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Matthew Rensi, Ph.D., LPCC - Guest
Matthew Rensi, Ph.D., LPCC, is a licensed counselor in California, Oregon, and Idaho. He holds a Ph.D. in counselor education and supervision, often teaching at various universities. He currently works primarily with law enforcement, veterans, firefighters, and active duty military personnel. His primary focuses are PTSD, substance use, ADHD, marital or couples issues, and anything that may be associated with that cluster of struggles. Matt conducts research on various topics as part of an independent research team. He is a clinical partner with The Headstrong Project and the SOF Network. Matt is also a clinician at the Institute for the Advancement of Psychotherapy and its specialty center, the Bay Area Center for ADHD. |
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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. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances 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. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today, I'll be speaking with Matt Renzi, who is a licensed counselor in California, Oregon, and Idaho.
Keith Sutton, Psy.D. (02:24):
He holds a PhD in counseling education and supervision, often teaching at various universities. He currently works primarily with law enforcement, veterans, firefighters, and active-duty military personnel. His primary focuses are PTSD, substance abuse, ADHD, marital and couples issues, and anything that may be associated with that cluster of struggles. Matt conducts research on various topics as part of an independent research team. He is a clinical partner with the Headstrong Project and the SOF Network. Matt is also a clinician at the Institute for the Advancement of Psychotherapy and its specialty center, the Bay Area Center for ADHD. Let’s listen to the interview. Well, hi Matt. Welcome.
Matthew Rensi, Ph. D., LPCC (03:06):
Good morning. Thanks, Keith.
Keith Sutton, Psy.D. (03:08):
Yeah, I'm glad we got a chance to do this. Yeah, so I know you—you’re in my group practice, or Institute for the Advancement of Psychotherapy—and you've been talking about some of the work that you've been doing. I know you do a lot of work with veterans, you do a lot of work with trauma. You also have published a number of articles recently, and I was reading through some of those and some of the linguistic analyses that you're doing, and I thought it would be great to hear more about what you're doing and about the work you've been engaged in. But first, I always like to start off with finding out how people got to doing what they're doing, you know, kind of the evolution of their thinking. So, yeah.
Matthew Rensi, Ph. D., LPCC (03:51):
Yeah. Well, I started in the therapy world as a client. I was in the Marine Corps, and I did three combat tours. I got out, and for lack of a better word, my screws were a little loose. And so I ended up doing my own therapy and found it very beneficial, and then eventually became a therapist myself.I started in community mental health, working with an unhoused population, a lot of psychosis, and then a lot of gang youth. I loved working there, but eventually wanted to go more into working with veterans and first responders, and exclusively trauma, and then ancillary work with ADHD too. And so that’s kind of how I ended up where I’m at right now.
Keith Sutton, Psy.D. (04:47):
Okay, great. And how about the research?
Matthew Rensi, Ph. D., LPCC (04:50):
Yeah. I never wanted to do research. I remember one of my master’s-level professors saying research is horrible—he hated the research world and the “publish or die” mentality. And so I always had that aspect of research, but I understood the math and statistics side of it, so that wasn’t a big barrier for me. People would feel overwhelmed about that, and I was like, I get that.And then doing my PhD, you had to publish—you published a dissertation. And the way our dissertation worked is there were two kinds of studies within it, so I was almost forced to do two studies. I was like, I have these done, I might as well try to get them published. After that, I got invited to a research group, and that just kind of kicked things off. It was like, oh, I got curious about this—let’s try to figure out what’s going on there, and what about this, and what about that. The linguistics side was something I just kind of dropped into because my dissertation advisor was doing it. But looking back, my mom was a Spanish teacher and my dad was an English literature teacher, so linguistics has always been kind of part of my family background and the culture I was in.
Keith Sutton, Psy.D. (06:22):
Oh, interesting. Very cool. So let me go over the work with veterans first. Can you talk a little bit about the work that you're doing? I know you’ve been part of our institute, sharing things that we're learning and research that we're reading, and you are always keeping up on the research on trauma. Maybe you can start off and tell me a little bit about that.
Matthew Rensi, Ph. D., LPCC (06:47):
Yeah. So therapy for veterans is a really tricky area because most of the space is dominated by the VA. The VA does a lot of good things, and it also has weaknesses or gaps. One of the gaps the VA has is that they tend not to hire a lot of people from my licensure. They tend to hire psychologists and social workers, not a whole lot of counselors. I’ve tried to apply at the VA and get a job there to work with veterans, and each time it’s kind of like, “Hey, you’ve got the wrong license.” And I’m like, “But I can do everything a social worker can. Why won’t you hire me?” So I kind of got stonewalled there.
Matthew Rensi, Ph. D., LPCC (07:44):
Okay, so I got kind of bitter for a bit, and I was like, “Well, maybe I just won’t do this.” I like working with unhoused people anyway, and there are plenty of veterans there, so I’ll serve veterans through that community. Then what happened is I got connected with an organization called the Headstrong Project. They were founded by a Marine Corps veteran, and they specifically focus on trauma therapy and a lot of suicide-prevention type work for active-duty military and veterans. It’s such a well-run organization—the values, how they approach things, and their insight into wanting to use high-quality therapy with culturally competent clinicians and get quick access to care has just been absolutely phenomenal. Measurement-based care, everything—it all checks the box for me.
Matthew Rensi, Ph. D., LPCC (08:49):
Working there with the veteran and active-duty military population, one of the big things that comes up is confidentiality. I know confidentiality is baked into our profession, but it’s especially important for veterans and active-duty military because sometimes they’re still operating. If they’re a SEAL, for example, they may be wondering, “Is this going to affect my ability to continue to operate if my command finds out?” Another thing is that it’s usually some type of traumatic event, but many of the people you work with—especially in special forces, but in the military in general—tend to have a higher proportion of difficult childhoods or difficult family lives. So there’s a history of things that have caught up to the most recent event. You also tend to see a lot of substance use, suicidality, and difficult relationships. Another component we have to figure out is whether there’s TBI or repeated blast-related brain injury and what’s going on there. So it’s kind of this nexus of things that revolves around trauma, but also includes these associated factors.
Keith Sutton, Psy.D. (10:23):
Well, and also, ADHD has a higher prevalence in the military population too. Barkley talks about how it’s such a structured environment that oftentimes people go in, and that really helps.
Matthew Rensi, Ph. D., LPCC (10:37):
Keith, about 50% of my veteran clients who have trauma also have comorbid ADHD. I’ll sit down with them and ask, “Have you been diagnosed with ADHD?” And they’re like, “You saw that in five minutes?” And it’s pretty evident.
Keith Sutton, Psy.D. (10:53):
Okay. So there’s the confidentiality aspect, and then there’s this mix of stuff that you have to tease out—what’s going on with the trauma, whether there’s a traumatic brain injury, and then oftentimes maybe the past trauma, which is leading the person to be more susceptible to PTSD in the more present situation. And tell me a little bit about what kind of work, what kind of approaches, you’re using in this work.
Matthew Rensi, Ph. D., LPCC (11:24):
So this gets into the whole conversation about evidence-based practice versus non–evidence-based practice and everything that goes into supporting that. Right now, most research is saying that the big three for treating trauma are prolonged exposure, cognitive processing therapy, and EMDR. You also have other up-and-coming therapy models that are being researched at the moment. There’s also kind of therapist lore out there, where therapists say, “I’m using this for that,” and it’s like, okay, I haven’t seen any research around that. So those are the big three models. The tricky thing with those is that prolonged exposure has kind of been the go-to. Edna does a lot of research around it. But what most people don’t talk about is that the dropout rate is around 40% for prolonged exposure.
Keith Sutton, Psy.D. (12:31):
Yeah.
Matthew Rensi, Ph. D., LPCC (12:32):
And that’s not just one study saying 40%. That’s meta-analyses across the board—consistently between 30% and 40% dropout. So you already have a population that’s hard to convince to get into therapy, and then once you get them in, about 40% drop out just because of the model. If you think about it, four out of ten clients dropping—it doesn’t sit well with me. The next thing is cognitive processing therapy, which is great. It’s a phenomenal therapy, but the only places you can get trained in it right now are the VA or the Headstrong Project, or something similar. So you have to be working with a military population to get trained in CPT. For most therapists, the only evidence-based practice that’s left overall is EMDR. EMDR is great too, but the problem—specifically for the military or veteran population—is the eye movement component. It doesn’t work well. I haven’t seen research on this, and I don’t know exactly what’s going on, but many of them will say that the eye movements are difficult. I think what’s happening is that there’s too much threat assessment in their day-to-day life visually.
Keith Sutton, Psy.D. (14:09):
Interesting.
Matthew Rensi, Ph. D., LPCC (14:10):
Tracking a moving target feels like threat assessment to them, so they have a hard time with the EMDR eye movements. But they can do the auditory or the tactile tapping or buzzing—anything like that works well.
Keith Sutton, Psy.D. (14:31):
Oh, interesting. And you haven’t seen research on this, but this is something you’ve noticed in your experience?
Matthew Rensi, Ph. D., LPCC (14:38):
I haven’t seen any research. There’s another clinician in the area who does EMDR exclusively with first responders—Karen Lansing—who’s written a book on it. I was talking with her and said, “I’m having trouble with the eye movements,” and she said, “Oh yeah, I don’t do eye movements at all. They get way too overstimulated.”
Keith Sutton, Psy.D. (14:56):
Yeah, that’s interesting too. I trained using the buzzers and the headphones, and I’ve never really used the eye movements. Even the formal EMDR training I took was tapping the whole time. I’ve done eye movements with some clients, but I prefer eyes closed because you can get so much more into the visual imagination. At least with my clients, it works incredibly well. So it’s interesting that for this specific population it might be harder or less effective, but if you change the modality to tactile or auditory, then it becomes more effective.
Matthew Rensi, Ph. D., LPCC (15:45):
Yeah. I haven’t seen anyone else talk about it either—again, Karen Lansing is the only one who’s brought it up with the populations we work with. But it’s been pretty consistent across the board. EMDR is still really effective without the eye movements. The way I was trained was “eye movements or nothing,” and I was like, I don’t know if I’m doing this wrong.
Keith Sutton, Psy.D. (16:05):
Yeah. Some people are very adamant about that now. And there was another piece you were bringing in around developing a tolerance for discomfort. What was that? I have to look at my notes—stress inoculation therapy.
