Mindful Happiness

Anthony Quintiliani, Ph.D, LADC

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Mindfulness Skills and Psychotherapy Outcomes

Mindfulness Skills and Psychotherapy Outcomes

There are at least ten good reasons why mindfulness training and regular practice may improve psychotherapy outcomes. These reasons assume the training is presented by a well-trained clinician-mindfulness practitioner. Of course improved outcomes also depend upon the client’s motivation and energy to actually practice mindfulness skills on a regular basis. One way to ensure this is to integrate such practices into every therapy session. Here is the list.

  1. Intention: Mutual intention to learn and practice mindfulness skills is required. Intention may also carry over to the client’s desire to make changes for the better. For both parties regular practice opens doorways to improved emotion regulation and awareness as well as possible spiritual development.
  2.  Attention: Attention is required for regular mindfulness practice. Such attentional improvements may help clients notice more clearly unhelpful patterns in cognition, emotion, behavior, and sensation. This also applies to therapists, who may find these skills improve their acuity in noticing small but important problems and changes in client behaviors.
  3. Awareness: Intention and attention tend to improve one’s level of awareness – for both positive and negative experiences. Awareness skills may be open or focused. Improved awareness of unhelpful experiences may challenge clients, but it will also help both parties to see more clearly what is important and what changes are needed. When awareness is matched with behavioral task analysis, it allow clear measurement of progress.
  4. Emotion Regulation: Improvement in emotion regulation is, perhaps, the single most beneficial change for both clients and therapists. Integrating various approaches from mindfulness-based therapies will ensure ample opportunity to practice emotion regulation, which is the single most problematic issue in most common problem areas (anxiety, depression, trauma, addictions, chronic pain).
  5. Mindfulness-Based Skills: Mindfulness-based therapies (MBSR, MBCT, ACT, etc.) offer a wide array of skill practices for both clients and therapist. Therefore, it is possible to match client needs with appropriate skill practices in sessions and  at home. Also the “self” of both parties is more strongly present in such practices. Who is this observer experiencing these conditions and situations of life.
  6. Subject-Object Observation: In the many problems people experience it is possible to match client needs with a specific set of mindfulness skills. The ongoing practice of subject-object observation (often without evaluation) allows various transformational experiences for clients. One that is most common is that thoughts, emotions, behaviors, and sensation are internal and external experiences that the “I” is having.  However, such experience is NOT-ME, they are simply current experiences in life. They are impermanent. The same is true for therapists. Also therapist may be able to use this formal process to investigate the quality of the therapeutic relationship and its core alliance. Transference and countertransference responses are Important!
  7. Interoception: Along with emotion regulation interoception skill, or the ability to recognize internal body sensations arising and the emotions that follow, is highly valuable in therapy. This allows both clients and therapists to recognize precursors to problematic thoughts, emotions, behaviors, and sensations. It enables a short window of time to act to prevent or mitigate negative experiences. It also brings in awareness of somatosensory experiences. Our sensory experiences are what we “are” in life.  Awareness os the “me.”
  8. There is ample, high quality research supporting the use of mindfulness skills in improving both depression and anxiety. Google it.
  9. There is high quality research supporting the use of mindfulness skills in improving chronic pain. Google it.
  10. There is good evidence supporting the use of mindfulness skills in improving both trauma symptoms and challenges, as well as improving addictive behaviors. These improvements come mainly from improved awareness,  emotional self-regulation, and interoceptive practices.

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  

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New Edition of Mindful Happiness in Production…Coming soon!

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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!