Creativity and Madness30 July 2013

WHAT MAKES PSYCHOTHERAPY WORK?PROFESSIONAL COMPETENCIES AND RESPONSIBILITIES

IntroductionFollowing a 2005 survey of New Mexico psychiatrists on the impact of

managed care on clinical practice I began a series of lectures and seminars at this meeting around the theme of psychotherapists reclaiming their professional ground in diagnosis, treatment and rehabilitation. The working alliance and improved psychNouch the theropuitri gotherapeutic outcomes, professional psychotherapist responsibilities, emotional factors in medical illness, secrets of psychotherapy in six easy lessons and four hard ones, how much is enough treatment and termination issues, the merger of professional ethics and best clinical practices have been presented, and today, professional competencies needed to be an effective clinician. I am pleased to be connected with Creativity and Madness, associated with Dr. Panter over the years, and thankful to have met many of you in clinical discussions.

I am troubled by the erosion of professional practice, concerned with the lack of well-developed clinical training programs, and frequently dismayed by the lowered standards of patient care. Our field requires much work. So I am here again, perhaps next year too, raising a fuss about professional responsibilities to self, patient, profession and society.

Sometimes I feel like a blind man being led by a seeing-eye dog, like an incident I saw coming out of the Metropolitan Opera at Lincoln Center in New York last month. The general message is be careful about making assumptions and not rushing to judgment.

Two beginning points:I have strong opinions about this topic but will never accept that there

is a single best way to do psychotherapy. So if I speak in a manner suggesting an absolute, give me a break and discuss your approach openly, even when I am right!

Secondly, please select two clinical cases from your practice setting, one

patient who has worked well, and a challenging patient with a less than ideal outcome.

Review Of Factors Considered Effective In Promoting Improved Outcomes

More than one hundred years of clinical experience and a variety of research approaches have identified multiple factors contributing to improved outcomes in clinical applications of psychotherapy. The term therapeutic alliance introduced by Edith Jacobson (1964) and Ralph Greenson’s (1967) working alliance are familiar terms and clinical research 1 | P a g e

has linked a strong alliance with improved treatment outcomes. Let me describe factors strengthening the interaction between patient and clinician without using the more complex alliance term.

Here are some identifiable factors that may be contributed by the patient, the psychotherapist, or their clinical interaction, elements that may overlap, yet seem to make psychotherapy work and can contribute to improving effective outcomes.

Referral (by self or other) prompts change, action suggests something may help

Patient wants relief and to be understood The patient begins interacting with an unfamiliar/unknown person Uninterrupted patient focus at defined point and for defined time The psychotherapist listens without judging the person Psychotherapist aware of receiving, recognizing, resonating, then

responding Interested psychotherapist asks questions without presumed answers No apparent agenda to program patient to respond in set manner Optimal responsiveness and distance balanced Active awareness of listening healer being with the patient Feelings are expressed (released) freely without creating an immediate

reaction Patient is invited to question in different manner Organization of life history in new and different fashion Professional inquiry established within holding environment Recall of events in memory stimulated and reviewed in present The release of dammed-up emotions assists desensitization and lowers

conflict Repetitions and patterns of behavior identified Patient attempts to make unknown person familiar with transference Defining and tracking a theme, a therapeutic focus Psychotherapist touches the therapeutic focus at least once every

session Patient’s internal processing determines the rate of change Psychotherapist seeks the optimal timing for questioning/intervening Hypothesizing and reconstructing Understanding new opportunities possible to change situation (hope) Discovery in self-observation and acquiring insights Shared work of interpretation Mourning lost objects and opportunities Increasing ability to endure the pain of psychological separateness Search for meaning continues as patient returns to developmental

pathway Promoting self-responsibility, self-esteem and personal autonomy Attain new levels of understanding with more desensitization of past

trauma Restructuring approaches to “old” representations and repetitions

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Experimentation with and practicing innovative strategies Acknowledging resumption of the healthy individuation process Reinforcement of shared venture with continuing self-inquiry

Please consider my two entry points again. The above factors come from

my reading, study in research design, and clinical experience, now applied to invite an inquiry about your clinical cases. Do not discharge me as a biased reporter who cannot understand your perspective when my wish is to stimulate your understanding, to invite your inquiry, to have you write a paper on this topic.

There are so many variables in defining the goals and methods of treatment, the setting in which assessment occurs, the personal attributes and theoretical context of the therapist, and a paucity of reporting on the technical structure and strategies of psychotherapy. There is lots of room for our discussion if we can tolerate differences and extend an attitude of inquiry to colleagues.

