Clinical Reflections

+ I was more concise. It was difficult. But I stayed calm. I became more aware of my own process. I was able to help the CL open up a little more, explore her thoughts, and articulate them better. (How did you do that?)

Things Learned:

1. Reframing or transforming the stated goal: Keep something (thoughts, feelings, etc.) from happening --> How to deal with it when it does come up?

2. When the CL is more practically oriented, spend less time on meaning making and more on problem solving.

3. Be aware of categorical thinking. Keep in mind of the "both...and..." and thinking in a continuum. It is not about "either A or B." You do not have to minimize/deny a negative event in order to be secure. Minimizing it actually adds more anxiety. Accept it, see it as it is, and move on.

SP08 CAPS Notes (1)

1/8/2008 Staffing

* Identity confusion: Who would you like to be? What do you want to do? (Explore options)

* Glimpse of health - Knowing what is NOT good.

1/18/2008 IND SUP

* Am I developing?

* Diagnostic assessment

* Scheme inventory

* Make the CL look smart and in power.

* Moment-by-moment process of "How is the CL taking it?" and learn to pull back when needed.

* Increase awareness to look for CL reaction cues & your own clinical judgment process. Consciously process and evaluation instead of on autopilot.

* When unclear, ask the CL to help out. Be appreciative when the CL shares anything remotely critical. Reinforce the CL to speak on his/her own behalf. Approval for dissent. Go after the information. "I am not sure I am on target."

1/15/08

* Be honest and realistic. But don't focus on the uncertain aspects. Be positive.
* Therapy is mostly tedious with few breakthroughs in between. You need to lay groundwork, explore to find ways, and discover possibilities.

Previously:

* Not fully committed to risk loving: how to lower risk? Increase a sense of control and safety.
* (Sexual abuse) Just because parents say it is not does not make it not.
* Explore options along with expected outcomes. Know the purpose of actions before acting.
* To "I don't know" responses. Pick something out. "I will wait when you think." 13-second rule
* Eastern Europe - less value on psychologically-mindedness. Depression - somatic, sth. in the air
* Think of empowerment.
* Consumer model of relationship. Find "the right one" for me.
* Substance Abuse Assessment: CAGE Cut down, Annoy, Guilty , Eye Opener
* Learn to be emotionally neutral and focus on the specifics. If we want the CL to rely more on internal validation, we need to void being colluded into the old pattern of giving external reinforcers.
* Always keep treatment goal and CL's needs in mind.
* Don't over-accommodate. Let the natural consequences get played out. Keep appropriate boundaries.
* Assume strengths and look for them. Build on them.
* Termination: clarify accomplishments. Re-evaluate goal, issue, pattern, and primary concerns the CL came in for. "It seems fine for now. Does it seem that way to you? There is something else you came in for. Would you like to try this out on your own to see how it works?"
* Guilt happens when we violate our own value code. It is useful for us to address the issue. Conditioned reaction. Recondition.


* Pay attention to attire. Observe the people group with the status you would like to have. Learn from them. Dress for the next level. Co-workers are not your friends. Prove yourself and build up your credibility. Choose wisely how to present yourself.
* Self-presentation. Always sell yourself.
* Learn from the feedback. Learn emotional protection of self. Know when is mine and when is others.

ODB - 1/14/2008

Revelation 2:1-7

Dear LORD, help me love with my first love. Keep me in reflection of how I first discovered your love, how refreshing it was, and how excited/satisfied/comforted & grateful I was. Dear LORD, keep me from never letting it grow old and cold. Keep my heart ablaze for you and you alone. Dear LORD, lead me and guide me and sustain me in this new semester and teach me your will and your wisdom. Love, Yours.

Therapy's Best (By Howard Rosenthal) - Part V Summary

* Accomplished therapists are modest.

* Accomplished therapists seemingly enjoy enhanced longevity.

* Accomplished therapists enjoyed, repected, and valued their education although they often went in totally new directions after graduation.

* When accomplished therapists created their novel ideas or systems of therapy, they were initially ostracized by their peers.

* Accomplished therapists truly believe in their strategies even when they are diametrically opposed to other experts.

