Mindful Happiness

Anthony Quintiliani, Ph.D, LADC

By

Psychodynamics of Alliance – Therapeutic Relationship Enhancement

Psychodynamics of Alliance – Therapeutic Relationship Enhancement

This post includes basic considerations, processes, and clinical skills necessary for developing a strongly positive clinical alliance and therapeutic relationship in therapy.  Here the alliance is required for any substantial change in psychotherapy, and the therapeutic relationship rides the quality of the initial alliance to expand and inter-penetrate the emotional b0nds between the client and the therapist. The combination of strong initial alliance and highly positive therapeutic relationship is a powerful enhancement for personal growth and positive change in therapy. However, it is doubtful that these factors alone will bring about meaningful change in the problem/s that brought the client into therapy. Without them, there will be no meaningful change.

Emotional Bonding and Therapeutic Presence Requires:

  1. Intentional empathic attachment by the therapist;
  2. Meaningful collaboration on important tasks and behaviors;
  3. Emotional exposure in safety, and emotional containment as needed;
  4. The client experiences being heard, cared about, and accepted unconditionally;
  5. The therapist provides a strong positive “holding environment” within “intersubjective space” (Winnicott);
  6. A social and psychological environment of mutual respect, compassion, and trust exists;
  7. The therapist may become a secure attachment (re-attachment) figure in this emotionally intimate process;
  8. The therapist’s “unconditional positive regard” is experienced and projected into the psychodynamic space (Rogers);
  9. The therapist may improve attunement with the client’s inner experience, emotions, and needs (Kohut); and,
  10. Within safety and trust both projection and projective identification occur (Alonso) as reciprocal introjective processes to ensure the potential for “going on being” (Winnicott).

Additional Specific Behaviors by the Therapist:

  1. Providing direct emotional support verbally and non-verbally;
  2. Holding a delicate balance in idealized projections;
  3. Rapid repair of emotional ruptures, and taking responsibility for same;
  4. Various forms of direct and indirect validation;
  5. Careful, strategic use of silence;
  6. Maintaining empathic understanding despite any negative countertransference;
  7. Working to improve “experience-near empathy” (Kohut);
  8. Acting on opportunities to improve the quality of object relations here and now;
  9. Serving as a “good mother” (or father) figure (Klein); and,
  10. Careful ongoing reflection on emotional, verbal, projective, transference, and countertransference processes.

Desired Self-Development Outcomes for the Client:

  1. Improved insight;
  2. Improved self-confidence and sense of security;
  3. Improved skills in mindful awareness;
  4. Reduced fixations on negative cognitive, emotional, and behavioral experiences in the past and present;
  5. Improved internal structure as well as object constancy and relatedness;
  6. More positive introjected experiences in therapy and in life;
  7. Reduced repetitive defensive and emotionally reactive patterns;
  8. Stronger, more positive sense of personhood; and,
  9. More effective views about self in the world of interpersonal life.

Caution: Most psychodynamic and psychoanalytic therapies place primary emphasis on the clinical relationship between the therapist and the client, and less emphasis on actual cognitive and behavioral change in presenting problems. Therefore, it may be a moral (not ethical) question as to whether a therapists uses only these approaches. It may be best to integrate them with a well researched evidence-based therapy. For supportive reviews see the work of Mark Solms, Edward Tronick, and C.A. Alfonso, R.C. Friedman, & J.I. Downey (Eds.) (2018). Advances in Psychodynamics Psychiatry. For a strong critique see Richards, A. (June, 2018). Psychoanalysis in trouble…Psychoanalytic Review, 102(3), June, 2018.

By David Rapp, Brian Tobin, and Anthony R. Quintiliani, PhD., LADC,

Author of Mindful Happiness  

Mindful Happiness cover designs.indd

New Edition of Mindful Happiness in Production…Coming soon

By

Setting Emotional Boundaries from Work to Life

Setting Emotional Boundaries from Work to Life

Anthony R. Quintiliani, Ph.D., LADC

Sometimes setting emotional boundaries from the psychotherapy room to your life outside of work can be a difficult thing to do. Shifting from “experience near empathy” (Kohut), “unconditional positive regard” (Rogers), “hovering attention” (Freud), “the holding environment” in “intersubjective space” (Winnicott),  and compassionate awareness to emotional distancing, separation, and dispassion is no easy task. In more in-depth clinical interactions, the process of projective identification between therapist and client may drain your emotional resources; sometimes being “as if” you were the experiencer of your client’s pain and suffering can take a serious toll on your own emotional resources. At time the therapist’s own emotional life lacks the quality of connection experienced in the therapy session. Success in setting emotional boundaries is a very important self-care skill. It may determine your success, failure, joy, or misery in the clinical work you do. It will definitely prevent most case of “burn out.”