Defining Psychotherapy As A Patient-Focused Inquiry When a distressed individual makes a connection with a

psychotherapist there is the expectation of feeling better and functioning better. The immediate focus on relief and return to expected life leads the patient to expect big things, a near magical intervention, to restore the person and get on with life. The psychotherapist is prepared to listen and assist, to be respectful and reach out in a compassionate manner. Unfortunately we fall short on magic and know that patient difficulties are determined by multiple forces converging on a single entry problem, yet convey hope when starting to explore together. By listening, attempting to see life through the eyes of the distressed person, asking questions when we do not understand, and being with the patient, the psychotherapist is supporting each successive step back toward the patient’s pathway.

Defining psychotherapy as a patient-focused inquiry becomes my entry to defining professional competencies required for clinical work. We start to develop an understanding of tasks of growth and development, a theory of personality and the delicate balances of adaptive capacity. Though heavily influenced by my background in psychoanalytic psychotherapy, I am interested in understanding the shared roots of main stream technique and treatment. I have heard great controversy and observed much wasted time and energy as self-focused advocates of this single approach and that specific method argue about what is truth.

And What Is Truth?After decades of theoretical controversy separating clinicians,

spawning hundreds of allegedly different treatment methods, the time for consolidation and integration has been approaching. Though competing theories continued, the arrival of evidence-based medicine demonstrated 3 | P a g e

how deeply the shared concerns of the mental health professions were eroded by internal controversy and fragmentation. Now we are scrambling for and acquiring research data documenting effectiveness of psychotherapy.

Changes in health policy and education lie ahead and suggest another round of squeezing out undocumented approaches. In The Psychoanalytic Vision, the distinguished chess player and clinical psychologist Reuben Fine (1981) describes “half-trained professions” who use “diplomas instead of analysis.” According to Fine, the founders and followers of new options, avoided the long and difficult, but spiritually rewarding path of psychoanalytic training. Fine notes each new method rarely offers a theory of personality and begins with an attack on psychoanalysis as “ineffective.” Fine emphasizes the alternatives use whatever works, usually techniques without vision. The names of the options carry propagandistic messages against analysis and jump to making the unconscious conscious. Then vague claims are made about results, often supported by a variety of “confirmatory” studies. Fine suggests the alternative therapies represent a cultural reaction to conditions, in which our society as “a culture widely inimical (hostile) to psychotherapy because it does not wish to look at itself,” thereby breeds a setting causing “inferior psychotherapies (to) flourish.” He notes, “bad therapy tends to drive out good because it is more seductive, and offers more immediate and tangible gratifications.”

In 2000 the Psychiatry Residency Review Committee of the Accreditation Council On Continuing Medical Education issued new guidelines to go into effect 1 January 2001 that consolidated the broad field of psychotherapeutic approaches into five avenues requiring psychiatric residents in training to demonstrate competency in five specified psychotherapeutic approaches of brief, cognitive behavioral, psychodynamic, supportive, and combined psychotherapy and psychopharmacology.

And since then how have you/we been doing?Reseach findings have been moving ahead collecting evidence. If you accept the merit of finding treatment principles integrating our

approaches, I bring some ingredients from my understanding of psychoanalytic psychotherapy techniques that may be applicable to this discussion that stops at your clinical doorway.

What can you accept from the items below that could connect to your vision? Do we have any shared agreement about treatment strategies? What do you want to talk about?Do you want to start an online discussion group?

Organizing Principles: Enabling The Patient To Enter Into Treatment Personality style describes a characteristic pattern of responses in

day-to-day coping. Style can be a wonderful ally, but when it gets turned on and can’t be turned off until it resolves a problem, we run the risk of getting bogged down in our own defensive operations. The self-evident truth restated: We become more like ourselves when stressed. Style is the basic 4 | P a g e

coping technique and one of the first elements for the patient to understand. Set aside competing theories and look for agreement on the simple premise that we all have a history. At any given point in development, we are the sum of significant past experiences, the reflection of current reality circumstances, and the repository of future goals and ideals, thus forming a continuum of past, present and future. The unconscious does not recognize neat time lines imposed by conscious awareness.

Since personal style is generally ego-syntonic and operates automatically, most of us function on “automatic pilot” slowing down, speeding up and changing altitude in our particular flight pattern from homebase. Only when something quite eventful occurs, like an engine sputtering or a bump from an external environmental change, do we bother to focus on how we have been purring along through life. Being able to look at one’s behavioral patterns can be important under healthy or stressful circumstances.

In an educative fashion and in developing a common language with the patient, I usually begin discussion of treatment recommendations at the end of the diagnostic evaluation with a personalized description of the Reaction: Personality: Situation model. A summary of problems and strengths linked with the triadic formula links the patient’s history with a discussion of self-esteem. This triadic model can be an important organizer for the shared language one strives to develop early in the clinical interaction.

