Mark Epstein on Mindfulness and Psychotherapy

Mark Epstein on Mindfulness and Psychotherapy

by David Bullard

Psychiatrist and author Epstein discusses his introduction to mindfulness meditation, dealing with desire, disappointment, and more.
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Buddhism and Psychotherapy

David Bullard: Mark, I am very grateful and thankful that you found the time for this interview in the midst of a wonderful three-day workshop on Buddhism and Psychotherapy, which you are presenting in tandem with Tenzin Robert Thurman at Menla Mountain Institute. I've probably done this interview 40 times in the last couple of weeks, but this will be different because you are actually here this time! In preparation, I've considered a series of questions which led into more questions, and have already gotten a huge gift from the anticipation of having this time together. On the other hand, this interview should probably be organic and free-form, and grow from our being in the present rather than from a pre-selected list of questions.
Mark Epstein: Well, it's great that you've been thinking about it so much, and to have really thoughtful questions formed could be very helpful.
DB: It could be, and that's my desire. You've written a lot about the nature of desire and disappointment—we'll have to see which this will be!
ME: Trust in your desire. We'll get into that.
DB: Let's begin with a brief review of your extensive writings on the integration of Buddhism and psychotherapy from psychoanalytic and psychodynamic perspectives, which include wonderful examples of your own process and journey. You have published five very influential books, as well as many articles and chapters; you have taught at NYU and have participated in many workshops, and, of course, continue your private practice. In Open to Desire: The Truth About What the Buddha Taught, your acknowledgement section lists 60 people, so you are certainly well connected in your professional and personal lives. I personally have also enjoyed your chapter "From Eros to Enlightenment" in Brilliant Sanity: Buddhist Approaches to Psychotherapy. So shall we begin the interview with your first exposure to Buddhist teachers and how they were helpful to you?
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Buddhist and Psychotherapy Teachers

I came to my first Buddhist teachers after a very short experience with psychotherapy; so those first encounters were framed with a beginning attempt to seek therapeutic help for myself at the student health services at Harvard, where I was given a practitioner of short-term psychodynamic psychotherapy. This therapist met me three times and told me not to worry—my anxieties were just a result of my Oedipal complex and once I understood that, I would be fine.

I went from there to a Buddhist summer camp in Boulder, Colorado where I met my first Buddhist teachers: Joseph Goldstein and Jack Kornfield. They taught me mindfulness meditation, in which I learned how to actually be physically with my emotional experience. They refused to name it or to encourage me to name it, but really taught me how to dig down into it and know it, with less fear. So that was the first great gift that I got from Buddhism.

... Continue Reading Interview >>
DB: Can you contrast that with any particular gifts received from your psychotherapy teachers and mentors?
ME: The insights from my psychotherapy teachers were many but came later, after, to my dismay, I realized that what I was learning from Buddhism still left me sometimes struggling, especially in my relational life. So I went back to psychotherapy informed by Buddhism, and then was touched by how deftly certain of my therapists worked with my relational self in the actual interactions with them in the moment. It seemed very Buddhist to me, only active and engaged. I have examples I have written about in my books, that crystallize for me what I think I learned from these interactions.

In one, a therapist suddenly interrupted me as I was clumsily trying to explain what I wanted to get out of therapy, and asked me if I was aware of how I was sitting. I found this annoying. What was wrong with the way I was sitting? But he pointed out that I was sitting on the edge of my seat. "You give yourself no support," he said.

In another, a therapist waited patiently for me to begin a session. I sat there wide-eyed, staring at him but with nothing to say. I was remembering how a spiritual teacher of mine, Ram Dass, used to begin our private sessions that way. "Blink!" my therapist broke in. He made me see how my efforts to prolong contact with him actually diminished it, that when you stare too long at someone or something, you actually lose touch with it. He was showing me something about the rhythm of intimacy and the pull of addiction.