Therapists may wish to complete a brief self-care assessment at the end of each emotionally demanding day. Some things to check are as follows:

  1. Are you taking care of your own physical, psychological, spiritual, and emotional needs?
  2. Are you using mindfulness, self-compassion, clinical supervision, or journaling to get to know how you are doing?
  3. Are you valuing yourself enough regarding self-rewards, positive self-talk, cognitive and behavioral restructuring?
  4. Are you giving yourself time to experience some form of creativity?
  5. What about your spiritual self?
  6. Do you spend quality time in nature, among the awe of it all?
  7. Are you involved in the type of quality relationship you desire?
  8. Be sure to act on your own behalf if you find problems in the above areas.

Another very powerful process is to develop improving self-compassion for yourself, often blurring the inner boundaries of your own emotional life experience and the clinical work you do. Therapists are, in the end, only people with a set of specific helping skills. We suffer just like other people do. Hopefully, our training and experience have given us a bit of a positive edge here. Here are some things you may wish to consider to improve your own level of self-compassion.

  1. Using mindful awareness, observe the level and intensity of your self-criticism.
  2. Let go of personal resistance to being real, being your true self.
  3. Get out of your head! Get out of the past!
  4. Do loving kindness meditation often.
  5. Recognize your own difficult emotions (shame, anger, revenge, trying to control others, etc.), and simply be with them as a sacred part of who you are and be real about it. Use emotion regulation to improve things.
  6. Practice much more self-appreciation.
  7. Do not dwell on the pain and suffering of your past. All that stuff probably made you a stronger person.
  8. Welcome and LOVE all of you, with special attention to the sacred quality of your own life suffering.
  9. When you experience or re-experience anxiety, depression, addictive behaviors, or trauma – hold an open, soft heart for it.  Then make changes to improve your life experience.
  10. Always get help when you need it, and do your best not to dwell on what you have little control over.
  11. Be certain too make changes to improve self-compassion regarding any problem areas above.

Fo more information refer to Norcross, J. C. and VandenBos, G. R. (2018). Leaving it at the Office: A Guide to Psychotherapist Self-Care. New York: Guilford.  Neff, K. and Germer, C. (2018). The Mindful Self-Compassion Workbook: A Proven Way to Accept Yourself, Build Inner Strength, and Thrive. New York: Guilford.

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!

 

By

Very “SAD” Facts about the Addictions Field

Very “SAD” Facts about the Addictions Field

A recent issue of the Addictions Professional presented very disturbing news about how clinicians in the field are doing.  NOT WELL! Addictions clinicians treat people with addictions but mainly people with co-occurring disorders – addictions with trauma, depression, anxiety and/or eating disorders.  Often there is also a co-occurring medical condition. This is very difficult work. People suffering from these conditions often relapse into one condition when they improve in another. Trying to attain a healthier client life in this work is no easy matter, and places huge emotional strains on families and clinicians. It is a profession of the heart.

To begin with it is so sad how poorly the American public understand addictions. I think much of this wrong opinion is based on stigma, shame, and very poor public education about addictions.  A recent Harris Poll of 2,184 adults, of which 692 were parents of children between the ages of 6 and 25, noted that 66% of the people polled thought addictions could be cured; nearly all professional groups believe it is a chronic, progressive disease/syndrome that can be managed. Recovery, of course, is quite possible; recovery, however, does not meet clinical criteria of a “cure.”  18% believed that recovery was hopeless once a person relapses after intervention. In reality, relapse is simply part of the recovery process and may indicate by its repetition how severe the addiction is (a brain-based, mind-body-spirit disorder). 55% had an opinion that a person with an addiction could not perform well at work. In reality this situation if quite variable. 42% to 47% of respondents would feel uncomfortable if a significant person (potential in-law, teacher, medical doctors) had an addiction. Well we all know how poorly informed the American public has been and still is about the realities of addictions. What is the problem here?