Self-esteem is the bottom line in improved treatment outcomes. When performing at a high level and reaching our ideals, we have a sense of strong self-esteem. Not attaining our goals, or not being able to accurately assess our own situation such as occurs in a depression, leads to a lowering of self-esteem. Thus clarity about realistic goals and what may be attained become important elements of the treatment plan. Not trying for impossible goals, and accurately assessing our current life situation puts a lot in order for the individual. So I may discuss the avoidance of distress and a variety of techniques to move from reality and distress.

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Therapists should work to restore optimal functioning as quickly as possible. This may mean allowing the patient to borrow organizational skills from the therapist at the beginning of treatment. Let me underline the importance of general health measures giving the person something to do immediately to demonstrate self-control. Stress reduction techniques can be of great help. Appropriate medication in an acute situation can be invaluable. Direct intervention with family members and the social network may be indicated.

When able to look at the problems directly, identifying the distress and looking at life in a different way, there are many things a patient can do on their own to restore a sense of control, to neutralize toxic behaviors.

Clinicians vary in their strengths and limitations, in addition to being predisposed to self-selecting certain types of disorder. On a personal level, I did not do well with addicted patients who could fool me anytime while deceiving themselves. The addictive behaviors are a “hustle behavior,” detouring patient and therapist from considering underlying distress within the person’s experiences. I cannot treat an obsessive-compulsive patient until the behavioral detours in thought and/or action are challenged by the patient, with cessation of the symptomatology the necessary step to deal with the anxiety and dread below the surface.

In a four hour diagnostic evaluation with a man suffering from paranoia I was in touch with him for a total of two to three minutes. While discussing the details of the tragic death of his son, I asked him to make a diagram of the accident scene and then took him to some observations he made. He started to cry, then he closed the chapter of that story and resumed his cognitive distortions.

Thus, confrontation, the shared agreement about what the problems are in the patient’s life space, becomes the entry to restoration, restructuring and redefinition of the self. This falls under the category of organizing and educating the patient as the encounter moves toward the therapeutic alliance.

Crisis loosens up rigid structure, allowing for change. If a patient can see oneself in transition, there are positive ways to use anger, anxiety, and depression. For example, depressive distress is like a barometer registering

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the internal climatic conditions of the person. When distress is present it serves as a monitor saying more change is necessary, it pushes toward a new balance at a higher developmental level.

You have probably heard the Mandarin Chinese symbol for crisis is a combination of two characters, danger and opportunity. In psychoanalytic developmental terms, the loosening of structure can cause regression to a prior level of development, when unfavorable circumstances are maintained a regression to a level using more primitive mechanisms of defense to maintain an earlier state of equilibrium. That’s a danger! The opportunity lies in the creative problem solving, understanding the use of psychotherapy in which the stimulus for further growth enhances development, the resulting mastery cementing the advances into a more fluid structure at a higher level of functioning. Thus, a positive benefit can be attributed to the individual coping with “new issues.” The ubiquitous anxiety can promote growth when we have adequate internal strength to listen to the cue and appropriate external support to handle the situation.

My father was a country doctor in Canada and kept a textbook in his office published around 1920 entitled Optimistic Medicine. I view the loosening process as an opportunity, a little self-prescribed optimistic medicine the patient can grow on. In developmental terms we encounter recurrent decision points in infancy, childhood, adolescence, adult life and later years. Our commitments and values are tested recurrently and the crises of adolescence and adult life are opportunities to work through old issues in a new manner and develop a higher level of adaptation. The therapeutic relationship is a dynamic interaction with a change in one person resonating in the other person. The therapeutic relationship is developmental with the patient altering their use of the alliance with the therapist, the goal being autonomy, self-reliance, The therapeutic relationship is a dynamic interaction with a change in one person resonating in the other person. The therapeutic relationship is developmental with the patient altering their use of the alliance with the therapist. The goal of the therapeutic alliance is self-reliance and is illustrated in Figure 1 below.

The patient (P) and therapist (T) have an unequal relationship at the outset with the therapist holding the expert position in directing the comprehensive diagnosis. Then the patient and therapist have an equal balance in the shared agreement on what problems will be addressed in treatment. Thereafter the patient works toward the highest level of function and directs the therapy. The therapist assists the patient in clarifying the sources of problems, hypothesizing a different view of the world and remaining available while the patient works through to their desired endpoint. The

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therapeutic goal is personal autonomy with the therapeutic experience integrated in the patient.