In a third example, I was speaking to my therapist about how '"part of me" was angry and "part of me" understood that I didn't need to be angry. He looked at me with barely disguised disdain and said, "Mark, you don't have parts." This has served as a koan for me over the years. "I don't have parts? What am I, then?"
DB: Could you tell us what particular thoughts you like to convey both to beginning students and experienced therapists, eager to learn or deepen their understanding of the art and science of psychotherapy through Buddhist psychology?
ME: A lot of therapists come to me with an interest in how to use Buddhist psychology to enhance their work. And often they are thinking much more concretely about "should I teach my patients to meditate," "how can I use Buddhist wisdom to help my patients feel better and help them resolve their neuroses," etc. I always feel that the most important way Buddhism can impact psychotherapy is by helping the therapist.
What Buddhism teaches very practically is a psychotherapeutic attitude: how to deploy psychotherapeutic attention both intrapsychically within the self and as well as interpersonally.
What Buddhism teaches very practically is a psychotherapeutic attitude: how to deploy psychotherapeutic attention both intrapsychically within the self and as well as interpersonally. When you are training as a psychotherapist you don't necessarily get specific help in how to deploy that kind of attention, but Buddhism is all about that. So I try to turn it back: "Here, this is for you." If you get something from it, maybe you will be able to make it come alive for your patients.
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Evidence-Based Buddhism?

DB: I'm smiling because I know that is your emphasis, in an era that is technique-oriented or theory-driven. Which brings us to the current hot topics of "evidence-based psychotherapy" and "empirically supported psychotherapy." It is being greatly debated with some divisiveness in psychology organizations. Can you offer us your perspective on that?
ME: I think there is a huge need to increase the cost-effective delivery of health care and to make psychotherapy understandable to the general population in terms of weighing the economic costs. In terms of doing research in what is therapeutic and isn't, I completely appreciate that way of thinking. And yet there is something to be said for the old-fashioned, psychoanalytic "not knowing" and groping around blindly in the unconscious—being able as a therapist to create an interpersonal field in which one doesn't know what will emerge, and yet trusting that what does emerge will potentially be therapeutic. Whether that turns out to be cost-effective or not, or operationalizable or not, we don't know yet, but is certainly worth the study.
DB: But are there other kinds of evidence, from the accumulation of thousands of years of Buddhist teachings that have survived, together with the Buddha's injunction that each person must explore deeply the applicability of the teachings, rather than to accept them on faith? Is this a kind of empiricism, a kind of "single case study" that Buddhism encourages?
ME: I think one has to be careful with this kind of reasoning.
Just because something has survived for centuries doesn't necessarily make it right. War has survived, for example.
Just because something has survived for centuries doesn't necessarily make it right. War has survived, for example. People thought the earth was flat for longer than they've accepted it being round. Buddhism has cultivated an introspective method over the centuries. It could just be a sophisticated kind of brainwashing. The scientific method is certainly capable of holding it up for study. That is already starting to happen.
DB: Yes, as we see from the labs of Richard Davidson and of Dan Siegel, among others, increasing our understanding of the impact of meditation on the brain. Many exciting issues are emerging from this collaboration between Buddhist psychology and neuroscience.

In another vein, therapist Michael Yapko recently said that he counted over 400 forms of psychotherapy. The vast majority of these, even if they are helpful, won’t be studied or validated by research. So what is psychotherapy?
ME: I think there is both science and method to successful psychotherapy, depending on the character structure and issues of the person needing psychotherapy. There are clearly different methodologies that are more or less effective, which a trained therapist will have some understanding of. And how these methodologies are deployed matters a lot—the fostering of a relationship that is beneficial or potentially destructive, or that could do nothing. So I think there is a lot to learn from all of the 400 schools—they probably all have something to teach. What I remember being impressed by, in terms of the research of the efficacy for a rather healthy population, is that the type of psychotherapy is less important than the relationship which ends up being fostered between the patient and therapist. And the quality of that relationship probably contains much of whatever it is that is healing in any kind of therapy. How to define that quality, other than using worlds like "love," and so on, I think will prove difficult, but clearly people know when there is a positive or trusting relationship, and when there isn't.
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Safety in Psychotherapy

DB: You've expanded a lot on Winnicott's idea of safety as a primary issue in psychotherapy.
ME: At least the possibility of safety. One finds in psychotherapy, even working with someone where there is a positive and good relationship, that there are things that people still don't want to talk about or don't feel safe talking about, that might emerge after many, many years into a given treatment. So even safety is a relative concept.
DB: So safety allows you to get to the edge of what they can talk about.
ME: There is always an edge to where someone feels safe, even with a therapist with whom one feels safe.
DB: No absolute safety.
ME: Yes, no absolute safety, and some fear, some trepidation, some insecurity. Pushing into that, playing with the edge of that, is something that can happen in a working psychotherapy that keeps it alive and vital and interesting.

