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  

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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  

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New Edition of Mindful Happiness in Production…Coming soon!

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Enhancing Hope in Psychotherapy

Enhancing Hope in Psychotherapy

The enhancement of personal hope is a key part of successful psychotherapy practice. Some view this requirement as a foundational aspect of the therapeutic alliance; others do not hold the same view.  In the case of serious co-occurring disorders, especially trauma and substance misuse, initiating, developing, and sustaining a hopeful future-view is highly important in client motivation and faith in beneficial change. In the client’s personal world of hopelessness (possibly helplessness), pain and suffering, a common expectation is that this “hell realm” will not end.  Therefore, to enhance hope in the intersubjective space of psychotherapy, therapists need to implement certain on-going hope-based strategic interventions.  Here is a list to consider.  Do you routinely do these things in your sessions?

  1. Be highly mindful of maintaining a strong therapeutic alliance, and counteracting our own conscious countertransference. To understand your unconscious countertransference, mindfully notice your emotional and behavioral reactions to your clients.
  2. In gentle and hearable ways, reframe psychological suffering as challenges and possible opportunities for creative experimentation. Use of metaphors may be helpful.
  3. The reality that suffering and non-suffering are both aspects of the same consciousness may be helpful here. Gently encourage the client to practice being more conscious of times when suffering may be less dominant and, especially, any times when it is non-existent in consciousness.
  4. Promote positive self-understanding through careful uses of attachment history and the client’s pros/cons of their attachment experiences with parents/care-takers, etc.
  5. Help the client understand the nature of their suffering.  Some of it may be based on their attachment history, and some of it may be based on their habitual habits in life – as ways to escape/improve the outcomes of their attachment history. Often self-medication is an example of self-defeating behavior in the client’s effort to improve the moment.
  6. Maintain a positive presentation of healing from suffering; do so without making any promises you cannot keep.
  7. Reinforce and celebrate concrete symptom reduction as experiential episodes of self over suffering. The augmented identity of a “healing self” is important here.
  8. Teach and practice in-session various intervention skills for stress reduction. Mindfulness-based stress reduction is a good starting point. Use SUDs scores (0-100) for changes in levels of suffering/stress reactivity as the client learns and uses these skills. The scores should go down! Celebrate positive improvements.
  9. Be a model for paying attention to positives – any small significant “difference that makes a difference” in one’s personal experience of suffering.
  10. Cooperate openly in-session with the client to foster positive expectancy (some placebo here) about any and all improvements in the present moment.  Help to extend these practices/experiences into the client’s life beyond their therapy time. Admittedly, this is difficult to do.
  11. Specific mindfulness-based practices have been shown (when practiced regularly) to improve emotion regulation (reduce reactivity) and open up sense-doorways to pleasant bodily experiences – even more happiness. Learn and practice forms of self-regulated calm breathing, brief meditation, yoga or stretches, tai chi, qi gong, and walking meditation as part of your hope-enhancing practice. Note and discuss any client responses to practice that may enhance hopefulness.
  12. Guide clients with guarded optimism. Practicing the above-noted interventions and skills may produce inner, more intrinsic, self-healing. Enhanced HOPE is our target.
  13. For most (not all) psychotherapists, using cognitive-behavioral therapy may be the most common approach to integrate hopefulness into clinical practice.
  14. If you consider yourself an advanced psychotherapist, you may want to take each area of my CABS-VAKGO-IS-Rels system and practice your own creative hopeful interventions for each area of human processing.  Note: CABs = cognition, affect, behavior – sensory-based; VAKGO = visual, auditory, kinesthetic, gustatory, and olfactory sensory processing – all sense doors that may be opened via hopefulness interventions.  CABs-VAKGO-IS-Rels mechanisms operate in past, present, and future orientations. Use intuition and spirituality when possible and appropriate. And, keep in mind that all these human functioning pathways operate in a relational sphere of being. These are complex formats for psychotherapy. Outcomes are worth the effort.

For more information refer to Briere, J. N. and Scott, C. (2015 End.). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Washington, DC: SAGE Publications, pp. 101-102. See also Quintiliani, A. R. (2014). Mindful Happiness…Shelburne, VT: Red Barn Books, pp. 3-9, 20-34,  75-81.

Anthony R. Quintiliani, PhD., LADC

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

Author of Mindful Happiness  

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New Edition of Mindful Happiness in Production…Coming soon!