Matthew Rensi, Ph. D., LPCC (16:29):
Yep. Stress inoculation therapy is coming up. It’s still kind of an up-and-coming therapy. There’s research happening around it right now, but it’s not considered an evidence-based practice yet. So it’s not one that I use at the moment. Working with the Headstrong Project, they want only the strongest evidence-based practices, and all my veteran clients are coming through them right now.
Keith Sutton, Psy.D. (17:06):
Well, and you do cognitive processing therapy. Yep. Talk a little bit about what that is, and also, having these different tools in your toolbox, how do you decide what you use with which clients?
Matthew Rensi, Ph. D., LPCC (17:21):
Yeah, great question. Can I make a confession? I think if you had asked me five years ago if I would have done manual-based therapy, I would have said never. I’m not doing it. I had a psychiatrist I worked with once, and he said, “We’ve turned therapy into Lego manuals,” and I didn’t want to reduce a person to a set of Lego steps to make them better. So when the opportunity came up to get trained in cognitive processing therapy, I said, you know, I’m pretty open to something. I’ll try it, I’ll see what happens, but I don’t want to turn someone into a manualized process. I took the cognitive processing therapy training and was like, oh—this is really good. Crap. I’ve got to reevaluate my bias about using a manual.
Matthew Rensi, Ph. D., LPCC (18:25):
Cognitive processing therapy walks people through 12 sessions, and it’s a CBT-adapted treatment, so it’s very cognitively based. It looks at what we would call cognitions—automatic thoughts or core beliefs—but in CPT they call them “stuck points.” There are assimilated stuck points and overaccommodated stuck points. Assimilated stuck points are beliefs I’ve taken directly from the trauma. Over-accommodated stuck points are beliefs where I’ve adjusted my thinking patterns because of the trauma. What we do first is give a brain-based explanation to the client about what’s going on with them in trauma, teach some coping skills, and then lay out the treatment across the board. Then we use the ABC model—activating event, belief, consequence—to have them break down events and thinking patterns within those events.
Matthew Rensi, Ph. D., LPCC (19:36):
Then they use challenging questions. The next session focuses on thinking patterns, which is very much cognitive distortions and cognitive reframing, but specifically around trauma and trauma-related stuck points. Then we put everything together using what they call a challenging questions worksheet. That includes the activating event, belief, emotions, thinking patterns, challenging questions, alternative belief, and then the emotions that come up with that. So it’s essentially a whole CBT framework laid out in one worksheet. Once you have that framework in place, you follow up on five themes. The themes are safety, trust, power and control, esteem, and intimacy. You work through stuck points in each of those areas. Then, at the end, you rework the traumatic narrative and look at what I believed before starting this and what I believe now.
Keith Sutton, Psy.D. (20:52):
Yeah. Interesting.
Matthew Rensi, Ph. D., LPCC (20:55):
Yeah.
Keith Sutton, Psy.D. (20:56):
So tell me about these five areas, because I think that’s great. Are these five areas seen as some of the core impacts of trauma?
Matthew Rensi, Ph. D., LPCC (21:06):
Yeah. I don’t want to say Patricia Resick developed the five areas—I don’t know exactly why she developed them—but they’re kind of a heuristic that I use now myself. Whenever I’m working with anyone around trauma, I’m looking for themes in those five areas. Trauma affects your sense of safety—either I felt safe before and now I don’t, or I didn’t feel safe before and the trauma reinforced that.
Keith Sutton, Psy.D. (21:35):
Yeah.
Matthew Rensi, Ph. D., LPCC (21:37):
It affects trust—trust in self and trust in others.
Keith Sutton, Psy.D. (21:44):
Yes.
Matthew Rensi, Ph. D., LPCC (21:45):
So I can trust myself or I can’t trust myself. I can trust others or I can’t trust others. And those beliefs either get broken or reinforced.
Keith Sutton, Psy.D. (21:55):
Yeah. Sometimes I think about trauma as breaking our trust in the world. Anything becomes possible. Most people don’t walk down the street worrying that a car is going to jump off the road and hit them. But after trauma, there’s that hypervigilance—knowing that it could happen.
Matthew Rensi, Ph. D., LPCC (22:13):
Yep. It’s like the world has lost its rules.
Keith Sutton, Psy.D. (22:16):
Yeah, yeah.
Matthew Rensi, Ph. D., LPCC (22:17):
Or boundaries. And gosh—oh man, I just lost it, Keith.
Keith Sutton, Psy.D. (22:26):
We’re talking about trust.
Matthew Rensi, Ph. D., LPCC (22:27):
Trust. Maybe—I’ll come back.
Keith Sutton, Psy.D. (22:30):
So the next piece is power and control.
Matthew Rensi, Ph. D., LPCC (22:33):
Yeah. Power and control is the sense of agency—whether I have agency over my life or I don’t have agency over my life. If I feel like I have agency over my life, trauma often makes me feel helpless. If I don’t feel like I have agency over my life, trauma makes me feel like, well, yep, I don’t have agency over my life.
Keith Sutton, Psy.D. (22:55):
Yeah.
Matthew Rensi, Ph. D., LPCC (22:56):
Keith, can I come back to the trust piece?
Keith Sutton, Psy.D. (22:58):
Oh yeah.
Matthew Rensi, Ph. D., LPCC (23:00):
The trust piece is also reflected in the research around human-involved traumas versus natural disasters.
Keith Sutton, Psy.D. (23:09):
Oh, interesting. Say more.
Matthew Rensi, Ph. D., LPCC (23:10):
So there are lower rates of PTSD for natural disasters.
Matthew Rensi, Ph. D., LPCC (23:16):
There are higher rates of PTSD if it’s a human-involved or human-initiated event. The component of that—or the theory of why that’s different—is because trust is a factor with human beings, whereas I don’t have trust for a tsunami.
Keith Sutton, Psy.D. (23:34):
Sure.
Matthew Rensi, Ph. D., LPCC (23:36):
And so that’s where the trust comes in.
Keith Sutton, Psy.D. (23:39):
Yeah. I was working with one couple, and one of the partners was struggling with feeling like, “I’m having trouble with my partner because they don’t believe that the nature of humans is good.” And part of that was his privilege—having never experienced trauma.
Matthew Rensi, Ph. D., LPCC (23:57):
Whereas--
Keith Sutton, Psy.D. (23:58):
For his wife, she was always anxious or worried about not being able to trust others and was actually very close to animals, pets, and so on. They were pure and natural and safe, but with humans, that trust was gone.
Matthew Rensi, Ph. D., LPCC (24:16):
Yeah. Yeah. And that totally makes sense. That’s a hard worldview for couples to cross if they have such different views on trust.
Keith Sutton, Psy.D. (24:31):
Yeah. Yeah, definitely.
Matthew Rensi, Ph. D., LPCC (24:33):
One of the things we do in cognitive processing therapy is have someone do what’s called a trust star. I don’t really like the star itself, but we’ll have people pick a person and write down different aspects of that person’s personality or things they do that make them more or less trustworthy.
Matthew Rensi, Ph. D., LPCC (24:54):
Then you rate how much—it’s almost like the O-S-S-R-S—where you put a tick on the line of whether it’s a plus or a minus. What that’s helpful for is that it breaks down trust not as a unified whole, but as something with nuance. You can say, “I can’t trust this person for these things,” or “I don’t really trust them here.” Once we get some movement there, people realize that the binary of trustworthy versus not trustworthy breaks down, and they have to think about trust in a more nuanced way.
Keith Sutton, Psy.D. (25:35):
Black-and-white, all-or-none. Yeah. It’s like the dialectics and DBT kind of aspect.
Matthew Rensi, Ph. D., LPCC (25:41):
Exactly. And also that sense—if I can’t trust anyone, well, how do you sleep next to your wife at night?
Keith Sutton, Psy.D. (25:48):
Yeah.
Matthew Rensi, Ph. D., LPCC (25:50):
“Oh, okay. Well, I can trust her.” Well, I kind of trust her. She’s not going to murder me in my sleep. It depends on how much of a fight we’ve gotten in before we’ve gone to sleep. But for the most part, I trust her.
Keith Sutton, Psy.D. (26:00):
Got it. Got it. Okay. And so there’s safety, trust, power and control—how about esteem?
Matthew Rensi, Ph. D., LPCC (26:08):
Yeah. I mean, we know abuse really tweaks people’s sense of self, value, and self-worth. Trauma can do the same thing, especially when there’s a sense of responsibility or guilt or shame there. And also, if the trauma was perpetrated against me, what does that say about me?
Keith Sutton, Psy.D. (26:40):
Yeah.
Matthew Rensi, Ph. D., LPCC (26:42):
Am I broken? Dirty?
Keith Sutton, Psy.D. (26:50):
So it’s really the person’s sense of self that’s significantly affected in this way.
Matthew Rensi, Ph. D., LPCC (26:59):
And for some people—for some of the military folks—it’s not really affected that much. But if it’s part of sexual assault, usually the sense of self is really tweaked to some degree.
Keith Sutton, Psy.D. (27:14):
Yeah. I’m wondering too—with the military piece—there’s often a feeling of letting others down or having been able to do more for someone.
Matthew Rensi, Ph. D., LPCC (27:28):
And that crosses over into the moral injury space.
Keith Sutton, Psy.D. (27:32):
Yeah. I was just looking up that term. Can you say more about moral injury?
Matthew Rensi, Ph. D., LPCC (27:37):
Moral injury is tricky because there’s so much overlap between moral injury and PTSD. But with moral injury, it’s like I did something wrong, or something was done wrong that transgresses my values, and now the entire structure of reality or morality or my value system has broken down. And there’s kind of this void.
Keith Sutton, Psy.D. (28:05):
Like, who am I now?
Matthew Rensi, Ph. D., LPCC (28:07):
Who am I—or even what’s right? You said something the other day in consultation: the antidote to shame is integrity. And what I would say is people with moral injury don’t even know what counts as integrity anymore, because everything’s broken down.
Keith Sutton, Psy.D. (28:31):
Yeah. That internal measuring stick of right and wrong—of “am I doing the right thing?”—has been totally thrown for a loop.
Matthew Rensi, Ph. D., LPCC (28:39):
Yeah. And can I trust anybody else to do the right thing if I don’t even know what the right thing is?
Keith Sutton, Psy.D. (28:43):
Yeah.
