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Anthony Quintiliani, Ph.D, LADC

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August 22, 2019 By Admin

Using Creativity in Clinical Supervision

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.

 

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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 SanghaChiYinYang_EleanorRLiebmanCenter

Author of Mindful Happiness  

Mindful Happiness cover designs.indd

New Edition of Mindful Happiness in Production…Coming soon!

Filed Under: ANTHONY QUINTILIANI, Clinical Practice, Clinical Supervison, Clinicians, Commentary, Featured, Learning, Training Tagged With: CLINICAL SUPERVISION, CLINICAL TRAINING, CREATIVITY, MINDFUL HAPPINESS, TRAINING

May 25, 2017 By Admin

Using Cognitive Defusion in Mindfulness Psychotherapy

Cognitive Defusion in Mindfulness Psychotherapy

A well-meaning therapist might ask: What is cognitive defusion. Well this practice, as used in Acceptance and Commitment Therapy, is beyond cognitive restructuring of cognitive distortions and automatic negative thoughts ( I call “Red Ants”). The practice concretely de-literalizes the personal truth and meaning of unhelpful, repetitive thoughts and words. As The Buddha warned: We probably should NOT believe the distinctions of thoughts in our heads. Our strong thoughts may be our best friends or our worst enemies. In neuroscience the fact that more negative than positive thoughts occur in humans implies we are more attached to limbic reactivity and fear than to positive thoughts and emotions. When we get stuck in negative cycles of thinking, feeling and doing our right brain and limbic area dominate. A very old mindfulness belief is that you are not your thoughts, your emotions, or your behaviors; these parts of you are simply associated with your life experiences. When a client learns to defuse a though it means they have changed its linguistic structure and removed it from being cemented into their CABs, or cognition-affect-behavior cycles. In all good therapies, especially Cognitive-Behavioral Therapy and various mindfulness therapies (MBCR, DBT, MBCT, MBRP, ACT), helpers often work on truth-analysis of unhelpful, repetitive, negative thoughts patterns – especially those embedded into CABs cycles of ineffective experiences. Self-medication, isolation, and avoidance are commonly associated with these realities. Sometimes this work includes meta-cognitive analysis regarding your thoughts about your thoughts or the patterns of your thoughts. The clear logic is that the words we often tell ourselves in times of stress or fear are NOT often true. Of course, if indeed you are seriously endangered best to allow your limbic brain area to save your life. The list below will note various approaches used to defuse thoughts from our experience of being, our CABs cycles.

  1. Stay the thoughts out loud and mindfully notice the sensations, images, emotions, and associated CABs cycles that arise. Now say the words over and over again for at least half a minute. Note any changes that follow.
  2. Use scrambling of the phrase to change it grammatical brain-connections. Your brain should react a different way to the “scrambled” message. It is like changing the code of the phrase. For example: try saying “am person a bad” or “person I a bad am” instead of “I am a bad person.”  Notice what your brain-mind does now.
  3. Speed up and then slow down the rate of inner and outer speech. Try all four options; notice any relief you have obtained.
  4. Reduce then intensify your energy level when saying the phrase. Notice, again.
  5. Elongate the sounds of the key words in your phrase.  Keep elongating and notice what happens. Elongate and slow as far as you can.
  6. I like this approach. Change the most important one or two words in your phrase.  Now say the phrase out loud with one or two slightly less harsh words.  You will need to repeat this technique for effects. For example: “I am so worthless” helps solidify your brain plasticity about personal meanings and images. Try this: “Sometimes I feel worthless” or “When really bad things happen, I can feel worthless”  or “My unpleasant feeling can relate to feeling less worthwhile.”
  7. Change the language code of your key word/s. For example: change “I am a terrible person” to “I am a spanty person.” Spanty being Czech for terrible or bad.  Notice how the brain/mind/body responds to this simple change.
  8. You could also sing your statement, or say it in a foolish voice tone.
  9. I have used defusion and added body movements to the process. Here are four examples.

A) Find a spot on the floor where you try to project all your bad feelings about your repetitive phrase. You are consciously projecting the bad feeling into the spot on the floor. Now stand in it and notice how your mind body reacts. Slowly, but with some bodily energetic force, step out of the spot on the floor.  Notice the effects.

