Clinical Practice Archives - Mindful Happiness

October 30, 2019 By Admin

Core Elements in Clinical Supervision

In addition to what supervisors bring into group supervision and clinical training, the list below will be used for discussion about YOUR supervisory role. The order of content below is generally random. The content noted applies to clinical supervision; it could also apply to doing effective therapy. The skills and knowledges here make up a toolbox for effective clinical supervision. That said, it cannot include everything.

DO NO HARM in all supervision modalities (individual, group, education/training)!
Know your code of ethics, especially sections relating to clinical supervision, education/training, clinical relationship, and the role of technology.
Understand how the past becomes the present – your own attachment and developmental history and experience. Your own “dragons.”
Know how to use strong empathy and therapeutic alliance/relationship skills.
Face the reality of co-occurring conditions in clinical practice. Even if your role is dealing with “the walking well,” there are most likely co-occurring conditions if not diagnoses.
Know how to use and supervise 2-3 evidence-based therapies ( BT, CT, CBT, CBT-M, Process-Based CBT, DBT, DBT-S, MBSR, MBCT, MBRP, ACT, Narrative and Solutions-Oriented approaches, etc.
Recognize that the EBTXs are the science behind the art of therapy. Client and supervisee progress require both art and science.
Experiment with creativity – but do no harm.
Know how to use restructuring and reframing.
Understand the science behind client-matching variables. Recognize the impact of anxiety, depression, trauma, addictions, etc.
Do your best to use a bio-psycho-social-spiritual model. Pay attention to preferences of people you supervise. Never impose a narrow focus.
Consider Quintiliani’s “neurotherapy” by using cognition, affect, behavior, sensory experiences (see, hear, feel,, etc.) as well as intuition, spirituality and relational variables and conditions. Refer to the Attachment-CABS-VAKGO-IS-Rels model.
Study more neuroscience and how it relates to cognitive and behavior change and the human mind-body system.
Learn and use effective emotion regulation skills and practices.
Focus on the impact of cognition (thoughts and deep structures), emotion, behavioral conditioning, social justice, marginalization, trauma (especially pre-verbal), addictions (include pesky cellphones), and mindfulness.
Observe! Observe! Observe! (direct observation of the work) and Respect! Respect! Respect!
Remain fully aware of possible transference and countertransference processes, especially projective identification.
Know that context, personal aspiration, and personal values matter.
Recognize parallel process from therapy to supervision and back again.
Know that in most states the supervisor is 100% responsible for the actions of the people they supervise, even if those actions were not recommended or are unknown to you.
Know how to use compassion in practical ways, especially with defensive ego-protective patterns in people.
Never make identifications of the whole person as their clinical condition of diagnosis. In fact, add much more to the individualized interventions.
As you observe and respect be a good mentor to motivate, but never forget client protection is the first priority. Their progress is a second priority.
Know your roles: hire, fire, oversight, evaluate, train, support, organize, coordinate, and DOCUMENT. Know abut all HIPAA and 42 CFR Pt 2 requirements.
Always use a written supervision contract/agreement, and recognize informed consent aspects as well as due process in it.
In co-occurring work, seek a role for 12 Steps and/or peer recovery support.
Keep strong BOUNDARIES in all aspect of this work.
Pay attention to learning styles.
Some of the work is a form of palliative care, in that counseling and therapy sometimes deal with life-or-death issues. It is a form of sacred work.
Know about duty to warn and protect – and its various implications.
Supervision (like therapy) needs to be structured but not rigid.
Recognize that generic “talking” has very little empirical support for supporting change in serious co-occurring disorders.
Be capable in dealing with conditions of potential suicide, self-harm, and harm to others.
Supervision needs to be based on an agreement, a professional development plan, and change-oriented interventions, techniques, and processes. In the final analysis, the supervisor is in charge – final decision making re. competence of supervisees and protection of others.
Look after your own self-development as lead clinicians and supervisors.
All may fail if you do not attend to your own SELF-CARE and the self-care of the people you supervise. Etc.!