Matthew Rensi, Ph. D., LPCC (28:45):
So--
Keith Sutton, Psy.D. (28:46):
Okay. And then how about intimacy?
Matthew Rensi, Ph. D., LPCC (28:49):
Yeah. Intimacy has everything. So you’ve got safety, power and control, trust, esteem—all of that then gets rolled into how I connect with another person. Am I safe with another person? Can I trust another person? Do I have power, or am I vulnerable? Do I have to be in power, or can I feel vulnerable? Am I a good person or a bad person? If I show this person who I am, will they accept me, love me, or not?
Matthew Rensi, Ph. D., LPCC (29:28):
And what ends up happening is that sometimes, because of the trauma, there’s a sense of being cut off from other people—that’s one of the symptoms. But sometimes also, especially with the military, if they go on deployment and then come back, they’re interacting with their partner or spouse and think, “I want to protect them from what I’ve seen.” And in protecting them from what I’ve seen, I need to protect them from me.
Keith Sutton, Psy.D. (29:57):
Yeah.
Matthew Rensi, Ph. D., LPCC (29:58):
So there becomes this barrier—I’m pulling back, I’m withdrawing, because I’m trying to protect them from what I’ve gone through. Then you’ve got the EFT cycle going on, trying to preserve the relationship and protect the partner. But the way the partner experiences it is: you’re distant, you’re cold, you’re not present, you don’t love me, you don’t care about the relationship.
Matthew Rensi, Ph. D., LPCC (30:25):
And the withdrawal is like, “No, I’m doing this because I do care about the relationship.” And all of that gets--
Keith Sutton, Psy.D. (30:35):
They’re shutting down or distancing to protect the partner and the relationship, but it feels like the opposite to the partner.
Matthew Rensi, Ph. D., LPCC (30:43):
Yeah. And in that also—would anybody even love me while I’m going through this and have all this going on?
Keith Sutton, Psy.D. (30:51):
Especially with the veteran population—my dad was a Marine in Vietnam. Marine Recon.
Matthew Rensi, Ph. D., LPCC (30:58):
Oh--
Keith Sutton, Psy.D. (30:59):
Yeah. And the bonds you make with your unit—the other people—oftentimes that’s a huge loss too when you come back. Not having those bonds even within your family, or the kind of bonds developed in those situations and in that trauma.
Matthew Rensi, Ph. D., LPCC (31:27):
Well, when someone leaves the military, we have added layers. They’ve lost their identity, their community, the structure of life, and almost a sense of life coherence. In the military, there are clear sequences—promotions, next steps. You know what you have to do to reach Lance Corporal, Corporal, Sergeant, Staff Sergeant, whatever rank structure you’re using.
Matthew Rensi, Ph. D., LPCC (32:03):
Then you enter the civilian world and it’s a smorgasbord of things, but there’s no structure. Where do I belong? Where do I fit? Who am I anymore? Maybe I flew helicopters. I had multimillion-dollar equipment in my hands—and now I drive a taxi. That sense of “I used to be something, and I’m not anymore.” Making sense of that, on top of everything else, throws another significant loop.
Keith Sutton, Psy.D. (32:40):
That’s interesting. Because even people who aren’t experiencing PTSD go through that readjustment period. And I imagine that having gone through trauma, plus losing that structure and sense of esteem—being a skilled helicopter pilot, for example—makes people even more susceptible. All of those aspects are shifting so quickly.
Matthew Rensi, Ph. D., LPCC (33:07):
Yeah. I was working with a SEAL who had done eight years in the SEALs, and so was a fairly senior SEAL by that time, and was getting out and starting a bachelor’s program. And they said, like, “I feel like I’m freaking resetting my entire life—like starting all over on everything.” Like, we’re showing up and people are like, “Wait, what assignment are we supposed to do? This syllabus is so overwhelming.” And they were like, “I can’t—like, we used to take hundreds of people out with explosives every day, and this is what you’re worrying about?” And I’m on this same level at the moment. And they just felt like, “I’ve made a huge mistake, and I’ve just reset my entire life.”
Keith Sutton, Psy.D. (33:45):
Yeah. I’m sure too—having gone from that high level of competence and skill and mastery, and then all of a sudden going into this situation where people are just kind of at the beginning of development.
Matthew Rensi, Ph. D., LPCC (33:58):
Yep. And also, there’s a sense of like, “Nobody knows who I was or cares.”
Keith Sutton, Psy.D. (34:06):
Yeah. Yeah, definitely. That’s where oftentimes maybe some of the war stories come too. Yeah. Yeah. So I like these five pieces—safety, trust, power/control, esteem, intimacy. And so you use that and you apply that to other situations, even when you’re not doing the cognitive processing therapy.
Matthew Rensi, Ph. D., LPCC (34:33):
Good question. Some clients come to me and they request a specific modality. So sometimes they’ll have a therapist at the VA, and their VA therapist is like, “You should really do some EMDR, but we’re not trained in EMDR,” so they’ll come on over for EMDR.
Keith Sutton, Psy.D. (34:50):
Got it.
Matthew Rensi, Ph. D., LPCC (34:52):
Some clients will come in and they’re requesting specifically CPT. “Yeah, I’ve heard about this. I heard it’s great. I’d like to do CPT.” If neither of those is the case, it’s kind of three things. First off, does the client’s symptom profile and presentation kind of warrant one or another? So let me give you an example. If the client has any type of neurological thing going on, I’m really hesitant to do EMDR—unless they’ve got a neurologist that has said, “Yes, good to go.” Also, if there’s significant dissociation—I know I can work with some dissociation with EMDR—but if they’re fuzzing out all the time, it’s like EMDR isn’t going to be super helpful. Because with your eyes closed, you’re probably going to be fuzzing out through a lot of that, and getting you regulated is going to be hard.
Keith Sutton, Psy.D. (36:01):
Right.
Matthew Rensi, Ph. D., LPCC (36:03):
And so then we’re looking at CPT. Okay. Some clients—especially if they have any type of OCD, or if they’re slightly on the spectrum at all—the CPT tends to work a lot better. The CPT also tends to work fairly well with the special forces.
Keith Sutton, Psy.D. (36:37):
Interesting.
Matthew Rensi, Ph. D., LPCC (36:37):
Because there’s not a whole lot of emotional engagement, and they don’t have to emote a whole lot with it. Where EMDR, oftentimes, they’re like—stuff’s going on. And so with CPT, they can be kind of cognitive and logical with it, and it feels more safe for them. And then the last piece is, if neither of those are in place, then I’ll often sit down with the client and I’ll talk them through both models and kind of give the theory under them, and then say, like, “Hey, is there one of these that’s landing more with you?”
Keith Sutton, Psy.D. (37:09):
Great. So collaborating with them and kind of giving them agency and making the decision, which is so helpful when somebody has trauma. Yeah, exactly. Okay, that’s great. And are you doing prolonged exposure, or was that—you were just kind of mentioning that? Because that’s one of the top three.
Matthew Rensi, Ph. D., LPCC (37:25):
I don’t. I don’t do it. It’s just one of the top three. It’s one that people will often get at the VA if they go to the VA.
Keith Sutton, Psy.D. (37:30):
Yeah. Yeah. Got it. Well, great. And then tell me a little bit about the research that you’ve been doing. I know you did a little research with depression and AI—linguistic analysis of substance abuse, addiction diagnoses, and the DSM, and personality disorder diagnoses in the DSM.
Matthew Rensi, Ph. D., LPCC (37:55):
My research interests look like someone who did cocaine and then decided to pick their research interests. So if you told me, “This guy has no research focus whatsoever—he is all over the place,” that’s absolutely the case. So I started research in the DSM—I mean, the book we all hate and love. Linguistic research just came up because it’s an easy and quick way to slice up data that has some objectivity to it.
Matthew Rensi, Ph. D., LPCC (38:38):
It’s also curious because it’ll expose the kind of patterns that are going on under the surface of the words that we’re using, even if we’re not aware of them being there. So things like—the probably most well-known name in this is Pennebaker. He’s got a book called The Secret Life of Pronouns. And it can get overstated, but you can predict characteristics of people based on their word usage—simple things like first-person singular versus first-person plural.
Matthew Rensi, Ph. D., LPCC (39:20):
So older people tend to use the first-person plural—“we.” Younger people tend to use first-person singular. There’s all types of things. One of my research projects was on boosters or hedges. Boosters are words that make you sound more sure about what you’re talking about. Hedges are words that make you sound tentative. So boosters would be like, “absolutely,” “it’s certainly evident this is the case.” Hedges are things like, “it might be,” “it could be,” “these seem to point to it.” And there’s a whole dictionary of these words.
Matthew Rensi, Ph. D., LPCC (40:31):
So I was looking at the DSM and asking: Is the DSM boosting more or hedging more? How is the DSM evolving over time? And the DSM is tracking research literature in general, which tends to be hedging more.
Keith Sutton, Psy.D. (40:30):
Yes.
Matthew Rensi, Ph. D., LPCC (40:31):
So there’s kind of this academic uncertainty that’s being communicated in our language. We’ve also done some studies on anxiety. Anxiety disorders in the DSM are getting more classified as social disorders rather than individual neuroses.
Keith Sutton, Psy.D. (40:55):
Oh, interesting. Say more about that.
Matthew Rensi, Ph. D., LPCC (40:57):
Well, like social anxiety disorder, agoraphobia—things like that. Those weren’t present in DSM-I and DSM-II. And the language is picking up more social language in regards to anxiety. So this kind of collective sense. And how much of that is societally driven, or consciousness around anxiety, or technology and connectivity driven—I don’t know. But for sure, it’s shifting there.
Keith Sutton, Psy.D. (41:27):
Interesting. Is there any data on when that was shifting? I’m just curious—thinking about more of an individualistic perspective, kind of fixed personality theory, versus more postmodern, being affected by context.
Matthew Rensi, Ph. D., LPCC (41:46):
That’s great. I would honestly have to pull up my article.
Keith Sutton, Psy.D. (41:50):
Don’t worry about it.
Matthew Rensi, Ph. D., LPCC (41:54):
It’s been a while since I—hold on, let me see here.
Keith Sutton, Psy.D. (41:57):
I would imagine in the late sixties or seventies.
Matthew Rensi, Ph. D., LPCC (42:05):
Yes. So the shift was from DSM-II to DSM-III, where we start getting words like separation, individual, but it really kind of picks up around DSM-IV. Separation, avoidance, social words like that are starting to increase.
