they would do this even with terminated and deleted accounts.

It’s been an adventure.

Oh, and if you wonder where I went with my data, I went to PSYBooks. Like I said, it’s not the most streamlined and it doesn’t have the best user experience. But, it is run by a caring and committed psychologist I know who has no intentions of ever selling or de-identifying user data. I was tempted by other platforms, but I hope to never have to migrate this data again. And she is local, so if she does something else with her platform, I can go bang on her door and ask her why. Also, her customer support team is exceptional. So that’s where I went and why.

As always, I am so curious about your thoughts and experiences. Please hit reply and tell me what this has been like for you.

I’ve sure missed talking to you all, but I didn’t have anything so meaningful to post about in a long while.

Best wishes,

Keely Kolmes

September 22, 2023: 9:56am Eastern: This post was  initially addressed to mental health professionals. But many of us are in therapy. And many of my readers are also people who obtain mental health services. If this issue has impacted you as a psychotherapy client, can you let me know? If you’re comfortable commenting, you can do that, or you can send me a note. Thanks!

The post It had to be you…(when your favorite EHR makes you break up with them) first appeared on Dr. Keely Kolmes.

When I was in graduate school studying to become a psychologist, we were encouraged to explore our counter-transference. We were told it was common to sometimes have strong feelings for our clients. We might feel anger, rage, sexual longing, disgust. I was warned about sexual attraction. I was warned about daydreams and fantasies about clients. But nobody prepared me for the love. Nobody adequately prepared me for the sense of closeness and care that I experience when sitting with a patient.

It didn’t bloom during the early stages of my career. Since I was usually limited to brief therapy in a college counseling center (6 – 8 sessions), there wasn’t much opportunity to develop such deep connections. I was too busy patching people up and referring them to other mental health professionals who would be the ones to hold their hands and walk a longer, deeper path with them.

College counseling may have been my first dream. But after eight years, it lost its luster. I wanted to see people past the crises they were having and to go deeper with them. So I found an office and started accepting private practice referrals.

It took a couple of years for me to begin to notice that clients who I met with for a couple of months were people I felt I barely knew. At my former job, these were the people I was seeing “long-term.” Now, meeting with someone for eight sessions feels like the tiniest tip of the iceberg.

Not every client becomes a longer-term patient, and not every client is looking to do that kind of work. But to deny the intimacy that we experience as mental health professionals is to miss something essential. There is nothing more lovely than looking at my appointment book for the week and seeing a list of the names of people I’ve come to care for deeply. I had no idea how intensely moved I would be by this work.

I don’t tell clients I love them. As a psychologist who is very much aware of licensing board complaints, risk management and transference concerns prevent me from saying much more than “I care about you and your well-being.”

But sometimes I get teary in a session watching a couple interact together in a way that seemed impossible when they first came to me and my heart explodes with joy. Sometimes, I witness a success with someone who has been in pain for a long time and so many parts of me want to dance around the room. Other times, I feel outrage when someone hurts a client who is dear to me. But I never feel like I can reveal my heart and show clients where they map inside it: how much some of them come to mean, how much I believe in them or hurt for them or adore them. It could make things weird. It could certainly disrupt the work and make me take up too much space in their therapy.

These feelings are not romantic or sexual. They are deep affection for who a person is, compassion, belief in them, and a sense that when they hurt, I hurt for them. There are also feelings that a client’s successes make me proud like a parent (not so much in a narcissistic way that our work brought them there, but just a natural pleasure in seeing them do well in life).

I have tried to discuss these feelings with other clinicians and have received a variety of responses. A few people are willing to admit they feel similar things. But their risk management sensors and clinical judgment similarly keeps them from making the care we feel so explicit. Cards to our vests, we are cautious and selective in the words we choose. But at the same time, the feelings seem important, and I wish we were not so confined to not express the very thing that might be extremely healing to some people.

So we love them in silence.

There are those who deny that love can even exist within a relationship with financial implications. This stuns me. The idea that someone paying — or receiving payment — for another would preclude the development of “true feelings” seems limited to me. I’ve seen and heard of many examples involving the exchange of money or “work” in which loving feelings have developed: nursing, sex work, massage therapy, childcare, teaching, physical therapy, spiritual counseling, traditional and arranged marriages…these are just some of the situations that immediately come to mind. It makes no sense to me to suggest that the exchange of money puts a cap on one’s emotional experience or connection. But perhaps the belief that it does serves as self-protection for some? Perhaps the worry about abusive relationships — which certainly can and do develop — makes it easier to say that this is all fantasy and projection. But I don’t believe that.