In talking about Winnicottian issues like safety, holding environment and good-enough mothering and so on, it's easy to conceptualize the therapist's role as being nothing but facilitating—psychotherapy as being primarily an empathic relating. But I think that that misses what the therapeutic task actually is. Therapists, in my view, have to be very clearly themselves, to be able to come from an authentically individualized place so that they are not just emoting or communing or sympathizing, not just providing a field. They have to be really there, and at the same time have to be able to not be so present that they are filling a space too much or intruding. Winnicott is excellent about talking about the middle ground or balance between impinging or intruding and abandoning. It's easy to misinterpret the kind of presence that Winnicott encourages as being more selfless than a good therapist has to be. Therapists have to be very clear about who they are, and be able to use their own responses and opinions, their own techniques and methods.

At the same time, a therapist has to primarily be able to wait, and wait, and wait, and wait, and not be so anxious to display his or her intelligence or understanding or insights into what they think is going on, and to trust that there will be a time when it is obvious that what needs to be said can be said.
DB: In being authentic in the way I think you are speaking, the therapist doesn't have to be perfect, and a client or patient's reacting to the therapist's imperfection can be a very deep part of the therapy work, providing for relational depth. For some, it can be very important to be able to challenge one's therapist.
ME: Yes. Well, perfection is impossible, so one will always be failing one's patients. But if you fail too much you do them no service, so there is a balance there, too. Using the word "authentic," however, has become a cliché—the authentic therapist being too authentic becomes inauthentic. It is their image of what an authentic person should be.
...the authentic therapist being too authentic becomes inauthentic. It is their image of what an authentic person should be.
DB: Maybe you are also speaking along the lines of a quote from Jung, who was asked how one learns to become a great therapist. My recollection of his comment is: "Go and read everything written about the art and science of psychotherapy, but then forget it all before you first peer into the human soul."
ME: We should be able to have them and not have them at the same time. I'm not sure you have to learn them and forget them. I think once you learn them they are there, but you don't have to be restricted by them. You can use them when you need them.
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Should We Desire To Have Desire?

DB: I like your modification of my paraphrase! This might be a good time to segue into issues you discussed in your book, Open to Desire. Would you like to start with the story of Nasrudin eating the peppers?
ME: I wrote the book about desire because in Buddhism, desire has a bad name. One of the shortcuts in understanding the Four Noble Truths is that the First Noble Truth is the truth of suffering—that all experience, even pleasurable experience, has a hint of unsatisfactoriness or dukkha or suffering, because we are conscious of its transience. The Second Noble Truth, the cause of suffering, is sometimes given as desire. A deeper reading of the word the Buddha used translates better as thirst, craving or clinging, but we confuse our idea of desire with the Buddha's notion of clinging. So I think that a lot of confusion has arisen about desire. Is desire okay? Is it evil? Is it bad? Is it wrong? My sense is that even within a Buddhist framework there is desire—the desire for liberation, the desire for enlightenment. That is obviously a desire. The Buddha's solution to the predicament of suffering wasn't to stamp out desire per se. It was to not cling to it, or to not cling to the object of it, more to the point.

I remember a phrase that came from an Indian teacher: "It's not desire that's the problem, it's that your desires are too small." I use that as a jumping-off place because the problems many people have with desire are that their desires are too small. They are locked into the seeking of pleasures that once provided a huge relief but that now, over time, repeatedly provide only a shadow of the relief that they once did. To our minds, they seem to be the only sources of relief. The Buddhist teachings are all about opening up the seeking to find other kinds of pleasure.