* Accomplished therapists often became famous or achieved uncommon notoriety after the publication of a highly successful book.
Robert Alberti - Your Perfect Right/Write; Albert Ellis - Reason and Emotion in Psychotherapy; Guide to Rational Living; Ray & Dorothy Becvar - Marriage Counseling; Richard Bolles - What Color Is Your Parachute?; Ray Corsini - Current Psychotherapies; Sam T. Gladding - Counseling: The Comprehensive Profession; William Glasser - Reality Therapy; Muriel James - Born to Win; Jeffrey Kottler & Jon Carlson - Mummy at the Dining Room Table; Edwin Shneidman - Deaths of Man

* Accomplished therapists often don't take their theories as literal as academicians.

* Accomplished therapists position themselves in the therapeutic marketplace.

* Since accomplished therapists are often highly critical of rival modes of treatment they are only selectively eclectic or integrative in their approach.

* Accomplished therapists often didn't set out to be an expert in their particular area of expertise.

Therapy's Best (By Howard Rosenthal) - Part IV

* Jeffrey Kottler - On Being a Therapist; Compassionate Therapy: Working with Difficult Clients; Travel That Can Change Your Life; Doing Good; and Making Changes Last. The Last Victim. What makes a very fine therapist - besides being moral, ethical, kind, caring, and other such qualities - is that we've each discovered our own unique way of helping that fits our personality, interpersonal style, clinical situation, and client population.

* Al Mahrer on Experiential Therapy - actualization forces, Adlerian social interest, Jungian polarities, deep-seated frustrations leading to aggressions, Allportian traits, behavior patterns shaped by positive and negative reinforcements, the unfortunate residue of pathological parents, the defining effects of my birth order, the soci0cultural imprinting of my background, and my unconscious wish. I learned the contents of my psyche.
Experiencing; The Complete Guide to Experiential Psychotherapy; Becoming the Person You can Become: The Complete Guide to Self-Transformation
1) Discover the deeper potential for experiencing; 2) Welcome, accept, cherish the deeper potential for experiencing; 3) Undergo a qualitative shift into being the deeper potential for experiencing in the context of recent, earlier, and remote life scenes; 4) Be the qualitatively whole new person in scenes from the forthcoming new post-session world.
Open the session by being able to unlock the usual controls, set aside the usual state of vigilant self-awareness and self-consciousness, free oneself of rigidly clining to the person one rigidly clings to being, entering a state of openness and readiness for deep-seated wholesale change.
1) Let go of, disengage from the continuing person you are and have probably always been, and to 2) throw yourself into fully and completely being the whole person who is the living, breathing deeper potential for experiencing that you had discovered.

* Nancy McWilliams on Psychoanalysis: We each have to do this work in a way that is authentic, that is true to our idiosyncratic self. Psychotherapy attracts rather androgynous people.
www.nancymcwilliams.com

* Lia Nower on Gambling Addiction: personality profile - impulsive, intensity seeking, addicted to other substances, and typically depressed or anxious, risk-taking behavior in childhood with abuse, neglect, and addicting caregivers.
1). initially for socialization, the addictive nature of variable ratio reinforcement; 2) family instability, low self-esteem or significant life losses, depression or anxiety, and/or comorbid addictions; 3) serious personality pathology, mood disorders, terrible childhoods, histories of antisocial behavior, and comorbid addictions, ADHD, risk-taking, impulsivity (biological components)
Be realistic. Gambling ~ fun, excitement, meaning, hope. You can't take that away from a person without replacing it.

* Edwin S. Shneidman on Suicidal Patients - Ten Psychological Commonalities of Suicide
A working, positive transference relationship is what, in my opinion, keeps chronically dysphoric pessimistic patients alive. What is needed is a safe sanctuary for exploration, for nonjudgmental disputation, for modeling with someone who affirms life's values.
The patient's proclivity for constriction of mental thought, all or nothing thinking; the therapist should have his third ear attuned to the word only, perhaps the most dangerous word in the suicidal patient's vocabulary. What is called for is to break up the binary way of thinking and to widen the patient's conceptual blinders.
Make a list of options. "And you can always commit suicide, but there is no reason to do that today." "Now, let's look at our list, and would you please rank order them from the absolutely least acceptable on up to the least distasteful."
The least-undesirable-choice-under-these-circumstances
Postvention
Pay close attention to the language.
The therapist's task is often not to take the question at face value but to change the question so it can be answered in a more life-affirming way.

* Henry A. Murray

Therapy's Best (By Howard Rosenthal) - Part III

* Jon Carlson - The truth is that CLs are a lot like us when we go to a doctor. We want to get in and get out and get our help and get on with our life.
- Advice: Be patient with yourself. Becoming a good therapist takes time. Practice. Get supervision. Read books. Learn different ways to work with people, as you will encounter many different types of people.
- Loss is so very different for different people. It is important to understand how one formulates the loss and whether or not he or she is really having a difficult time.

