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Celia Falicov, Ph.D. - Guest
Celia Falicov, Ph.D. is a clinical psychologist and family therapist in San Diego, California. Celia is the Director of Mental Health Services at the Student-Run Free Clinic Project of the Department of Family Medicine at University of California, San Diego. She was also the previous president of the American Family Therapy Academy (AFTA) and has published numerous books and articles, including: Family Transitions: Continuity and Change Over the Life Cycle, Cultural Perspectives in Family Therapy and Latino Families in Therapy, and Multiculturalism and Diversity in Clinical Supervision with Falender and Shafranske. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:21)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. Today I'll be speaking with Celia Falicov PhD, who is a clinical psychologist and family therapist in San Diego, California. Celia is the director of the Mental Health Services at the Student Run Free Clinic Project of the Department of Family Medicine at the University of California San Diego. She's also a past president of the American Family Therapy Academy and has published numerous books and articles including Family Transitions, Continuity and Change Over the Lifecycle, Cultural Perspectives in Family Therapy and Latino Families in Therapy, and has co-authored the book Multiculturalism and Diversity in Clinical Supervision. Let's listen to the interview. Well, hi Celia. Welcome.
Dr. Celia Falicov: (01:20)
Hi Keith. Good to see you, and to say hello. Yeah.
Dr. Keith Sutton: (01:25)
Yeah. Thank you so much for joining me on the podcast today. So I, uh, know of your work from, of course reading your work in graduate school, and particularly I think my first introduction was in Monica McGoldrick's Family Life Cycle book. Um, I got to see you at the Association of Family Therapists of Northern California Conference when you came for the weekend, um, teaching about working with Latinx families. Um, and, uh, particularly, you know, just been interested in your work and was, you know, reaching out to you to see what you've been up to lately and now. And, um, so, but first before we got into that, cuz you, you sent on some great articles and some of the process kind of work you're doing and, and kind of looking at, you know, collaboration with clients, uh, and therapists, particularly in, in low income and diverse populations. But before we even get into that, I'd love to hear your story. I'm always interested in folk’s kind of evolution of their thinking and how they got to be thinking about what they're working on today.
Dr. Celia Falicov: (02:26)
Okay. Okay. Uh, so I don't know how much, uh, you know, about sort of my personal history, but I think it is somewhere, uh, I think, um, importantly connected to my way of thinking and my development as a therapist. I was born and raised in Argentina, and I'm actually the first person in my family born in Argentina because my parents and my grandparents were immigrants. And, uh, so a little bit of the paradox of my life is that I grew up in an environment of immigrants and, but I also came to this country fairly early in my life, uh, newly married. And, uh, and so then, and, and for, you know, socio-political reasons we could not really return because there was a military dictatorship and my husband and I had been somewhat involved on political things that were left wing, and at that time it was a right wing dictatorship, so we remain in this country.
Dr. Celia Falicov: (03:29)
So I have a lot of personal experience of immigration. And, um, and I also have I think a lot of personal experience of living in a very large environment - large family, large extended family with my parents and my grandparents living very close to each other in a radius of about two or three blocks. I had all my aunts and uncles on both sides of the fence. So because they were immigrants fleeing the violence of Europe towards Jews at that time, and for programs, and, uh, you know, recently, uh, I found out something that I had never written about, uh, that, uh, in doing some research on my family immigration history, and I don't know whether they knew this either, uh, was that the, uh, person that I have that was my name was given to me by my great, my grandmother, and it was the name of her mother.
Dr. Celia Falicov: (04:29)
And, uh, and the same thing is too, with my brother, the name of her father, both of those people and through more, uh, died in, uh, concentration camps. And, and we, you know, didn't know that until last year when I did some research. So I have always been very aware that socio-political events, you know, that social context influence a family's life in ways that are beyond their control. I'm sure that, you know, they didn't want to leave, that was their home. And so, but they had to, and that has, uh, created a great deal of empathy towards the immigrant, uh, point, uh, for me. And so, um, maybe I will be saying something that, I'm jumping to my work, but I wanna say that I believe that one of the things that I've done from the very beginning is include and culture, also context, because it completely, you know, alters the situation. And I also think that it's very important for people to learn about the impact of immigration in family lives, which is very different than looking at culture in a fixed way, you know, or culture as separate from context. So yeah.
Dr. Keith Sutton: (05:54)
So kind of thinking about culture on the bigger context, but also on the individual experience of through immigration or kind of those multiple kind of layers.
Dr. Celia Falicov: (06:02)
Yes, yes. And that, you know, we talk about cultural competence, but the truth is that we should also have migration specific competencies.
Dr. Keith Sutton: (06:13)
Yeah.
Dr. Celia Falicov: (06:13)
And I have, and I think a lot of my work is, and, you know, it reflects that, reflects an interest in understanding immigrant family process.
Dr. Keith Sutton: (06:24)
Mm-hmm, definitely.
Dr. Celia Falicov: (06:27)
Okay. Um, so tell me again what question we are asking me about my background. Yeah, so your evolution of your-
Dr. Keith Sutton: (06:35)
Of your thinking. So yeah. So you're talking about kind of your experience with migration yourself, and, uh, yeah. Would love to hear other experiences that's kind of led to your thinking.
Dr. Celia Falicov: (06:48)
Yes. And also being the first child born in a different country, it put me very much in the position of a cultural broker between cultures, and as we know, the second generation many times does, you know. Yeah. And, so, and that was also a kind of separation, you know, emotional separation because I was the first one to go to school, the first one to be educated. And so I, in many ways, I lived in two worlds. And so that I think I, I thought that the way of growth was education, and education was free in Argentina. So that's where I really started going to the University of Buenos Aires. And I first started with philosophy because I was very interested in philosophy, and I still am. Um, but I decided that I, that it also was important to make a living and, and I was in, and psychology was part of philosophy at that time.
Dr. Celia Falicov: (07:51)
Mm. And so that's how I started studying psychology. But then in my early twenties, got married at age 20 actually. And, uh, my husband was a physician and was just out of medical school. And so we came together for postgraduate training for him. And so eventually I, after having different jobs, you know, as an EKG technician, as a file clerk, I began studying back in the United States. It was very important to me. Uh, and I had to do a lot of equivalencies, you know, like learning American history, learning geo American geography, uh, so that I could have the equivalent of an undergraduate degree here. Then I went for a master's in psychology to Loyola University. And, and I was very lucky during an externship, I met a professor who said, but you should really should go on for say, PhD.
Dr. Celia Falicov: (08:58)
And I said, well, no, it's impossible. I can't afford a PhD. And it wasn't a time where you could really get great scholarships. And I was very lucky I was able to, and the place that I decided to go into that path, psychology as part of it was at the University of Chicago, uh, the Committee on Human Development. And the reason I bring this up is that it is very important to what happens to me professionally. I think it's probably the best thing that happened in my life. You know, I, I love the program, I love the university, but also, um, it, it taught me that you need more than one discipline to understand, you know, the human phenomenon. And that committee was anthropology, sociology, biology, and psychology. And so, and every stage of the life cycle was seen through those four lenses.
Dr. Keith Sutton: (09:55)
Oh, great.
Dr. Celia Falicov: (09:56)
And so I learned to think culturally and developmentally all the time, and I think I brought that into learning about family therapy. My dissertation actually was going from a dyad to a triad, and cause that was the, and I did that during my first pregnancy. So, because I was very interested in how a couple becomes a family. And so, uh, I think that's when I began to think about family as a, a way of, of solving problems as well as creating problems. So, I think probably I would say that I became a family therapist and as soon as I finished graduate school in, in early 1970s.
Dr. Keith Sutton: (10:47)
Yeah. And that was really the, the heyday of family therapy and really kind of, you know, a lot of, a lot of movement and a lot of exciting things going on in that field.
Dr. Celia Falicov: (10:55)
Yes. Yes. I was very lucky enough to be a chartering member of the American Family Therapy Academy and meet a lot of the people who were writing about it. So, so I was, uh, and then in, actually immediately after graduate school, I went to the Tavistock Clinic in London and did postgraduate training there. And that was also very influential, uh, because I had been, particularly at Loyola, I learned a lot of psychoanalysis. And the Tavistock Clinic at that time was very strong in that. Um, but I was very lucky that Sal was there for three months sabbatical, and I started following him. And I had been quite, um, shocked, uh, in, in the, in the child department there, because in ground rounds, many of the therapists were presenting the work with children and they were never, never seen the parents, the parents were seen by the social worker. And, uh, and they would make all kinds of hypotheses about the parents, usually quite dysfunctional, usually quite negative.
Dr. Keith Sutton: (12:15)
Yeah. Kinda without apologizing.
Dr. Celia Falicov: (12:17)
Yes, yes. Without ever meeting the parents because they wanted the child to have transference towards them, and they wanted, you know, to not be disturbed in any way in terms of understanding the inner life of the child-
Dr. Keith Sutton: (12:30)
-and the therapist being a good attachment figure.
Dr. Celia Falicov: (12:33)
Exactly. Exactly. Yes. And I thought that was an injustice to the parents. Not only because I was a young parent myself at that time, but also because I thought, you know, it's like, this is very hypothetical what they think is happening, you know? Rather than really touching the reality of the child's life, which the child, of course will go back every day to the parents, right? to them. So that's, I think, when I really began to, to want to do family work. And I came back to Chicago Uhhuh and became part of the family systems program at the Institute of Juvenile Research, and I stayed there for almost nine years.
Dr. Keith Sutton: (13:16)
Wow. Great.
Dr. Celia Falicov: (13:18)
So that was really the basis of my training, and everybody went through there called Whitaker. You know, they were lecturing, they were being invited to do that. And I, you know, sort of began to think of it as, uh, very important, you know, very instructive, very nurturing from an intellectual point of view, but at the same time, too many directions in which to go. So, and because we were working with a very indigent, very, you know, poor population of whites, Latinos and blacks in the west side of Chicago, the Philadelphia Child Guidance Clinic approach seemed very appropriate. Yeah. So in 1976, I went for a summer to Philadelphia to study there.
Dr. Keith Sutton: (14:11)
Oh, great.
Dr. Celia Falicov: (14:12)
So I have a strong basis on structural family therapy from that experience. Yeah. And, uh, and then I went for a course at, uh, MRI now, which yeah. No longer that program is strategic like it used to be, but I had a month of that work there. And so, so that was, and so it felt a little bit like the parable of the Chinese parable of the, all the people touching an elephant and having it a part of it, you know? So, um, but it was-
Dr. Keith Sutton: (14:46)
-well it’s integrating, right? And kind of learning from all those different perspectives. That's so important. It sounds like you got incredible training.
Dr. Celia Falicov: (14:53)
Yeah. So, so it served me very well, because then I could see that I could use different things for different families. And so it was, it was a great, yeah. And during those years, you know, of work and in Chicago, I also became a very sociopolitically active. And, uh, there was psychologists for social responsibility, there was a fantastic speech that Martin Luther King gave to the APA that influenced me a lot, you know, because he really encouraged psychologists to, uh, create a society for creative maladjustment. And, and it was like humorous, like creative maladjustment. But he then described that it was creative maladjustment, uh, to fight back a society that discriminated against people that affected their mental health through racism, through, you know, classism. And so, uh, and there was all the gender issues at that time too. You know, we, we keep on revisiting the same issues and hopefully improving a little bit each time, but, you know, they come back. And so, uh, the whole issue of women's liberation was very important at that time too. And I joined the group and continue to be in touch with those women actually. So that's, uh, yeah. So, and that has also, you know, influenced my work a lot,
Dr. Keith Sutton: (16:27)
Social justice.
Dr. Celia Falicov: (16:29)
Yes, yes. Absolutely. And I think, you know, a lot of what has happened in the cultural competence world is that we talk about, you know, culture in ways that are, you know, quite fixed and stereotyped and conflated with social justice. And I really do think that they require different interventions, you know, and different thinking when we see families. So hopefully that's happening more and more, you know, the difference separating-
Dr. Keith Sutton: (17:00)
-Those two pieces out, the, the cultural competence and the social justice pieces.