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Using Your Compassionate Mind in Psychotherapy

Using Your Compassionate Mind in Psychotherapy

For you to become a more compassionate therapist, follow the details noted below. These preconditions, skills, and practices are required as a baseline for  compassionate practice.

  1. You need the ability to access calmness in an environment of emotional suffering, chaos, or conflict.  Most people do this by breathing in calm, slow, deep patterns – and maintaining equanimity in their interpersonal processes.
  2. You need to understand the relative power of the three main parts of the brain: prefrontal/frontal (executive); reward centers (habits); and, the limbic system (survival, emotions).
  3. You need to fully understand the relative power of cognition, emotion, and behavior – sequential and complex systemic interactions.compassion_mindfulhappiness
  4. You need too be skilled in regular mindfulness practices. Regular means regular!  No textbook applications without personal experience in mindfulness practice.
  5. You need to have or cultivate an open, warm, soft-heartedness in dealing with yourself and others.
  6. You need to be skilled in empathic alliance building with your clients, resting mainly on unconditional positive regard and kindness.
  7. You need to be skilled in at least one evidence-based therapy in the process of helping.
  8. Lastly, you need to know the differences between mindfulness ad metallization.

Here are some core differences between mindfulness and metallization processes.

Mindfulness, among other things, includes: Observation with prolonged attention; inner calmness; skill mindfulhappiness_compassiondescribing what you observe; ability to concentrate your awareness; being nonjudgmental; being nonreactive; and, acting in the best interests of others – placing others before your own self-interests.

Metallization, among other things, includes: recognition of your own metacognition about your own immediate
experience; having mental awareness when change occurs; understanding your emotional experience when interacting with others; reflection on the mind-motivations of others when they behave with you in various ways; using limited theories about the mind-set (motivation) of others when they harm you emotional or physically.

So, you see there are huge differences between the practice of mindfulness an the uses of metallization in your work.

Worksheet on the practice of more compassionate connection with others:

After recognizing what has happened (the why) to motivate you to become more compassionate in your work, respond to the following inquiries.

  1. WHO is directly involved?
  2. WHAT will you do behaviorally – your immediate compassionate intention and response?
  3. WHEN will you do it?
  4. HOW will you do it – back to the what?
  5. Can you notice the difference in your inner feeling state as you apply KINDNESS in your interaction?
  6. WHAT outcome was desired, an what outcome occurred?

To improve your practice of compassionate therapy, obtain more training and supervision. You will also NEED to apply the same compassion to yourself when you suffer. See if you can live with more compassion in your

entire life not just in your work.  If you are also a spiritual person, how can you use this quality to improve how you live with/work with compassion?  Good luck! In the final analysis, practicing with more compassion will most likely improve your outcomes and your level of personal satisfaction – even happiness.

For more information refer to Gilbert, P. (2009). The Compassionate Mind: A New Approach to Life’s Challenges. Oakland, CA: New Harbinger, pp. 421-446.  See also Stewart, J. M. (ed.). (2014). Mindful Acceptance and the Psychodynamic Evolution.  Oakland, CA: New Harbinger, pp. 111-132.

 

By Anthony R. Quintiliani, PhD., LADC

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

Author of Mindful Happiness  

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New Edition in Production…Coming soon!

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“Ignorance” of Documentation Requirement Could End Your Clinical Career

“Ignorance” of Requirements Could End Your Clinical Career

Recently various insurance, Medicaid, and Medicare fraud cases have been in the national headlines. Although these fraud cases grab headlines, the truth is that many clinically licensed helpers still do not understand clinical/legal documentation requirements.  In Buddhism, “ignorance” gets in our way; we never approach true liberation via enlightenment. Practice takes years and years to produce experienced movement from samsara to liberation.  Sometimes our progress is very subtle. In clinical practice “ignorance” gets in our way; it takes years and years to become educated and clinically licensed – all of which may be lost if we appear to practice in fraudulent ways. All those years of learning; all those years of supervised practice; all your own costs to be where you are; and, all those years of  billing for our sacred services.  Yes, your services are sacred in that they reduce human suffering, and may sometimes bring happiness to people. rmindfulhappiness_clinicaldocumentationPsychotherapy SAVES  LIVES!