Be well and reduce suffering!

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton Sangha

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

October 2, 2019 By Admin

Essential Knowledge for Clinical Supervisors

This post will include information and skills dealing with research on role induction practices, quality of clinical supervision, psychodynamics of alliance, and progress measurement. Since the information and skills for all these topics is complex, I will do my best to keep it as clear as possible. This information aims to improve existing clinical supervision practices.

Reducing anxiety of less experienced supervisees by role induction strategies

First of all clarify both supervisee and supervisor roles, expectations, behaviors, skills, rights, responsibilities, and clinical development.
Support supervises via clear information on process and skills training about cognitive, behavioral and emotional processes, skills, and clinical expectations.
Include lowering anxiety and improving competence as ongoing clinical supervision activities. Measure them!
Work directly on supervisees self-awareness capacities.
Clinical and psychological development issues may exist; adjust clinical supervision to fit these parameters.
Improvement in supervisees clinical competence and psychological health are ongoing goals.
Important variables that impact success or failure are supervisor competence and supervisee openness to growth and emotional regulation patterns.
Keep the quality of supervision in mind, and participate in mutual evaluation and openness to feedback. For best results keep supervisee input about the supervisor as anonymous as possible. Otherwise, supervisee anxiety will increase.
Recall that ethics requires that there be a reasonably detailed supervision contract.
Effective clinical supervision often translates into effective psychotherapy, which leads to improved client progress, better job satisfaction and self-esteem.

The Importance of clinical, evidence-based and psychodynamic training

Perhaps the single most important aspect of effective clinical supervision is the quality of the alliance. This is a parallel process with the therapy itself.
With improved training in psychodynamic alliance-building skills comes client self-reports of experiencing a stronger therapeutic alliance in therapy. Keep in mind the training is cognitive, behavioral, and affective in nature. It is experienced!
Research is mixed about the differences in alliance quality regarding psychodynamic training vs other training (CT, CBT, humanistic, interpersonal, etc.). The study noted suggests that improved emphasis on psychodynamics skills and processes ends with a better therapy alliance, which is consistent with better outcomes for clients. Although other studies refute this finding, it does appear to be logical that a training program specializing in psychodynamic therapy would produce better outcomes for psychodynamics, thus perhaps a better clinical alliance.
Manualized psychodynamic therapy training also showed substantial improvement in the clinical alliance and the amount of psychodynamic skills being used in therapy.

Comparative quality of clinical supervision and its implications

Research including over 300 clinicians concluded that 69-79% received inadequate clinical supervision.
What is more concerning is that the same research noted that 25-40% of clinicians received harmful clinical supervision.
At other measurement times 51-55% of clinicians noted that they received exceptionally helpful clinical supervision. Last I heard a 50% range is a grade of F. We need to work on improving this reality!
Research also supports that there are great differences between supervisee perceptions vs objective criteria used effectively to measure comparative quality of clinical supervision. So the indication is to use both – supervisee anonymous evaluation and direct observation and measurement of clinical performance.
86-92% of clinicians did receive some form of clinical supervision but both the regularity and quality varied.

The reality of using progress monitoring measures for clinician development

The use of clinical progress monitoring measures regarding client clinical change improves outcomes. However they are used rarely.
Clinicians noted that the use of such measures in therapy required technical expertise, additional costs, time in the session, some
increased anxiety, and was sometimes accompanied by negative responses from clients, other clinicians, and managers.
There were few differences in use and barriers between agency clinicians and private practice clinicians.
Since the benefits of progress monitoring in clinical practice is well established and is often part of evidence-based endorsements for therapies, it is important to increase the use of progress monitoring.
Furthermore, the lack of progress monitoring may have negative impacts on clients and third-party payments for therapy.