B) Stand in the same spot, and pretend you are taking off a pair of pants – BUT when you are out of the imaginary pants, immediately step aside. Notice.

C) Find a pleasant place to go for a brief walk. Enjoy the environment, but say your statement to yourself. Split your attention in two: attention to the beauty of the walk (and watch your step), and attention to repeating your phrase. Notice any changes and shifts that occur.

D) This one is out-there but fun. Energize yourself (if healthy enough) into a rapid skipping movement. At the same time say your phrase, and pay attention to where you are skipping. Your body will respond by contrasting the negative statement against the body-memory of good-old skipping. For most adults, skipping was a fun thing to do. Notice the effects.

For more information refer to: Blackledge, J. T. (2015). Cognitive Defusion in Practice: A Clinician’s Guide… Oakland, CA: Context Press/New Harbinger, pp. 3-42, 87-109, 159-162.

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!

Filed Under: Clinical Practice, Clinicians, Cognitive Behavioral Therapy, Featured, Ideas & Practices, Meditation, Meditation Activities, Mindful Awareness, MIndfulness, MIndfulness Activities, Mindfulness Training, Psychotherapy, Therapy, Therapy Tagged With: ANTHONY QUINTILIANI, COGNITIVE DEFUSION, MINDFUL HAPPINESS, MINDFULNESS

March 26, 2017 By Admin

How to Improve Client/Patient Collaboration

Improving Client/Patient Collaboration  in Treatment

To improve collaboration between you and your clients/patients, simply practice the following behaviors as your norms.  See the

list below, and practice, practice, practice.

  1. Present with an attitude of helpfulness and authentic caring. Empathy and authentic concern are required.
  2. Recognize the reality that clients/patients are at different levels of readiness to make changes – almost alway NOT where you are in the process.
  3. Know how to use cognitive-behavioral therapies, mindfulness-based stress reduction, deepo psychodynamics in alliance building, and other effective approaches.
  4. Complete a cost-benefit analysis grid with the person, and work with pros/cons of staying the same vs changing.
  5. Do whatever you can to enhance the quality of the clinical relationship.
  6. Act within an understanding of equality; you are not able to control any person who is suffering.
  7. Provide psychoeducation where needed.
  8. Anticipate barriers to making desired changes; offer concrete support and help in doing so.
  9. Your clinical interventions should be evidence-based for a higher probability of success.
  10. Use the person’s personal hopes, goals, and motivations.
  11. Use task analysis as a behavioral method to break down larger tasks into smaller, more manageable tasks.
  12. Be willing to try harm reduction when people appear pre-contemplative in stages of change.
  13. Provide direct feedback, with more emphasis on reinforcing praise rather than scolding.
  14. Remain in the Middle Way regarding too much/too little expected change, as well as the timing and time required for any changes to occur.
  15. Be highly mindful of both your own emotion regulation and that of the person you are working with. Practice emotion regulation skills often.
  16. Intervene quickly in anxiety, depression, substance misuse, and trauma.  Intervene carefully, intelligently, and again with evidence-based actions.
  17. Remember in crisis situations that  safety is first, stabilization is second.
  18. Identify people, places, and things that help and hinder progress into healthier life patterns.
  19. Monitor serious symptoms and act accordingly.  If medications are required, be part of the monitoring system and do “check-ins” often.
  20. Use self-help groups if the client/patient finds them helpful.  One needs to participate to know the correct answer here.
  21. Do GOOD self-care and get effective clinical supervision when needed.

For more information refer to Daley, D. C. and Zuckoff, A. (1999). Improving Treatment Compliance: Counseling and Systems Strategies for Substance Abuse and Dual Disorders. Center City, MINN. Hazelden.

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!

Filed Under: ANTHONY QUINTILIANI, Clinicians, Counselor Activites, Featured, Ideas & Practices, Leadership, MIndfulness, Practices, Self -Kindness, Self Care, Self Compassion, Self Esteem, Stress Reduction, Therapist, Therapy, Thoughts & Opinions, Training

February 16, 2017 By Admin

Details About Cognitive-Behavioral Therapy

Understanding Cognitive-Behavioral Therapy?