Some therapists have admitted to me that they told long-term patients who were dying that they loved them. It intrigues me that only in the face of death will some clinicians feel free to say the unspeakable. Is this a good or a bad thing? Is it because there is a looming time cap on the relationship and reduced fear of a board complaint?

Others tell me they don’t feel this love at all. They insist that loving feelings must be romantic or sexual. For these people, I feel sad. I know what my romantic and sexual feelings are like. They are accompanied by attraction, fantasy, longing, desire for more, thinking about someone in a craving sort of way. This isn’t what I’m talking about. To put a finer point on it, there is nothing unrequited about this love. It just looms quietly in the shadows, ironically unspoken in rooms otherwise punctuated with the most taboo words and stories.

I wonder if those who insist this is sex or romance have ever really experienced love in a more pure form? It worries me to think that people who don’t have access to such feelings are doing this work.

The times I’ve felt most aware of the love has usually been when a client is hurt, feeling shame, wanting to disown an aspect of self, struggling with self-love, and I wish I could loan mine out. Instead I try to beam the love to them through my face, my eyes, while I use words to remind them they are human and working hard on very difficult things and that I care deeply about them in this work and respect how they are showing up and being vulnerable.

But it’s interesting because I think in this one way, I am my least authentic self with clients. When I feel love, I circumvent it or find another way to convey it because it is too dangerous to speak. I regret that at times.

Here is another thing: I learned long ago that something that has a pretty significant impact on the effectiveness of one’s psychotherapy treatment isn’t the style of therapy or theoretical orientation, length of treatment, or even the number of years of experience the therapist has. One of the things that is connected to better treatment outcomes is our ability to create an emotional connection with a client and the client’s belief that we actually like them. Since I learned that, I have considered it a matter of both ethics and clinical efficacy to not take on a client unless I believe at the start that I can come to care for them deeply and make a real emotional connection. It is one of my principles. Sure, we are also supposed to work through our countertransference if we feel negativity and have other unpleasant feelings stirred by our clients. But why bother starting treatment with someone if I feel that way?

I have never told a client I love them. These words are too easily misinterpreted. Even the term “therapist love,” which is cute and tries to put a frame around it feels cheap and minimizing. I understand that a one-sided weekly therapy relationship over the years or even multiple-sessions-a-week therapy for decades, isn’t the same as a friendship, romance, or a family relationship. I understand it isn’t the same love that would develop if this were a reciprocal relationship. But I’m not going to let people tell me what is and isn’t real in my heart. And I’ll be damned if I’ll let people tell me that what I experience as love isn’t really love. Even if it goes unnamed and must exist in the air and the spaces between the words we actually speak. I’ll just have to hope that my clients can feel it and hear it in the spaces in-between, behind the ticking of the clock and the hum of the white noise machine.

The post The Love That Dare Not Speak Its Name first appeared on Dr. Keely Kolmes.

She tells me that last part and her voice breaks. I don’t know whether to laugh or cry for her. She leads with tears. “Yes, I live in San Francisco, but I have had three bladder infections this year because I’m terrified of going to the bathroom at work. I’m not sure which to use and I’m scared of what someone might do if I use either one.”

While the rest of the country may imagine it’s easy to be transgender in San Francisco, “easy” is a relative thing. Living as an out transgender person — especially if you do not pass as male or female — does not mean living without fear, harassment, or worry. Sure, it may be better than living in North Carolina, but it’s no picnic to be transgender on the street or in the office, even if you have a supportive community. It can be much worse for people of color or those living with a disability.

Meanwhile, I’m having my own challenges, in the form of administrative headaches. I have written four letters this year. This missive is going to be number five. I tried to complete a member profile on two Bay Area Psychological Association websites and part of the required information for my profile was that I had to choose male or female. I tried not to choose either one but the systems would not let me progress further. There was no “other” (although what could be more “othering” than having to identify one’s self as “other”?). I wondered why I was able to specify that working with transgender and gender non-conforming people was one of my practice specialties, but I wasn’t able to identify myself as anything but male or female? What about clients who might turn to such psychotherapy directories to find a transgender or gender non-conforming clinician? I suppose they can only choose a male or female therapist too.

This experience was replicated when I tried to sign up for a Continuing Education class at a graduate school. In order to take the class, I was forced to identify as male or female. My skin felt prickly and I felt a wave of nausea. They wanted my date of birth too. Why would I need to identify my gender and give up my birth date just to take an ethics class? That wound up being letter number three.