Psychotherapy builds on the strengths of the patient. The assets of the individual can be polished, lubricated, and put into operation. The use of assets restores a sense of control and helps the patient to be reassured about parts of themselves that are intact. We know traumatic experience, especially early in infancy and child development, can have devastating effects on subsequent organization and functioning. In our clinical encounters we learn of incredible injuries and see the effects on self-concept and style. Yet, we can marvel at how well someone has handled other areas of life. So the skilled clinician builds on the strengths.

The comprehensive diagnostic evaluation can reveal major injury, yet also outline significant strengths. We can identify solid areas of functioning and the completion of important developmental tasks side by side with maladaptive behaviors that seem to thwart attainment of one’s life goals. Pointing out the accomplishments and crediting the patient with their gains has great merit. The message for treatment is the focus on what remains to be done, to assist the patient to find the rest of their way. At successive steps in treatment, we ask ourselves (and may even rephrase the question aloud with the patient), “Where is this person now?” When the patient reports a real gain, the therapist can say with sincerity, “That must please you.” Personal achievement is cemented into growing adaptive capacity.

Life presses forward. When a distressed patient reaches a point of feeling overwhelmed, a highly self-focused and defensive stance may threaten the tenuous connection with outside events. The ability to react to things outside oneself, if jeopardized, suggests despair may give way to withdrawal, a partial disconnection with the world. If this continues unabated, the patient may progress to a full detachment. Self-absorbed, preoccupied and cut off from outside events, the individual compensates for the loss of stimulation with increasing self-referencing as a means of explaining events. Self-blame, personalization and negative thought process can account for life events, thus making everything more readily understood. “I am at fault this has been my failure I’ve created this situation.” That internal world of the depressed patient is part of a cycling down into major disorder. The therapist must move to optimize the patient’s anticipation of events, to plug the patient into external realities. The patient must be confronted with the reality in which self-focus cannot explain all outside events, that we are always dealing with people and situations beyond reasonable control. In an active fashion, we invite the patient to anticipate events. We invite the patient to stay connected to the rest of the world.

The identification of problems, confrontation with oneself and a shared agreement about what therapeutic tasks lie ahead, can help to reduce the overwhelmed feeling (turning a large chunk of distress into bite-sized nuggets chewed one at a time). Clarification of what happens when, using the conscious time lines of past, present and future, can further reduce the chaotic turmoil of disorder. These steps of confrontation and clarification 8 | P a g e

lead to a fitting together in the interpretation or construction phase of treatment. We invite the patient to also anticipate feeling relief, being able to add to their own ability to handle distress and reach out for the necessary psychological oxygen in friendships and nurturance fostering human growth.

Destination. Asking an individual about goals counters disorganization. Discussion about goals allows greater efficiency in planning, clarifying there is a gap between “where I am now and where I want to end up.” Stating the desired end point(s) for treatment introduces reality to the therapeutic experience. Are the goals reasonable and appropriate to the amount of time one has for therapy? Goals within one’s grasp add efficiency to therapy by keeping the patient and therapist on target. Stated objectives for treatment allow the patient to self-evaluate their progress. Realistic goal setting obliges an acceptance of what can be attained by the patient, often becoming more moderate, more flexible, less demanding and more tolerant of what can and cannot, should and should not be expected. Bits of energy may coalesce and motivate the patient toward clear strategies about how the patient can self-appropriate the necessary work.

Developmental trauma is a term used to keep a focus on infancy and childhood events where the resulting “understructured” or “structured” operations emerging from those early years form the basis of coping in subsequent years. Freud’s terse phrase, “the past as a present force” defines the integral part of the unconscious mind, the basic building block for studying inner structure, the base for apperceptions that shape present interactions of the individual. Although the clinician collects the most objective history of development possible, we know the response to trauma, rather than the actual event is the focus of our therapeutic work. Arlow (1985) focuses attention on the disorganizing, disruptive combination of impulses and fears integrated into a set of unconscious fantasies -- the “fantasied reality” impacting subsequent stages of life.

The belief in an unconscious mind suggests everyone has a history. History repeats. We invite the patient to identify repetition as a daily replica of the past. Although you may not align with psychoanalytic approaches, “transference” reactions do occur. Interactions in the current reality situation, if one accepts the impact of the unconscious mind, reflect significant past experiences. The individual will respond on the basis of the relative success of internal structure building, with our varying patterns reflecting the ability to view external events as apart from us and discrete, or merged with parts of a more primitive self.