* Raymond J. Corsini - Six Therapists and One Client;

* Albert Ellis on REBT - Unconditional self-acceptance (USA). Unconditional other-acceptance (UOA), Unconditional life-acceptance (ULA)

* Robert & Lisa Firestone on Voice Therapy - Separation theory; express self-attacks in the second person in a dialogue format and react emotionally. (1) verbalizing the self-critical inner voices and releasing the accompanying feelings; (2) developing insights regarding their sources; (3) formulating corrective suggestions for important changes in life.
deep-feeling release therapy - primal therapy

* Samuel T. Gladding on Creativity

* William Glasser on Choice Theory, the new Reality Therapy - controlling ourselves; Counseling with Choice Theory: The New Reality Therapy, I get rid of criticizing, blaming, complaining, nagging, threatening, punishing, and briding. Fibromyalgia: Hope from a Completely New Direction

* Les Greenberg on Emotion Focused Therapy - www.emotionfocusedtherapy.org; core emotions need to be brought into awareness to change them. Both the therapeutic relationship and the specific change processes are seen as important in promoting change. warm, supportive, empathic, validating; access and transform affects; dyadic regulation of affect; access adaptive emotions to promote change, resilience, and strength; Empathic attunement to affect and differential intervention to promote emotional processing. Intervening at the level of the moment-by-moment processes or by asking someone to pay attention to what's going on inside his or her body which is making a specific moment-by-moment intervention. Or suggesting a larger task such as asking someone to imagine a significant other in an empty chair and engage in the a dialogue with the imagined other in order to facilitate a particular kind of processing found to be most helpful for that type of problem state. Emotion is needed to change emotion. Know which emotions to change and which to be changed by. Increase emotional awareness and help people with their affect regulation with reflecting on emotions to make sense of them and on transforming emotion with emotion. Change in meaning; create meaning by dialectically synthesizing influences from biology and culture;
1) bonding and awareness (empathic attunement & CL's emotional awareness); 2) evoking and exploring (evocation is not used until regulation is achieved); 3) constructing alternatives (making sense & generating new adaptive emotions); 4) Consolidating new meaning.
Acceptance of emotion -- Learning to tolerate and regulate unpleasant emotions - evaluate our own emotions

* Muriel James on Transactional Analysis & Gestalt --> redecision therapy - Good therapy is educational and good education is therapeutic. In transactional analysis theory, typical responses from the Child ego state to criticism, advice, or encouragement, are compliance, rebellion, or withdrawal.
Spiritual dimension of life; self-reparenting/self-remodeling your inner parent; Breaking Free & It's Never Too Late to Be Happy
"I wonder if by any chance it could be true, or partly true, what I and/or my client is saying?"
"What do you want that will enhance your life?"
"What do YOU need to do to get what you want?"
"What are you WILLING to do?"
For positive change, contracts to think of options, and organize a plan of action using the Adult ego state, are often useful.

Therapy's Best (By Howard Rosenthal) - Part II Job Hunting Special

* Richard Nelson Bolles on Job-Hunting: Resume --> Interview --> Job; "A resume is something you should never send ahead, but always leave behind (after the interview)." Customize it by the information through the interview.

* Interview tips: 1) Try to let the interviewer speak half the time; while you speak the other half. 2) When you are asked a question by the interviewer, your answer to each question should last between twenty seconds to two minutes. No more. If you need more time for that question, say, "I could amplify this if you wish." 3) Put yourself in the chair; and mind-set, of the interviewer.

* A resource to help the employer instead of a job beggar. Think primarily of what he or she can do for the employer, not primarily about what the employer can do for him or her. Send a thank-you note after the interview.

* www.jobhuntersbible.com

* Transferable skills - advising, budgeting, developing, illustrating, auditing, coordinating, diagnosing, fixing, lecturing, driving, negotiating, painting, planning, recruiting, selling, singing, typing, troubleshooting, writing, etc.

* Career & Vocational Counselors: It is not your "techniques" that are most helpful to your CLs. It is your empathy and your compassion. For example, it is your ties to the internal world of spirit, not your knowledge of salaries in the workplace, which makes you the most helpful.

Therapy's Best (By Howard Rosenthal) - Part I

* Robert Alberti on Assertiveness: teach a self-expressive style that is respectful of others; Pay attention to the "real world" of your clients/patients. Find out what really goes on in the lives of your patients/clients, and help them to discover or develop the tools they need to become the persons they want to be.

