Mindful Happiness

Anthony Quintiliani, Ph.D, LADC

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Even More Psychoanalytic Gems

Psychoanalytic Gems – Even More

D. W. Winnicott has made significant clinical contributions to both building therapeutic alliance and maintaining a positive, helpful focus in psychotherapy. Below I have noted various approaches to
use in your therapy.  Use of these “gems” requires considerable knowledge and skill by the therapist.  Here is the list:

  1. Respect the client’s agency, and do nothing to exert direct control over her/him.
  2. Continue to support personal goals, striving, and motivation in your client.  Promote healthy maturational processes in this growth.
  3. If you understand how, use transitional space/transitional objects in our therapy to enhance positive emotional holding and nurturing of the client’s true self. Build more safety.
  4. Work to improve the client’s self-identifications, self-image, and self-objects. Where helpful note that initial introjections are the product of attachment experience. They occupy both intrapsychic and interpersonal space and time.
  5. Introduce playful free association as a method in your therapy. Use interpretation only when it is helpful.
  6. Support directly the client’s need for “continuity of being” in both therapy and day-to-day life experiences. This often includes integration of the true self and false self.
  7. Use gentle reflection to help move insight into action: changes in thoughts, emotions, and behaviors.
  8. Notice both transference and cuntertransference experiences in therapy. Use these to better understand your client, as well as yourself.
  9. When possible enhance the client’s safe use of self soothing behaviors as a form of “primal satisfaction.”
  10. Help your client to integrate fragments of unhelpful past experiences.  This process should help to enhance the presence of a coherent self-narrative.   Such narratives often involve early traumatic experiences, and may be activated in the here-and-now of therapy.
  11. Do whatever is possible to re-integrate the sense of a secure self.  Maintain a safe and accepting therapeutic environment to do so.

For more refer to  Giovacchini, P. L. (1990). Tactics and Techniques in Psychoanalytic Therapy. Vol. 3, The Implications of Winnicott’s Contributions. Northvale, NJ: J. Aronson, pp.1- 243.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

Mindful Happiness cover designs.indd

New Edition of Mindful Happiness in Production…Coming soon!

 

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Psychoanalytic Gems – Again

More Psychoanalytic Gems –

D.W. Winnicott

In an earlier post, I noted a list of Psychoanalytic Psychotherapy Gems, including a later post on D.W. Winnicott’s approaches to building a therapeutic alliance.  My general aversion to this form of therapy has more to do with its slowness and high costs than to its effectiveness. It is effective!  However, other approaches are faster and less expensive for clients.  Also, there is the issues of prolonged suffering while a slower therapy takes its time to work. Is there an ethical question here? When is deeper, more permanent positive change more important than reducing suffering as fast as possible? I have no answer to this question.

Here I will expand that earlier Winnicott post.  Winnicott offers a great deal to therapists about How To form and improve therapeutic alliance.  Below I have listed a dozen ideas from Winnicott’s work. These skills are beyond basic psychotherapy work; these skills require highly competent therapists with strong clinical under-pinnings to be effective.  If you are well-informed about attachment and attachment therapies,  you will see that much of what Winnicott offers relates directly to earlier attachment experience of the client. Here is my list.

  1. Work very hard to develop a psychological holding environment with the client. Such an environment serves as a metaphor for positive psychological associations with protection and safety within it. Strong empathic responses with good mirroring are required.
  2. Within the potential space, Winnicott suggests we work on improving interactional quality: safety, acceptance, non-impingement, and will to interact, etc.
  3. Try your best to use Winnicott’s views on the middle way between merging with and separating from the client. Too much merging and too much separating causes breaks in the homeostasis of the developing alliance.  Too much merging and separating may lead to mistrust, fantasy, and stuck alliance status.
  4. Always maintain a slow, gentle, compassionate attitude toward the client.
  5. Act in a non-impinging manner, respecting physical and emotional boundaries as well as the client’s personal readiness to share personal stories and make changes.
  6. Maintain a relaxed, confident demeanor as you facilitate both the alliance and helpful change.
  7. Never use shaming techniques. Such interventions harm both the true self (inner, private) and the false self (outer, social). Both of these self-experiences are true, and both need to be engaged in therapy. The source of more dramatic improvement rests with the inner true self.
  8. Work hard to understand the client’s attachment history (positives and negatives) as well as your own attachment history (positives and negatives). You are in a dyadic interaction, both coming from your own attachment histories. As the therapist, you cannot escape the outcomes of your own attachment realities.
  9. Recognize that for some clients anxiety and depression are norms. Do your best to calm the anxiety (fear, discomfort) and the improve the sadness. Notice what memories and conversations activate these mood states. Utilize corrective emotional experience in session to calm anxiety and lift depression.  You are the client’s new object, so use yourself in this manner.
  10. Use object constancy.  Be stable in your interactional role to foster expected outcomes of acceptance, patience, emotional support, and safety.
  11. Work to improve weak and negative object related introjections in the client. If you are skilled enough, use Roger’s complete acceptance (unconditional positive regard)  and Kohut’s transmuting internalizations (perhaps a form of conscious use of projective identification process). This will be most important with clients who have unhelpful attachment and traumatic histories.  It may be even more important for the majority of such clients who have self-medicated their pain and suffering from the past. Their negative self-objects are deep inside.
  12. Lastly, do your absolute best to be a “good enough” therapist. Maintaining friendly compassion, understanding, acceptance, and safety in the intersubjective space of therapy. For clients who may be less willing to engage in conversations, try using Winnicott’s indirect “squiggling” technique (only if you know how to do so).
  13. For more information refer to Grolnick, S. (1990). The Work and Play of Winnicott. New York: Jason Aronson, pp. 133-166. 