Inappropriate, intense and tenacious responses from the past can be played out automatically in the present. When these events occur in the therapeutic encounter, the transfer of past to present, representation of the past in the immediate allows access to the unconscious patterning carried forward from earlier circumstances. Understanding how maladaptive techniques developed to cope with early events, now reflected in the present, remains a key to successful outcome. A simple example: Attitudes the patient has had toward mother during early childhood will replay as the then 9 | P a g e

stressed patient parentifies the caregiver. If mother was warm and nourishing in contrast to a harsh and critical parent, the patient will reflect that past experience on the present caregiver.

Resistance to change happens! The therapeutic action of psychoanalytic psychotherapy may derive from new ways of thinking and behaving involving the development of new cognitive constructions and behavioral alternatives. The release of old “anxiety” previously glued into maladaptive techniques, involves an ongoing struggle between wished for mastery and apprehension about change. Castelnuovo-Tedesco (1989) describing the patient’s fear of change suggests therapists should appreciate the risks encountered by any patient allowing an intervention, which will influence the self, and the fantasies that accompany the change process. Bugental and Bugental (1984) emphasize the state of well being, the maintenance of a sense of continuity in one’s way of living in the world an existential issue placing the individual at risk when change is invited. The Bugentals invite the therapist to continually demonstrate a conviction that the patient can protect against the threatened loss, while relinquishing that which is crippling to the patient’s life. To protect ourselves against loss, pain or further injury, a variety of forces (almost equal and the opposite to the force for change) automatically deploy when the threat of change arises. The patient may not hear what is said by the clinician or be aware of an unwillingness to allow any random expression of thoughts and feelings during the therapy. Why would someone appear for treatment and not explore everything inside? Too dangerous? Understanding the nature of one’s resistance and what purposes those forces serve can ease the patient toward optimal return of function.

We all need to have a sense of meaning, making a difference to someone or some thing. Helping the patient master situations brings a sense of purpose and strengthens a sense of identity. In the patient-focused inquiry, the integrity of the individual in treatment is valued highly by the effective therapist. We assist patients in finding their own way because it is their journey, their essence to be developed.

The therapist fosters the patient’s autonomy, with self-regulation the fabric of self-governance. Self-responsibility the term says it all. Gertrude and Rubin Blanck (1994) have used the concept of “extracting from the environment” what one needs for survival, development and balance. The patient in treatment, borrowing from the structure and organization in the therapeutic alliance initially, is always working toward the goal of autonomy and self-analysis. The patient must assume self-responsibility or there is a perpetual risk of enforced dependency on external people and situations, which can interfere with personal development. In reality we all stand alone. There is little gain in complaining that one did not get enough mothering growing up when all of us have the responsibility for being a good mother to ourselves. That is reality, and acceptance of reality facilitates healthy development, whether in or out of therapy.

So how can we apply these principles to the clinical situation?10 | P a g e

Let me suggest that clarity about your list of operating principles will assist you and the patient defining shared goals for treatment? There must be discussion about therapeutic goals. The therapist carries the responsibility to involve the patient in a broad definition of what they wish to attain. We do not undertake brief, short-term or long-term therapy without discussion and “informed consent” on what is involved. Too often the patient will come in with a narrow focus, pervasive negative thoughts, feelings and behaviors synchronous with the psychopathology, but out of line with the broader aspects of the patient’s capabilities. In asking patients about their goals, the therapist must consider what they wish to attain in regard to marriage, family, social and work life, their fitness, social interactions, wished-for intimacy, spiritual concerns and economic needs. Toward the end of the diagnostic evaluation the therapist should assist the patient to match the available therapeutic resources with their own goals. In a creative way, the skilled therapist helps patients to close the gap between where they are now and where they want to be at their destination.

Forces In Clinical Setting Influencing Diagnostic And Treatment Strategies.

Though policies of healthcare organizations, government regulations and other external forcing factors shape the public setting, the confidential setting behind closed doors of the therapeutic alliance is constructed around professional therapist responsibilities. In the past 30 years, the professional protest against third party intrusion into the private setting came about when we had no clinical evidence to support the benefits of clinical treatment. The professional ground was lost to skeptics, business for profit, and economists anticipating the rising costs of care. Discrimination and professional apathy, coupled with no data to support our claims of value, led to a low point in fragmenting the body, brain, soul and spirit of the person.

More than three decades of distinguished educators and clinicians were lost; academic research followed the money in drug management; the overwhelming numbers of distressed persons using public programs lost humane treatment options; educational niches decreased, poorly trained graduates of clinical programs drifted into alternative programs with narrowed focus and vulnerability to the lowered educational and practice standards. Computerization and required reporting of clinical encounters clicked out for the business office and review organizations stripped the session of in-depth working through with the disappearance of thoughtful handwritten notes that can bring cohesion to therapeutic work.