* Dorothy & Ray Becvar on Marriage Counseling: Our marriage works because we have never let the honeymoon end, meaning that we have remained aware of the importance of nurturing our relationship. What we share is mutual acceptance, respect, support, and unconditional love. - practice: interdependence, process rather than content, mutual influence/therapists perturb, behaviors as logical in context, subjectivity as inevitable, the uniqueness of each client system, the focus is on the ways in which problems are being maintained and a related search for solutions. There is awareness of the storied nature of reality and the participation of each person in its creation; both/and complementaries are valued.
Referring to clients as "resistant" or "not wanting to change" or "in denial" is evidence of the violation of the systemic paradigm. It is very difficult in therapy to get "resistance" unless one is pushing or pulling. It is a recursive dance - it cannot be otherwise from a systemic perspective.
Paradoxical injunction & Therapeutic double bind
Shared awareness - whatever we create, we do it together. So, if Ray is a "tad out of line," I always must consider my part in the process and recognize that if I want him to change, I also must be willing to change.

* Milton H. Erickson was fond of saying that peopel come in with problems they cannot solve and that what we would do was give them problems they could solve. Strength focused, abilities within self and social system to resolve problems; evoke & utilize them in the service of change

* Bob Bertolino on Solution-Oriented Brief Therapy: focus on competencies, abilities, and strengths, search for differences, exceptions, and solutions to problems, emphasize the present and the future, and view therapists and clients as being coexperts and collaborators in all aspects of the therapeutic milieu. SOBT draws attention to what people are capable of as opposed to what they are incapable of.
A future focus as helpful (Duncan, Miller, & Sparks, 2004; Miller, Duncan, & Hubble, 1997; Wampold, 2001); By working with cleints to create or rehabilitate a sense of the future we can learn what they want different in their lives. The miracle question is but one way of helping to gain a future focus. (Alfred Adler - the Question; Milton Erickson's pseudo-orientation in time - the Crystal Ball) "Let's say that as a result of us meeting together, the problem that brought you here was resolved. How would you know?" or "How will you know when the problem is no longer a problem? What specifically will be better?" or "How will you know when you no longer need to come to therapy? What will be different?"
Help clients to determine what they want different in their lives and then figure out how to make the visions come to fruition.
Exception questions are designed to orient clients to times when their concerns or problems are less dominating or absent altogether from their lives. "Tell me about a time when the problem would typically occur, but it didn't." or "How far back would you have to go to find a time when the problem didn't affect you the way it has recently? What was different?" "It seems like you've really been struggling with your concern. And as I sit here, I wonder how you've managed to make it to work on time everyday this week. How have you done it?"
CLs convince clinicians of their strengths, abilities, resources, and coping skills through actions they have already taken.
Language & Interactions; the impact of context; help CLs to "restory" or "reauthor" new narratives of hope and change
The human element in therapy. It is important to have a good understanding of the CL's story, what his or her concerns are, what their ideas are as to how change has occurred in the past and how it might occur in the future, and what strengths, abilities, and resources the CL brings into the therapeutic milieu that we can help him/her to utilize in the service of change. What CL wants; what CLs see as influences on their problems and then working with them in ways that match those perspectives;
* The miracle questions; * scaling questions; * the first session task
We ask CLs to teach us about their lives, their traditions, their rituals, and so on. We then work with CLs in ways that are respectful of how they live and breathe in the world.
We take the time to learn from clients what their concerns are and then continue this collaborative process by creating and offering ways of addressing their concerns that fit with their views.
Strengthening the therapeutic relationship and alliance
Give permission for internal experience but not permission for actions that may be harmful to self or others - "It's okay to be so angry at your mom that you'd like to yell at her and it's not okay to yell at her."
Positive change is always possible. Be hopeful and realistic. H.O.P.E. Humanism, Optimism, Possibilities, Expectancy
Be a good speaker - First, always be respectful of the audience. Acknowledge other's point of view. Don't embarrass them if they ask a question that seems out of context, inappropriate, or something you've already answered. Always treat people with respect and be genuine. Next, you can't be an expert on everything. ... Use multiple ways of engaging people. Visual, Auditory, or Kinesthetic. Learn from evaluations.

* Bill O'Hanlon on Possibility Therapy - It helps therapists to work with cleints to acknowledge and validate their internal experience, understand their concerns and problems, identify strengths and solutions, and remain present to future-focused without downplaying the past.