All of these letters were replied to and people did something to make changes. Either the question was no longer made mandatory and one organization added more gender options. But I wonder how many people before me didn’t have the stamina to reach out and complain? How many people picked the wrong gender because they had already paid dues and they just wanted to have the same membership benefits of other members without having to set aside time to choke back anger and write a polite email to the organization? Maybe they were busy with other important things. Writing these letters is fatiguing and upsetting. Of course, the pain of writing these letters pales in comparison to being arrested for using the restroom  or walking down the street fearful of being harassed, raped, or beaten.

My fourth letter was when I had the same issue occur on the American Psychological Association’s website. This is our national organization which spent money to put together a Task Force to develop Guidelines on Working with TGNC people. What a wonderful piece of work! But if you want to be listed in their Psychologist Locator, you can only identify as male or female. Maybe they forgot to read their own Guidelines?

It is wonderful to live in a sanctuary city. It’s great that mental health organizations are taking steps to provide guidelines for treatment and research with gender diverse individuals. But it seems hollow when our organizations support developing competence to treat diverse populations but continue to indicate their belief that no psychologist could also be nonbinary themselves.

I would like this to be my last letter.

The post Dear Everyone: Letters on Being TGNC first appeared on Dr. Keely Kolmes.

Fighting about money? Financial therapy gets to the heart of the matter

One of my areas of specialty is counseling people in relationships about their feelings and values around money. Often, people aren’t aware of the underlying emotions they have during arguments, especially about money. One of the ways I help is to guide partners in a process to discover and talk about their feelings and the needs they have. This process helps root you in developing a connection with your partner, and for many people, this is a brand new way to resolve conflicts.

This blog post explains a little more about some of the themes and emotions that frequently come up when partners have fights about money.

Fear Motivates

Fear comes up often around money. Most of us can identify fear when we delve deeply enough to see what motivates us. What’s behind the job offer we just accepted and the other job we never applied for? We might admit, at least to ourselves, “I was scared.”

Of course, fear is an essential emotion. It alerts us to run from the proverbial burning building. So we can’t live without it, but do we know how to recognize it and get support when we’re in it? Most of have a hard time with that and need some help. A relationship counselor can help you identify the emotions you’re having and provide a supportive environment to discuss them with our partner.

When Security Turns to Fear turns to Anger

In addition to fear, we also might feel very positive during conversations with our partners about money; many of us feel adventurous, secure, appreciated, and grateful. And yet I’ve seen each of these emotions turn quickly to fear.

For example, someone will tell their partner about their ideal vacation plans for an adventurous time away, filled with excitement in one of our sessions. But fear may creep up and anger can turn to rage when their partner brings up all the debt they’re trying to pay off. The shift can happen in the blink of an eye.

Very quickly, they may start to try to prove to each other why they need to spend money this way or that. They may even start to feel their very relationship is being threatened…how can anyone spend the rest of their life with someone who will never go on a vacation?! And how can anyone think NOW is a good time to spend money on luxuries…we must not have the same priorities so this will never work!

The Heart of the Matter

Here, as with many money arguments, they’re missing the dialogue that will get to the heart of the matter: an open hearted dialogue about what they’re feeling and what underlying needs their actions are fulfilling. For example, what does an adventurous vacation mean to your sense of vitality or other needs you have? What would it feel like to share that experience with a partner? And how do you feel when you’re in debt and want out? Would paying debt meet your need for autonomy and freedom? Or perhaps there are other needs that would be met?

According to Marshall Rosenberg, psychologist and author of Nonviolent Communication: A Language of Life, this process of developing awareness of – and sharing with others – our feelings and needs brings us to a natural state of compassion for ourselves and our loved ones. For most of us this is a new mindset and a new way of viewing conflict.

CONNIE LINAS, LCSW (LCS22837) is a financial therapist, couples counselor, and psychotherapist in Oakland, California specializing in the areas of money, health, and relationships. Learn more at www.EastBayWellness.org.

The post Fighting about money? Financial therapy gets to the heart of the matter | Guest Post by Connie Linas first appeared on Dr. Keely Kolmes.

Sharing Fantasies

There are many depictions of sexual fantasies in modern media, television and film. However, with the growing popularity of the “50 Shades of Grey” books by EL James have brought some of the less mainstream fantasies into a more “acceptable” light.

But why is it that “kinky” sex often has an air of the forbidden, or even shame? Why are so many people afraid to share their darkest longings with their partners?