Clinical research may be catching up to clinical experience now. Growing evidence supporting what we know occurs each day inside the office is alive and well. Societal values may be changing also.

Federal legislation this past year mandates parity of mental disorders with medical insurance benefits that means nondiscrimination and stigma may diminish but not without continuing challenge from the insurance

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industry collecting premiums but still seeking loopholes to limit and deny claims.

Here is a comment made 18 May 2013 by Susan Lazar, M.D., of the Committee on Psychotherapy of the Group for the Advancement of Psychiatry:

“We are in the midst of a national mental health care crisis with respect to the provision of mental health benefits, including psychotherapy, just as national health care reform, the Affordable Care Act, is being implemented.

“For the past three years, many insurance companies, including Cigna, United Healthcare, and Kaiser Permanente, began severe restrictions on mental health benefits, including psychotherapy” she said. “Psychotherapy is an effective and often highly cost-effective medical intervention for many serious psychiatric conditions….The patients who are most in need of more prolonged and intensive psychotherapy are those with personality disorders and those with chronic complex psychiatric conditions often including severe anxiety and depression. These patients, if inadequately treated, are extremely costly to society in increased medical and emergency services, disability, and, for certain groups, destructive and antisocial behavior. Certain children and adolescents with learning disabilities and those with severe psychiatric disorders also require more than brief treatment.”

So be clear about your professional responsibilities to report abuses and violations in clear and direct terms to the insurance company, professional societies and government. And send a copy of your complaints to Frank Yeomans, M.D., chair of the Committee on Psychotherapy of the Group for the Advancement of Psychiatry, at frankyeomans@hotmail.com.

With more hard work, greater clarity in our educational standards and integration of the mental health professions’s shared goals, psychotherapy and psychotherapists may be pointing toward a professional renewal contributing to clinical practice and compassionate outreach to vulnerable populations.

Now back to work discussing psychotherapist responsibilties enroute to specifying competencies needed to be be a psychotherapist.

What Is Required Of The Psychotherapist?When patient and therapist meet and the mantle of trust is provided to

the professional, the gift of our predecessors carries responsibilities. Patients trust because of the wise professionals paving the way for you. The therapist is to serve the needs of the patient. The autonomy of the patient is the organizing principle of therapeutic work. The therapeutic process stretches toward personal growth, self-control and self-responsibility, allowing the patient to separate from the therapist. 12 | P a g e

Let me summarize my opinions on what the therapist contributes to treatment and invite you to assemble a working outline of your professional requirements.

1. The therapist creates a space that provides a safe, pleasing, quiet andconfidential setting where clinical diagnosis and therapeutic work can develop. We give a full measure of time to each and every patient following a contractual agreement about professional fees.

2. The therapist interacts with the patient within well-establishedtherapeutic boundaries. The therapist is not there to gratify his or her own needs. Therapists do not reveal personal history, problems, or frustrations. Reactions and internal responses to the patient are not shared directly but applied to furthering the therapeutic work of the patient.

3. We do not touch the patient except for shaking hands and we do not give

or receive gifts.4. The therapist develops an active listening approach and maintains an

attitude of inquiry, discovering why events occur in the patient’s life, and does so without an attitude of judgment. Therapists do not intrude in the patient’s work when the process is moving toward established goals.

5. The therapist brings a flexible theoretical structure on psychopathology that organizes the patient’s material.

6. The professional contributes their clinical expertise in making a comprehensive diagnostic evaluation with a treatment plan.

7. Psychotherapists should not accept a patient in treatment unless and until

there is a feeling of confidence in the therapist’s ability to assist that patient with their work. Consultation and referral to other

colleagues in the community may provide a better therapist-patient match.

8. The therapist accepts the patient’s vulnerability and provides a “holding environment” appropriate to the needs of the patient.

9. The therapist defines the strengths of the patient and helps in defining therapeutic goals that relate to tasks not yet worked out by the person.

10. The therapist practices analyzing functions of confrontation, clarification,

interpretation and working through to the defined patient goals. 11. The therapist’s problem-solving attitude invites the patient to consider

new and different ways of viewing his or her world.12. The therapist respects the resistance and the unconscious repetition

process triggered by therapy.13. The therapist touches the core conflict once every session. 14. Therapist interventions should not go beyond the patient’s level of 13 | P a g e

understanding. Tentative hypotheses and constructions are offered in contrast to rigid interpretation.

15. The therapist accepts his or her professional limits. Consultation is sought when clinical work is not progressing.

16. The therapist accepts responsibility for life-long learning. Supervision and personal therapy combine to improve therapeutic use of the professional self.