Cognitive-Behavioral Therapy (or Cognitive-Behavior Therapy, hereafter CBT) has been noted as the most common evidence-based therapy approach used in the United States.  That said, the most common “therapy” approach used here remains generic talk therapy with more or less psychodynamic characteristics. Given the absolute limited level of outcome-based evidence for effectiveness of generic “talk therapy,” it amazes me how many licensed therapists still use it. Perhaps there is a reciprocal – perhaps unconscious – emotional/attachment need satisfaction process between client and therapist. Most clients like this “talk therapy,” and they will continue to show up mainly because of the positive, accepting nature of the therapeutic relationship.  In some cases, the clinical alliance and therapeutic relationship may be qualitatively superior than in other therapies. However, in cases of severe co-occurring disorders (those that tend to make mental health-behavioral health treatment the most costly of all), the alliance is essential for progress but the relationship alone does NOT cure. It is interesting that systems paying for professional therapy services still fund this generic form of therapy.  Back to CBT.

A general way to understand CBT is to note it is present minded (a mindfulness characteristic), with ample skills learning AND PRACTICE in sessions, as well as in homework.  To get clients to pay attention to homework practices, best to begin them in the session. CBT is time-limited, solutions-oriented, and aimed at problem improvement/resolution and recovery processes. The behavioral components, those that are required to distinguish CBT from cognitive therapy, include behaviorally-oriented action learning.  Learning to do better, to live better, by DOING. CBT is collaborative, requires a good clinical alliance, includes ample psychoeducation, and importantly is skilled-based. It is by way of both insight and new cognitive-behavioral skills to cope better with life’s challenges/stressors that makes CBT so effective.  It must be done correctly, however, to be effective. Although effective CBT requires effective assessment of past causes and conditions, it remains present-to-future oriented in its intention and direction. Some uninformed therapists may think they are doing CBT, but without the behavioral components they are simply doing cognitive therapy.  Whereas CBT includes processes and skills from both cognitive and behavioral therapies, the earliest version was A. Ellis’ Rational-Emotive Behavior Therapy.  More on the cognitive components to follow below.

The process of CBT includes interactive, systemic cycles of repeated thoughts and behaviors.  The A-B-C model (quite behavioral) is often used. In this process model, events lead to thoughts/beliefs, which have emotional consequences.  The emotional consequences (good vs bad), lead to behavioral activations (some impulsive).  The thoughts and their related behaviors produce consequences.  CBT is a highly structured therapy, and one that includes verbal reviews of progress (from treatment), check-ins, clarification of the session plan, etc. Cognitive components of CBT include identification of idiosyncratic automatic negative thoughts (I call them “Red Ants’) and their correction via disputation techniques. Do not use the term irrational; it is outdated and insulting to clients. How would you feel if a person told you “your thoughts are irrational?” Clients are helped to recognize advantages and disadvantages of their self-defeating thought patterns (more meta-cognition than single thoughts) by examination of consequences for having such thoughts – often depression, anxiety, helplessness, hopelessness, and loss of motivation. Reattribution of responsibility for outcomes is also important, as is the reframing process often used to establish reattributions. A more balanced locus of control may be a goal. Thought records are used.  However, to do a better job using both cognitive and behavioral aspects, I suggest using an Experience Record that includes events, thoughts, emotions, sensations, behaviors (especially self-medication), consequences of behaviors and an evaluation of the helpfulness of the consequences.  Using the cost-benefits analysis grid may also be helpful. This approach includes a quadrant regarding actual good consequences about keeping the thoughts/behaviors; actual negative consequences about maintaining the thoughts and behaviors; expected good consequences about changing the thoughts and behaviors; and, expected barriers/roadblocks about making such changes.  CBT can include a harm reduction process in slowly improving thoughts and behaviors, especially in related substance misuse or self-harm aspects of problem solving. I suggest the most important parts of CBT are a solid therapeutic relationship, use of both cognitive and behavioral skills for modifying unhelpful thoughts and behaviors, and built-in behavioral reinforcement for any changes made by the client.  Now we go into the behavioral components of CBT.