As a therapist, I often am in the room when partners divulge emotional “secrets” to their partners; feelings they may have held, fears they had been hiding for years. But when it comes to sex, there is hesitance, a fear of the forbidden. I often find my role as creating safety and space for these conversations to happen.

In the new HBO show, “Togetherness”, one of the main characters, a housewife with two children at home, is introduced as refusing her husband’s early morning sexual advances. However, as the show progresses, we see her masturbating as she reads 50 Shades of Grey and her husband walks in. He is hurt and offended that she would be pleasuring herself, alone, when they haven’t been having sex. It turns out (spoiler alert) that she has been discovering that she may have more kinky interests than he and is unsure of how to introduce this into their sex life. Her sister helps her devise a plan to surprise him and act out her fantasy. Now, this may be all well and good, but in the scene that follows, he is clearly confused and unsure of why she is bossing him around (yes, she is the one who want to dominate—a refreshing role reversal from most mainstream depiction of BDSM). Just as it seems he is getting into it, the fun comes to a screeching halt when she is spanking him and accidentally hits his scrotum. Flash forward, they both are bundled in sweats on the couch, miles between them, watching TV.

What’s wrong with this picture? Is this how America thinks that we are supposed to introduce our sexual fantasies to our partners? How might have things gone differently if she had been able to sit down with her husband and tell him about her newly awakened interest in domination and roleplay? How could they have talked about boundaries, limits, and their own needs in a way that would have been satisfying and intimate?

As a sex-positive therapist, I propose that we embark on these journeys of sexual exploration with our partners in healthy, bonding ways. Let’s open these conversations with curiosity and excitement, not shame and fear.

Here are a few suggestions:

• Share erotica or porn that demonstrates a style of sexual activity that interests you. If you aren’t comfortable watching or reading together, give it to your partner and ask them to discuss their thoughts afterwards.
• Try writing your own “ideal sexual encounter”. Use all 5 senses. Be specific about what sensations, sounds, smells, etc turn you on. Share this with your partner and ask them to share theirs.
• Educate yourself about your newfound turn-on. Take a class together or read a book and discuss! This is particularly relevant if this is a type of sexual play that has potential to be dangerous if executed without the proper skills, such as rope or impact play.
• Ask them to share their fantasies or interests with you in the same way.
• Most importantly, have fun with it! Share this experience as an opportunity to get to know yourself and your partner better. Sometimes fantasies are better in the mind than in reality, and that’s ok! Trial and error is all part of the process.

However, even with these suggestions, sometimes it can be hard to start these conversations. If you are wanting to share your sexual needs and desires with your partner, it can be helpful to see a therapist who specializes in sex therapy to help create a safe space to explore together.

GEORGIA HILL, MFTi is a couples and individual therapist who is passionate about helping people of all kinds in the pursuit of healthy, fulfilled relationships. Her approach to therapy is a collaborative, integrative approach focusing on each client’s particular needs, drawing from internal strength and relationship. She has particular interest and training in working with trauma, queer issues, life transitions, and a broad range of individual and couple sexual issues. Learn more at her website: GeorgiaHillTherapy.com

The post Sharing Fantasies | Guest Post by Georgia Hill first appeared on Dr. Keely Kolmes.

In Love and Struggle: Creating Space for Difficult Dialogues About Power, Privilege, and Oppression in Intimate Relationships

Photo by Sha Grogan-Brown: http://www.etsy.com/shop/ArtBySha

As a social justice oriented psychotherapist, my work is highly informed by considerations of how systemic power structures and varied cultural identities affect a person’s self-concept, well-being, and relationships. For this reason, people in relationships who want a therapist who “gets” the complexities of who they are in the social world often contact me to get help navigating power dynamics and cultural differences within their relationships. While I cannot claim to understand all the nuances of every client’s cultural identities, it is in my value system as a therapist to make space for discussions about culture, including those concerning power, privilege, and marginalization and to help my clients in intimate relationships to enhance awareness and communication of these dynamics.

Most dominant or popular approaches to relationships, whether it be in pop psych magazines or in formal training for relationship therapists, rely on oversimplified models of discussing difference. We’ve all been exposed to these ideas. They include sweeping generalizations such as, “Men are from Mars, women are from Venus”. They fail to examine the complexity of culture as they rely heavily on stereotypes that may have kernels of truth for few and negate the rich cultural meanings of identity for many.

So what’s missing? A view of relationships situated in the real world, one informed by intersectionality (a term coined by Black feminist scholar Kimberle Crenshaw). In this approach, there is a consideration of the many cultural identities that exist within or are placed on a person and the numerous ways that privileged and/or marginalized experiences that accompany these identities intersect with each other.