Keith Sutton, Psy.D. (42:42):
Interesting. Yeah. So that’s from like 1968 to 1994.
Matthew Rensi, Ph. D., LPCC (42:49):
Yes, exactly. That transition.
Matthew Rensi, Ph. D., LPCC (42:52):
Yeah. So I did some research on that, and joined a research group. We researched critical incident stress management, then burnout among first responders. But the article we dug into the most was playing around with AI. We’ve got a couple articles and studies we’re working on with AI right now.
Matthew Rensi, Ph. D., LPCC (43:46):
But AI is super controversial, and I want to caveat this: I don’t use any AI in my practice whatsoever. I don’t use it to transcribe sessions, I don't analyze treatment plans or anything like that, because I don’t trust what’s happening with the data at the moment.
Matthew Rensi, Ph. D., LPCC (44:57):
So what we did instead was ask: How good could AI be at diagnosing someone? But it didn’t feel ethical to use real people, and we’d have to go through an IRB. So we used case vignettes. We scoured the literature and said, “Let’s find case vignettes.” We also wanted easier diagnoses—unipolar depression rather than bipolar, anxiety disorders rather than OCD, though we did include schizophrenia.
Matthew Rensi, Ph. D., LPCC (45:21):
We avoided diagnoses that are harder to tease apart, like intermittent explosive disorder or conduct disorder versus ODD. And there aren’t that many good clinical vignettes in the literature. I’d read one and think, “They diagnosed this person with MDD, but they’ve only listed three A-criteria symptoms—what are you doing?” So we ended up with only about a dozen per category, which really isn’t enough.
Keith Sutton, Psy.D. (45:56):
Oh, interesting. I remember back in grad school, the DSM casebook—using that to really understand diagnoses.
Matthew Rensi, Ph. D., LPCC (45:31):
So we snagged the depression, but there are only 10 depressive disorders in there. Yeah. And they’re not all MDD—some of them are like dysthymia, persistent depressive disorder, or medically induced depression, and it’s like, I can’t use that one. Yeah. So we pulled those ones and then pulled from other research literature as well, and we got into the teens. And so we were like, that’s not high enough. So we did a power analysis—it’s fancy math to say, how much, what’s our sample size? Yeah, yeah, exactly. And we were like, we need like 50 vignettes in each category. We were like, oh, we… if we publish something on this, it wouldn’t even work. So people have been playing around with synthetic data, and we were like, I wonder if we could make synthetic vignettes out of this. And so we fed the vignettes that we had into an LLM—a large language model—and then said, generate some vignettes. And Keith, that was an entire freaking odyssey.
Keith Sutton, Psy.D. (46:42):
Wow.
Matthew Rensi, Ph. D., LPCC (46:43):
We probably could have written a research paper just on trying to figure that out. But we spent months and months trying to get the LLMs to actually develop a solid vignette and follow the prompt instructions that we had set forward through it.
Keith Sutton, Psy.D. (47:03):
And LLMs meaning language learning models, which are like used for ChatGPT or… you know.
Matthew Rensi, Ph. D., LPCC (47:09):
Large, large language model. Large.
Keith Sutton, Psy.D. (47:11):
Language. Yeah.
Matthew Rensi, Ph. D., LPCC (47:12):
So the thing is, if we had online ones, and then I have local LLMs—which means I have a model that is downloaded from the internet—I can run it not connected to the internet, and so the data’s not going out anywhere.
Matthew Rensi, Ph. D., LPCC (47:28):
Interesting. Wow. And so we were using Claude, we started using some of these creative LLMs, like Claude Opus, we were using Pose creative writing LLM, where they would come back with these vignettes that would be like, “Bill is experiencing the dark stormy seas of a black nut,” and you’re like, nope, that’s not going to work. You know, like… anyways, we got them to finally generate vignettes and we were like, sweet. Cool. So we got the vignettes generated, and then we tested three models. We tested Gemini, we tested ChatGBT, and we tested Claude. And we said, can they differentiate between a depressive disorder and a non-depressive disorder? Okay, and we did this fancy math called a confusion matrix. And what came back was ChatGBT did worse than Chance. Claude came back just like Chance. Gemini came back at like a 97% accuracy rate. Wow. Gemini did phenomenal. It did really, really well.
Matthew Rensi, Ph. D., LPCC (48:51):
So the outcome of the research essentially was that yes, LLMs could theoretically diagnose somebody from a vignette. But different LLMs have different strengths in what they’re doing and are better for different purposes. And all of these—the thing is, all of these LLMs are black boxes as far as the underlying thinking—they’re proprietary, so it’s not out there for us to look at. But what we found through that is Gemini was really accurate, factually interesting; ChatGPT was more creative; and Claude was kind of a balance between the two. And so that was kind of the outcome. Now, where’s the use case for something like this? Well, we have a couple. The first use case that I think is most helpful would be to have a diagnostic aid for graduate students. Yeah. So as you’re learning the process of diagnosis, being able to have an LLM where you input everything in, and it comes back to you and says, “Hey, based on what you’ve entered, here’s the possible diagnosis,” but then gives them the follow-up questions to ask to do differential diagnosis, because they don’t have that skillset yet. I think that would be super cool. I think that’d be super rad. And anyways, yeah. So yeah.
Keith Sutton, Psy.D. (50:29):
Well, I mean, yeah, there could be so much application too in helping out therapists even, you know, in, you know, when they're unsure, or again, like whatever—they're not brushed up on a certain thing, or they're like, "It's this," right? They can get consultation, or even, right, do a little research, like most of us do when there's something that we're not so sure about. Yeah. We might grab some research articles, go buy that book on that, just a kind of check to make sure we're not missing anything.
Matthew Rensi, Ph. D., LPCC (50:56):
I even train people on the DSM all the time, and I'll sit down and be like, "Hey, let's talk about the differential diagnosis section of each diagnosis." And they'll be like, "What?" And I'm like, "You haven't heard about the differential diagnosis section?" And they're like, "No." And I'm like, "Let's, let's go to the di…" So we have diagnostic criteria, diagnostic features, associated features, which is all super helpful stuff you should be looking at. But then we kept going, and we got differential diagnosis. And whenever I'm considering, eh, is this major depressive disorder versus something else, you know, major depressive disorder with atypical features versus generalized anxiety disorder, going to the differential diagnosis section and looking at something like that, yeah.
Keith Sutton, Psy.D. (51:42):
So I—that, you know, some of the research right now is finding that AI is not doing too well with actually providing therapy for folks. No. You know, that—I know there was a recent study that came out from Stanford, and that, you know, oftentimes because the AI is so affirming, it might be like, "Wow, you're doing a great job going off your bipolar medication. You're really taking a…" Yeah, over your life. But, you know, there are also other uses for it, particularly in our field, where—yeah—especially for research, and the information and combing through information so quickly has been really nice.
Matthew Rensi, Ph. D., LPCC (52:17):
Yeah. Well, the research that's coming out on AI is mixed. So AI is not good for a freeform, open, just-response therapist. It's horrible for that. It also is really bad for any type of atypical thinking—so delusion, hallucination, obsession, rumination, things like that. It tends to reinforce those or affirm those.
Keith Sutton, Psy.D. (52:48):
So the AI psychosis—people developing, or their psychosis intensifying from using AI because it's reinforcing their delusional thinking. Yes.
Matthew Rensi, Ph. D., LPCC (52:58):
AI is good at delivering CBT. It's really good at delivering CBT. It actually beats some therapists in a research study, oh—interesting—as far as being better at delivering or having better outcomes with the clients. Ah.
Keith Sutton, Psy.D. (53:11):
And is that—and the clients are knowing that it's AI versus human?
Matthew Rensi, Ph. D., LPCC (53:15):
Yeah.
Keith Sutton, Psy.D. (53:16):
Interesting.
Matthew Rensi, Ph. D., LPCC (53:17):
So it's also helpful as far as an aid to therapy.
Keith Sutton, Psy.D. (53:23):
Yeah.
Matthew Rensi, Ph. D., LPCC (53:24):
So having an AI companion that helps with homework has been found to be helpful as well. Very. So there's mixed research there on it, but it can be—as far as just a no-structure or guardrails on therapy, it's scary.
Keith Sutton, Psy.D. (53:52):
Yeah. Yeah. Well, yeah, and we're at the beginning of this new frontier of AI and what this is going to look like in all fields particularly. And yeah, I'm interested to see how it's going to play out in our field as therapists. So it sounds like you're doing incredible work, and I really like hearing about the trauma work and the work as you're thinking about it, and your work with veterans and first responders and other clients. And that I'm really going to take away those five pieces from the CPT, which I think are really helpful and applicable to all trauma, and really kind of a nice frame to almost evaluate where maybe the focus should be. It makes me think of, like, in motivational interviewing, there's the acronym DARN-CAP: like, is that the desire, is it the ability, is it the reason, is it the need? And sometimes they can help you focus on where you really need to intervene. That might be interesting too, even applying those five to linguistics. I know, especially with motivational interviewing, they do a lot of psycholinguistic analysis. Yeah. And then, yeah, it's great, with beginning to get this research going with AI and looking at its uses, and where it's helping and where the limits are, as we go into this new frontier.
Matthew Rensi, Ph. D., LPCC (55:14):
Yeah. Yeah. It's very much in the beginning. I want to see where it goes. I'm also incredibly cautious, so yeah, I'm not using any of it myself at the moment. I will poke around with it research-wise, but as far as clinical practice, I'm not using any of it.
Keith Sutton, Psy.D. (55:31):
Yeah. Yeah. I've been using it for research—having conversations with Gemini. I am like, "I thought I had heard this before. Is there any research to back that up?" Yep. And going into that, or in writing an article, you know, yep, looking at ideas and getting references and so on, and then kind of reading those references. Yep.
Matthew Rensi, Ph. D., LPCC (55:49):
So if you're doing that, and for any clinician out there, I recommend OpenEvidence right now. OpenEvidence is an AI-powered search platform, but it requires you to have an NPI number to log in.
Keith Sutton, Psy.D. (56:04):
Oh, interesting.
Matthew Rensi, Ph. D., LPCC (56:05):
So you’ve got to have an NPI number, you log into it, and it will give you a great high-level overview of the research. It's really solid.
Keith Sutton, Psy.D. (56:14):
Great. Wonderful. Well, Matt, thank you so much. It's great to hear about your work in more depth, and glad to have you as part of our group practice. You're doing awesome work, and thanks so much for the time today.