Dr. Celia Falicov: (17:06)
Yes, yes. Yeah. What is cultural diversity, you know? And we need to study that, but we also need to understand social justice and how they interact and sometimes, you know.
Dr. Keith Sutton: (17:17)
Definitely.
Dr. Celia Falicov: (17:20)
So, um, I think when you met me, um, my belief is that it must have been about 2010, it was in northern California, right?
Dr. Keith Sutton: (17:38)
Probably, yeah. Probably around then.
Dr. Celia Falicov: (17:40)
Yes. And I thought that at that time I spoke, uh, about what you said, uh, but maybe the title was One Size Doesn't Fit All.
Dr. Keith Sutton: (17:50)
Mm, I think so.
Dr. Celia Falicov: (17:52)
Yeah. And, uh, and it's possible that, you know, at that time, uh, that, and I still today, I think what I mean by that is that we tend to, um, we have tended and, and unfortunately still today, um, used, um, knowledge, let's call it that way, that is developed in even within family therapy as, as universally applicable, as it fits everybody. And so, for instance, I was telling you earlier that I grew up very much in a three generational family. My grandparents were incredibly important to me. I saw them every day. And, uh, and when you look at what is it that we do in actual family work, we utilize the principles that apply very well to nuclear families, but not, don't apply so well to very large sibling groups, to, you know, three generational families or grandparents should be part of the therapy
Dr. Celia Falicov: (19:00)
And so, uh, things like that, you know, the fact that we tend to develop things that are good for white, middle class nuclear families. And then translate them fast into thinking that families that are families of color or, or different religion with very large number of children, uh, and sometimes three and four generations living together, because parents tend to have children much younger when they come from lower socioeconomic levels. And then we just think, oh, no, you have to pay more attention to this child. Now that is being, when this child is being taken care by many other people, all their siblings. So I think all those things are very important for family therapists to understand, you know, that one size doesn't fit all.
Dr. Keith Sutton: (19:53)
Yeah. Yeah. Jim Climb, uh, uh, is part of my group, and we talk about sometimes he wrote about kind of the hard side and the soft side of hierarchy. The hard side of structure and rules and so on. And the soft side, the attachment, the relationship, who soothes whom, and oftentimes in, uh, multi-generational families that the grandparents may be, you know, providing that, that kind of attachment and kind of, you know, warmth and so on, whereas the parents might be providing more of the structure or, you know, that these, these roles may be kind of, you know, held by different parts of the system, rather than kind of just saying, feeling like one person has to hold all of that together. And oftentimes that's a, a lot of difficulties of families that immigrate to the United States, because sometimes they leave that generation in their, their country that they came from, and then now are trying to learn how to deal with kind of creating more of that balance or shifting to meet the needs of the kids.
Dr. Celia Falicov: (20:52)
That's an excellent description. Yes. That, you know, that covers both the issue of family structure and also the evolution of those things, you know, and how, yeah, in, you know, with immigration. So, and the other way in which one size doesn't fit all is that within groups, you know, say the Latino group or the African American group or the Asian groups, there's enormous variability.
Dr. Keith Sutton: (21:19)
Yes.
Dr. Celia Falicov: (21:20)
So when, when we are given a number of characteristics from an ethnic focus point of view, it doesn't take into account the multidimensionality of, you know, every group really.
Dr. Keith Sutton: (21:35)
Yeah.
Dr. Celia Falicov: (21:35)
Many, many subgroups within every group. So I have, if we go back to sort of my historical development professionally, I think Monica McGoldrick, like you mentioned, invited me to write in the book on the family life cycle. And so it was my first chapter publication in an edited book. And, and I did write also an ethnicity and family therapy book and tried, uh, you know, hard to, just looked at only the cultural piece. But then in 1983, I published and edited my first edited book, which was Cultural Perspectives in Family Therapy. And at that time, it's a small book, uh, by Aspen Systems corporation. And in that book, I invited several family therapists, the younger ones at that time, like Jayla and Bravo, to write chapters in that, in that book that had to do with race, with class, uh, al wrote, um, on class, uh, and on rural and urban families. So it was a much broader way of looking at culture.
Dr. Keith Sutton: (22:59)
Yes. Yes. Definitely.
Dr. Celia Falicov: (23:01)
And that, and that remained that way for me, that you really have to look at all of those dimensions and not just-
Dr. Keith Sutton: (23:08)
The intersectionality
Dr. Celia Falicov: (23:10)
Exactly, exactly. Pieces. Exactly.
Dr. Keith Sutton: (23:12)
Definitely.
Dr. Celia Falicov: (23:13)
Yeah. I called it ecological context at that time, but it's the intersectionality of all those issues.
Dr. Keith Sutton: (23:19)
Yeah. Yeah. And I think that, you know, cultural competency is not just knowing kind of the, the bullet points about these different cultures, but both kind of the larger macro culture, the emic culture, as well as the microculture of the person's experience and kind of that piece. But, and also, I don't know what your thoughts are, but I also think about, especially as a white, you know, cisgender male therapist, that also looking at one's privilege, that one's bringing into the work, rather than just focusing on how the other is other.
Dr. Celia Falicov: (23:51)
Yes, yes. Absolutely. And that, you know, that brings us to, uh, the, the idea of cultural humility Because cultural humility, which in fact was something developed within the group or, or the, the discipline, say, that, that I'm very involved now, which is, uh, family medicine, you know, and, uh, it, it is family medicine that first came up with cultural humility, teaching physicians that they needed to understand how much power they have in that relationship and be aware, you know, of the fact that the client should be more of an expert on their own lives, you know, the patient. And, uh, so cultural humility is both understanding that you bring it, which is another way in which one size doesn't fit all, right. Like, whatever the, the provider, uh, thinks is just, it's also culturally based, you know? And so to, to understand that, what, what are your cultural values? And what is your privilege, like you said. So it's both the diversity and the power issue.
Dr. Keith Sutton: (25:06)
Yeah. And I always think that, you know, and when I'm supervising or teaching is that, you know, when we kind of run up against like, oh, it should be this way, kind of in our head, that's the cue to actually step back and get curious, because often we might be super imposing our own beliefs and values onto the client's experience, and then getting curious, we can oftentimes learn about where that may not be fitting.
Dr. Celia Falicov: (25:30)
And be careful not to impose your
Dr. Keith Sutton: (25:33)
Yeah, exactly. Yeah. Then you created a model for actually looking at all these aspects of culture. Um, I think you called it the MECA model, right? The multi-dimensional, ecological comparative approach.
Dr. Celia Falicov: (25:48)
Uh, I actually, let's see. We make a little bit of history. Um, I started, uh, with presenting the model in 1995 in a family process article called Training to Think Culturally. And the basic idea was that by having either a universal approach where everybody is saying, or having a paid particularistic approach where each person is different, both of which are, are valid, um, in that we do have a lot of similarities. And in fact, you know, we also have very significant difference with each one of us is unique and singular. Um, but sometimes, I know I give the example of we share 99.9% our DNA,, biologically and also psychologically we have a lot of similarities. But it's also true that our thumbs are, each one is different, and that's why we can identify an individual that way,
Dr. Celia Falicov: (26:58)
and I think therapists need to absolutely know both things, the universal processes and, and also investigate what's particular about the person. And then we had the ethnic focus approach, which gave us a lot of information about various ethnic groups and cultures, but I thought, you know, that, that we need yet another approach that combined those three in the sense that we could ask what difference to really make a difference to us as therapist. You know, things like foods or rituals we can find out from people if it's necessary, but they're not really essential to the processes of that, but I came up with four things in which I think, um, they're sort of like vessels without content necessarily, where we can investigate those four dimensions or domains, and they are migration acculturation, which generally has been neglected in cultural competent cultures.
Dr. Celia Falicov: (28:08)
as migration specific competencies, uh, then ecological context, you know, everything that has to do with how everyday life of people is influenced by the environment they live in. And, uh, then a family organization, which I think it does vary across cultures and, uh, and family life cycle, that it also has its own values and norms and, uh, learning for transitions, you know. So, I came up with those four domains in which I believe there are, there are differences and also similarities. That's why, and I call that in a rather complicated way, the multidimensional, comparative, ecological approach. MECA called multidimensional, ecological, comparative approach. And multidimensional is because we have to take into account everything that intersectionality today takes into account: race, class, religion, political ideology, sexual orientation, all of those. And so that's why culture is multidimensional. And, um, then, I think that the ecological part of course, is what I already described as, as people's social circumstances and comparative, is because I thought that by having so many dimensions, within the focus approach, it would be hard to compare the therapist with the client, the including the supervisor with a therapist and the client.
Dr. Keith Sutton: (30:01)
Sure.
Dr. Celia Falicov: (30:02)
So this days I actually call in the majority of my workshops, psychotherapy as a multicultural encounter.
Dr. Keith Sutton: (30:11)
Hmm.
Dr. Celia Falicov: (30:12)
Cause it isn't like it with cultural competence, we have to know about the cultural of the other. And this a kind of otherness that is established in the beginning, you know, by studying about the other instead of spying about self of the therapist.
Dr. Keith Sutton: (30:28)
Yes.
Dr. Celia Falicov: (30:30)
And so then I, by doing that, I sort of invited a knowing and not knowing attitude towards culture. Like I know that something may be going on when it comes to migration, ecological context, and family organization of family life cycle, but I don't know exactly what it is. So I could ask about those domains. In the slides that you're gonna put online, the last one is something that people have begun to use as an intake form.
Dr. Celia Falicov: (31:10)
There are the four dimensions. So four domains are something that therapists can fill out while they're talking to, to their client. Uh, but they can also do it by the templates.
Dr. Keith Sutton: (31:28)
Sure.
Dr. Celia Falicov: (31:29)
Or they can even do it together with the client and the family, and, you know, put it like a big sheet of paper on the wall or in a blackboard.
Dr. Keith Sutton: (31:41)
Yeah, great.
Dr. Celia Falicov: (31:43)
And usually it tells you then where the issues might be that people wanna work on. And you can also ask, would you like us to start with, you know, your transitions that have to do with generational differences, different migration, or should we start with the fact that you are a large family and you know, and a small family and have issues with this, with your extended family.
Dr. Keith Sutton: (32:17)
Definitely. Well, great. Yeah. And having those conversations together as a family, which may, you know, kind of bring some things to the forefront that maybe, you know, can be good conversation or maybe other parts haven't really talked about out loud or so on. And I think like you're saying, that kind of interplay between the therapist and the client, because I, I think that, like you're saying, and particularly me, you know, as a white cisgender male, heterosexual, you know, person with, you know, multiple levels of privilege, that as a therapist, my work is to be aware of myself and also my privilege. And, rather than just the focus of, focus on how somebody else might be culturally different, because I think that that's so important, like you're saying, is that interplay between the therapist and our client, rather than just kind of focusing on the client being different and understanding those differences.
Dr. Celia Falicov: (33:17)
Yeah. And so that's much more about cultural humility than about cultural competence for your awareness. Yeah. Your awareness of both, you know, your possible differences in, in values cultures, but also your power differential. So in a way that helps a little bit to equalize the relationship more.
Dr. Keith Sutton: (33:40)
Definitely.
Dr. Celia Falicov: (33:42)
Yeah. You could even say things like, uh, you know, for me culturally, it would work this way, but I'd like to understand more of how it would work for you to do this, or you know. Or how would people in your culture would advise you, yeah. How to deal with your daughter, approach it.
Dr. Keith Sutton: (34:04)
Yeah. Yeah. And I think about that too, when, when teaching or supervising that, oftentimes when the therapist is thinking, oh, well it should be this way or so on, or things aren't going right or so on, rather than actually moving forward, that's the moment to step back and actually be curious because, you know, when you think like, why is that happening that way? It doesn't seem right or something like that, then we may be imposing some of our own cultures or assumptions and, and being curious and kind of oftentimes sharing that in a transparent one down way may help actually open up a conversation and a deeper understanding. But again, rather than saying like, you know, how are you different from me? More saying, this is the way I think, I'm wondering if that is similar or different from your experience.