So how does one make space for these difficult dialogues? There is no simple “how-to” guide because none of these conversations sound the same. But here are some key considerations and suggestions for application that you may find helpful.

Know thyself. Yes, you! I am starting here because I cannot stress enough how essential it is for you to be aware of and engage in a continual process of understanding how you hold power in the world or how you may have internalized an “ism” directed at you (e.g., racism, ableism, sexism, transphobia, classism) or both. This will help you to understand yourself in every context of your life, not just your romantic relationships. It will help you to understand and challenge reactions or projections you might have about others. Reflect on how your identities contribute to the interactions that occur between you and your partner(s).

Experiences of privilege and oppression do not exist on a binary. We all have a number of different cultural markers. Some of these may afford us privilege. Others may make us targets of interpersonal or systemic/institutional prejudice or discrimination. It is overly simplistic to say that one person has privilege and the other does not. To truly learn how to be in relationship with someone who is different, which is always the case, we must learn to tolerate the anxiety that can come up when people cannot be easily categorized.

What privilege? Most of us are much more aware of the injustices we have experienced than the ways we have had advantages that others do not. It can be more challenging to see what isn’t as visible or what blends into what the dominant culture holds up as normal or better. Be gentle and generous with yourself and others, knowing that they may have varying levels of awareness about different aspects of their identity, and be willing to name unconscious enactments of power that come from a privileged identity or experience. For example, be willing to examine how you might take up space in your relationships. This may vary from speaking more in conversations to being the one to make most of the decisions. Ask yourself how having privilege in certain aspects of your identity might inform how you play a certain role in your relationships.

Don’t get hooked into judging the Oppression Olympics. Make it clear that these discussions are not about “finding the bad guy” but rather to help cultivate understanding and compassion for the ways in which wounds caused by oppression can get opened by intimate relationship conflicts. It can be helpful to name systems as being responsible rather than blame any one partner. This can prevent you and your partner(s) from feeling blamed or getting defensive.

Validate the other person’s subjective experiences. Then follow the feelings. You can never know what it’s like to live in another’s skin, so treat your partner(s) as the expert(s) on their own experiences. Then go deeper by following the feelings. This usually means dropping into the wisdom of the body and avoiding discussions that start feeling too heady or intellectual. Uncover deeper needs, wishes, and desires for connection. Pay close attention to how you might interpret cultural (or any other) differences that threaten your connection with your partner(s), and try your best to pay attention to and express these vulnerabilities. Experiences of discrimination or “othering” early in life play a role in the negative cycles that intimate partners can fall into. If you can bring curiosity to these conversations, you will come to better understanding, compassion, and connection.

Ask for help. If these are difficult or charged topics that only lead to disconnection and despair about the future of your relationship, seek help from a relationship therapist who is skilled in working with cultural and power differentials in relationships. A skilled therapist is often able to facilitate conversations that you would never feel safe to begin otherwise.

Questions for self-reflection: Here are just a few questions you ask yourself to help you bring conscious attention to the role of cultural power dynamics in your relationship(s).

In this particular situation/conflict/interaction, what cultural identities influence how I see myself? Or how I see or interact with my partner(s)?

How do cultural differences play into the conflicts that arise with my partner(s)?

What is the role of power, privilege, and oppression in our interactions with each other?

Are there any repeat arguments that we have that might have something to do with underlying feelings of hurt related to racism, sexism, transphobia, religious discrimination, abilism, homophobia, classism, or some other form of systemic oppression?

How can we each become better allies to the other person in healing from wounds inflicted by systemic oppressions?

If/when I insist on being “right”, might it have anything to do with parts of me that are privileged?

If/when I assume that I’m the one to blame or the one who needs to apologize, might it have anything to do with experiences of marginalization?

You may be able to respond in great length to these questions, or perhaps these are difficult questions that will take necessary time to reflect upon. Don’t worry if you don’t have the answers; sometimes you just need to ask these questions to communicate that it’s okay to talk about the hard stuff. I wish I could tell you that asking the right questions or following a few simple steps will remedy the problems in your relationship related to cultural differences, but I would be lying. This kind of growth takes work. It is a lifelong and sometimes difficult journey of understanding yourself as a cultural being in the contexts of multiple systems of power and difference. Most people don’t even want to try to understand these things because it can be painful and unpleasant. So while I cannot give you any easy formulas or solutions, what I can assure you is this: when it comes to cultivating healthy and fulfilling intimate relationships, it’s worth the work.