Matthew Rensi, Ph. D., LPCC (56:29):
Yeah, thanks for having me, Keith. I appreciate it. Take care. Bye-bye.
Keith Sutton, Psy.D. (56:33):
Bye. Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances 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. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c):(3): nonprofit, so all donations are tax deductible. Today, I'll be speaking with Matt Renzi, who is a licensed counselor in California, Oregon, and Idaho.
Keith Sutton, Psy.D. (02:24):
He holds a PhD in counseling education and supervision, often teaching at various universities. He currently works primarily with law enforcement, veterans, firefighters, and active-duty military personnel. His primary focuses are PTSD, substance abuse, ADHD, marital and couples issues, and anything that may be associated with that cluster of struggles. Matt conducts research on various topics as part of an independent research team. He is a clinical partner with the Headstrong Project and the SOF Network. Matt is also a clinician at the Institute for the Advancement of Psychotherapy and its specialty center, the Bay Area Center for ADHD. Let’s listen to the interview. Well, hi Matt. Welcome.
Matthew Rensi, Ph. D., LPCC (03:06):
Good morning. Thanks, Keith.
Keith Sutton, Psy.D. (03:08):
Yeah, I'm glad we got a chance to do this. Yeah, so I know you—you’re in my group practice, or Institute for the Advancement of Psychotherapy—and you've been talking about some of the work that you've been doing. I know you do a lot of work with veterans, you do a lot of work with trauma. You also have published a number of articles recently, and I was reading through some of those and some of the linguistic analyses that you're doing, and I thought it would be great to hear more about what you're doing and about the work you've been engaged in. But first, I always like to start off with finding out how people got to doing what they're doing, you know, kind of the evolution of their thinking. So, yeah.
Matthew Rensi, Ph. D., LPCC (03:51):
Yeah. Well, I started in the therapy world as a client. I was in the Marine Corps, and I did three combat tours. I got out, and for lack of a better word, my screws were a little loose. And so I ended up doing my own therapy and found it very beneficial, and then eventually became a therapist myself.I started in community mental health, working with an unhoused population, a lot of psychosis, and then a lot of gang youth. I loved working there, but eventually wanted to go more into working with veterans and first responders, and exclusively trauma, and then ancillary work with ADHD too. And so that’s kind of how I ended up where I’m at right now.
Keith Sutton, Psy.D. (04:47):
Okay, great. And how about the research?
Matthew Rensi, Ph. D., LPCC (04:50):
Yeah. I never wanted to do research. I remember one of my master’s-level professors saying research is horrible—he hated the research world and the “publish or die” mentality. And so I always had that aspect of research, but I understood the math and statistics side of it, so that wasn’t a big barrier for me. People would feel overwhelmed about that, and I was like, I get that.And then doing my PhD, you had to publish—you published a dissertation. And the way our dissertation worked is there were two kinds of studies within it, so I was almost forced to do two studies. I was like, I have these done, I might as well try to get them published. After that, I got invited to a research group, and that just kind of kicked things off. It was like, oh, I got curious about this—let’s try to figure out what’s going on there, and what about this, and what about that. The linguistics side was something I just kind of dropped into because my dissertation advisor was doing it. But looking back, my mom was a Spanish teacher and my dad was an English literature teacher, so linguistics has always been kind of part of my family background and the culture I was in.
Keith Sutton, Psy.D. (06:22):
Oh, interesting. Very cool. So let me go over the work with veterans first. Can you talk a little bit about the work that you're doing? I know you’ve been part of our institute, sharing things that we're learning and research that we're reading, and you are always keeping up on the research on trauma. Maybe you can start off and tell me a little bit about that.
Matthew Rensi, Ph. D., LPCC (06:47):
Yeah. So therapy for veterans is a really tricky area because most of the space is dominated by the VA. The VA does a lot of good things, and it also has weaknesses or gaps. One of the gaps the VA has is that they tend not to hire a lot of people from my licensure. They tend to hire psychologists and social workers, not a whole lot of counselors. I’ve tried to apply at the VA and get a job there to work with veterans, and each time it’s kind of like, “Hey, you’ve got the wrong license.” And I’m like, “But I can do everything a social worker can. Why won’t you hire me?” So I kind of got stonewalled there.
Matthew Rensi, Ph. D., LPCC (07:44):
Okay, so I got kind of bitter for a bit, and I was like, “Well, maybe I just won’t do this.” I like working with unhoused people anyway, and there are plenty of veterans there, so I’ll serve veterans through that community. Then what happened is I got connected with an organization called the Headstrong Project. They were founded by a Marine Corps veteran, and they specifically focus on trauma therapy and a lot of suicide-prevention type work for active-duty military and veterans. It’s such a well-run organization—the values, how they approach things, and their insight into wanting to use high-quality therapy with culturally competent clinicians and get quick access to care has just been absolutely phenomenal. Measurement-based care, everything—it all checks the box for me.
Matthew Rensi, Ph. D., LPCC (08:49):
Working there with the veteran and active-duty military population, one of the big things that comes up is confidentiality. I know confidentiality is baked into our profession, but it’s especially important for veterans and active-duty military because sometimes they’re still operating. If they’re a SEAL, for example, they may be wondering, “Is this going to affect my ability to continue to operate if my command finds out?” Another thing is that it’s usually some type of traumatic event, but many of the people you work with—especially in special forces, but in the military in general—tend to have a higher proportion of difficult childhoods or difficult family lives. So there’s a history of things that have caught up to the most recent event. You also tend to see a lot of substance use, suicidality, and difficult relationships. Another component we have to figure out is whether there’s TBI or repeated blast-related brain injury and what’s going on there. So it’s kind of this nexus of things that revolves around trauma, but also includes these associated factors.
Keith Sutton, Psy.D. (10:23):
Well, and also, ADHD has a higher prevalence in the military population too. Barkley talks about how it’s such a structured environment that oftentimes people go in, and that really helps.
Matthew Rensi, Ph. D., LPCC (10:37):
Keith, about 50% of my veteran clients who have trauma also have comorbid ADHD. I’ll sit down with them and ask, “Have you been diagnosed with ADHD?” And they’re like, “You saw that in five minutes?” And it’s pretty evident.
Keith Sutton, Psy.D. (10:53):
Okay. So there’s the confidentiality aspect, and then there’s this mix of stuff that you have to tease out—what’s going on with the trauma, whether there’s a traumatic brain injury, and then oftentimes maybe the past trauma, which is leading the person to be more susceptible to PTSD in the more present situation. And tell me a little bit about what kind of work, what kind of approaches, you’re using in this work.
Matthew Rensi, Ph. D., LPCC (11:24):
So this gets into the whole conversation about evidence-based practice versus non–evidence-based practice and everything that goes into supporting that. Right now, most research is saying that the big three for treating trauma are prolonged exposure, cognitive processing therapy, and EMDR. You also have other up-and-coming therapy models that are being researched at the moment. There’s also kind of therapist lore out there, where therapists say, “I’m using this for that,” and it’s like, okay, I haven’t seen any research around that. So those are the big three models. The tricky thing with those is that prolonged exposure has kind of been the go-to. Edna does a lot of research around it. But what most people don’t talk about is that the dropout rate is around 40% for prolonged exposure.
Keith Sutton, Psy.D. (12:31):
Yeah.
Matthew Rensi, Ph. D., LPCC (12:32):
And that’s not just one study saying 40%. That’s meta-analyses across the board—consistently between 30% and 40% dropout. So you already have a population that’s hard to convince to get into therapy, and then once you get them in, about 40% drop out just because of the model. If you think about it, four out of ten clients dropping—it doesn’t sit well with me. The next thing is cognitive processing therapy, which is great. It’s a phenomenal therapy, but the only places you can get trained in it right now are the VA or the Headstrong Project, or something similar. So you have to be working with a military population to get trained in CPT. For most therapists, the only evidence-based practice that’s left overall is EMDR. EMDR is great too, but the problem—specifically for the military or veteran population—is the eye movement component. It doesn’t work well. I haven’t seen research on this, and I don’t know exactly what’s going on, but many of them will say that the eye movements are difficult. I think what’s happening is that there’s too much threat assessment in their day-to-day life visually.
Keith Sutton, Psy.D. (14:09):
Interesting.
Matthew Rensi, Ph. D., LPCC (14:10):
Tracking a moving target feels like threat assessment to them, so they have a hard time with the EMDR eye movements. But they can do the auditory or the tactile tapping or buzzing—anything like that works well.
Keith Sutton, Psy.D. (14:31):
Oh, interesting. And you haven’t seen research on this, but this is something you’ve noticed in your experience?
Matthew Rensi, Ph. D., LPCC (14:38):
I haven’t seen any research. There’s another clinician in the area who does EMDR exclusively with first responders—Karen Lansing—who’s written a book on it. I was talking with her and said, “I’m having trouble with the eye movements,” and she said, “Oh yeah, I don’t do eye movements at all. They get way too overstimulated.”
Keith Sutton, Psy.D. (14:56):
Yeah, that’s interesting too. I trained using the buzzers and the headphones, and I’ve never really used the eye movements. Even the formal EMDR training I took was tapping the whole time. I’ve done eye movements with some clients, but I prefer eyes closed because you can get so much more into the visual imagination. At least with my clients, it works incredibly well. So it’s interesting that for this specific population it might be harder or less effective, but if you change the modality to tactile or auditory, then it becomes more effective.
Matthew Rensi, Ph. D., LPCC (15:45):
Yeah. I haven’t seen anyone else talk about it either—again, Karen Lansing is the only one who’s brought it up with the populations we work with. But it’s been pretty consistent across the board. EMDR is still really effective without the eye movements. The way I was trained was “eye movements or nothing,” and I was like, I don’t know if I’m doing this wrong.
Keith Sutton, Psy.D. (16:05):
Yeah. Some people are very adamant about that now. And there was another piece you were bringing in around developing a tolerance for discomfort. What was that? I have to look at my notes—stress inoculation therapy.
Matthew Rensi, Ph. D., LPCC (16:29):
Yep. Stress inoculation therapy is coming up. It’s still kind of an up-and-coming therapy. There’s research happening around it right now, but it’s not considered an evidence-based practice yet. So it’s not one that I use at the moment. Working with the Headstrong Project, they want only the strongest evidence-based practices, and all my veteran clients are coming through them right now.