This list is for review and discussion with your colleagues in the hope of stimulating development of your outline of factors. What do you disagree

with here? Can you write your own guidelines now?

Specifying Competencies Improving Psychotherapy OutcomesThere are four areas of competencies outlined below starting with a

novice preparing to enter the field, the psychotherapeutic process, professional development, and the experienced clinician contributing to self, patient, profession and community. There is no discussion herein about standardized evaluation measures measuring competence, no criteria stating minimally acceptable levels of competence, no scaling up from beginner to mature clinician and no comment on educational or curricular structure.

Levels of competency may involve acquisition of knowledge, a higher level of integration understanding what has been acquired, the development of skills to work in the field, attitudes influencing how one applies developing competencies, and the integrated activity in clinical problem solving. Each point below has a beginning, evolves with experience, and reaches toward the highest level of professionalism over time. In that sense, each point below grows and develops rather than being over and ended. Though beginning on an apprentice model, our scientific advances in this digital age suggest professional behaviors build on learning in the moment to moment actions of practicing the art and science of psychotherapy.

COMPETENCIES AT THE ENTRY Personal Attributes:

Tolerant of differences, accepting, balance of warmth andfirmness, genuine, congruent, caring, steady, trustworthy, responsive, predictable yet creative, responsive, active engagement, etc.

Communication Skills: Clear and direct with peers, colleagues and others

Aware of Self: Personal history and what one brings to professional training Understanding assets and liabilities in interacting with othersUsing own responses to situations as avenue to understanding

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Attitude of Inquiry: Opening topic rather than closing down discussion

Places high value on the individual’s personal autonomy and self-responsibility

Theoretical Foundations:o Has a growth and development model of human behavior, an

interactive functional model, with concepts of normal and deviations from norm

o Has an integrated model of biological, psychosocial and sociocultural factors shaping mind, brain, body and spirit

o An integrated theory of cultural diversity at individual, marital, family and neighborhood levels impacting the community

o Understanding of health and sickness within a psychopathology theory

o Understanding rationale for treatment methods with knowledge of comparative models of psychotherapy

COMPETENCIES REQUIRED FOR PSYCHOTHERAPEUTIC PROCESS Create space and setting: Quiet, secure, confidential, uninterrupted Pay attention to personal hygiene, health, and professional

appearance Set professional policies and standards regarding office

management, business, legal and ethical issues Define purposes for evaluation in different settings such as

emergency room, clinic, medical consultation, forensic, competency, or outpatient setting as candidate for psychotherapy

Demonstrate ability to listen to the story of the person with minimal cueing

Conduct a psychiatric interview with an introduction, a period of open patient-focused inquiry, a detailed inquiry to collect necessary information, and move to closure defining next steps and next meeting before interruption

Collect and integrate all appropriate information from all available sources

WHAT IS TO BE TREATED? Define in collaboration with patientComplete a comprehensive diagnostic evaluation

Accurate identification of problems Summary of background history and environmental

factors Psychodynamic formulation Nomenclature(DSM V) diagnosis Prognosis (if no treatment) Treatment Recommendations Interactional Predictions (in stress of clinical

encounter) Consultation if indicated

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Matching patient needs with best available clinician (including self) Shift from diagnostician to psychotherapist Enabling the patient to GET INTO TREATMENT

o Defining therapeutic focus Organizing theme Vehicle to monitor progress in therapy

o Defining destination o Agreement on what has already been accomplished, tasks

remaining, and how the collaboration will reach desired goals

Enabling the patient TO STAY IN TREATMENT o Confrontation with shared agreement on problemso Clarification about past, present, future -- what goes

where? o Hypothesizing connectionso Working througho Respecting resistanceo Using transference and countertransference cues to shift

focus back to understanding patient needs o Maintain steady,predicable structure of problem solving

routineso Using therapeutic focus to measure progress toward

destination pointso Self-analytic techniques (therapist as model) pleasing to

patiento Responsive to negative behaviors handled as underlying

reactions to loss, frustration, shame, disappointment, cognitive distortions and maladaptive patterns

o Confront misalliances or breaks in therapeutic work in direct and honest way with corrective action o Flexibility in open discussion of therapist “fit” reaching

goals o Timing of therapist interventions based on patient

readiness o Continual tracking of patient emotionally charged

concernso Aware of separation issues practicing to leave treatment

HOW MUCH IS ENOUGH TREATMENT and anticipating fading of connection

Balancing rules with patient need, experimenting, creativity and innovations

Continuing inquiry with self-analysis by patient and psychotherapist Return to refresh the therapeutic connection, share progress and

clarify the transferential and real relationship.