Dr. Celia Falicov: (34:52)
Yes, yes. And, you know, you mentioned curiosity. It's a very good idea to have that kind of openness of talking and not assuming that you know, or that not assuming that you have the right way. And I've seen, unfortunately, sometimes I've seen therapists say, for example, on the belief I may not be in direct belief that the person should take medication. And, but then they, they, they would interpret as resistance. They, they kind of react to do that instead of asking, so, you know, why do you feel this way? Are there other things you are doing? Or, uh, you know, tell me more about this because I've seen therapists, like why can't, why can't you do that? and, you know, shrug their shoulders. You know, in a way that is not so totally respectful. So curiosity and respect are very, very important, you know?
Dr. Keith Sutton: (35:49)
Definitely. Yes.
Dr. Celia Falicov: (35:51)
And many times people, many people from different cultures are sufficiently acculturated that they know that we are providing a service that may be somewhat different, but it would be in their cultures and maybe they still want to have both, you know, they're exploring what we call the dual system of treatment. Yeah.
Dr. Keith Sutton: (36:11)
Yeah, definitely.
Dr. Celia Falicov: (36:12)
And having a conversation about that and gaining the trust. Right. Building trust by doing that. Um, but you know, I don't wanna forget about the issue of comparison, because this is also an instrument that allows you, as a therapist to, can you imagine yourself in the same thing, in the same domain. You know, do you have any experience with immigration that your family have it did your three generations ago, had it, uh, sort, sort of in a way, you know, again, it humanizes you by being able to compare all the same domains, you know.
Dr. Keith Sutton: (37:00)
When I found, I know that I found your way work very, uh, powerful and when I was in grad school and thinking about my own experience of, you know, migration, which again, I was born in the United States, but I, you know, moved away from home for college and then graduate school and so on. And so very different experience than somebody who came from a whole different country or so on. But I mean, part of our work as therapist is to be able to imagine what that might be like, to be able to connect with our own sense of feeling disconnected maybe from our family or from our home, or, you know, kind of, uh, needing to all of a sudden build new social supports and these kinds of things. Again, on, on much of a, uh, a much lower level of my own experience, but then kind of connecting that to, you know, my understanding and my experience of my clients because, you know, we can't truly understand our clients if we can't connect with that part of ourselves. That has felt a similar feeling.
Dr. Celia Falicov: (37:58)
Yes. Absolutely. Very well put. And we could use that metaphor for many types of relocation, even just leaving home from the west coast to go to the East coast for college. Even if you have that privilege, it doesn't mean that that first year is, it's a very difficult, uh, that patient, right. Of knowing a lot of new things that you didn't know before. You know? So, so, um, and, and it is also the case that supervisors have their own cultures and many times, including their own belief systems about theory. Having a comparison, a way to compare themselves both to the supervisee and the family they're talking about together. It's something that organizes what we are thinking.
Dr. Celia Falicov: (38:54)
And, uh, recently I've been giving workshops, the title, our supervision as co-vision instead of supervision as being able to carry your way of seeing things that the supervising has to adapt, but one that is a collaboration and, and in which both people and the family are transparent about their values or beliefs, and their experiences even.
Dr. Keith Sutton: (39:22)
So not only kind of the therapist working with the family, family and looking at similarities and differences together, but also the supervisor and the therapist as well as the supervisor and the family that they're discussing. You know, kind of those, those multiple levels of, of transparency and, um, curiosity.
Dr. Celia Falicov: (39:43)
You know, the supervisees that I have talked to say that when that is happening, when they use this way of talking to each other, that their anxiety decreases. That they're feeling more like they're human beings their thoughts and their values and their feelings. And so, uh, it is a good way to start, you know, rather than what are your problems with, with the family you're seeing.
Dr. Keith Sutton: (40:16)
Definitely. Excellent. Well, great. Well, these are wonderful resources and definitely be helpful for clinicians as well as clinicians in trainings and supervisors, uh, you know, and one to look at these kind of multiple aspects that are the client's experience and affecting the client, as well as also reflecting on how that interplay with the therapist's experience, and supervisor and supervisee.
Dr. Celia Falicov: (40:42)
Yes. I believe that it is also a way to avoid just using stereotypes, cultural stereotypes, because you are engaged in a different process of understanding rather than inclusive. So, I think that's, I, you know, I think it sends the message that we all are encompassing in for the domain in similar and different ways. And so, uh, it avoids the danger of the single story, both for white people, because we also should avoid having a single story for what white privilege is or, you know, or superior positions are. And, uh, and what it is to be.
Dr. Keith Sutton: (41:34)
I think that, you know, one of the things I thought was really important about, and I'll, I'll let you kind of set it up and everything, but was, it was interesting because it was, it's focused on collaboration, but also I think that it makes an important point of the therapist also being directive while at the same time collaborative. And I think that that kind of aspect I thought was just so interesting as kind of a melding, cuz I think some therapists get a little worried about how they're collaborating with clients and also around working around culture or working around the issues that the, the clients are dealing with and, and bridging those gaps. Um, yeah.
Dr. Celia Falicov: (42:11)
Well, I could start by giving you a little bit of the context of that article. Yes, so the article I think is called Communicative Practices, that center or decenter clients, client's voices, something close to that, that's, oh, I think it's called Centering the client's voice. Right. Centering client's voices. Um, in the last two falls before the pandemic, I was in the Harvard Medical School during the autumn and, uh, as a visiting professor in the Multicultural Practices Unit, that is directed by Margarita. And if you are visiting, they don't just let you visit. You have come up with a project. And use their data in the project. And they had this research going on. They had several types of research, but this, the research that attracted me was one where they were training mental health workers, therapists primarily, on something that came from the medical field called shared decision making.
Dr. Celia Falicov: (43:35)
And, they were training, you know, hundreds of therapists. And so they had a lot of quantitative data, but they hadn't done any qualitative work. And so I wanted to take a few of those cases, and study, uh, in depth the processes that went on. They had lots and lots of audio tapes, so I could have, could ask them to do transcripts of the audio tapes. And so shared decision making is something that medical students are learning about setting the agenda, with the patient, rather than just the, the doctor, you know, saying, This is what you need to do,
Dr. Keith Sutton: (44:24)
Rather than just talking at them
Dr. Celia Falicov: (44:26)
Yes. Talking at them in a sort of paternalistic way, you know, and I'm sort of not aware of what you were saying earlier about their privilege and their power and so shared decision making equalizes a little bit more. This is therapy situation. So that is in some ways the first take to towards collaboration. So one of the first things, so I came up in my analysis with I think five different things, five different themes, right. By analyzing the processes. And the first one was how many times therapists come in and don't really say what would you like to talk about today? They would say things like, so what happened the last time you were telling me last time such and such? And, uh, so what happened with that? What happened when you came to your child's school?
Dr. Celia Falicov: (45:27)
Or what happened when you, the social worker interviewed you? And so that's set up already the agenda, rather than saying, what would you like to talk about today? How would you, like, what would you like us to do together? Right. And so that, and the idea of revisiting the previous session certainly was, you know, a way of connecting. Meaning I know you, you know, I have an alliance with
Dr. Keith Sutton: (45:55)
Bridging.
Dr. Celia Falicov: (45:56)
Reaching, yes. Which wasn't necessarily bad, but I was surprised at how many times the therapist ran with that and kept on asking more questions about the meeting that they had or, yeah. And rather than giving any voice, centering the voice of, because in some ways you invite change, by, by saying, what would you like to talk about today? Rather than saying, we're talking about only the same themes.
Dr. Celia Falicov: (46:24)
Well, people change, maybe they have a new preoccupation, or maybe they resolve what they did before, or it can come back later in the session. So it's very important that, so I started thinking, I think at that time, like we all talk about collaboration. That's our new, new way of thinking, right? We all talk about the patients being experts on their lives rather than us coming in as experts, but how do we actually do it. So in this more microscopic look, I was able to come up with some ideas about how do people, which are the therapists that then score in shared decision making, and the ones who scored more. The second theme, uh, was just simply looking and it was easy to do a percentage of time that therapist talked in relation to percentage of time that the, um, client talked. And, uh, there was, there was one of the cases where a woman was very, very distressed over the fact that her children had been taken away from her.
Dr. Celia Falicov: (47:37)
And, uh, and that she was doing her best to bring them back with her behavior, stopping some of the more, uh, negative things. And, uh, the therapist just talked the whole time about, uh, what she should be doing, you know, from take a shower, uh, stop doing this, you know, and, and, and the patient, you know, the client was saying all the time. Hmm, hmm. Mm You know, like honoring something that was, uh, helping the therapist in a way by saying, oh, I understand. But, you know, was she gonna do it?
Dr. Keith Sutton: (48:19)
Yeah. Being maybe somewhat agreeable, but not necessarily emphatically like, yes, that's that's what I need.
Dr. Celia Falicov: (48:24)
That's, or elaborating or asking a question. Like, well, it's hard for me to do that, or, you know, anything. So, um, it's not necessarily that it has to be equal balance, but it's an important thing to look at, you know, how much space are you leaving for an exchange or even for hearing the client's voice.
Dr. Keith Sutton: (48:47)
Yeah. And it was, uh, in that article too, you kind of pointed out like there was, you know, one, one extreme where it was a therapist talking the majority of the time. Then also another extreme where it was just the client talking the majority of the time, and the therapist not really kind of, you know, guiding or kind of helping shift. And so that, that creating some balance, which again, like you're saying, doesn't necessarily need to be 50/50, but, but not necessarily kind of one extreme or the other.
Dr. Celia Falicov: (49:11)
Yes. They, both of those approaches seem less successful in terms of really coming up at the end of the session with some kind of collaborative sense that we've done this together and we can move forward. And as you were saying earlier, it's not that the therapist cannot, uh, present their point of view, but, and, and, and present even their expert point of view. But it's also, and this is where I think the work of, uh, Harlene Anderson's very important on collaborative therapy about presenting things in a more tentative way, rather than this is the way things are, you know that, that, uh, expressing some sort of relativity, you know, like I myself many times say, will, I don't know if this will fit you. Or, you know, I don't know how, how it could, it would work out for you. So I, I want, want to hear that, but I sometimes I heard that is helpful for people to do this. Or I've heard that when it comes to, uh, stepfamilies they do better if they wait a little bit longer until the stepparent is more incorporated, and what do you think of that idea? So, so it's tentative, you know.
Dr. Keith Sutton: (50:36)
Our knowledge is not necessarily the truth with the capital T that we have ideas, but they, the, the assumption that it's not necessarily gonna fit for everybody, but seeing and and critic space for the client to say, no, actually that doesn't fit or so on, without feeling like they're, they're being uh, contrary or, or whatever it might be.
Dr. Celia Falicov: (50:55)
Yeah. And, you know, that fits very well with your impactful comment isn't that the therapist has to abandon their position of having something to contribute. That's not what collaboration means, you know, it's a contribution without imposing, right. And so, it's not a absolute or a certainty that you're presenting, and that, I think, collaborative meaning making out of the situation fits well with that, you know? That's the fourth topic in that most people come up with what is the problem that it's, it's, uh, you know, that you're suffering from, which is very different than diagnostic labor. In some of these cases that you read in the article, people are being diagnosed in a very direct way, you know, like, you suffer from an anxiety disorder, or if you don't do this, you're going to, oh, yes. What was it? There was a therapist that was saying, well, you attempt to repress or, or suppress what your real feelings are. But it's like a volcano waiting to erupt and it's going to blow the lid off, and then where are you gonna be? And so she gave you this metaphor, you know, uh, of, you know, something,
Dr. Keith Sutton: (52:26)
How things are gonna go.
Dr. Celia Falicov: (52:28)
Yes. How things are gonna go and what you're doing wrong. And so it was not focusing on strength. No. It was not focusing on the possibilities of, uh, of working with this vulnerability in a constructive way that comes from the conversation.