Keith Sutton, Psy.D. (17:06):
Well, and you do cognitive processing therapy. Yep. Talk a little bit about what that is, and also, having these different tools in your toolbox, how do you decide what you use with which clients?
Matthew Rensi, Ph. D., LPCC (17:21):
Yeah, great question. Can I make a confession? I think if you had asked me five years ago if I would have done manual-based therapy, I would have said never. I’m not doing it. I had a psychiatrist I worked with once, and he said, “We’ve turned therapy into Lego manuals,” and I didn’t want to reduce a person to a set of Lego steps to make them better. So when the opportunity came up to get trained in cognitive processing therapy, I said, you know, I’m pretty open to something. I’ll try it, I’ll see what happens, but I don’t want to turn someone into a manualized process. I took the cognitive processing therapy training and was like, oh—this is really good. Crap. I’ve got to reevaluate my bias about using a manual.
Matthew Rensi, Ph. D., LPCC (18:25):
Cognitive processing therapy walks people through 12 sessions, and it’s a CBT-adapted treatment, so it’s very cognitively based. It looks at what we would call cognitions—automatic thoughts or core beliefs—but in CPT they call them “stuck points.” There are assimilated stuck points and overaccommodated stuck points. Assimilated stuck points are beliefs I’ve taken directly from the trauma. Over-accommodated stuck points are beliefs where I’ve adjusted my thinking patterns because of the trauma. What we do first is give a brain-based explanation to the client about what’s going on with them in trauma, teach some coping skills, and then lay out the treatment across the board. Then we use the ABC model—activating event, belief, consequence—to have them break down events and thinking patterns within those events.
Matthew Rensi, Ph. D., LPCC (19:36):
Then they use challenging questions. The next session focuses on thinking patterns, which is very much cognitive distortions and cognitive reframing, but specifically around trauma and trauma-related stuck points. Then we put everything together using what they call a challenging questions worksheet. That includes the activating event, belief, emotions, thinking patterns, challenging questions, alternative belief, and then the emotions that come up with that. So it’s essentially a whole CBT framework laid out in one worksheet. Once you have that framework in place, you follow up on five themes. The themes are safety, trust, power and control, esteem, and intimacy. You work through stuck points in each of those areas. Then, at the end, you rework the traumatic narrative and look at what I believed before starting this and what I believe now.
Keith Sutton, Psy.D. (20:52):
Yeah. Interesting.
Matthew Rensi, Ph. D., LPCC (20:55):
Yeah.
Keith Sutton, Psy.D. (20:56):
So tell me about these five areas, because I think that’s great. Are these five areas seen as some of the core impacts of trauma?
Matthew Rensi, Ph. D., LPCC (21:06):
Yeah. I don’t want to say Patricia Resick developed the five areas—I don’t know exactly why she developed them—but they’re kind of a heuristic that I use now myself. Whenever I’m working with anyone around trauma, I’m looking for themes in those five areas. Trauma affects your sense of safety—either I felt safe before and now I don’t, or I didn’t feel safe before and the trauma reinforced that.
Keith Sutton, Psy.D. (21:35):
Yeah.
Matthew Rensi, Ph. D., LPCC (21:37):
It affects trust—trust in self and trust in others.
Keith Sutton, Psy.D. (21:44):
Yes.
Matthew Rensi, Ph. D., LPCC (21:45):
So I can trust myself or I can’t trust myself. I can trust others or I can’t trust others. And those beliefs either get broken or reinforced.
Keith Sutton, Psy.D. (21:55):
Yeah. Sometimes I think about trauma as breaking our trust in the world. Anything becomes possible. Most people don’t walk down the street worrying that a car is going to jump off the road and hit them. But after trauma, there’s that hypervigilance—knowing that it could happen.
Matthew Rensi, Ph. D., LPCC (22:13):
Yep. It’s like the world has lost its rules.
Keith Sutton, Psy.D. (22:16):
Yeah, yeah.
Matthew Rensi, Ph. D., LPCC (22:17):
Or boundaries. And gosh—oh man, I just lost it, Keith.
Keith Sutton, Psy.D. (22:26):
We’re talking about trust.
Matthew Rensi, Ph. D., LPCC (22:27):
Trust. Maybe—I’ll come back.
Keith Sutton, Psy.D. (22:30):
So the next piece is power and control.
Matthew Rensi, Ph. D., LPCC (22:33):
Yeah. Power and control is the sense of agency—whether I have agency over my life or I don’t have agency over my life. If I feel like I have agency over my life, trauma often makes me feel helpless. If I don’t feel like I have agency over my life, trauma makes me feel like, well, yep, I don’t have agency over my life.
Keith Sutton, Psy.D. (22:55):
Yeah.
Matthew Rensi, Ph. D., LPCC (22:56):
Keith, can I come back to the trust piece?
Keith Sutton, Psy.D. (22:58):
Oh yeah.
Matthew Rensi, Ph. D., LPCC (23:00):
The trust piece is also reflected in the research around human-involved traumas versus natural disasters.
Keith Sutton, Psy.D. (23:09):
Oh, interesting. Say more.
Matthew Rensi, Ph. D., LPCC (23:10):
So there are lower rates of PTSD for natural disasters.
Matthew Rensi, Ph. D., LPCC (23:16):
There are higher rates of PTSD if it’s a human-involved or human-initiated event. The component of that—or the theory of why that’s different—is because trust is a factor with human beings, whereas I don’t have trust for a tsunami.
Keith Sutton, Psy.D. (23:34):
Sure.
Matthew Rensi, Ph. D., LPCC (23:36):
And so that’s where the trust comes in.
Keith Sutton, Psy.D. (23:39):
Yeah. I was working with one couple, and one of the partners was struggling with feeling like, “I’m having trouble with my partner because they don’t believe that the nature of humans is good.” And part of that was his privilege—having never experienced trauma.
Matthew Rensi, Ph. D., LPCC (23:57):
Whereas--
Keith Sutton, Psy.D. (23:58):
For his wife, she was always anxious or worried about not being able to trust others and was actually very close to animals, pets, and so on. They were pure and natural and safe, but with humans, that trust was gone.
Matthew Rensi, Ph. D., LPCC (24:16):
Yeah. Yeah. And that totally makes sense. That’s a hard worldview for couples to cross if they have such different views on trust.
Keith Sutton, Psy.D. (24:31):
Yeah. Yeah, definitely.
Matthew Rensi, Ph. D., LPCC (24:33):
One of the things we do in cognitive processing therapy is have someone do what’s called a trust star. I don’t really like the star itself, but we’ll have people pick a person and write down different aspects of that person’s personality or things they do that make them more or less trustworthy.
Matthew Rensi, Ph. D., LPCC (24:54):
Then you rate how much—it’s almost like the O-S-S-R-S—where you put a tick on the line of whether it’s a plus or a minus. What that’s helpful for is that it breaks down trust not as a unified whole, but as something with nuance. You can say, “I can’t trust this person for these things,” or “I don’t really trust them here.” Once we get some movement there, people realize that the binary of trustworthy versus not trustworthy breaks down, and they have to think about trust in a more nuanced way.
Keith Sutton, Psy.D. (25:35):
Black-and-white, all-or-none. Yeah. It’s like the dialectics and DBT kind of aspect.
Matthew Rensi, Ph. D., LPCC (25:41):
Exactly. And also that sense—if I can’t trust anyone, well, how do you sleep next to your wife at night?
Keith Sutton, Psy.D. (25:48):
Yeah.
Matthew Rensi, Ph. D., LPCC (25:50):
“Oh, okay. Well, I can trust her.” Well, I kind of trust her. She’s not going to murder me in my sleep. It depends on how much of a fight we’ve gotten in before we’ve gone to sleep. But for the most part, I trust her.
Keith Sutton, Psy.D. (26:00):
Got it. Got it. Okay. And so there’s safety, trust, power and control—how about esteem?
Matthew Rensi, Ph. D., LPCC (26:08):
Yeah. I mean, we know abuse really tweaks people’s sense of self, value, and self-worth. Trauma can do the same thing, especially when there’s a sense of responsibility or guilt or shame there. And also, if the trauma was perpetrated against me, what does that say about me?
Keith Sutton, Psy.D. (26:40):
Yeah.
Matthew Rensi, Ph. D., LPCC (26:42):
Am I broken? Dirty?
Keith Sutton, Psy.D. (26:50):
So it’s really the person’s sense of self that’s significantly affected in this way.
Matthew Rensi, Ph. D., LPCC (26:59):
And for some people—for some of the military folks—it’s not really affected that much. But if it’s part of sexual assault, usually the sense of self is really tweaked to some degree.
Keith Sutton, Psy.D. (27:14):
Yeah. I’m wondering too—with the military piece—there’s often a feeling of letting others down or having been able to do more for someone.
Matthew Rensi, Ph. D., LPCC (27:28):
And that crosses over into the moral injury space.
Keith Sutton, Psy.D. (27:32):
Yeah. I was just looking up that term. Can you say more about moral injury?
Matthew Rensi, Ph. D., LPCC (27:37):
Moral injury is tricky because there’s so much overlap between moral injury and PTSD. But with moral injury, it’s like I did something wrong, or something was done wrong that transgresses my values, and now the entire structure of reality or morality or my value system has broken down. And there’s kind of this void.
Keith Sutton, Psy.D. (28:05):
Like, who am I now?
Matthew Rensi, Ph. D., LPCC (28:07):
Who am I—or even what’s right? You said something the other day in consultation: the antidote to shame is integrity. And what I would say is people with moral injury don’t even know what counts as integrity anymore, because everything’s broken down.
Keith Sutton, Psy.D. (28:31):
Yeah. That internal measuring stick of right and wrong—of “am I doing the right thing?”—has been totally thrown for a loop.
Matthew Rensi, Ph. D., LPCC (28:39):
Yeah. And can I trust anybody else to do the right thing if I don’t even know what the right thing is?
Keith Sutton, Psy.D. (28:43):
Yeah.
Matthew Rensi, Ph. D., LPCC (28:45):
So--
Keith Sutton, Psy.D. (28:46):
Okay. And then how about intimacy?
Matthew Rensi, Ph. D., LPCC (28:49):
Yeah. Intimacy has everything. So you’ve got safety, power and control, trust, esteem—all of that then gets rolled into how I connect with another person. Am I safe with another person? Can I trust another person? Do I have power, or am I vulnerable? Do I have to be in power, or can I feel vulnerable? Am I a good person or a bad person? If I show this person who I am, will they accept me, love me, or not?