A recent Quality of Life survey of 650 addictions clinicians found that in 2015 71% intended to work in the field until retirement. That number was reduced in 2016, with only 68% planning to retire from their current work. In 2017 the number went down again with only 59% of current addictions professionals intending to remain in the field until they retired. That is a 12% drop in just three years. Almost 10% noted that they would most likely seek another career. Workloads have increased and salaries have not move very much. 52% of a sample of workers noted that their caseload has increased over the past two years. What about compensation? Not so good! In 2017 71% noted that their current salary DID NOT reflect their training, experience, and job requirements. 35% have quit a job in addictions work.  13%noted that their clinical supervision needed improvement or was not good at all. These numbers are dismal.

At the same time documentation requirements of state and federal government funding, as well as health insurance company funding, have increased dramatically. In my own experience I supervised clinicians working with very difficult addiction clients. Most of them had to spend about 51% of their time documenting the work they did, while only 49% of their time or less was actually working with clients.  It was common for people to go back to work on weekends to complete overdue paper/computer documentation. I often joke that to be an addictions counselor you need to fill out more paper and/or computer screens than to transport nuclear waste across state line or to buy a house.  I think this may be true!  I call this “Organic Bureaucracy,” where record keeping and management functions increase to the detriment of time with clients. Is it not the goal to help client learn skills and stabilize emotions so that they may enter recovery process? This requires TIME!

How about self-care. Surely in such a “strained” field – often called the poor sister or poor brother of health care – where demand for services outpaces staff and funding availability – self-care must be seen as important. Perhaps not! Survey data suggests that only about 1/3 of addictions counselors perceive self-care as a high priority at their place of employment. 25% note that self-care receives little or no attention.  41% note that self-care is an occasional topic in the workplace. I fear that marginal supervisors may be fearful of emphasis on self-care, perhaps suggesting that the job really cannot be done in a healthy way. Lots and lots of “burn-out.”

Let’s HOPE that somewhere up the federal bean stock somebody wakes up. In not, we may see huge shortages of qualified addictions professional. Yes there are other resources, but often far less trained and experienced in helping people work their way out of their addictions and other clinical conditions. Then what?

For more information refer to Addiction Professional (Fall, 2016), pp. 16-18, 20, 40.

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!

By

Helping Therapists Work with Diversity

Help For Therapists: Working with Diversity

Clinical interventions, especially strongly evidence-based interventions, impact clients via new skills and practices in mind-body clinical realities. No matter how good (or “good enough” ) a clinical intervention is it requires a highly positive, active therapeutic relationship. As ample research suggests, a strong and positive therapeutic relationship in therapy enhances client trust and courage – thus expanding their experimenting with new ways of being, thinking, and doing. A huge problem is establishing such a therapeutic relationship is the inability of some therapist to bond with diverse people – people not exactly like the therapist. Below I will present information from clinical  and social psychology about
what general variables/differences to be most mindful about.  This information will be noted in three categories: Universals; Group Differences; and, Individual Self-Development (within groups). If therapists practice paying more attention to some of these basic realities in their clients, the expectation is that their therapeutic relationship/alliance will improve along with their clinical outcomes.

UNIVERSALS: Here is the listing – Similar Life Experiences/History, Biological Similarities, Social Similarities, Psychological Similarities, Emotional Similarities, Self-Awareness Valences, Use of Symbols, Use of Art, Compassion and Aggression, Love and Hate, and, Differences in the Above. Noticing, being mindful of, and using these realities in therapy should improve alliance and clinical outcomes.

GROUP DIFFERENCES AND SIMILARITIES: Here is the listing – Gender, SES, Age, Geography, Race, Ethnicity, Culture, Abilities, Disabilities, Religion, Marital Realities, Sexual Orientation, Urban/Rural, Education, Environmental Exposure (good/bad), etc. Again, therapists who are highly mindful of these realities will do their best to integrate them into their work with clients.  Good work here will improve the alliance and clinical outcomes.

INDIVIDUAL SELF-DEVELOPMENT: Here is the list – Genetic Transfer, Modeling Transfer, Familial Transfer, and All Non-Shared Experiences in Life. Therapist who make it a norm to differentiate carefully between individuals in therapy – and who actively use these differences in their work – will most likely experience stronger emotional ties/alliances and better clinical outcomes.

If you have not been fully conscious of using such differences and similarities in working with your clients, you may want to select a few variables and begin.  Begin NOW!

For more information refer to Pomerantz, A. M. (2017). Clinical Psychology: Science, Practice, and Culture. Los Angeles, CA: SAGE Publications, pp. 69-93. See also the DSM-V emphasis on culture and diversity in treatment.

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!

 

By

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!