Dr. Keith Sutton: (52:47)
Yeah. In motivational interviewing, they, I think they call it the writing reflex that the therapist wants to get the client on the right track and will sometimes, yeah, use something like if you go down that path, this bad thing's gonna happen. So to kind of get the person to change their experience, but, but again, like you're saying, it's not collaborative, it's not staying with the client's experience and kind of helping them, instead kind of saying that's wrong and this is right, which, which can create that distance and, and lead to losing the client.
Dr. Celia Falicov: (53:17)
Yeah. And you know, I described in the article, uh, because I don't want people to leave with the impression that I'm being critical of this therapist. Because what happened was this therapist was trained in shared decision making and then had to listen to her on tape, which by the way, if we go back to my old, old history and listening to your tapes or seeing your own video videotapes is an incredible way to learn. And so this therapist, as well as everybody that was in the study except the control group, went back and then had to talk to a coach.
Dr. Keith Sutton: (53:55)
Yes.
Dr. Celia Falicov: (53:56)
And she came into that coaching session saying, I realized that I am not letting the patient talk or the client, because, I go and say, do this and do that, and do this and do that. And maybe she was doing it on her own anxiety, you know, because there are, like you say, they wanna fix things and, uh, but she recognized it. So training in, in collaboration, it's a very important thing.
Dr. Keith Sutton: (54:29)
Definitely. Definitely. Yes. But I think too, I don't know about you, but I know I still have that at times. And sometimes I'll be like afterwards, oh, I got caught up there and like I, I miss the client, you know, and oftentimes we'll then wanna circle back around or the next session say, you know, gosh, I, I missed that. Cuz as therapists we make these mistakes. Um, or yeah, our own worry gets a hold of us at times.
Dr. Celia Falicov: (54:50)
Yes, yes.
Dr. Keith Sutton: (54:51)
Yeah. And that transparency and collaboration to come back and say, I mistepped.
Dr. Celia Falicov: (54:55)
Exactly, exactly. And maybe she could back the next session and say, I'm sorry that I sort of talk so much I wanna hear, you know, from you and you know, what works best for you. And that, you know, takes me to the, um, co-constructing the behavioral task because we all give homework. I don't know how current that is today, but I think, you know, many therapists, when I hear the tapes, do suggest things.
Dr. Keith Sutton: (55:24)
Yeah.
Dr. Celia Falicov: (55:25)
And so, and the issue again, if we go back, particularly with working with low income clients, but, everybody, you know, the reviewers of this article, they all said, but this applies to not only low income. It could be, it could be for all therapists, not all social classes. Uh, and that is if you prescribe something to be done, you really need to check, what are the elements of the context of the client that will allow them to do or not do it. Or whether they need to, you know, twist it, shift it, do it more in a way that would work for them or could fit their lifestyle. And, uh, so, it means that co-constructing the behavioral task, rather than saying do this. And that, to me, can be classified as collaborative. But we arrive together at the task.
Dr. Keith Sutton: (56:29)
Well, I think that's so important cuz I think yes, sometimes there's extremes on either sides where the therapist's like, okay, this is what you're gonna do without necessarily having that collaboration or the other side where the therapist is being so non-directive or, um, you know, I I, I originally focused in more post-modern approaches, narrative therapy and so on when I first started training, but I'm also a very kind of engaged person and so on. And so I was, you know, I had a supervisor or a teacher that was like, why don't you just teach this mom timeouts? And I was like, oh, okay. I did that. And all of a sudden things changed. I've been trying to bring that resource out for several sessions. So, but I think that kind of collaboration around bringing in skills as well as drawing out resources and that one doesn't necessarily negate the other in, in having a collaborative relationship with your client. And so, and not that that's necessarily based in narrative or so on, but I think that aspect that I think particularly as a learning therapist in the beginning, trying to be respectful, but, you know, finding that kind of balance and being able to bring yourself, but keeping that one down position.
Dr. Celia Falicov: (57:34)
Yes, absolutely. Absolutely. You're so right, because there's also the possibility that clients do want, that they want to hear about the skills. But they just, you know, they, they're coming to that, they're paying for that. And so, uh, you know, if you remain silent and just not provide sufficient content.
Dr. Keith Sutton: (57:57)
Yeah. I actually just read an article recently on some research around that and it was, I forget exactly, it was 60 or 70% of clients preferred a more directive therapist. Um, and only about 10 or 12% preferred non-directive. But when they evaluate the therapist, the majority of the therapists preferred a non-directive approach. So there was this kind of amiss, but clients are coming in for help and needing something. And so I think that that kind of, you know, those aspects that you're talking about, like the agenda around kind of balancing the talking and not being to one way or another, and again, that collaborating around tentativeness and relativity, and not that we necessarily are the holders of the truth, but really collaborating on that meaning making, and then that kind of evolves to that co-construction of the task and what's actually gonna be done to potentially help create change.
Dr. Celia Falicov: (58:47)
Yes. Yes. And so it could be, you know, important to really understand that you're hearing both voices, right? That you're bringing both types of strengths, the ones that the client brings and the one and the therapist. Do you want me to talk a little bit about what else I'm doing right now?
Dr. Keith Sutton: (59:08)
Yeah, I'd love to hear what else you're doing. I mean, I don't know if we have enough time to get into it. Uh, one of the things that struck me, one of the things that you talked about in the training was about, was the cultural mask, which I thought has really stuck with me. I don't know if you remember, like about sometimes the client might say, well, this is part of my culture, and then that's kind of the sign for the therapist to totally back off. But sometimes kind of finding where, but that, that might be a whole bigger subject or someone
Dr. Celia Falicov: (59:35)
Concept
Dr. Keith Sutton: (59:36)
Yes. In a way to be able to listen and acknowledge the culture, but at the same time to kind of work beyond that or through that, or, but again, this is, that's a, that's a big topic for less than 12 minutes.
Dr. Celia Falicov: (59:49)
Okay. Okay.
Dr. Keith Sutton: (59:50)
Whatever you think would be, yeah. Where you wanna go next.
Dr. Celia Falicov: (59:53)
Um, well, I don't know what I'm doing right now. I don't know how applicable it will be to, to many therapists. So, but um, if we go back to what you were saying in a different way about the cultural mask, I think it is important to understand that we should not idealize culture. That culture, uh, sometimes is, you know, at its extremes can have negative consequences. You know, we know that about, for instance, the oppression of women, you know? That one could say is, you know, it's part of the culture, or the domination of males can say it's part of the culture, but it's not a part of the culture that we should support. And, and sometimes, you know, clients will say, I can't help it, you know, uh, it's just how my culture is.
Dr. Celia Falicov: (01:00:46)
Yeah. And, and that it becomes, you know, it's like a closest issue. Right. And also I think know, therapists might say no, for example, I gave the example of children being intermediaries, with the parents in immigration situations. Well, yes, in many ways, that is not a negative in the sense that it creates responsibility, even in young children, it gives them an important sense of agency in the family. But at the same time, you know, if the know girls are always cleaning the house, and they're, and you know, and they're always serving the boys or, and they are. So it is part of the culture, that they should be helping the parents, but when is it too much, you know? Or when that it is, uh, impinging on their development. Or, or their sense of autonomy. So culture is a tricky thing, you know, that one could even discuss with our clients is this-
Dr. Keith Sutton: (01:01:53)
That's, that's the piece of opening up that conversation. Cuz I think in the, in the conference, uh, you had talked about that cultural mask and that sometimes the client might say, well, this is part of the culture, and sometimes the therapist will say, okay, I can't, I can't deconstruct that with them because I need to back away from that and say the person saying, oh, well, you know, being machismo is part of my culture, so on. But kind of to the extreme, like kind of, you know, as a justification for, you know, the domestic violence or whatever it might be, when it may actually be a distortion of kind of what the, that aspect of culture is and being able to kind of take the time to understand and kind of deconstruct that and really look at that together, rather than just, you know, especially if the therapist is from a different culture, you know, kind of stepping back and saying, okay, well we can't look at that because I'm not of that culture, whatever it might be.
Dr. Celia Falicov: (01:02:46)
Yes. So mistaking perhaps the idea of respect, curiosity and respect. But yes, I'm curious about that, but also I'm very respectful and I won't touch it. And when, so you know, I don't know if you've ever come across an article that I wrote on cultural Constructions of machismo. It's called The Devil Never Sleeps. It's a family process, and it's about changing constructions of masculinity among Latino men and the differences between malignant machismo and benign machismo. And uh, and how sometimes, you know, very powerful domineering men will really advance the idea that, well, you know, I have all these benign elements of machismo, so why are you criticizing me for, and also they have learned to say, I, you know, to, to a different sort of mask. I am not a machista. I'm not, I'm not a male who, but you know, they may be in some aspects, but by saying I'm not, they also stop you. So it's important for therapists not to be intimidated by, you know, those statements and to just say, well, I wanna know more about it. And the other people, what do other people in your family think about this? You know? If your daughter was here, your son was here, your, you know, your wife was here, what would they say about this?
Dr. Keith Sutton: (01:04:24)
Yeah. And really understanding the clients, again, that kind of micro cultural experience. Um, cuz I think that too, that this, this also, you know, extends beyond just, you know, specific cultural groups such as Latinx or African American or so on. That also, you know, all these intersectionalities are also happening in, you know, white kind of, you know, Euro Caucasian, American families too, around gender, around. Uh, and, and I think you've talked about too, that oftentimes socio socioeconomic status is also kind of, you know, not looked out as much. And how that interplays, although lower socioeconomic status because of systemic racism includes a lot of people of color, but also that, that a multitude of clients of different race and background also have these experiences and that clients or therapists need to be understanding and, and again, collaborating around.
Dr. Celia Falicov: (01:05:23)
Absolutely. That's a very good point, yes. So about the other thing that I'm learning from my current work is a new element that, and, and my teaching to medical students that it, that it is been labeled by one of the medical students fireside chats. You know, like, like Russo used to do and that, and that they're also very collaborative in the sense that the interpreters in this case, you know, they're Spanish speaking interpreters and medical students and the psychologists are, you know, marriage and family therapists too, get together with them and discuss issues of mental health, you know, that are, that are most culturally respectful and sensitive, but they are done in a way that is very also collaborative in the sense of like a fireside chat. You know, I, yes, we have some expertise?
Dr. Celia Falicov: (01:06:27)
But we also would like to hear how, how can you apply it in your setting. And I've been, I have start, and one of the things that we have learned over the, all these years of working in an immigrant, you know, underserved population clinic, a medical clinic that now incorporates mental health, is that flexibility of time and flexibility of space are extremely important to contact therapy with low income families because we can't really expect people that don't have transportation, that don't have really working computers and cell phones to be able to act in the same way as middle class and upper class people. So I think those are another way where some of our structures for therapy need to be questioned, you know, uh, when we work with the current, another one size doesn't fit.
Dr. Keith Sutton: (01:07:35)
Yeah. Yeah. How do we accommodate, or how do we help work around those barriers to be able to provide those services to clients without them getting kind of apologized or kicked out after missing a session or so on.
Dr. Celia Falicov: (01:07:47)
Yes. Or interpreting as resistance. Or, or a stigma, you know, they, they're, they don't like to come because they cold client or something like that. They don't wanna be called crazy or, when in fact we haven't provided a setting, that fits with their lives.
Dr. Keith Sutton: (01:08:05)
Definitely.
Dr. Celia Falicov: (01:08:06)
So, uh, okay.
Dr. Keith Sutton: (01:08:08)
Well thank you so much. This has been so wonderful to hear about what you're doing and the work that you're doing and just, you know, hearing about the evolution of your thinking. And I really encourage folks to read your article and I, uh, cuz I think that centering the voice of the client on becoming a collaborative practitioner with low income individuals and families, and I think that, you know, even beyond just the low income and so on, just again, that aspect of those five points that you are making around collaboration, because I think, like you're saying, collaboration is this word that we often use, but really what does that look like in a process kind of analysis of sessions and, and really kind of looking at the nuances of that are, are so significant and important to, it's a great contribution.
Dr. Celia Falicov: (01:08:53)
Okay. Thank you so much, Keith, for inviting me. I think you're doing a fantastic job with, it was, you know, how easy it is to talk to you, but also how valuable it is, what you're doing in the podcast for people. So, so thank you very much. Thank you for thinking about me and inviting.