Matthew Rensi, Ph. D., LPCC (29:28):
And what ends up happening is that sometimes, because of the trauma, there’s a sense of being cut off from other people—that’s one of the symptoms. But sometimes also, especially with the military, if they go on deployment and then come back, they’re interacting with their partner or spouse and think, “I want to protect them from what I’ve seen.” And in protecting them from what I’ve seen, I need to protect them from me.
Keith Sutton, Psy.D. (29:57):
Yeah.
Matthew Rensi, Ph. D., LPCC (29:58):
So there becomes this barrier—I’m pulling back, I’m withdrawing, because I’m trying to protect them from what I’ve gone through. Then you’ve got the EFT cycle going on, trying to preserve the relationship and protect the partner. But the way the partner experiences it is: you’re distant, you’re cold, you’re not present, you don’t love me, you don’t care about the relationship.
Matthew Rensi, Ph. D., LPCC (30:25):
And the withdrawal is like, “No, I’m doing this because I do care about the relationship.” And all of that gets--
Keith Sutton, Psy.D. (30:35):
They’re shutting down or distancing to protect the partner and the relationship, but it feels like the opposite to the partner.
Matthew Rensi, Ph. D., LPCC (30:43):
Yeah. And in that also—would anybody even love me while I’m going through this and have all this going on?
Keith Sutton, Psy.D. (30:51):
Especially with the veteran population—my dad was a Marine in Vietnam. Marine Recon.
Matthew Rensi, Ph. D., LPCC (30:58):
Oh--
Keith Sutton, Psy.D. (30:59):
Yeah. And the bonds you make with your unit—the other people—oftentimes that’s a huge loss too when you come back. Not having those bonds even within your family, or the kind of bonds developed in those situations and in that trauma.
Matthew Rensi, Ph. D., LPCC (31:27):
Well, when someone leaves the military, we have added layers. They’ve lost their identity, their community, the structure of life, and almost a sense of life coherence. In the military, there are clear sequences—promotions, next steps. You know what you have to do to reach Lance Corporal, Corporal, Sergeant, Staff Sergeant, whatever rank structure you’re using.
Matthew Rensi, Ph. D., LPCC (32:03):
Then you enter the civilian world and it’s a smorgasbord of things, but there’s no structure. Where do I belong? Where do I fit? Who am I anymore? Maybe I flew helicopters. I had multimillion-dollar equipment in my hands—and now I drive a taxi. That sense of “I used to be something, and I’m not anymore.” Making sense of that, on top of everything else, throws another significant loop.
Keith Sutton, Psy.D. (32:40):
That’s interesting. Because even people who aren’t experiencing PTSD go through that readjustment period. And I imagine that having gone through trauma, plus losing that structure and sense of esteem—being a skilled helicopter pilot, for example—makes people even more susceptible. All of those aspects are shifting so quickly.
Matthew Rensi, Ph. D., LPCC (33:07):
Yeah. I was working with a SEAL who had done eight years in the SEALs, and so was a fairly senior SEAL by that time, and was getting out and starting a bachelor’s program. And they said, like, “I feel like I’m freaking resetting my entire life—like starting all over on everything.” Like, we’re showing up and people are like, “Wait, what assignment are we supposed to do? This syllabus is so overwhelming.” And they were like, “I can’t—like, we used to take hundreds of people out with explosives every day, and this is what you’re worrying about?” And I’m on this same level at the moment. And they just felt like, “I’ve made a huge mistake, and I’ve just reset my entire life.”
Keith Sutton, Psy.D. (33:45):
Yeah. I’m sure too—having gone from that high level of competence and skill and mastery, and then all of a sudden going into this situation where people are just kind of at the beginning of development.
Matthew Rensi, Ph. D., LPCC (33:58):
Yep. And also, there’s a sense of like, “Nobody knows who I was or cares.”
Keith Sutton, Psy.D. (34:06):
Yeah. Yeah, definitely. That’s where oftentimes maybe some of the war stories come too. Yeah. Yeah. So I like these five pieces—safety, trust, power/control, esteem, intimacy. And so you use that and you apply that to other situations, even when you’re not doing the cognitive processing therapy.
Matthew Rensi, Ph. D., LPCC (34:33):
Good question. Some clients come to me and they request a specific modality. So sometimes they’ll have a therapist at the VA, and their VA therapist is like, “You should really do some EMDR, but we’re not trained in EMDR,” so they’ll come on over for EMDR.
Keith Sutton, Psy.D. (34:50):
Got it.
Matthew Rensi, Ph. D., LPCC (34:52):
Some clients will come in and they’re requesting specifically CPT. “Yeah, I’ve heard about this. I heard it’s great. I’d like to do CPT.” If neither of those is the case, it’s kind of three things. First off, does the client’s symptom profile and presentation kind of warrant one or another? So let me give you an example. If the client has any type of neurological thing going on, I’m really hesitant to do EMDR—unless they’ve got a neurologist that has said, “Yes, good to go.” Also, if there’s significant dissociation—I know I can work with some dissociation with EMDR—but if they’re fuzzing out all the time, it’s like EMDR isn’t going to be super helpful. Because with your eyes closed, you’re probably going to be fuzzing out through a lot of that, and getting you regulated is going to be hard.
Keith Sutton, Psy.D. (36:01):
Right.
Matthew Rensi, Ph. D., LPCC (36:03):
And so then we’re looking at CPT. Okay. Some clients—especially if they have any type of OCD, or if they’re slightly on the spectrum at all—the CPT tends to work a lot better. The CPT also tends to work fairly well with the special forces.
Keith Sutton, Psy.D. (36:37):
Interesting.
Matthew Rensi, Ph. D., LPCC (36:37):
Because there’s not a whole lot of emotional engagement, and they don’t have to emote a whole lot with it. Where EMDR, oftentimes, they’re like—stuff’s going on. And so with CPT, they can be kind of cognitive and logical with it, and it feels more safe for them. And then the last piece is, if neither of those are in place, then I’ll often sit down with the client and I’ll talk them through both models and kind of give the theory under them, and then say, like, “Hey, is there one of these that’s landing more with you?”
Keith Sutton, Psy.D. (37:09):
Great. So collaborating with them and kind of giving them agency and making the decision, which is so helpful when somebody has trauma. Yeah, exactly. Okay, that’s great. And are you doing prolonged exposure, or was that—you were just kind of mentioning that? Because that’s one of the top three.
Matthew Rensi, Ph. D., LPCC (37:25):
I don’t. I don’t do it. It’s just one of the top three. It’s one that people will often get at the VA if they go to the VA.
Keith Sutton, Psy.D. (37:30):
Yeah. Yeah. Got it. Well, great. And then tell me a little bit about the research that you’ve been doing. I know you did a little research with depression and AI—linguistic analysis of substance abuse, addiction diagnoses, and the DSM, and personality disorder diagnoses in the DSM.
Matthew Rensi, Ph. D., LPCC (37:55):
My research interests look like someone who did cocaine and then decided to pick their research interests. So if you told me, “This guy has no research focus whatsoever—he is all over the place,” that’s absolutely the case. So I started research in the DSM—I mean, the book we all hate and love. Linguistic research just came up because it’s an easy and quick way to slice up data that has some objectivity to it.
Matthew Rensi, Ph. D., LPCC (38:38):
It’s also curious because it’ll expose the kind of patterns that are going on under the surface of the words that we’re using, even if we’re not aware of them being there. So things like—the probably most well-known name in this is Pennebaker. He’s got a book called The Secret Life of Pronouns. And it can get overstated, but you can predict characteristics of people based on their word usage—simple things like first-person singular versus first-person plural.
Matthew Rensi, Ph. D., LPCC (39:20):
So older people tend to use the first-person plural—“we.” Younger people tend to use first-person singular. There’s all types of things. One of my research projects was on boosters or hedges. Boosters are words that make you sound more sure about what you’re talking about. Hedges are words that make you sound tentative. So boosters would be like, “absolutely,” “it’s certainly evident this is the case.” Hedges are things like, “it might be,” “it could be,” “these seem to point to it.” And there’s a whole dictionary of these words.
Matthew Rensi, Ph. D., LPCC (40:31):
So I was looking at the DSM and asking: Is the DSM boosting more or hedging more? How is the DSM evolving over time? And the DSM is tracking research literature in general, which tends to be hedging more.
Keith Sutton, Psy.D. (40:30):
Yes.
Matthew Rensi, Ph. D., LPCC (40:31):
So there’s kind of this academic uncertainty that’s being communicated in our language. We’ve also done some studies on anxiety. Anxiety disorders in the DSM are getting more classified as social disorders rather than individual neuroses.
Keith Sutton, Psy.D. (40:55):
Oh, interesting. Say more about that.
Matthew Rensi, Ph. D., LPCC (40:57):
Well, like social anxiety disorder, agoraphobia—things like that. Those weren’t present in DSM-I and DSM-II. And the language is picking up more social language in regards to anxiety. So this kind of collective sense. And how much of that is societally driven, or consciousness around anxiety, or technology and connectivity driven—I don’t know. But for sure, it’s shifting there.
Keith Sutton, Psy.D. (41:27):
Interesting. Is there any data on when that was shifting? I’m just curious—thinking about more of an individualistic perspective, kind of fixed personality theory, versus more postmodern, being affected by context.
Matthew Rensi, Ph. D., LPCC (41:46):
That’s great. I would honestly have to pull up my article.
Keith Sutton, Psy.D. (41:50):
Don’t worry about it.
Matthew Rensi, Ph. D., LPCC (41:54):
It’s been a while since I—hold on, let me see here.
Keith Sutton, Psy.D. (41:57):
I would imagine in the late sixties or seventies.
Matthew Rensi, Ph. D., LPCC (42:05):
Yes. So the shift was from DSM-II to DSM-III, where we start getting words like separation, individual, but it really kind of picks up around DSM-IV. Separation, avoidance, social words like that are starting to increase.
Keith Sutton, Psy.D. (42:42):
Interesting. Yeah. So that’s from like 1968 to 1994.
Matthew Rensi, Ph. D., LPCC (42:49):
Yes, exactly. That transition.