Common behavioral components of CBT include the use of learning theory, reinforcement, and conditioning. These clinical skills are not easy to use. As clients learn to use new behavioral coping skills they actively monitor and track their situations, their thoughts, and especially their behaviors. It is common to use an activity schedule to help clients engage more fully with helpful behaviors that may slowly come to replace older unhelpful (rewarding) behaviors. Clients learn how to recognize and monitor both external conditions and internal states of being in response to the external conditions. Of course, there are also internal conditions that may be monitored as well: depression, anxiety, fear, dread, sensation-emotion links, etc.  Relaxation and mindfulness training (MBSR or ACT may be best) are used to help client cope better with
real and imagined (in session) challenging causes and conditions.  Such stress reduction and equanimity skills are taught and practiced in sessions. Sometimes a behavioral hierarchy may be used (task analysis, exposure hierarchy, etc.). In this highly organized setting, clients practice related relaxation/mindfulness coping skills as they slowly make progress up the hierarchy; the process is matching effective coping skills with imagined or real life challenges along the way. It is common to use SUDs measures: from zero to 100 how much discomfort exists right now? Since SUDs scores tend to be used with negative situations, I have developed a SUPs scale. In SUPs: from zero to 100 how pleasant is this situation right now?In such learning, clients come to recognize how conscious and unconscious cues and stimuli may trigger internal negative states; such states have in the past caused maladaptive responses, thus making bad situations worse. A very powerful intervention is to enhance self-efficacy. As clients become more skilled and competent to deal effectively with life problems and challenges, they develop an inner sense of “can-do-it-ness.” This change has dramatic impact on both self-esteem and courage to carry on. In more advanced practice of CBT, many mindfulness-based interventions may be added. I refer to this as CBT-M. For effectiveness all mindfulness skills must be practiced, personally, by the therapist. Both cognitive an behavioral aspects of CBT are used in relapse prevention practices, where new insights (cognitive) may lead to new skill applications (behavioral).  CBT, when effectively delivered and experienced, can produce highly positive changes in long-term problematic cycles of thinking and behaving.

For more information refer to Meichenbaum, D. (1977). Cognitive-Behavioral Modification: An Integrative Approach. New York: Plenum Press. Beck, A.T., Rush, A. J., Shaw, B. F. and Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press. Wilson, G. T. and Franks, C. M. (Eds.) (1982). Contemporary Behavior Therapy: Conceptual and Empirical Foundations.  New York: Guilford Press. Persons, J. B., Davidson, J, and Tomkins, M. A. (2001). Essential Components of Cognitive-Behavior Therapy for Depression. Washington, DC: American Psychological Association. Padesky, C. A. and Greenberger, D. (1995). Clinician’s Guide to Mind Over Mood. New York: Guilford Press. Bandura, A. (1997). Self-Efficacy: The Exercise of Control. New York: W. H. Freeman. Germer, C. K., Siegel, R. D. and Fulton, P. R. (2005). Mindfulness and Psychotherapy. New York: Guilford Press. Freeman, C. and Power, M. (2007). Handbook of Evidence-Based Psychotherapies: A Guide for Research and Practice. Hoboken, NJ: J. Wiley. I have noted some classics because their details are far more specific and explicit than some more current publications.

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!

Filed Under: ANTHONY QUINTILIANI, Clinical Practice, Clinicians, Cognitive Behavioral Therapy, Featured, Practices, Therapy Tagged With: CBT, CLINCAL, COGNITIVE BASED THERAPY

January 20, 2017 By Admin

Trauma Therapy Basics from Experts

Trauma Therapy:  Basics from Some Expert Clinicians

For many years trauma therapist have used many approaches in their psychotherapy. Most of these approaches lack strong empirical support for outcomes, and are often the “favorites” of these therapists.  One might wonder what benefits therapists derive from using approaches that are not evidence-based. If an intervention fails to support timely positive changes in people suffering from trauma, WHY would a professional use it? It is common for therapists to use psychodynamic therapy, cognitive therapy, behavior therapy, and cognitive-behavioral therapy (including dialectical behavior therapy).  While it is quite true that people suffering from serious trauma requires an exceptional therapeutic alliance (psychodynamic therapy), modifications in automatic negative thoughts (cognitive therapy), changes in unhelpful behaviors, like self-medication of pain (behavior therapy, and combinations like very well executed cognitive-behavioral therapy), commonly long-term healing outcomes have been somewhat disappointing.  Perhaps an experienced and skilled therapist able to develop a high quality psychodynamic clinical alliance as well as highly effective cognitive-behavioral interventions may achieve admirable outcomes; however, that specific combination of skills is not common. I am suggesting that a high quality helping alliance and successful interventions in thinking and behavior problems may be helpful for people suffering from serious trauma.  However, most of these approaches (other than informed and skilled DBT) miss the mark when it comes to integrated positive impact on the mind-body system.  Even in DBT (and CBT), it is common for it to be used as a form of cognitive therapy – leaving the important behavioral and body-based areas out all together. To take a new look at the traumatized mind-body, witness current successes in trauma-informed yoga and meditation for PTSD.  Recent meta-analytical reviews have noted that meditation (and yoga to a lesser degree) do improve depression, anxiety, physical pain (emotional pain?), and emotion regulation. Therefore, such body-based approaches improve three (depression, anxiety, self-medication) of the common clinical conditions associated with serious trauma.