SAND CHANG, Ph.D. is a Chinese American genderqueer therapist specializing in gender diversity, EMDR therapy, relationship concerns, addictions/compulsions, and eating disorders. They have a private practice in Oakland, CA and work at Kaiser Permanente’s clinic serving the trans* community. Sand is also the Chair of the American Psychological Association’s Committee for LGBT Concerns and a member of APA’s Transgender Practice Guidelines Task Force.

Website: sandchang.com

The post In Love and Struggle: Creating Space for Difficult Dialogues About Power, Privilege, and Oppression in Intimate Relationships | Guest Post by Dr. Sand Chang first appeared on Dr. Keely Kolmes.

“Whole Lot of Driving Goin’ On”: Poly and Kinky in Rural America

People with altsex identities, including the poly kink (PK) communities in cities often feel that they live in a small community. This post focuses on PK folks living in rural settings. You go to a party and there’s your ex. You meet someone you want to date and then you find out that one of their sweetie’s sweeties is your therapist.

But imagine if you REALLY lived in a small town, a town where everyone in town knows each other. There’s one second grade classroom and that’s where your kid goes to school. You can’t go grocery shopping without running into ten people you know. And if you want to see a therapist, even if there’s a therapist in your community, you just may not feel comfortable seeing them. While all professional therapists are bound by confidentiality, the reality of small town life is there are multiple unavoidable dual relationships that may impact your comfort level, especially if you are poly or kinky. (For a great piece on dual relationships being unavoidable and not necessarily a bad thing, I refer you to Ofer Zur’s excellent writings on this topic). People know things about you (or THINK they do) just from living in the same town.

Small towns and rural areas are not necessarily more conservative. Mendocino, Arcata and Ashland are great examples of progressive small towns. There are without a doubt PK people who have been living in these communities quietly for many years just under the radar screen of most people.

But what if you want to date? Do you feel comfortable dating in a small community as a PK person, knowing how hard privacy is to maintain? Especially if you are a “pillar of the community?”

The reality is that if you are a rural PK person, you most likely do a lot of driving to be able to find and date like-minded folks. Dating takes more time. Met somebody online and want to have a simple coffee date? Not so simple when you live three hours away. What if you want to go to a party that ends at 11? Do you really want to drive home?

So living as a rural PK person who wants to date means extra money in gas costs, extra time, the exhaustion that driving long distances incurs, especially on rural roads, and challenges finding places to stay.

Here are some concrete suggestions for people who entertain or date rural PK people to show your support of their situation.

1. Offer to pay for their gas – or at least to split the costs
2. Offer to do the driving on your date – they’ve already done a whole lot more just to see you
3. If you are hosting an event, offer a way for people to spend the night rather than have to deal with finding a hotel or driving home
4. If you are dating someone who has come to see you but also has other dates or events scheduled in your area, try to schedule your time with them so that they don’t have a challenge finding a place to stay. For example, if you have a date on Friday night and you know they are supposed to see another sweetie on Sunday, you can change your date to Saturday, see if the other sweetie will change to Saturday, extend your date to two nights, or help them find someplace else to stay.

Finally it goes without saying that if by some chance you do end up visiting them at home, you take your cues from them about how “out” to be.

KARIN WANDREI, LCSW, PHD, lived and worked for sixteen years in a rural northern California county. She does short-term therapy within Rohnert Park and online and loves to work with people in rural communities. Her web site is at www.karinwandrei.com.

The post “Whole Lot of Driving Goin’ On”: Poly and Kinky in Rural America | Guest Post by Karin Wandrei first appeared on Dr. Keely Kolmes.

Fading friendship: When to seek relationship counseling or assistance

Couples and partners often wait until communication, emotional connection, and kindness have completely dissolved before finding their way to a therapist. In fact, according to Dr. John Gottman, a pre-eminent marital researcher and psychologist, couples wait — on average — six years before seeking counseling to help resolve their relationship problems. While relationship therapy can still be helpful after years of relationship distress, seeking therapy as early as possible is one of the most proactive and positive decisions one can make to heal their partnership. (As a primary benefit of seeking counseling earlier, you may enjoy a longer-lasting, fulfilling, and more pleasurable partnership; as a secondary benefit, you will be helping your checkbook, as fewer sessions will be needed.)