Dr. Keith Sutton: (01:09:10)
Great. Thank you so much for your time. Take care. Bye-bye.
Dr. Celia Falicov: (01:09:14)
Bye-bye.
Dr. Keith Sutton: (01:13:40)
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. Today I'll be speaking with Celia Falicov PhD, who is a clinical psychologist and family therapist in San Diego, California. Celia is the director of the Mental Health Services at the Student Run Free Clinic Project of the Department of Family Medicine at the University of California San Diego. She's also a past president of the American Family Therapy Academy and has published numerous books and articles including Family Transitions, Continuity and Change Over the Lifecycle, Cultural Perspectives in Family Therapy and Latino Families in Therapy, and has co-authored the book Multiculturalism and Diversity in Clinical Supervision. Let's listen to the interview. Well, hi Celia. Welcome.
Dr. Celia Falicov: (01:20)
Hi Keith. Good to see you, and to say hello. Yeah.
Dr. Keith Sutton: (01:25)
Yeah. Thank you so much for joining me on the podcast today. So I, uh, know of your work from, of course reading your work in graduate school, and particularly I think my first introduction was in Monica McGoldrick's Family Life Cycle book. Um, I got to see you at the Association of Family Therapists of Northern California Conference when you came for the weekend, um, teaching about working with Latinx families. Um, and, uh, particularly, you know, just been interested in your work and was, you know, reaching out to you to see what you've been up to lately and now. And, um, so, but first before we got into that, cuz you, you sent on some great articles and some of the process kind of work you're doing and, and kind of looking at, you know, collaboration with clients, uh, and therapists, particularly in, in low income and diverse populations. But before we even get into that, I'd love to hear your story. I'm always interested in folk’s kind of evolution of their thinking and how they got to be thinking about what they're working on today.
Dr. Celia Falicov: (02:26)
Okay. Okay. Uh, so I don't know how much, uh, you know, about sort of my personal history, but I think it is somewhere, uh, I think, um, importantly connected to my way of thinking and my development as a therapist. I was born and raised in Argentina, and I'm actually the first person in my family born in Argentina because my parents and my grandparents were immigrants. And, uh, so a little bit of the paradox of my life is that I grew up in an environment of immigrants and, but I also came to this country fairly early in my life, uh, newly married. And, uh, and so then, and, and for, you know, socio-political reasons we could not really return because there was a military dictatorship and my husband and I had been somewhat involved on political things that were left wing, and at that time it was a right wing dictatorship, so we remain in this country.
Dr. Celia Falicov: (03:29)
So I have a lot of personal experience of immigration. And, um, and I also have I think a lot of personal experience of living in a very large environment - large family, large extended family with my parents and my grandparents living very close to each other in a radius of about two or three blocks. I had all my aunts and uncles on both sides of the fence. So because they were immigrants fleeing the violence of Europe towards Jews at that time, and for programs, and, uh, you know, recently, uh, I found out something that I had never written about, uh, that, uh, in doing some research on my family immigration history, and I don't know whether they knew this either, uh, was that the, uh, person that I have that was my name was given to me by my great, my grandmother, and it was the name of her mother.
Dr. Celia Falicov: (04:29)
And, uh, and the same thing is too, with my brother, the name of her father, both of those people and through more, uh, died in, uh, concentration camps. And, and we, you know, didn't know that until last year when I did some research. So I have always been very aware that socio-political events, you know, that social context influence a family's life in ways that are beyond their control. I'm sure that, you know, they didn't want to leave, that was their home. And so, but they had to, and that has, uh, created a great deal of empathy towards the immigrant, uh, point, uh, for me. And so, um, maybe I will be saying something that, I'm jumping to my work, but I wanna say that I believe that one of the things that I've done from the very beginning is include and culture, also context, because it completely, you know, alters the situation. And I also think that it's very important for people to learn about the impact of immigration in family lives, which is very different than looking at culture in a fixed way, you know, or culture as separate from context. So yeah.
Dr. Keith Sutton: (05:54)
So kind of thinking about culture on the bigger context, but also on the individual experience of through immigration or kind of those multiple kind of layers.
Dr. Celia Falicov: (06:02)
Yes, yes. And that, you know, we talk about cultural competence, but the truth is that we should also have migration specific competencies.
Dr. Keith Sutton: (06:13)
Yeah.
Dr. Celia Falicov: (06:13)
And I have, and I think a lot of my work is, and, you know, it reflects that, reflects an interest in understanding immigrant family process.
Dr. Keith Sutton: (06:24)
Mm-hmm, definitely.
Dr. Celia Falicov: (06:27)
Okay. Um, so tell me again what question we are asking me about my background. Yeah, so your evolution of your-
Dr. Keith Sutton: (06:35)
Of your thinking. So yeah. So you're talking about kind of your experience with migration yourself, and, uh, yeah. Would love to hear other experiences that's kind of led to your thinking.
Dr. Celia Falicov: (06:48)
Yes. And also being the first child born in a different country, it put me very much in the position of a cultural broker between cultures, and as we know, the second generation many times does, you know. Yeah. And, so, and that was also a kind of separation, you know, emotional separation because I was the first one to go to school, the first one to be educated. And so I, in many ways, I lived in two worlds. And so that I think I, I thought that the way of growth was education, and education was free in Argentina. So that's where I really started going to the University of Buenos Aires. And I first started with philosophy because I was very interested in philosophy, and I still am. Um, but I decided that I, that it also was important to make a living and, and I was in, and psychology was part of philosophy at that time.
Dr. Celia Falicov: (07:51)
Mm. And so that's how I started studying psychology. But then in my early twenties, got married at age 20 actually. And, uh, my husband was a physician and was just out of medical school. And so we came together for postgraduate training for him. And so eventually I, after having different jobs, you know, as an EKG technician, as a file clerk, I began studying back in the United States. It was very important to me. Uh, and I had to do a lot of equivalencies, you know, like learning American history, learning geo American geography, uh, so that I could have the equivalent of an undergraduate degree here. Then I went for a master's in psychology to Loyola University. And, and I was very lucky during an externship, I met a professor who said, but you should really should go on for say, PhD.
Dr. Celia Falicov: (08:58)
And I said, well, no, it's impossible. I can't afford a PhD. And it wasn't a time where you could really get great scholarships. And I was very lucky I was able to, and the place that I decided to go into that path, psychology as part of it was at the University of Chicago, uh, the Committee on Human Development. And the reason I bring this up is that it is very important to what happens to me professionally. I think it's probably the best thing that happened in my life. You know, I, I love the program, I love the university, but also, um, it, it taught me that you need more than one discipline to understand, you know, the human phenomenon. And that committee was anthropology, sociology, biology, and psychology. And so, and every stage of the life cycle was seen through those four lenses.
Dr. Keith Sutton: (09:55)
Oh, great.
Dr. Celia Falicov: (09:56)
And so I learned to think culturally and developmentally all the time, and I think I brought that into learning about family therapy. My dissertation actually was going from a dyad to a triad, and cause that was the, and I did that during my first pregnancy. So, because I was very interested in how a couple becomes a family. And so, uh, I think that's when I began to think about family as a, a way of, of solving problems as well as creating problems. So, I think probably I would say that I became a family therapist and as soon as I finished graduate school in, in early 1970s.
Dr. Keith Sutton: (10:47)
Yeah. And that was really the, the heyday of family therapy and really kind of, you know, a lot of, a lot of movement and a lot of exciting things going on in that field.
Dr. Celia Falicov: (10:55)
Yes. Yes. I was very lucky enough to be a chartering member of the American Family Therapy Academy and meet a lot of the people who were writing about it. So, so I was, uh, and then in, actually immediately after graduate school, I went to the Tavistock Clinic in London and did postgraduate training there. And that was also very influential, uh, because I had been, particularly at Loyola, I learned a lot of psychoanalysis. And the Tavistock Clinic at that time was very strong in that. Um, but I was very lucky that Sal was there for three months sabbatical, and I started following him. And I had been quite, um, shocked, uh, in, in the, in the child department there, because in ground rounds, many of the therapists were presenting the work with children and they were never, never seen the parents, the parents were seen by the social worker. And, uh, and they would make all kinds of hypotheses about the parents, usually quite dysfunctional, usually quite negative.
Dr. Keith Sutton: (12:15)
Yeah. Kinda without apologizing.
Dr. Celia Falicov: (12:17)
Yes, yes. Without ever meeting the parents because they wanted the child to have transference towards them, and they wanted, you know, to not be disturbed in any way in terms of understanding the inner life of the child-
Dr. Keith Sutton: (12:30)
-and the therapist being a good attachment figure.
Dr. Celia Falicov: (12:33)
Exactly. Exactly. Yes. And I thought that was an injustice to the parents. Not only because I was a young parent myself at that time, but also because I thought, you know, it's like, this is very hypothetical what they think is happening, you know? Rather than really touching the reality of the child's life, which the child, of course will go back every day to the parents, right? to them. So that's, I think, when I really began to, to want to do family work. And I came back to Chicago Uhhuh and became part of the family systems program at the Institute of Juvenile Research, and I stayed there for almost nine years.
Dr. Keith Sutton: (13:16)
Wow. Great.
Dr. Celia Falicov: (13:18)
So that was really the basis of my training, and everybody went through there called Whitaker. You know, they were lecturing, they were being invited to do that. And I, you know, sort of began to think of it as, uh, very important, you know, very instructive, very nurturing from an intellectual point of view, but at the same time, too many directions in which to go. So, and because we were working with a very indigent, very, you know, poor population of whites, Latinos and blacks in the west side of Chicago, the Philadelphia Child Guidance Clinic approach seemed very appropriate. Yeah. So in 1976, I went for a summer to Philadelphia to study there.
Dr. Keith Sutton: (14:11)
Oh, great.
Dr. Celia Falicov: (14:12)
So I have a strong basis on structural family therapy from that experience. Yeah. And, uh, and then I went for a course at, uh, MRI now, which yeah. No longer that program is strategic like it used to be, but I had a month of that work there. And so, so that was, and so it felt a little bit like the parable of the Chinese parable of the, all the people touching an elephant and having it a part of it, you know? So, um, but it was-
Dr. Keith Sutton: (14:46)
-well it’s integrating, right? And kind of learning from all those different perspectives. That's so important. It sounds like you got incredible training.
Dr. Celia Falicov: (14:53)
Yeah. So, so it served me very well, because then I could see that I could use different things for different families. And so it was, it was a great, yeah. And during those years, you know, of work and in Chicago, I also became a very sociopolitically active. And, uh, there was psychologists for social responsibility, there was a fantastic speech that Martin Luther King gave to the APA that influenced me a lot, you know, because he really encouraged psychologists to, uh, create a society for creative maladjustment. And, and it was like humorous, like creative maladjustment. But he then described that it was creative maladjustment, uh, to fight back a society that discriminated against people that affected their mental health through racism, through, you know, classism. And so, uh, and there was all the gender issues at that time too. You know, we, we keep on revisiting the same issues and hopefully improving a little bit each time, but, you know, they come back. And so, uh, the whole issue of women's liberation was very important at that time too. And I joined the group and continue to be in touch with those women actually. So that's, uh, yeah. So, and that has also, you know, influenced my work a lot,
Dr. Keith Sutton: (16:27)
Social justice.
Dr. Celia Falicov: (16:29)
Yes, yes. Absolutely. And I think, you know, a lot of what has happened in the cultural competence world is that we talk about, you know, culture in ways that are, you know, quite fixed and stereotyped and conflated with social justice. And I really do think that they require different interventions, you know, and different thinking when we see families. So hopefully that's happening more and more, you know, the difference separating-
Dr. Keith Sutton: (17:00)
-Those two pieces out, the, the cultural competence and the social justice pieces.
Dr. Celia Falicov: (17:06)
Yes, yes. Yeah. What is cultural diversity, you know? And we need to study that, but we also need to understand social justice and how they interact and sometimes, you know.
Dr. Keith Sutton: (17:17)
Definitely.