Clinicians like Bessel van der Kolk remind us to pay attention to trauma-formed brain changes: the amygdala, the hippocampus, and the prefrontal area (especially medial PFC). These areas have been impacted, possibly sensitized, to trauma and its sequelae. Such changes may strongly impact the person’s future-orientation to life as less than hopeful, and cause sensitized body-based emoltionaland bodily reactions to conscious and unconscious (autonomic) traumatic cues. MRI research supports the trama-caused changes in both limbic and executive brain centers. It is believed that trauma causes changes in the neurocircuitry of the brain. Such important processes as interoception (mindfulness) and neuroception (polyvagal implications) play important roles in post-traumatic experience. The suggestion is that mindfulness, body-based interventions (meditation, yoga, body scanning, etc.) may be helpful in the experienced therapists’ hands. Recall, however, when it comes to using body-based and mindfulness-based interventions in trauma, the best therapists are also practitioners in these practices. Limbic  and prefrontal interventions, NOT psychodynamic and cognitive interventions, may be highly helpful in effective trauma-informed psychotherapy.

Peter Levine reminds us that the body-based implantation of trauma may be used to slowly assist people suffering from trauma to be one with their memories without becoming powerless over them.  Thus, specifically designed body movement with their associated emotional and memory components as well as verbal processing may be utilized to support recovery from even the most severe traumatic experiences.  He does not forget the role the body plays in trauma and recovery from it.

Stephen Porges of Polyvagal Theory fame, notes that traumatic experience impacts the brain and the central nervous system. He notes a keen focus on the huge implications of the vagal nerve systems. It is possible to use neuroception, which functions as a risk detection system in people with trauma, to slowly help people adjust to the way their body responds to any form of traumatogenic cues – both internal and external. Utilizing adult attachment theory and process in therapy, as well as the possibility of feeling safe in social interactions, helps people with trauma move if slowly into recovery. Physical gestures, body reactions, voice quality, posture, and facial emotions – all part of post-trauma deficits – may be modified so as to assist people to enter recovery.

Pat Ogden, famous for her unique body-based and movement-based approaches, explains how habitual, conditioned body-based reactions may be modified as a new story of the body. These new experiences help to form a new better integrated story about trauma that guides the recovery process and reduces fear. She suggests that very specific forms of body movements may be most helpful here. Perhaps, the brain’s insula and thalamus have also been sensitized to reminders of traumatic experience, thus rendering their typical functions less adaptive.

Note that all of these leading trauma specialists have shifted to interventions with the body rather than typical “talk therapy” that is so often used.  Yes, we do need to have important conversations with people suffering from trauma, but the real power for change comes from working with their bodily memories, reactions, and impulses along with limited verbal interactions. Inner peace, interpersonal safety, and slow readjustment to life are all part of recovery.

For more details and available clinical training refer to www.nicabm.com/holiday 2016… retrieved on December 28, 2016. See also Harrison, P. (August 13, 2014). Long-term course of PTSD revealed. www.medscape.com/viewarticle/829872…retrieved on August 14, 2014.  Also refer to Buczynski, R. (October 23, 2014). PTSD, the hippocampus, and the amygdala – How trauma changes the brain. www.nicabm.com…/ptsd… Retrieved on October 24, 2014.

 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!

 

Filed Under: Clinical Practice, Clinicians, Featured, People, Therapy, Trauma Tagged With: ANTHAONY QUINTILIANI, BESSEL VAN DER KOLK, CLINICIANS, PAT OGDEN, PETER LEVINE, POLYVAGAL THEORY, PTSD, STEPHEN PORGES, THERAPY., TRAUMA, TRAUMA THERAPY BASICS

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