For more information refer to Ellis, M. V., Hutman, H., Chapin, J. (2015). Reducing supervisee anxiety…Journal of Counseling Psychology, 62, No. 4, 608-620. Hilsenroth, M. J., Kivlighan, D. M., Slavin-Mulford, J. (2015). Structured supervision of graduate clinicians in psychodynamic psychotherapy…Journal of Counseling Psychology, 62, No. 2, 173-183. Ellis, M. V., Creaner, M., Hutman, H., Timulak, L. A comparative study of clinical supervision… Journal of Counseling Psychology, 62, No. 4, 621-631. Ionita, G., Fitzpatrick, M., Tomaro, J., Chen, V. V., Ovington, L. (2015). Challenges in using progress monitoring measures…Journal of Counseling Psychology, 63, No. 2, 173-182.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton Sangha

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

August 22, 2019 By Admin

Using Creativity in Clinical Supervision

Effective clinical supervision is a combination of hearable direction about clinical practice, gentle-direct leadership, clinical “Know-How,” evidence-based skills, complex psychodynamics, and the willingness to work with others on their developmental processes. There are risks involved. I have provided clinical supervision and consultation to other clinicians for 43 years without a legal or ethical issue. I do not think you should allow your creative spirit to run wild; there are many very serious ethical and legal implications in supervision. These are not benign; most states hold clinical supervisors 100% accountable for the actions of their supervisees, whether those actions were known and recommended by the supervisor or not.

Here we will look at the work of Leonardo DaVinci, the genius in art, science, engineering, and humanities. He saw art as science and science as art – most clinicians recognize these combinations in their own clinical work. I will simply note a list of documented attitudes, values and behaviors that DaVinci mastered. Here is the list. Courage may be needed to move off your comfort-path.

Practice intense curiosity and deep awareness about the specific details of your work. As you do this apply a sense of wonder about your observations and different possible perspectives you encounter. Multiple realities of perspectives do exist. There may not be one absolutely correct response.
Observe! Observe! Observe! Notice how your supervisees do their work, and how their idiosyncratic personalities and attitudes influence that work and your supervision. Be certain to pay close attention to the facts of reality, but better to procrastinate a bit before making big decisions. Be sure you have all the correct facts. You may need to test your hypothesis.
Use your personal imagination more, and visualize the situations that cause you the greatest concerns. Remember: Do No Harm! In some situations it may actually be ok to use day dreaming and helpful fantasy for new perspectives for problem solving.
Be sure to keep written lists of all the things you need to do. Also, write in your own “supervision development journal” about new things you learn and lessons you wish you already knew. Review selected parts of that journal with your own supervisor.
It pays to be a little obsessive when dealing with supervisees and the welfare of their clients. Your growth also depends upon being a bit obsessive with learning new clinical processes and evidence-based interventions. However, remain creative and highly responsible in your role. Document everything you do in your role.
For more see Isaacson, W. (2017). Leonardo DaVinci…New York: Simon & Schuster.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton Sangha

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

June 8, 2019 By Admin

Increasing Creativity and Hope in Your Therapy

Sometimes even the most effective therapists get worn out; when this happens, our creative spirit may disappear from the therapy office. In this post I will present some research-based information about being more creative in our work, and add additional information about using mindfulness to enhance your clients’ hope. This information will also expand your own hope. We all know that hope is one of the most important element in therapy and counseling. Here are a few suggestion from Scientific American for enhancing our creative energies.