Matthew Rensi, Ph. D., LPCC (42:52):
Yeah. So I did some research on that, and joined a research group. We researched critical incident stress management, then burnout among first responders. But the article we dug into the most was playing around with AI. We’ve got a couple articles and studies we’re working on with AI right now.
Matthew Rensi, Ph. D., LPCC (43:46):
But AI is super controversial, and I want to caveat this: I don’t use any AI in my practice whatsoever. I don’t use it to transcribe sessions, I don't analyze treatment plans or anything like that, because I don’t trust what’s happening with the data at the moment.
Matthew Rensi, Ph. D., LPCC (44:57):
So what we did instead was ask: How good could AI be at diagnosing someone? But it didn’t feel ethical to use real people, and we’d have to go through an IRB. So we used case vignettes. We scoured the literature and said, “Let’s find case vignettes.” We also wanted easier diagnoses—unipolar depression rather than bipolar, anxiety disorders rather than OCD, though we did include schizophrenia.
Matthew Rensi, Ph. D., LPCC (45:21):
We avoided diagnoses that are harder to tease apart, like intermittent explosive disorder or conduct disorder versus ODD. And there aren’t that many good clinical vignettes in the literature. I’d read one and think, “They diagnosed this person with MDD, but they’ve only listed three A-criteria symptoms—what are you doing?” So we ended up with only about a dozen per category, which really isn’t enough.
Keith Sutton, Psy.D. (45:56):
Oh, interesting. I remember back in grad school, the DSM casebook—using that to really understand diagnoses.
Matthew Rensi, Ph. D., LPCC (45:31):
So we snagged the depression, but there are only 10 depressive disorders in there. Yeah. And they’re not all MDD—some of them are like dysthymia, persistent depressive disorder, or medically induced depression, and it’s like, I can’t use that one. Yeah. So we pulled those ones and then pulled from other research literature as well, and we got into the teens. And so we were like, that’s not high enough. So we did a power analysis—it’s fancy math to say, how much, what’s our sample size? Yeah, yeah, exactly. And we were like, we need like 50 vignettes in each category. We were like, oh, we… if we publish something on this, it wouldn’t even work. So people have been playing around with synthetic data, and we were like, I wonder if we could make synthetic vignettes out of this. And so we fed the vignettes that we had into an LLM—a large language model—and then said, generate some vignettes. And Keith, that was an entire freaking odyssey.
Keith Sutton, Psy.D. (46:42):
Wow.
Matthew Rensi, Ph. D., LPCC (46:43):
We probably could have written a research paper just on trying to figure that out. But we spent months and months trying to get the LLMs to actually develop a solid vignette and follow the prompt instructions that we had set forward through it.
Keith Sutton, Psy.D. (47:03):
And LLMs meaning language learning models, which are like used for ChatGPT or… you know.
Matthew Rensi, Ph. D., LPCC (47:09):
Large, large language model. Large.
Keith Sutton, Psy.D. (47:11):
Language. Yeah.
Matthew Rensi, Ph. D., LPCC (47:12):
So the thing is, if we had online ones, and then I have local LLMs—which means I have a model that is downloaded from the internet—I can run it not connected to the internet, and so the data’s not going out anywhere.
Matthew Rensi, Ph. D., LPCC (47:28):
Interesting. Wow. And so we were using Claude, we started using some of these creative LLMs, like Claude Opus, we were using Pose creative writing LLM, where they would come back with these vignettes that would be like, “Bill is experiencing the dark stormy seas of a black nut,” and you’re like, nope, that’s not going to work. You know, like… anyways, we got them to finally generate vignettes and we were like, sweet. Cool. So we got the vignettes generated, and then we tested three models. We tested Gemini, we tested ChatGBT, and we tested Claude. And we said, can they differentiate between a depressive disorder and a non-depressive disorder? Okay, and we did this fancy math called a confusion matrix. And what came back was ChatGBT did worse than Chance. Claude came back just like Chance. Gemini came back at like a 97% accuracy rate. Wow. Gemini did phenomenal. It did really, really well.
Matthew Rensi, Ph. D., LPCC (48:51):
So the outcome of the research essentially was that yes, LLMs could theoretically diagnose somebody from a vignette. But different LLMs have different strengths in what they’re doing and are better for different purposes. And all of these—the thing is, all of these LLMs are black boxes as far as the underlying thinking—they’re proprietary, so it’s not out there for us to look at. But what we found through that is Gemini was really accurate, factually interesting; ChatGPT was more creative; and Claude was kind of a balance between the two. And so that was kind of the outcome. Now, where’s the use case for something like this? Well, we have a couple. The first use case that I think is most helpful would be to have a diagnostic aid for graduate students. Yeah. So as you’re learning the process of diagnosis, being able to have an LLM where you input everything in, and it comes back to you and says, “Hey, based on what you’ve entered, here’s the possible diagnosis,” but then gives them the follow-up questions to ask to do differential diagnosis, because they don’t have that skillset yet. I think that would be super cool. I think that’d be super rad. And anyways, yeah. So yeah.
Keith Sutton, Psy.D. (50:29):
Well, I mean, yeah, there could be so much application too in helping out therapists even, you know, in, you know, when they're unsure, or again, like whatever—they're not brushed up on a certain thing, or they're like, "It's this," right? They can get consultation, or even, right, do a little research, like most of us do when there's something that we're not so sure about. Yeah. We might grab some research articles, go buy that book on that, just a kind of check to make sure we're not missing anything.
Matthew Rensi, Ph. D., LPCC (50:56):
I even train people on the DSM all the time, and I'll sit down and be like, "Hey, let's talk about the differential diagnosis section of each diagnosis." And they'll be like, "What?" And I'm like, "You haven't heard about the differential diagnosis section?" And they're like, "No." And I'm like, "Let's, let's go to the di…" So we have diagnostic criteria, diagnostic features, associated features, which is all super helpful stuff you should be looking at. But then we kept going, and we got differential diagnosis. And whenever I'm considering, eh, is this major depressive disorder versus something else, you know, major depressive disorder with atypical features versus generalized anxiety disorder, going to the differential diagnosis section and looking at something like that, yeah.
Keith Sutton, Psy.D. (51:42):
So I—that, you know, some of the research right now is finding that AI is not doing too well with actually providing therapy for folks. No. You know, that—I know there was a recent study that came out from Stanford, and that, you know, oftentimes because the AI is so affirming, it might be like, "Wow, you're doing a great job going off your bipolar medication. You're really taking a…" Yeah, over your life. But, you know, there are also other uses for it, particularly in our field, where—yeah—especially for research, and the information and combing through information so quickly has been really nice.
Matthew Rensi, Ph. D., LPCC (52:17):
Yeah. Well, the research that's coming out on AI is mixed. So AI is not good for a freeform, open, just-response therapist. It's horrible for that. It also is really bad for any type of atypical thinking—so delusion, hallucination, obsession, rumination, things like that. It tends to reinforce those or affirm those.
Keith Sutton, Psy.D. (52:48):
So the AI psychosis—people developing, or their psychosis intensifying from using AI because it's reinforcing their delusional thinking. Yes.
Matthew Rensi, Ph. D., LPCC (52:58):
AI is good at delivering CBT. It's really good at delivering CBT. It actually beats some therapists in a research study, oh—interesting—as far as being better at delivering or having better outcomes with the clients. Ah.
Keith Sutton, Psy.D. (53:11):
And is that—and the clients are knowing that it's AI versus human?
Matthew Rensi, Ph. D., LPCC (53:15):
Yeah.
Keith Sutton, Psy.D. (53:16):
Interesting.
Matthew Rensi, Ph. D., LPCC (53:17):
So it's also helpful as far as an aid to therapy.
Keith Sutton, Psy.D. (53:23):
Yeah.
Matthew Rensi, Ph. D., LPCC (53:24):
So having an AI companion that helps with homework has been found to be helpful as well. Very. So there's mixed research there on it, but it can be—as far as just a no-structure or guardrails on therapy, it's scary.
Keith Sutton, Psy.D. (53:52):
Yeah. Yeah. Well, yeah, and we're at the beginning of this new frontier of AI and what this is going to look like in all fields particularly. And yeah, I'm interested to see how it's going to play out in our field as therapists. So it sounds like you're doing incredible work, and I really like hearing about the trauma work and the work as you're thinking about it, and your work with veterans and first responders and other clients. And that I'm really going to take away those five pieces from the CPT, which I think are really helpful and applicable to all trauma, and really kind of a nice frame to almost evaluate where maybe the focus should be. It makes me think of, like, in motivational interviewing, there's the acronym DARN-CAP: like, is that the desire, is it the ability, is it the reason, is it the need? And sometimes they can help you focus on where you really need to intervene. That might be interesting too, even applying those five to linguistics. I know, especially with motivational interviewing, they do a lot of psycholinguistic analysis. Yeah. And then, yeah, it's great, with beginning to get this research going with AI and looking at its uses, and where it's helping and where the limits are, as we go into this new frontier.
Matthew Rensi, Ph. D., LPCC (55:14):
Yeah. Yeah. It's very much in the beginning. I want to see where it goes. I'm also incredibly cautious, so yeah, I'm not using any of it myself at the moment. I will poke around with it research-wise, but as far as clinical practice, I'm not using any of it.
Keith Sutton, Psy.D. (55:31):
Yeah. Yeah. I've been using it for research—having conversations with Gemini. I am like, "I thought I had heard this before. Is there any research to back that up?" Yep. And going into that, or in writing an article, you know, yep, looking at ideas and getting references and so on, and then kind of reading those references. Yep.
Matthew Rensi, Ph. D., LPCC (55:49):
So if you're doing that, and for any clinician out there, I recommend OpenEvidence right now. OpenEvidence is an AI-powered search platform, but it requires you to have an NPI number to log in.
Keith Sutton, Psy.D. (56:04):
Oh, interesting.
Matthew Rensi, Ph. D., LPCC (56:05):
So you’ve got to have an NPI number, you log into it, and it will give you a great high-level overview of the research. It's really solid.
Keith Sutton, Psy.D. (56:14):
Great. Wonderful. Well, Matt, thank you so much. It's great to hear about your work in more depth, and glad to have you as part of our group practice. You're doing awesome work, and thanks so much for the time today.
Matthew Rensi, Ph. D., LPCC (56:29):
Yeah, thanks for having me, Keith. I appreciate it. Take care. Bye-bye.
Keith Sutton, Psy.D. (56:33):
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