Allen Gabriel Vayner, Psychotherapist

Clinical Philosophy

Trauma-Informed

As a trauma-informed clinician, Allen places strong emphasis on understanding how past trauma manifests in the present

Biopsychosocial Paradigm

How biological, environmental, and social factors interact to shape mental health and behavior.

I think there are some major problems with turning down clients, or choosing a clinician, based purely on perceived symptoms/diagnoses, in most cases (sometimes it is warranted, such as with very specific symptoms). Here are some of the problems I’ve noticed:

  1. Self-Diagnosis: Clients increasingly self-diagnose
  2. Incorrect or Incomplete Diagnoses: Previous providers have misdiagnosed clients, or fail to identify the appropriate primary diagnosis
  3. Subjective Interpretation of Symptoms: Sometimes our interpretation of “what is wrong” changes, or we offer the short-term perspective versus the long-term, or we can’t find the right words to describe what we’re actually experiencing

Modern managed care encourages us—patient and clinician alike—to chase symptoms and labels, rather than root causes. My first goal in my relationship with clients is to actuate a paradigm shift. Something happened to you at some point that you did not fully process, either because you were physiologically vulnerable or you have not been able to “make sense” of it from a cognitive perspective. That’s it. That is the fundamental premise of trauma. It does not require a warzone, or a car accident, or a natural disaster, or a formal diagnosis. We are all, to some extent, traumatized–the question is one of degree. How does your trauma manifest? Does your nervous system activate whenever your spouse comes home? Is is a trigger word or image? Do your IBS symptoms “suddenly” flare up in response to something? I do not treat symptoms–I treat the root trauma.I work with virtually all kinds of clients, the common denominator usually being most frequently addressing issues related to stress, trauma, mood, and neurodevelopmental deficits like ADHD and Autism. This can range from individuals having difficulty navigating everyday stressors to those feeling “stuck” in high-pressure jobs, family environments or major life transitions.

The above image is of the ouroboros, an ancient alchemical symbol that depicts a snake eating itself. It is a powerful image rooted in ancient alchemy, Egyptian iconography and the Greek magical tradition. In the context of alchemy and ancient mythology, it represented a variety of things, but mainly transmutation, an alteration in fundamental form or matter, as in changing copper into gold, and eternal cyclic renewal. In my life and my clients’ lives, however, it more fittingly represents transformation–major change not in who they fundamentally are, but positive change actuated by healing, being born anew after consuming the parts of them that no longer served them, residual trauma, and outgrown perspectives on life that were holding them back.

I did not randomly choose the image of the ouroboros to represent my practice; it came into my life by way of one of my first EMDR clients and is likely the most “fantastical” thing I have had happen to me.

The short version of the story is that I was working with a mother who was experiencing trauma symptoms. Her son, recently off to college, had had a difficult childhood marred by behavioral problems, including threats of suicide. For eighteen years, his mother “walked around on eggshells,” waiting for the next outburst, the next temper tantrum, the next school refusal. Finally, one day, he had “moved on.” In many ways, life had moved on: her son was stable and in college, her home life was calm, and she and her husband had a wonderful marriage. Yet she felt stuck. Her anxiety symptoms had worsened with time (and now came with gastrointestinal upset) and she experienced recurrent flashbacks, intrusive thoughts, and rumination. She was plagued with the what if?’s–what if she had tried a different medication? What if she had allowed him to go to an inpatient facility instead of obstinately refusing? What if

The Biopsychosocial Approach

The first day of my first child developmental course in graduate school, my professor asked the class “what’s the difference between a clinical social worker and a psychologist?” He told us a story from early in his career, about a young boy with increasingly disturbing behavioral problems. As the years went by, the boy only grew more aggressive and deviant. The boy’s mother, exasperated, had taken him to all manner of doctors, psychologists, family therapists, and school counselors. He had been placed on multiple different medications and was collecting an impressive slew of diagnoses and labels: ADHD, Defiant Disorder, Conduct Disorder, Antisocial Personality. All the typical frontline “textbook” psychological interventions were attempted: CBT, DBT, parenting coaching. Some responses were simply prejudicial (because she was a single mom, her child was doomed to misbehave).

With each specialist they visited, the clinical picture seemed to grow more complicated. After multiple years of this, no treatment seemed to help, and the boy began to have suicidal thoughts. In his early teens, he made an attempt on his life and his mother rushed him to the ER. There, my professor was shadowing his supervisor, a veteran clinical social worker with decades of experience. After a thorough intake interview, she asked the mother what section of the city she lived in, and what condition their housing was in. They lived in a dilapidated part of the city known for having “relaxed” standards when it came to public health codes like https://www.phila.gov/documents/lead-paint-regulations/ and, as such, many of the houses still had hazardous materials in them, including lead. Lead, as we have known for quite a long time, can explain “deviant” behavior and deficits in intellectual development (https://ajph.aphapublications.org/doi/epdf/10.2105/AJPH.82.10.1356)

To this day, a disproportionate amount of Philly children are exposed to lead (https://whyy.org/articles/philadelphia-children-lead-exposure/).

Clinical social workers are trained to approach problems from a multifactorial perspective. When we say “biopsychosocial”, we mean that we take into account the biological, psychological, and social context of a presenting problem. That is to say, we are trained to understand that mental health complaints rarely occur in a vacuum.

Collaborative Care

A collaborative care model is one in which a patient’s providers communicate with one another regularly to optimize healthcare outcomes. It means your psychotherapist is talking to your psychiatrist and PCP—and anyone else in your care team—to make sure we’re all collectively doing what’s in your self-interest.

Makes sense, right? Yet, this collaborative model seems to be the exception, not the rule in real-life practice. It is a rarity to see clinicians working as a tight-knit team because the unfortunate reality is that our nation’s health system has never rewarded or even provided a common language to sustain an interdisciplinary approach. Furthermore, modern managed care means that insurance companies, not you or your provider, are the de facto authority on the nature and extent of care you receive as long as you depend on them for healthcare access (which most Americans do). This makes it virtually impossible for providers who accept insurance to invest the time and resources into care that a patient deserves.

In 2013, the American Medical Association (AMA) replaced the long-held 50-minute session code (90806) with “Current Procedural Terminology (CPT)” codes that specify specific time ranges:

  • 90832: 30-minute session (16-37 minutes)
  • 90834: 45-minute session (38-52 minutes)
  • 90837: 60-minute session (53+ minutes)

In 2023, “prolonged service” add-on codes, which allowed therapists to bill for extended (90+ minute) sessions, were also eliminated. This means that a therapist is reimbursed the same amount of money for a 60 minute session as they are a 90 minute, or a 2-hour, session.

insurance companies recently changed the definition of a standard therapy session to be thirty-eight to forty-five minutes long. As a psychotherapist, this is simply an insufficient

Education

I believe my job as a therapist isn’t just to fix you while you’re under my care; I believe in equipping you with the tools you’ll need to provide adequate self-care in the future to yourself.

Rapport

There is absolutely such a thing as a particular therapist not being a good fit. This is another key difference between a medical intervention and a psychological one. Yes, there is something to be said for having a healthy collaborative relationship with your doctor, but, ultimately, once you’re under anesthesia, it hardly matters to the knife and the scalpel whether or not you loved the surgeon. Good therapy, by contrast, is virtually impossible without long-term trust and rapport.

What you need is:

  • clinical acumen
  • rapport/trust
  • time (to build the relationship/resourcing/psychoeducation)
  • financial compatibility (are you going to leave right when the therapeutic relationship is finally fertile?)
  • consistency
  • (relative) stability
  • commitment (do you show up or are you just there?)