Stop just talking! It is important to utilize all pathways of consciousness, not just verbal, cognitive, and prefrontal activation.
Use lots of sensory interventions. Plan and implement interventions using all the human senses.
Use lots of symbols in therapy, and have your client come up with their own symbols to represent what they are experiencing in life. Symbols for solutions are very important.
Use lots of metaphors in your talking cures. Invite your client to come up with their own metaphors.
Utilize your own clinical knowledge, and go deeply into your client’s beliefs, aspirations, and behavioral activations in those aspirations.
Remain open to the possibilities within creativity – your own and your client’s.
Do not be critical of “off-the-wall” ideas your client may have. Criticism stifles creativity and open conversation. How might you use their suggestions in creative ways?
Do your best to remain positive in the work. This requires good self-care and clinical supervision.
Use left-hemisphere powers to plan and evaluate interventions and new behaviors; use right hemisphere powers to activate more creative ways of doing the business of change.
Use lots of colors to help your client develop visual images and pictures of desired changes. Add symbols and metaphors within the projective drawing interventions. No “stick-figures!”
When you are stuck, use free association to see what comes into consciousness about moving on.

Others with psychological background suggest that there are at least seven ways to enhance creativity. These ways include conscious and unconscious aspects of creative process and emotions. Use your personal values and reflective introspection to find sources of creativity in love, in nature, using the muse, in your own suffering, via regular meditative practice, in sacredness, and in art.

You may also find it helpful to use writing and poetry. Sometimes it helps by using the creativity of others. In the final analysis we all know we cannot simply turn-on creativity just because we wish to do so; it comes when we are ready to use it well. Follow the suggested areas above to stimulate your readiness to be more creative int your therapy and in your life.

Hopefully this information will help you to experiment with being more creative in your counseling and therapy. Now let’s take a look at ideas for enhancing and expanding hope. Using mindfulness and presence while practicing the Zen Buddhist paramitas or perfections may open up pathways to patience and caring. In our current disruptive world it is easy to get lost in the “I-Smart” phone next contact (an addiction); it is easy to allow others to influence our expectations and moods – often for the worse. The I/Me/Mine attitude of our narcissistic culture may be modified by the self-affirming realties of “The Perfections” (to give and to receive with grace, to use skillful actions, to be patient, to augment effort, to meditate, and “see” clearly). Engaging in these behaviors may help us return to the true self and an authentic life. The wisdom of these ancient teachings may open up the light in our dark nights of the soul. Living the foundations of The Perfections may liberate our deep hope for the better. Correctly taking and giving with patience and effort can enter our regular meditation practice. We may see more clearly what is important, as well as what path to take in any given challenge. Living our life with The Perfections in mind, body, and behavior expands hope for ourselves and for others. How might you creatively introduce The Perfections to your client (only with permission – they are Buddhist)?

For more information refer to DiChristina, M. (Ed.). (2008). Brainstorming: Using Science to Spark Maximum Creativity. New York: MacMillan Audio Books. See also Rizzetto, D. (2019). Deep Hope: Zen Guidance for Staying Steadfast When the World Seems Hopeless. Boulder, CO: Shambhala Publications. Quibell, D. A., Selig, J. L., and Slatery, D. P. (2019). Deep Creativity: Seven Ways to Spark Your Creative Spirit. Boulder, CO: Shambhala Publications.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton Sangha

Author of Mindful Happiness

New Edition of Mindful Happiness in Production…Coming soon!

May 5, 2019 By Admin

Introducing Your Clients to Brief Meditations

Psychotherapists often ask about ways to introduce mindfulness and meditation to clients. There are other posts on this Blog that offer basic introductory information on both content and process. Here I will simply introduce you to four brief, basic meditations for clients suffering from anxiety and/or depression, along with pervasive cognitive “stuckness” on unhelpful thoughts and related emotions. Once our clients – and ourselves for that matter – get stuck on unhelpful cognitions and emotions from the past, we need to move to the present moment and be there in calmness and safety. Of course other interventions are required when psychosis, intoxication, or extreme emotional dysregulation occur; meditation is not the recommended response in these conditions. One of the best ways to introduce your clients to meditation is to simply allow a gentle focus on the breath, just as it is. Relaxation-focused manipulation of the deep breath, especially for client with untreated trauma and polyvagal complications, may lead to the opposite effect – stimulating anxiety. Once your client can focus gently on her/his breath and benefit from brief exposures, he/she may be ready for brief meditations.