Dr. Celia Falicov: (17:20)
So, um, I think when you met me, um, my belief is that it must have been about 2010, it was in northern California, right?
Dr. Keith Sutton: (17:38)
Probably, yeah. Probably around then.
Dr. Celia Falicov: (17:40)
Yes. And I thought that at that time I spoke, uh, about what you said, uh, but maybe the title was One Size Doesn't Fit All.
Dr. Keith Sutton: (17:50)
Mm, I think so.
Dr. Celia Falicov: (17:52)
Yeah. And, uh, and it's possible that, you know, at that time, uh, that, and I still today, I think what I mean by that is that we tend to, um, we have tended and, and unfortunately still today, um, used, um, knowledge, let's call it that way, that is developed in even within family therapy as, as universally applicable, as it fits everybody. And so, for instance, I was telling you earlier that I grew up very much in a three generational family. My grandparents were incredibly important to me. I saw them every day. And, uh, and when you look at what is it that we do in actual family work, we utilize the principles that apply very well to nuclear families, but not, don't apply so well to very large sibling groups, to, you know, three generational families or grandparents should be part of the therapy
Dr. Celia Falicov: (19:00)
And so, uh, things like that, you know, the fact that we tend to develop things that are good for white, middle class nuclear families. And then translate them fast into thinking that families that are families of color or, or different religion with very large number of children, uh, and sometimes three and four generations living together, because parents tend to have children much younger when they come from lower socioeconomic levels. And then we just think, oh, no, you have to pay more attention to this child. Now that is being, when this child is being taken care by many other people, all their siblings. So I think all those things are very important for family therapists to understand, you know, that one size doesn't fit all.
Dr. Keith Sutton: (19:53)
Yeah. Yeah. Jim Climb, uh, uh, is part of my group, and we talk about sometimes he wrote about kind of the hard side and the soft side of hierarchy. The hard side of structure and rules and so on. And the soft side, the attachment, the relationship, who soothes whom, and oftentimes in, uh, multi-generational families that the grandparents may be, you know, providing that, that kind of attachment and kind of, you know, warmth and so on, whereas the parents might be providing more of the structure or, you know, that these, these roles may be kind of, you know, held by different parts of the system, rather than kind of just saying, feeling like one person has to hold all of that together. And oftentimes that's a, a lot of difficulties of families that immigrate to the United States, because sometimes they leave that generation in their, their country that they came from, and then now are trying to learn how to deal with kind of creating more of that balance or shifting to meet the needs of the kids.
Dr. Celia Falicov: (20:52)
That's an excellent description. Yes. That, you know, that covers both the issue of family structure and also the evolution of those things, you know, and how, yeah, in, you know, with immigration. So, and the other way in which one size doesn't fit all is that within groups, you know, say the Latino group or the African American group or the Asian groups, there's enormous variability.
Dr. Keith Sutton: (21:19)
Yes.
Dr. Celia Falicov: (21:20)
So when, when we are given a number of characteristics from an ethnic focus point of view, it doesn't take into account the multidimensionality of, you know, every group really.
Dr. Keith Sutton: (21:35)
Yeah.
Dr. Celia Falicov: (21:35)
Many, many subgroups within every group. So I have, if we go back to sort of my historical development professionally, I think Monica McGoldrick, like you mentioned, invited me to write in the book on the family life cycle. And so it was my first chapter publication in an edited book. And, and I did write also an ethnicity and family therapy book and tried, uh, you know, hard to, just looked at only the cultural piece. But then in 1983, I published and edited my first edited book, which was Cultural Perspectives in Family Therapy. And at that time, it's a small book, uh, by Aspen Systems corporation. And in that book, I invited several family therapists, the younger ones at that time, like Jayla and Bravo, to write chapters in that, in that book that had to do with race, with class, uh, al wrote, um, on class, uh, and on rural and urban families. So it was a much broader way of looking at culture.
Dr. Keith Sutton: (22:59)
Yes. Yes. Definitely.
Dr. Celia Falicov: (23:01)
And that, and that remained that way for me, that you really have to look at all of those dimensions and not just-
Dr. Keith Sutton: (23:08)
The intersectionality
Dr. Celia Falicov: (23:10)
Exactly, exactly. Pieces. Exactly.
Dr. Keith Sutton: (23:12)
Definitely.
Dr. Celia Falicov: (23:13)
Yeah. I called it ecological context at that time, but it's the intersectionality of all those issues.
Dr. Keith Sutton: (23:19)
Yeah. Yeah. And I think that, you know, cultural competency is not just knowing kind of the, the bullet points about these different cultures, but both kind of the larger macro culture, the emic culture, as well as the microculture of the person's experience and kind of that piece. But, and also, I don't know what your thoughts are, but I also think about, especially as a white, you know, cisgender male therapist, that also looking at one's privilege, that one's bringing into the work, rather than just focusing on how the other is other.
Dr. Celia Falicov: (23:51)
Yes, yes. Absolutely. And that, you know, that brings us to, uh, the, the idea of cultural humility Because cultural humility, which in fact was something developed within the group or, or the, the discipline, say, that, that I'm very involved now, which is, uh, family medicine, you know, and, uh, it, it is family medicine that first came up with cultural humility, teaching physicians that they needed to understand how much power they have in that relationship and be aware, you know, of the fact that the client should be more of an expert on their own lives, you know, the patient. And, uh, so cultural humility is both understanding that you bring it, which is another way in which one size doesn't fit all, right. Like, whatever the, the provider, uh, thinks is just, it's also culturally based, you know? And so to, to understand that, what, what are your cultural values? And what is your privilege, like you said. So it's both the diversity and the power issue.
Dr. Keith Sutton: (25:06)
Yeah. And I always think that, you know, and when I'm supervising or teaching is that, you know, when we kind of run up against like, oh, it should be this way, kind of in our head, that's the cue to actually step back and get curious, because often we might be super imposing our own beliefs and values onto the client's experience, and then getting curious, we can oftentimes learn about where that may not be fitting.
Dr. Celia Falicov: (25:30)
And be careful not to impose your
Dr. Keith Sutton: (25:33)
Yeah, exactly. Yeah. Then you created a model for actually looking at all these aspects of culture. Um, I think you called it the MECA model, right? The multi-dimensional, ecological comparative approach.
Dr. Celia Falicov: (25:48)
Uh, I actually, let's see. We make a little bit of history. Um, I started, uh, with presenting the model in 1995 in a family process article called Training to Think Culturally. And the basic idea was that by having either a universal approach where everybody is saying, or having a paid particularistic approach where each person is different, both of which are, are valid, um, in that we do have a lot of similarities. And in fact, you know, we also have very significant difference with each one of us is unique and singular. Um, but sometimes, I know I give the example of we share 99.9% our DNA,, biologically and also psychologically we have a lot of similarities. But it's also true that our thumbs are, each one is different, and that's why we can identify an individual that way,
Dr. Celia Falicov: (26:58)
and I think therapists need to absolutely know both things, the universal processes and, and also investigate what's particular about the person. And then we had the ethnic focus approach, which gave us a lot of information about various ethnic groups and cultures, but I thought, you know, that, that we need yet another approach that combined those three in the sense that we could ask what difference to really make a difference to us as therapist. You know, things like foods or rituals we can find out from people if it's necessary, but they're not really essential to the processes of that, but I came up with four things in which I think, um, they're sort of like vessels without content necessarily, where we can investigate those four dimensions or domains, and they are migration acculturation, which generally has been neglected in cultural competent cultures.
Dr. Celia Falicov: (28:08)
as migration specific competencies, uh, then ecological context, you know, everything that has to do with how everyday life of people is influenced by the environment they live in. And, uh, then a family organization, which I think it does vary across cultures and, uh, and family life cycle, that it also has its own values and norms and, uh, learning for transitions, you know. So, I came up with those four domains in which I believe there are, there are differences and also similarities. That's why, and I call that in a rather complicated way, the multidimensional, comparative, ecological approach. MECA called multidimensional, ecological, comparative approach. And multidimensional is because we have to take into account everything that intersectionality today takes into account: race, class, religion, political ideology, sexual orientation, all of those. And so that's why culture is multidimensional. And, um, then, I think that the ecological part of course, is what I already described as, as people's social circumstances and comparative, is because I thought that by having so many dimensions, within the focus approach, it would be hard to compare the therapist with the client, the including the supervisor with a therapist and the client.
Dr. Keith Sutton: (30:01)
Sure.
Dr. Celia Falicov: (30:02)
So this days I actually call in the majority of my workshops, psychotherapy as a multicultural encounter.
Dr. Keith Sutton: (30:11)
Hmm.
Dr. Celia Falicov: (30:12)
Cause it isn't like it with cultural competence, we have to know about the cultural of the other. And this a kind of otherness that is established in the beginning, you know, by studying about the other instead of spying about self of the therapist.
Dr. Keith Sutton: (30:28)
Yes.
Dr. Celia Falicov: (30:30)
And so then I, by doing that, I sort of invited a knowing and not knowing attitude towards culture. Like I know that something may be going on when it comes to migration, ecological context, and family organization of family life cycle, but I don't know exactly what it is. So I could ask about those domains. In the slides that you're gonna put online, the last one is something that people have begun to use as an intake form.
Dr. Celia Falicov: (31:10)
There are the four dimensions. So four domains are something that therapists can fill out while they're talking to, to their client. Uh, but they can also do it by the templates.
Dr. Keith Sutton: (31:28)
Sure.
Dr. Celia Falicov: (31:29)
Or they can even do it together with the client and the family, and, you know, put it like a big sheet of paper on the wall or in a blackboard.
Dr. Keith Sutton: (31:41)
Yeah, great.
Dr. Celia Falicov: (31:43)
And usually it tells you then where the issues might be that people wanna work on. And you can also ask, would you like us to start with, you know, your transitions that have to do with generational differences, different migration, or should we start with the fact that you are a large family and you know, and a small family and have issues with this, with your extended family.
Dr. Keith Sutton: (32:17)
Definitely. Well, great. Yeah. And having those conversations together as a family, which may, you know, kind of bring some things to the forefront that maybe, you know, can be good conversation or maybe other parts haven't really talked about out loud or so on. And I think like you're saying, that kind of interplay between the therapist and the client, because I, I think that, like you're saying, and particularly me, you know, as a white cisgender male, heterosexual, you know, person with, you know, multiple levels of privilege, that as a therapist, my work is to be aware of myself and also my privilege. And, rather than just the focus of, focus on how somebody else might be culturally different, because I think that that's so important, like you're saying, is that interplay between the therapist and our client, rather than just kind of focusing on the client being different and understanding those differences.
Dr. Celia Falicov: (33:17)
Yeah. And so that's much more about cultural humility than about cultural competence for your awareness. Yeah. Your awareness of both, you know, your possible differences in, in values cultures, but also your power differential. So in a way that helps a little bit to equalize the relationship more.
Dr. Keith Sutton: (33:40)
Definitely.
Dr. Celia Falicov: (33:42)
Yeah. You could even say things like, uh, you know, for me culturally, it would work this way, but I'd like to understand more of how it would work for you to do this, or you know. Or how would people in your culture would advise you, yeah. How to deal with your daughter, approach it.
Dr. Keith Sutton: (34:04)
Yeah. Yeah. And I think about that too, when, when teaching or supervising that, oftentimes when the therapist is thinking, oh, well it should be this way or so on, or things aren't going right or so on, rather than actually moving forward, that's the moment to step back and actually be curious because, you know, when you think like, why is that happening that way? It doesn't seem right or something like that, then we may be imposing some of our own cultures or assumptions and, and being curious and kind of oftentimes sharing that in a transparent one down way may help actually open up a conversation and a deeper understanding. But again, rather than saying like, you know, how are you different from me? More saying, this is the way I think, I'm wondering if that is similar or different from your experience.