The intention of this blog post is to provide three concrete recommendations for when your relationship would benefit from seeking assistance before communication, connection, and kindness are jeopardized. While people in relationships seek counseling for several reasons, such as conflict management, sexual distress/incompatibility, or difficulty resolving finances, this article focuses upon when the friendship and companionship aspects of romantic partnership become weakened. These are three common (and unhealthy) occurrences that can develop within relationships and may serve as indicators of when your partnership may benefit from counseling, a wake-up call, or extensive time for reflection and conversation.

1. You listen and respond to your respected co-worker with more attention and appreciation than your partner(s).

Imagine this: your co-worker sends you an email suggesting a brilliant, new sales strategy to be explored at your afternoon meeting; you immediately reply expressing your gratitude and enthusiasm for your co-worker’s recommendation and integrate this new sales strategy into the afternoon meeting.  Now consider this: your partner sends you a text about possible weekend plans; after initially becoming annoyed that your partner has interrupted your work day, you neglect to respond to the text as you are busy with meetings throughout the day.

If you begin to notice a repeated pattern where you offer more kindness and responsiveness to your co-worker than to your partner(s), this may be indicative of challenges within your relationship that may benefit from being addressed in relationship counseling. There may be several reasons for failing to respond to the hypothetical text message, including stress at work, frequent or excessive text messages from your partner, forgetfulness, or resentment towards your partner for scheduling your weekend.  However, failure to attend to the needs of your partner(s) over a prolonged period of time can lead to emotional distancing, distress, conflict or increased arguments, or looking to others for connection.

2. You find yourself confiding in friends more than with your partner(s).

When you first met your partner(s), you probably spent hours talking about everything – from the embarrassing moments you experienced in high school to the frustrations you have with your boss. Currently, who is the primary person in your life that you turn towards for emotional support, guidance, and nurturing?

If you find that you seek the solace of a friend or a family member more frequently that your romantic partner(s), or if the amount that you used to confide in your partner(s) has been reduced substantially, this may be an indication of turmoil within your relationship; specifically, the decline of your emotional connection and friendship.

While it is wonderful to have friends and family outside of your romantic relationship to provide you with nurturing and support, your relationship may suffer if you no longer experience safety and comfort in sharing vulnerabilities with your partner.

3. You stop noticing the beauty, humor, intelligence, and kindness that initially drew you to your partner(s).

Do you look at your partner and predominantly see flaws? Perhaps you are irritated by how she chews her food, how he fails to take out the trash (despite it overflowing), or how they contribute to conversations with friends. Do you find yourself looking at your friends’ partners and wondering what life would be like if you had a different partner? Have you stopped laughing at the jokes your partner makes, even though they used to make you giggle? This may be a symptom of trouble between you and your partner(s).

Unfortunately, relationships can begin to unravel by having negative patterns of communication become enacted. This can occur due to several reasons, including resentment towards how you have been treated by your partner, psychological difficulties, stress, or simply by failing to attend to your partner’s emotional and sexual needs.

The patterns mentioned above may not indicate imminent doom or destruction of your relationship. However, they may suggest that it is time for you to take action in order to strengthen and re-align the friendship within your romantic partnership(s).

A struggling relationship does not always consist of screaming matches, sleeping in separate beds, or secret extramarital affairs. Often, emotional distancing and feelings of isolation become one of the first symptoms of a struggling relationship. This distancing slowly deteriorates the original friendship that holds a strong relationship together. By acknowledging these signs and symptoms as soon as possible, you have a much better chance at healing the emotional connection with your partner(s), strengthening your foundational friendship, and enhancing your loving partnership.

DR. BETH GADOMSKI is a Bay Area-based psychologist with a private practice located in San Francisco’s Financial District. After several years providing counseling at the University of California, Berkeley, and Stanford University, Dr. Gadomski currently provides therapy to individuals, couples, and partners in her downtown office. Her areas of specialty include depression/anxiety, grief/loss, couple/partners’ therapy, identity integration/development, alternative sexualities, and eating disorders. Dr. Gadomski is an Associate of Dr. Keely Kolmes and has a page on this site; you can find out more about Dr. Gadomski through her own website, www.integrativecounseling.com.

The post Fading friendship | Guest Post by Dr. Beth Gadomski first appeared on Dr. Keely Kolmes.

Tell-Alls and Say-Nothings: Differences in Sexual Communication Styles

Every time James’ wife came home from her Book Club, faced flushed and happy from the walk, her husband questioned her about what lover she was with and the details of her assignation.  James was 85 and his wife a pretty and youthful 74.  Theirs had been a monogamous union for more than 25 years and he would have sworn to her fidelity.

Nonetheless, he was eager to hear about her sexual adventures, real or imagined.