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COMPETENCIES REQUIRED FOR PROFESSIONAL DEVELOPMENT Computer skills allowing scientific searches and communication Self-evaluation: self-observation contrasting expected and actual

interventions Consultation: interview potential mentor/supervisors/clinicians Supervision with respected clinicians in sequence Personal psychotherapy or psychoanalysis Review and summarize professional procedures and clinical routines Maintenance of clinical records available for informed consent release Confidential work product guiding psychotherapy, track themes and

focus Continued education on evidence-based outcome studies Define special interests and skills with special populations/problems

CONTINUING CONTRIBUTIONS TO SELF, PROFESSION AND COMMUNITY Accepting a professional challenge to individuals and societies on

improved standards of care, education and continuing societal responsibilities

Start or join a clinical case conference and present cases Consider teaching Consider supervising less experienced after review of literature on

topic Consider clinical research on psychotherapy structure and

techniques Join the local branch of your professional association Develop collegial relationships sharing interests in improved care Start a scientific paper on topic relevant to your clinical practice

setting Identify gaps in community resources and join forces to close gaps Make a personal difference in your community, applying your skills

to a cause beyond your usual clinical routine.

How are competencies measured? Please join the discussion. Stay tuned to your colleagues and review your professional journals, enhanced by a search on PubMed of theNational Library of Medicine. Consider writing something on the topic.

Current Research On Neurobiology And PsychotherapyThe future evidence documenting the contributions of psychoanalysis

and psychotherapy lies in the trajectory of neuropsychotherapy research with advances in functional imaging, neurochemistry, individualization of genomic studies -- the myriad interactions of brain, mind, spirit and body. Key findings on memory and learning will lead the way in my opinion.

Just as the past is reflected in each successive day, so too the future can be anticipated in the present. New research from the Weizmann Institute of Science (2013) in Rehovot, Israel reported 25 June 2013 shows 17 | P a g e

emerging brain activity patterns preserve traces of previous cognitive activity. Imagine the future neuropsychotherapist being able to reveal the past experiences in memory and learning that contribute to our individual pathways. Consider studies of brain imaging that may classify depression in new ways and link the findings with predictors of selected treatment methods matching patient needs. The evidence in psychotherapy research will grow, the reliability and validity of psychotherapy will be documented in new and exciting ways.

While we are waiting for the results to be found there is much practical work to be done on our own clinical and professional integration to conduct, discussing shared concerns, dismissing discussion on wasteful my way is better than your way, focusing on what we have in common raising standards of training and clinical practice Reclaiming the Professional Ground (which happens to be the title of a monograph I hope to publish next year).Toward Closure

Psychotherapists speak of the therapeutic setting as a “holding environment.” Lest you forget the origin of that term, I remind you of one of our predecessors, Donald Winnicott, a British psychoanalyst, who had his roots in pediatrics. Winnicott died in 1971 but left us a rich legacy in his letters, papers, and texts. Esman (1990) reviewing three books, by and about Winnicott, summarizes his position:

“Winnicott’s therapeutic technique was firmly rooted in his development concepts. He was explicit in his view that the patient must find his own way in analysis, and that the analyst’s role was to provide an environment in which this could be done - a holding environment appropriate to the needs of the individual patient.”

Finding “his own way” suggests the secrets are inside the patient rather than the magic of the treatment or the therapist.

We need to understand the internal world of the patient. Where does the person come from? What characterizes their internal struggle and the coping difficulties with the external world? Schwaber (1992) has said, in such a setting, “we sustain the position that the reality we seek lies within the patient’s experience, with its conscious and unconscious conflictual, defensive, verbal, and nonverbal expressions.”

By our listening and sensing the world through the eyes and experience of the patient, we learn to understand. The holding environment and the listening ability are powerful factors we contribute to this “different point of view” in our clinical work. The patient invites the therapist into their world, wanting to be understood. Therein lies the trust and privilege assigned to the listening healer. We try to have the patient feel understood. The patient is the beneficiary of the therapist’s struggle to integrate a working model of human behavior and a therapeutic rationale. In the holding environment, the patient can use what they need of the therapist, when they need it, and for the period of time required before integrating the corrective functions within the self.

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There is no single best way no single school of thought nor single method to understand all patient problems. The beginning therapist is required to understand his or her own values, and to integrate contributions of different theoretical positions into an approach to treatment. The therapist attempts to understand the patient’s view of the world. Listening, without judging, while keeping the patient involved in their internal inquiry process with minimal intrusion, can create the setting for the patient’s learning experience, a new way of observing their world.

Best wishes with your work, in your setting. And please send me a copy of your clinical paper.

Respectfully,

John R. Graham, MD CM FRCPC FAPAabqparadox@comcast.net

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