Dr. Celia Falicov: (34:52)
Yes, yes. And, you know, you mentioned curiosity. It's a very good idea to have that kind of openness of talking and not assuming that you know, or that not assuming that you have the right way. And I've seen, unfortunately, sometimes I've seen therapists say, for example, on the belief I may not be in direct belief that the person should take medication. And, but then they, they, they would interpret as resistance. They, they kind of react to do that instead of asking, so, you know, why do you feel this way? Are there other things you are doing? Or, uh, you know, tell me more about this because I've seen therapists, like why can't, why can't you do that? and, you know, shrug their shoulders. You know, in a way that is not so totally respectful. So curiosity and respect are very, very important, you know?
Dr. Keith Sutton: (35:49)
Definitely. Yes.
Dr. Celia Falicov: (35:51)
And many times people, many people from different cultures are sufficiently acculturated that they know that we are providing a service that may be somewhat different, but it would be in their cultures and maybe they still want to have both, you know, they're exploring what we call the dual system of treatment. Yeah.
Dr. Keith Sutton: (36:11)
Yeah, definitely.
Dr. Celia Falicov: (36:12)
And having a conversation about that and gaining the trust. Right. Building trust by doing that. Um, but you know, I don't wanna forget about the issue of comparison, because this is also an instrument that allows you, as a therapist to, can you imagine yourself in the same thing, in the same domain. You know, do you have any experience with immigration that your family have it did your three generations ago, had it, uh, sort, sort of in a way, you know, again, it humanizes you by being able to compare all the same domains, you know.
Dr. Keith Sutton: (37:00)
When I found, I know that I found your way work very, uh, powerful and when I was in grad school and thinking about my own experience of, you know, migration, which again, I was born in the United States, but I, you know, moved away from home for college and then graduate school and so on. And so very different experience than somebody who came from a whole different country or so on. But I mean, part of our work as therapist is to be able to imagine what that might be like, to be able to connect with our own sense of feeling disconnected maybe from our family or from our home, or, you know, kind of, uh, needing to all of a sudden build new social supports and these kinds of things. Again, on, on much of a, uh, a much lower level of my own experience, but then kind of connecting that to, you know, my understanding and my experience of my clients because, you know, we can't truly understand our clients if we can't connect with that part of ourselves. That has felt a similar feeling.
Dr. Celia Falicov: (37:58)
Yes. Absolutely. Very well put. And we could use that metaphor for many types of relocation, even just leaving home from the west coast to go to the East coast for college. Even if you have that privilege, it doesn't mean that that first year is, it's a very difficult, uh, that patient, right. Of knowing a lot of new things that you didn't know before. You know? So, so, um, and, and it is also the case that supervisors have their own cultures and many times, including their own belief systems about theory. Having a comparison, a way to compare themselves both to the supervisee and the family they're talking about together. It's something that organizes what we are thinking.
Dr. Celia Falicov: (38:54)
And, uh, recently I've been giving workshops, the title, our supervision as co-vision instead of supervision as being able to carry your way of seeing things that the supervising has to adapt, but one that is a collaboration and, and in which both people and the family are transparent about their values or beliefs, and their experiences even.
Dr. Keith Sutton: (39:22)
So not only kind of the therapist working with the family, family and looking at similarities and differences together, but also the supervisor and the therapist as well as the supervisor and the family that they're discussing. You know, kind of those, those multiple levels of, of transparency and, um, curiosity.
Dr. Celia Falicov: (39:43)
You know, the supervisees that I have talked to say that when that is happening, when they use this way of talking to each other, that their anxiety decreases. That they're feeling more like they're human beings their thoughts and their values and their feelings. And so, uh, it is a good way to start, you know, rather than what are your problems with, with the family you're seeing.
Dr. Keith Sutton: (40:16)
Definitely. Excellent. Well, great. Well, these are wonderful resources and definitely be helpful for clinicians as well as clinicians in trainings and supervisors, uh, you know, and one to look at these kind of multiple aspects that are the client's experience and affecting the client, as well as also reflecting on how that interplay with the therapist's experience, and supervisor and supervisee.
Dr. Celia Falicov: (40:42)
Yes. I believe that it is also a way to avoid just using stereotypes, cultural stereotypes, because you are engaged in a different process of understanding rather than inclusive. So, I think that's, I, you know, I think it sends the message that we all are encompassing in for the domain in similar and different ways. And so, uh, it avoids the danger of the single story, both for white people, because we also should avoid having a single story for what white privilege is or, you know, or superior positions are. And, uh, and what it is to be.
Dr. Keith Sutton: (41:34)
I think that, you know, one of the things I thought was really important about, and I'll, I'll let you kind of set it up and everything, but was, it was interesting because it was, it's focused on collaboration, but also I think that it makes an important point of the therapist also being directive while at the same time collaborative. And I think that that kind of aspect I thought was just so interesting as kind of a melding, cuz I think some therapists get a little worried about how they're collaborating with clients and also around working around culture or working around the issues that the, the clients are dealing with and, and bridging those gaps. Um, yeah.
Dr. Celia Falicov: (42:11)
Well, I could start by giving you a little bit of the context of that article. Yes, so the article I think is called Communicative Practices, that center or decenter clients, client's voices, something close to that, that's, oh, I think it's called Centering the client's voice. Right. Centering client's voices. Um, in the last two falls before the pandemic, I was in the Harvard Medical School during the autumn and, uh, as a visiting professor in the Multicultural Practices Unit, that is directed by Margarita. And if you are visiting, they don't just let you visit. You have come up with a project. And use their data in the project. And they had this research going on. They had several types of research, but this, the research that attracted me was one where they were training mental health workers, therapists primarily, on something that came from the medical field called shared decision making.
Dr. Celia Falicov: (43:35)
And, they were training, you know, hundreds of therapists. And so they had a lot of quantitative data, but they hadn't done any qualitative work. And so I wanted to take a few of those cases, and study, uh, in depth the processes that went on. They had lots and lots of audio tapes, so I could have, could ask them to do transcripts of the audio tapes. And so shared decision making is something that medical students are learning about setting the agenda, with the patient, rather than just the, the doctor, you know, saying, This is what you need to do,
Dr. Keith Sutton: (44:24)
Rather than just talking at them
Dr. Celia Falicov: (44:26)
Yes. Talking at them in a sort of paternalistic way, you know, and I'm sort of not aware of what you were saying earlier about their privilege and their power and so shared decision making equalizes a little bit more. This is therapy situation. So that is in some ways the first take to towards collaboration. So one of the first things, so I came up in my analysis with I think five different things, five different themes, right. By analyzing the processes. And the first one was how many times therapists come in and don't really say what would you like to talk about today? They would say things like, so what happened the last time you were telling me last time such and such? And, uh, so what happened with that? What happened when you came to your child's school?
Dr. Celia Falicov: (45:27)
Or what happened when you, the social worker interviewed you? And so that's set up already the agenda, rather than saying, what would you like to talk about today? How would you, like, what would you like us to do together? Right. And so that, and the idea of revisiting the previous session certainly was, you know, a way of connecting. Meaning I know you, you know, I have an alliance with
Dr. Keith Sutton: (45:55)
Bridging.
Dr. Celia Falicov: (45:56)
Reaching, yes. Which wasn't necessarily bad, but I was surprised at how many times the therapist ran with that and kept on asking more questions about the meeting that they had or, yeah. And rather than giving any voice, centering the voice of, because in some ways you invite change, by, by saying, what would you like to talk about today? Rather than saying, we're talking about only the same themes.
Dr. Celia Falicov: (46:24)
Well, people change, maybe they have a new preoccupation, or maybe they resolve what they did before, or it can come back later in the session. So it's very important that, so I started thinking, I think at that time, like we all talk about collaboration. That's our new, new way of thinking, right? We all talk about the patients being experts on their lives rather than us coming in as experts, but how do we actually do it. So in this more microscopic look, I was able to come up with some ideas about how do people, which are the therapists that then score in shared decision making, and the ones who scored more. The second theme, uh, was just simply looking and it was easy to do a percentage of time that therapist talked in relation to percentage of time that the, um, client talked. And, uh, there was, there was one of the cases where a woman was very, very distressed over the fact that her children had been taken away from her.
Dr. Celia Falicov: (47:37)
And, uh, and that she was doing her best to bring them back with her behavior, stopping some of the more, uh, negative things. And, uh, the therapist just talked the whole time about, uh, what she should be doing, you know, from take a shower, uh, stop doing this, you know, and, and, and the patient, you know, the client was saying all the time. Hmm, hmm. Mm You know, like honoring something that was, uh, helping the therapist in a way by saying, oh, I understand. But, you know, was she gonna do it?
Dr. Keith Sutton: (48:19)
Yeah. Being maybe somewhat agreeable, but not necessarily emphatically like, yes, that's that's what I need.
Dr. Celia Falicov: (48:24)
That's, or elaborating or asking a question. Like, well, it's hard for me to do that, or, you know, anything. So, um, it's not necessarily that it has to be equal balance, but it's an important thing to look at, you know, how much space are you leaving for an exchange or even for hearing the client's voice.
Dr. Keith Sutton: (48:47)
Yeah. And it was, uh, in that article too, you kind of pointed out like there was, you know, one, one extreme where it was a therapist talking the majority of the time. Then also another extreme where it was just the client talking the majority of the time, and the therapist not really kind of, you know, guiding or kind of helping shift. And so that, that creating some balance, which again, like you're saying, doesn't necessarily need to be 50/50, but, but not necessarily kind of one extreme or the other.
Dr. Celia Falicov: (49:11)
Yes. They, both of those approaches seem less successful in terms of really coming up at the end of the session with some kind of collaborative sense that we've done this together and we can move forward. And as you were saying earlier, it's not that the therapist cannot, uh, present their point of view, but, and, and, and present even their expert point of view. But it's also, and this is where I think the work of, uh, Harlene Anderson's very important on collaborative therapy about presenting things in a more tentative way, rather than this is the way things are, you know that, that, uh, expressing some sort of relativity, you know, like I myself many times say, will, I don't know if this will fit you. Or, you know, I don't know how, how it could, it would work out for you. So I, I want, want to hear that, but I sometimes I heard that is helpful for people to do this. Or I've heard that when it comes to, uh, stepfamilies they do better if they wait a little bit longer until the stepparent is more incorporated, and what do you think of that idea? So, so it's tentative, you know.
Dr. Keith Sutton: (50:36)
Our knowledge is not necessarily the truth with the capital T that we have ideas, but they, the, the assumption that it's not necessarily gonna fit for everybody, but seeing and and critic space for the client to say, no, actually that doesn't fit or so on, without feeling like they're, they're being uh, contrary or, or whatever it might be.
Dr. Celia Falicov: (50:55)
Yeah. And, you know, that fits very well with your impactful comment isn't that the therapist has to abandon their position of having something to contribute. That's not what collaboration means, you know, it's a contribution without imposing, right. And so, it's not a absolute or a certainty that you're presenting, and that, I think, collaborative meaning making out of the situation fits well with that, you know? That's the fourth topic in that most people come up with what is the problem that it's, it's, uh, you know, that you're suffering from, which is very different than diagnostic labor. In some of these cases that you read in the article, people are being diagnosed in a very direct way, you know, like, you suffer from an anxiety disorder, or if you don't do this, you're going to, oh, yes. What was it? There was a therapist that was saying, well, you attempt to repress or, or suppress what your real feelings are. But it's like a volcano waiting to erupt and it's going to blow the lid off, and then where are you gonna be? And so she gave you this metaphor, you know, uh, of, you know, something,
Dr. Keith Sutton: (52:26)
How things are gonna go.
Dr. Celia Falicov: (52:28)
Yes. How things are gonna go and what you're doing wrong. And so it was not focusing on strength. No. It was not focusing on the possibilities of, uh, of working with this vulnerability in a constructive way that comes from the conversation.
Dr. Keith Sutton: (52:47)
Yeah. In motivational interviewing, they, I think they call it the writing reflex that the therapist wants to get the client on the right track and will sometimes, yeah, use something like if you go down that path, this bad thing's gonna happen. So to kind of get the person to change their experience, but, but again, like you're saying, it's not collaborative, it's not staying with the client's experience and kind of helping them, instead kind of saying that's wrong and this is right, which, which can create that distance and, and lead to losing the client.