In audit terms, there are three enemies of clinically appropriate documentation: fraud, waste and/or abuse. I will not make clarifications about these three situations in this post. The standard definition of fraud notes that it involves the clinician receiving something of value via willful misrepresentation. In this post I will simply notes a couple well-known lists of clinical documentation requirements. I am always amazed how graduate training programs and professional associations have not been consistent in how they inform “psychotherapists” about documentation requirements. The main pathway to successful employment is effective clinical skill (alliance and outcomes); the major pathway to getting paid for that good work and staying out of court is following published documentation requirements. One of the major problems with documentation requirements is that they change based on the system paying for the sessions.  Another problem is that any system’s requirements may change without prior notice to providers of clinical services.  Clinicians need to pay attention to what their payments require, both in coding changes and in documentation changes.

The American Psychological Association has recommended the following minimum documentation requirements for clinical records per session.

  1. Date of service
  2. Correct diagnosis
  3. Duration of service event – start and stop times
  4. Types of therapeutic interventions – all evidenced-based
  5. Target symptoms (assessed via interview, DSM, formal assessment, etc.)americanpsychologicalassociation_mindfulhappiness
  6. Progress in achieving treatment (treatment plan) goals – good progress notes about measured outcomes
  7. Very clear documentation of crisis-oriented services (not specified by this source)
  8. Rational for extended sessions

The CMS Comparative Billing Reports suggests the following additional documentation requirements.

  1. All billed services are medically necessary
  2. No excessive use of psychotherapy code – 45 minute session (or other codes)
  3. Documented client/patient interactions with therapist
  4. Patient/client reaction to the session
  5. Changes is symptoms related to prior session
  6. Changes in behavior related to prior session
  7. Very clear documentation of crisis oriented services (not specified by this source)

Disclaimer – I provide this information as it has been provided to me.  I cannot say if it is totally accurate. You are responsible for checking into your own documentation requirements based on what systems pay you for your clinical services.  It is so, so sad that such sacred work requires accounting-like documentation.  I have often commented that psychotherapy records mimic documentation for transporting nuclear waste actress state lines.  So much documentation; so little time to actually DO the psychotherapy. Hope this post shakes you up a bit regarding your current clinical documentation habits.

How did we get into such a bureaucratic way of doing business?  Well, that is it – psychotherapy is now a business. Perhaps our very generous payments to medical staff caused this (other than primary care American medical doctors are some of the world’s highest paid professionals providing such services). When therapists decided to make a living from doing psychotherapy, and when many university programs opened graduate training programs for psychotherapists, education, business and “organic bureaucracy” (my terms) became ONE. Following the old “medical model,” psychotherapy became a way to earn a middle class living, sometimes a very good middle class living.  Behavioral health, however, will never be funded at levels needed to improve the mental health (and addictions health) of the American public.  Pills alone will psychotherapybusiness_mindfulhappinessNOT DO IT! Our problems are NOT simply biological; they are biopsychosocial-spiritual in nature.  How else could we be about 5% of the world’s population consuming about 60-70% of the world’s illicit drug? Are we empty inside? Let’s hope that psychotherapy does not follow
medical practice in hospitals, where well-documented data show that about 100,000 people a year die due to medical errors. Some researchers believe that number is actually higher. Powerful lobbying groups hope to influence the federal government so such data will not be available to the American people. And, there are the added burdens of requiring external “certification” of your program’s comparative quality. The various “commissions” that dictate documentation requirements in behavioral and medical health care systems ADD MORE AND MORE DOCUMENTATION REQUIREMENTS AT HUGE COSTS.  As if documentation alone implies quality. Let’s get rid of the onerous documentation requirements and simplify the system; let’s pay for carefully rationalized clinical outcomes and end the dollar drain of accreditation commission-dictated documentation requirements. Such a rational shift may cause an unemployment crisis in bureaucracy, but it may help preserve the slim margins of funding in behavioral health. The American health care system needs BIG changes, but we lack insightful and courageous leadership to make such big changes. What will the future of behavioral health look like? Better start lobbying for your own interests before you have no profession to lobby for at all.

national_psychologist_logo

For more information refer to your own payment systems, Medicaid, Medicare, private insurance and other documentation requirements. See also Hartman-Srien, P. E. (November-December, 2016). Fraud grabs headlines… The National Psychologist, p. 6.

By 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!