Below I have noted four scripts for you to use or modify as needed. Follow the rule-of-third by introducing the meditation cognitively (explain it); then with your client’s due process permission, do the brief meditation (in the body); and, after five or less minutes stop and process the meditation cognitively (talk about it). Always allow your client to stop the meditations at any time if they desire to do so. Comfort and safety are key values of psychotherapy process and relationship. If you or your client have doubts about comfortably completing the meditations, your client may prefer to be phased into them. Do this minute-by-minute by breaking down the five minutes into shorter time periods. Complete one or two minutes (half the scripts) rather than the full five minutes. Since mindfulness and meditation have been proven in thousands of studies to be helpful in anxiety, depression, chronic pain, and emotion regulation (trauma and addictions), the more comfortable your client feels, the more likely he/she will continue practicing. It is sometimes helpful to remind your client that if/when distraction occurs, that is the time to simply bring attention back to the task at hand. Return attention again.

Five-Minute Meditation for Opening Up the Flow of Energy – Sit, relax, and breathe calmly with your eyes open. If you are comfortable with your eyes closed, that is fine. If you like your eyes open, you may want to glance gently downward toward the floor about three feet in front of you. Do your best to hold your head in a relaxed and level position. Now loosen your jaw and notice. Practice releasing any tension that you may be carrying in your throat. Let it go very gently, and open up your throat. Now bring attention to the area of your heart center, and imagine a warm, glowing, gentle inner light there. Notice the feeling. Allow it to nurture you. To end simply be with your natural breath; after a few breaths, allow it to bring you to full attention. This meditation is over.
Five-Minute Meditation on Not Judging – Sit, relax, and breath naturally with your eyes opened or closed. Be as quiet inside as you can, and practice non-judging. Simply notice what comes into awareness for you, but without judging or evaluating it. Simply allow yourself to be with it. If your eyes are open, please close them if comfortable. Notice what comes into awareness BUT without judging or evaluating. If your eyes are closed, please open them; simply note what comes into your awareness BUT without judging or evaluating it. Be as quiet inside as possible – enjoy the silence if it is there. Count five breaths and end this meditation.
Five-Minute Meditation on Letting Go of Your Thoughts – Sit, relax, breathe calmly or naturally, and allow your eyes to remain opened or closed. Pay close attention to the thoughts (sometimes voices of others) in your head. If unhelpful thoughts arise, do your best not to react; instead simply notice without responding or reacting. Perhaps your thoughts are about people, places, things, images, body feeling, or personal experiences. As consciousness presents you with each item, one by one, simply notice and LET IT GO. Do your best NOT to get entangled with them; do not engage with your thoughts, or carry on conversations in your mind. Thoughts are just thoughts! As each one come into awareness, just practice non-judging and LET IT GO. Allow each thought to arise and fall – just LET IT GO! Yes, just let it go. Now complete a few in-out breaths, and end the meditation.
Five-Minute Self-Acceptance Meditation – Sit, relax, breath naturally and have your eyes opened or closed (it is up to you). As you sit simply allow thoughts, images, feelings to arise and fall; just notice them without engagement – LET EACH ONE GO. Be the “watcher.” Try not to get hooked by them. Now repeat this statement to yourself: “May I accept and love myself just as I am, with imperfections.” You may note this statement in your mind and be more specific be replacing “imperfections” with another word. Repeat this statement several times without distractions. Now rub your hands together until you feel heat. When your hands feel hot, gently place them on your face – covering your eyelids, cheeks, etc. Just sit there in your warmth and notice. Be the warmth. Feel free to rub your hands again and repeat the process. Count to five and end this meditation.

Anthony R. Quintiliani, PhD., LADC

From the Eleanor R. Liebman Center for Secular Meditation in Monkton, Vermont and the Home of The Monkton Sangha

Author of Mindful Happiness