Whenever Lila’s wife returned home in the evening she was greeted with a perfunctory kiss and a rather cold “I hope you had a nice time.” Lila and her wife had an open relationship and her wife had, in fact, been meeting her other lover.  Their agreement was no overnights and no sharing of details whatsoever.  Each woman demanded and received her privacy.

James was a Tell-All, even if all there was to tell was a fantasy or a long ago memory. Lila was a Say-Nothing, with no asking, telling or sharing of sexual outside events.

These classifications are the result of a small study I did years ago into the agreements couples make about sex outside their relationship for my Master’s Thesis. I’m sure you have encountered people like this.

As long as all people in a relationship have the same communication style – wanting to share and hear about sexual events or fantasies or keeping one’s mouth shut about such things – there is unlikely to be a problem.  If one wants to talk about them and the other not to hear or even know, there is likely to be discontent or even blow-ups. Identifying these styles won’t solve the disparity but it does help to know that each has an individual preference. Acknowledge this, and work on setting boundaries around this issue. If you need help, a psychotherapist with experience working with open relationships may be able to assist you.

ISADORA ALMAN is a California licensed MFT, a Board certified sexologist,  and author of several books including Doing It.  Her syndicated sex and relationship column Ask Isadora ran in alternative weekly papers worldwide for more than 20 years. Web surfers can find her on Psychology Today Online or her online or her free interactive Sexuality Forum at www.askisadora.com.  She conducts her private psychotherapy practice in Alameda.

The post Tell-Alls and Say-Nothings: Differences in Sexual Communication Styles | Guest Post by Isadora Alman first appeared on Dr. Keely Kolmes.

The Brave Act of Seeking Connection

“Here we go again.  He won’t stop criticizing everything I do.  I don’t know where his anger is coming from, but I can’t take it anymore.  I feel like I can’t do anything right.  So what do I do in response?  Naturally, I shut down.  What am I going to do, keep arguing with him?  It’s so much easier to just go off on my own.  I don’t need him.  I don’t “need” anyone.  Do I miss those times when I feel close to him, when he makes me feel like there’s no one else in the world?  Of course I do.  But there’s no way I can tell him that I miss him.  He’ll probably just laugh in my face, and then I’d look weak.  So of course I’m going to pull away.  And the crazy thing is that when I pull away, he nags even more.  I just can’t catch a break.  This has been going on forever.”

My friends, this vicious cycle of criticizing and withdrawing is extremely common.  The bad news is that it can lead to frustration and heartache.  The good news is that there’s a way to break the cycle, and that’s through seeking connection.  Sure, it’s scary to admit that we might actually need another human being.  From the time we leave our parents’ homes, we’re taught to be self-sufficient.  Our Western culture tells us to be rugged individualists, to handle our emotions and our problems ourselves.  And yes, there’s always a risk in revealing our “softer” side: the part of us that wants to hold our partner, the part of us that wants to be held.  What if we reach for our partner, revealing this vulnerable part of us, and they don’t respond?

In couples therapy, there’s a way to break this vicious cycle.  Let’s dig beneath the criticizer’s anger; what often lies beneath is an unexpressed longing.  Let’s look at what the withdrawer is really feeling; after endless torrents of criticism, often it’s a feeling of “not being good enough.”  Let’s introduce a new cycle of “turning towards each other,” of directly expressing our needs.  Want to know what can happen when we do?  Despite what we thought when all we saw was the criticizer or the withdrawer, our partner is actually a human being, full of compassion!  Our partner will likely be surprised to learn that we really feel as we do.  Our partner will likely be touched by seeing and hearing about our struggle, our pain.  And what will our partner’s natural inclination be?  To embrace us.  So what happens when we take this risk and seek connection?  Often, we find that our partner will “be there” for us.  This is so comforting to know.  In the future, when we need them, they will be there.  Having experienced this, we’re more likely to “turn towards” our partner, again and again.  Through the brave act of seeking connection, we can create a solid and predictable base of support from which we can conquer future challenges – together.

ANDREW KUSHNICK is a Marriage and Family Therapist Intern at the Well Clinic in San Francisco’s Financial District.  As a former practicing attorney, Andrew brings conflict resolution skills and an analytical sense to his work with couples, while offering a gentle and compassionate perspective.  Andrew can be reached at 415.496.5321 or at andrew@wellsanfrancisco.com. Visit his webpage at www.wellsanfrancisco.com/staff/andrew-kushnick/

The post The Brave Act of Seeking Connection | Guest Post by Andrew Kushnick first appeared on Dr. Keely Kolmes.