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

Mindful Happiness cover designs.indd

New Edition of Mindful Happiness in Production…Coming soon!

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Object Relations Therapy for Trauma

Trauma: Object Relations Therapy

Object relations therapists, D. W. Winnicott especially, have presented a logical analysis on how to provide object-relations-oriented therapy to people suffering from the effects of psychological trauma. Such attachment-based trauma therapy provides support and healing from trauma, loss and long-term trauma-effects.  The interventions below combine the best of object relations therapy, mindfulness therapy (MBSR, ACT), and cognitive-behavioral therapy. Here is the listing of therapeutic functions and interventions.

  1. Provide support for “going-on-being” in the therapeutic alliance and the therapy itself. (Winnicott)
  2. Unconditional positive regard is a must. (Rogers)
  3. Recognize, work with and work through the splitting process as it activates in therapy. (Lineman)
  4. Safely and with effective skill help to re-connect the person with safe transitional space. (Winnicott)
  5. Carefully build and monitor the emotional “holding environment” in both alliance and therapy. (Rogers, Winnicott)
  6. Include contextual stimuli and symbols of the traumatic experience, from very general to specific and shift slowly over time. (Briere)
  7. Once there is a firm alliance and safety in the therapy, be more specific in exposure to traumatic experiences – monitor carefully. (Briere)
  8. In all exposure work, best to utilize SUDs scores from 0 to 100 – larger range between numbers allows deeper investigation and specificity.
  9. Work hard to understand and utilize body-based communications. (Ogden, Fisher, van der Kolk)
  10. Use mindfulness attention and skills (MBSR, ACT) to remain in The Middle Way between traumatic re-exposure and the safety of “going-on-being.” (Briere, van der Kolk)
  11. Check in with the experiences of transference and countertransference as you use images and defenses to support progress. (A. Freud)
  12. Use multi-sensory interventions in gentle, safe, re-exposure to traumatic materials – using one step removed and cognitive processes first. (Quintiliani)
  13. If skilled in its use, utilize the Attachment-CABs-VAKGO-IS-Rels formula for interventions. (Quintiliani – see mindfulhappiness.org for more details)
  14. Using items #s 8-13 above, aim for development of a safe cognitive schema and narrative clarification about the traumatic event/s.
  15. Work closely with the person to help them internalize the growth-benefits of all of the above. Take time with this process.
  16. Be a “good object” and always return to safety over and over again – check-in and stabilizes often.
  17. Slowly and with safety move up the hierarchy of trauma exposure process, possibly experiencing the full array of sensory experience. (Briere, Foa)
  18. Listen, support emotionally, radically accept, validate and understand the process and the person. This is your best way to develop a “good enough” self-object via “transmuting internalization.” (Kohut)  Various mindfulness and CBT skills will be used here.
  19. Use mindfulness and good CBT to make space for acceptance and validation for post-traumatic growth. (Lineman)
  20. Help to impact these positive changes into a “different” memory system as you expand and deepen the narrative.
  21. Support and directly reinforce (behaviorally) the improved self – a “felt sense” of a healthier self psychologically and physically.
  22. Place more and more safety into the transitional space, and generalize this process into therapy and life practices.
  23. Finally, expand the person’s capacity for pleasure, joy, self-esteem, success and HAPPINESS before therapy ends.

For more information refer to Savage Scharff, J. and Scharff, D. E. (1994).  Object Relations Therapy of Physical and Sexual Trauma. Northvale, NJ: J. Aronson.

Note: The ideas have been presented in this text, but I have added more current interventions and details based on new research and treatments.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, VermontChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

Mindful Happiness cover designs.indd

New Edition of Mindful Happiness in Production…Coming soon!