Dr. Celia Falicov: (53:17)
Yeah. And you know, I described in the article, uh, because I don't want people to leave with the impression that I'm being critical of this therapist. Because what happened was this therapist was trained in shared decision making and then had to listen to her on tape, which by the way, if we go back to my old, old history and listening to your tapes or seeing your own video videotapes is an incredible way to learn. And so this therapist, as well as everybody that was in the study except the control group, went back and then had to talk to a coach.
Dr. Keith Sutton: (53:55)
Yes.
Dr. Celia Falicov: (53:56)
And she came into that coaching session saying, I realized that I am not letting the patient talk or the client, because, I go and say, do this and do that, and do this and do that. And maybe she was doing it on her own anxiety, you know, because there are, like you say, they wanna fix things and, uh, but she recognized it. So training in, in collaboration, it's a very important thing.
Dr. Keith Sutton: (54:29)
Definitely. Definitely. Yes. But I think too, I don't know about you, but I know I still have that at times. And sometimes I'll be like afterwards, oh, I got caught up there and like I, I miss the client, you know, and oftentimes we'll then wanna circle back around or the next session say, you know, gosh, I, I missed that. Cuz as therapists we make these mistakes. Um, or yeah, our own worry gets a hold of us at times.
Dr. Celia Falicov: (54:50)
Yes, yes.
Dr. Keith Sutton: (54:51)
Yeah. And that transparency and collaboration to come back and say, I mistepped.
Dr. Celia Falicov: (54:55)
Exactly, exactly. And maybe she could back the next session and say, I'm sorry that I sort of talk so much I wanna hear, you know, from you and you know, what works best for you. And that, you know, takes me to the, um, co-constructing the behavioral task because we all give homework. I don't know how current that is today, but I think, you know, many therapists, when I hear the tapes, do suggest things.
Dr. Keith Sutton: (55:24)
Yeah.
Dr. Celia Falicov: (55:25)
And so, and the issue again, if we go back, particularly with working with low income clients, but, everybody, you know, the reviewers of this article, they all said, but this applies to not only low income. It could be, it could be for all therapists, not all social classes. Uh, and that is if you prescribe something to be done, you really need to check, what are the elements of the context of the client that will allow them to do or not do it. Or whether they need to, you know, twist it, shift it, do it more in a way that would work for them or could fit their lifestyle. And, uh, so, it means that co-constructing the behavioral task, rather than saying do this. And that, to me, can be classified as collaborative. But we arrive together at the task.
Dr. Keith Sutton: (56:29)
Well, I think that's so important cuz I think yes, sometimes there's extremes on either sides where the therapist's like, okay, this is what you're gonna do without necessarily having that collaboration or the other side where the therapist is being so non-directive or, um, you know, I I, I originally focused in more post-modern approaches, narrative therapy and so on when I first started training, but I'm also a very kind of engaged person and so on. And so I was, you know, I had a supervisor or a teacher that was like, why don't you just teach this mom timeouts? And I was like, oh, okay. I did that. And all of a sudden things changed. I've been trying to bring that resource out for several sessions. So, but I think that kind of collaboration around bringing in skills as well as drawing out resources and that one doesn't necessarily negate the other in, in having a collaborative relationship with your client. And so, and not that that's necessarily based in narrative or so on, but I think that aspect that I think particularly as a learning therapist in the beginning, trying to be respectful, but, you know, finding that kind of balance and being able to bring yourself, but keeping that one down position.
Dr. Celia Falicov: (57:34)
Yes, absolutely. Absolutely. You're so right, because there's also the possibility that clients do want, that they want to hear about the skills. But they just, you know, they, they're coming to that, they're paying for that. And so, uh, you know, if you remain silent and just not provide sufficient content.
Dr. Keith Sutton: (57:57)
Yeah. I actually just read an article recently on some research around that and it was, I forget exactly, it was 60 or 70% of clients preferred a more directive therapist. Um, and only about 10 or 12% preferred non-directive. But when they evaluate the therapist, the majority of the therapists preferred a non-directive approach. So there was this kind of amiss, but clients are coming in for help and needing something. And so I think that that kind of, you know, those aspects that you're talking about, like the agenda around kind of balancing the talking and not being to one way or another, and again, that collaborating around tentativeness and relativity, and not that we necessarily are the holders of the truth, but really collaborating on that meaning making, and then that kind of evolves to that co-construction of the task and what's actually gonna be done to potentially help create change.
Dr. Celia Falicov: (58:47)
Yes. Yes. And so it could be, you know, important to really understand that you're hearing both voices, right? That you're bringing both types of strengths, the ones that the client brings and the one and the therapist. Do you want me to talk a little bit about what else I'm doing right now?
Dr. Keith Sutton: (59:08)
Yeah, I'd love to hear what else you're doing. I mean, I don't know if we have enough time to get into it. Uh, one of the things that struck me, one of the things that you talked about in the training was about, was the cultural mask, which I thought has really stuck with me. I don't know if you remember, like about sometimes the client might say, well, this is part of my culture, and then that's kind of the sign for the therapist to totally back off. But sometimes kind of finding where, but that, that might be a whole bigger subject or someone
Dr. Celia Falicov: (59:35)
Concept
Dr. Keith Sutton: (59:36)
Yes. In a way to be able to listen and acknowledge the culture, but at the same time to kind of work beyond that or through that, or, but again, this is, that's a, that's a big topic for less than 12 minutes.
Dr. Celia Falicov: (59:49)
Okay. Okay.
Dr. Keith Sutton: (59:50)
Whatever you think would be, yeah. Where you wanna go next.
Dr. Celia Falicov: (59:53)
Um, well, I don't know what I'm doing right now. I don't know how applicable it will be to, to many therapists. So, but um, if we go back to what you were saying in a different way about the cultural mask, I think it is important to understand that we should not idealize culture. That culture, uh, sometimes is, you know, at its extremes can have negative consequences. You know, we know that about, for instance, the oppression of women, you know? That one could say is, you know, it's part of the culture, or the domination of males can say it's part of the culture, but it's not a part of the culture that we should support. And, and sometimes, you know, clients will say, I can't help it, you know, uh, it's just how my culture is.
Dr. Celia Falicov: (01:00:46)
Yeah. And, and that it becomes, you know, it's like a closest issue. Right. And also I think know, therapists might say no, for example, I gave the example of children being intermediaries, with the parents in immigration situations. Well, yes, in many ways, that is not a negative in the sense that it creates responsibility, even in young children, it gives them an important sense of agency in the family. But at the same time, you know, if the know girls are always cleaning the house, and they're, and you know, and they're always serving the boys or, and they are. So it is part of the culture, that they should be helping the parents, but when is it too much, you know? Or when that it is, uh, impinging on their development. Or, or their sense of autonomy. So culture is a tricky thing, you know, that one could even discuss with our clients is this-
Dr. Keith Sutton: (01:01:53)
That's, that's the piece of opening up that conversation. Cuz I think in the, in the conference, uh, you had talked about that cultural mask and that sometimes the client might say, well, this is part of the culture, and sometimes the therapist will say, okay, I can't, I can't deconstruct that with them because I need to back away from that and say the person saying, oh, well, you know, being machismo is part of my culture, so on. But kind of to the extreme, like kind of, you know, as a justification for, you know, the domestic violence or whatever it might be, when it may actually be a distortion of kind of what the, that aspect of culture is and being able to kind of take the time to understand and kind of deconstruct that and really look at that together, rather than just, you know, especially if the therapist is from a different culture, you know, kind of stepping back and saying, okay, well we can't look at that because I'm not of that culture, whatever it might be.
Dr. Celia Falicov: (01:02:46)
Yes. So mistaking perhaps the idea of respect, curiosity and respect. But yes, I'm curious about that, but also I'm very respectful and I won't touch it. And when, so you know, I don't know if you've ever come across an article that I wrote on cultural Constructions of machismo. It's called The Devil Never Sleeps. It's a family process, and it's about changing constructions of masculinity among Latino men and the differences between malignant machismo and benign machismo. And uh, and how sometimes, you know, very powerful domineering men will really advance the idea that, well, you know, I have all these benign elements of machismo, so why are you criticizing me for, and also they have learned to say, I, you know, to, to a different sort of mask. I am not a machista. I'm not, I'm not a male who, but you know, they may be in some aspects, but by saying I'm not, they also stop you. So it's important for therapists not to be intimidated by, you know, those statements and to just say, well, I wanna know more about it. And the other people, what do other people in your family think about this? You know? If your daughter was here, your son was here, your, you know, your wife was here, what would they say about this?
Dr. Keith Sutton: (01:04:24)
Yeah. And really understanding the clients, again, that kind of micro cultural experience. Um, cuz I think that too, that this, this also, you know, extends beyond just, you know, specific cultural groups such as Latinx or African American or so on. That also, you know, all these intersectionalities are also happening in, you know, white kind of, you know, Euro Caucasian, American families too, around gender, around. Uh, and, and I think you've talked about too, that oftentimes socio socioeconomic status is also kind of, you know, not looked out as much. And how that interplays, although lower socioeconomic status because of systemic racism includes a lot of people of color, but also that, that a multitude of clients of different race and background also have these experiences and that clients or therapists need to be understanding and, and again, collaborating around.
Dr. Celia Falicov: (01:05:23)
Absolutely. That's a very good point, yes. So about the other thing that I'm learning from my current work is a new element that, and, and my teaching to medical students that it, that it is been labeled by one of the medical students fireside chats. You know, like, like Russo used to do and that, and that they're also very collaborative in the sense that the interpreters in this case, you know, they're Spanish speaking interpreters and medical students and the psychologists are, you know, marriage and family therapists too, get together with them and discuss issues of mental health, you know, that are, that are most culturally respectful and sensitive, but they are done in a way that is very also collaborative in the sense of like a fireside chat. You know, I, yes, we have some expertise?
Dr. Celia Falicov: (01:06:27)
But we also would like to hear how, how can you apply it in your setting. And I've been, I have start, and one of the things that we have learned over the, all these years of working in an immigrant, you know, underserved population clinic, a medical clinic that now incorporates mental health, is that flexibility of time and flexibility of space are extremely important to contact therapy with low income families because we can't really expect people that don't have transportation, that don't have really working computers and cell phones to be able to act in the same way as middle class and upper class people. So I think those are another way where some of our structures for therapy need to be questioned, you know, uh, when we work with the current, another one size doesn't fit.
Dr. Keith Sutton: (01:07:35)
Yeah. Yeah. How do we accommodate, or how do we help work around those barriers to be able to provide those services to clients without them getting kind of apologized or kicked out after missing a session or so on.
Dr. Celia Falicov: (01:07:47)
Yes. Or interpreting as resistance. Or, or a stigma, you know, they, they're, they don't like to come because they cold client or something like that. They don't wanna be called crazy or, when in fact we haven't provided a setting, that fits with their lives.
Dr. Keith Sutton: (01:08:05)
Definitely.
Dr. Celia Falicov: (01:08:06)
So, uh, okay.
Dr. Keith Sutton: (01:08:08)
Well thank you so much. This has been so wonderful to hear about what you're doing and the work that you're doing and just, you know, hearing about the evolution of your thinking. And I really encourage folks to read your article and I, uh, cuz I think that centering the voice of the client on becoming a collaborative practitioner with low income individuals and families, and I think that, you know, even beyond just the low income and so on, just again, that aspect of those five points that you are making around collaboration, because I think, like you're saying, collaboration is this word that we often use, but really what does that look like in a process kind of analysis of sessions and, and really kind of looking at the nuances of that are, are so significant and important to, it's a great contribution.
Dr. Celia Falicov: (01:08:53)
Okay. Thank you so much, Keith, for inviting me. I think you're doing a fantastic job with, it was, you know, how easy it is to talk to you, but also how valuable it is, what you're doing in the podcast for people. So, so thank you very much. Thank you for thinking about me and inviting.
Dr. Keith Sutton: (01:09:10)
Great. Thank you so much for your time. Take care. Bye-bye.
Dr. Celia Falicov: (01:09:14)
Bye-bye.
Dr. Keith Sutton: (01:13:40)
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