The story that you were referring to is where Nasrudin, who is a kind of amalgam of wise man and fool, is sitting in the marketplace eating handfuls of hot, red chili peppers and tears are weeping from his eyes. His friends come to him and they ask, "What's with you? Why are you always eating peppers that are making you sick?" And he says, "Oh, I'm looking for a sweet one!" So the small reading of the story is that desire is the source of suffering, "so why don't you just stop eating the peppers?"—the idea that stopping acting on desire will stop suffering. The more nuanced reading of the story is that Nasrudin, in the guise of the fool, is demonstrating the potential of desire to ultimately find something sweet for his soul. I'm not sure which reading is right.
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Disappointment and Relationship

DB: I came across a quote from Soren Kierkegaard you may know from the Western philosophical tradition: "Perfect love means to love the one through whom one becomes unhappy."

Can you share some thoughts about relationship and desire, the real world of living in a relationship, and disappointments?
ME: Disappointment in love relationship is often taken as the exit door, especially in our culture where it's become more acceptable to actually exit. In many cases, that might be the right thing to do. And it's impossible even for a therapist to be able to say for any given person. Often as therapists we are put in the position of "should I stay or should I go," but that is a tough call, even for the individual in the relationship. But certainly from the Buddhist perspective, and I think from a psychodynamic perspective also, there is no love without disappointment. Even in what appears to be a true or perfect love, the idea that one could rest forever in that state, and that it would last unchangingly, clearly that is too much to ask of love. So then the question arises: Should we take disappointments as a defeat, or take them as an obvious shadow of love? A lot of that is in the attitude and the ability of both partners to continually reconnect without necessarily solving those aspects of a relationship that lead to frustration, disappointment or anger. I think there is something to be learned from both the Buddhist side and the psychoanalytic side. Instinctively, not too many people know how to do that easily.
DB: At last year's workshop on Integrating Buddhism and Psychotherapy, Columbia University Professor and Buddhist scholar Dr. Robert Thurman reported that his wife once advised him: "Bob, you are going to disappoint people, so you might as well do it sooner rather than later." I think that embodied a lot of wisdom! A week after Bob said that, a colleague of mine who is a longtime Zen priest and psychotherapist reminded me that disappointment is a major Zen teaching.
ME: In relation to this question I always read Winnicott, who talks so beautifully about both how important it is for a mother to be able to fail her child, and how normal it is for children to hate their parents and parents to hate their children. The "good-enough" mother doesn't need to be taught, but intuitively knows her task, in relation to her child's anger: to simply survive, not to retaliate or abandon, but simply to survive. And I think there is something in that intuitive sense that one needs to survive, without the need to abandon. To stay in that place allows an experience of both separation and union, so that it continues to unfold in an ongoing way.
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Further Reading in Mindfulness and Psychotherapy

DB: Given the current emphasis on mindfulness in psychotherapy and its recently fashionable use in our culture (even in the speeches of politicians!), are there particular books that you recommend to therapists with a beginning interest in mindfulness or meditation?
ME: I would recommend Zen Mind, Beginner's Mind by Shunryū Suzuki. While not being an operational manual in mindfulness or cognitive behavioral therapy, it gives you the flavor or taste or feeling of what it is to look at life from that perspective.
DB: One of Suzuki-Roshi's quotes that my cognitive-behavioral friends will love is: "It is not the thoughts that create problems for us. It is our harboring them."
ME: I would also recommend The Psychoanalytic Mystic by the psychoanalyst Michael Eigen. It is not very well known, but is a beautiful synthesis on his part of both psychoanalytic wisdom and compassion drawn from various of the world's religious traditions and from the point of view of a working psychotherapist, showing how he brings these threads together in a very alive and helpful way.
DB: In the 10th-anniversary edition of Thoughts Without A Thinker: Psychotherapy from a Buddhist Perspective, your preface highlighted the evolution of your understanding of both Buddhism and of psychotherapy over those years. You cite the work of Stephen Batchelor in highlighting the shift in our understanding of meditation as being interpersonal rather than solely intrapsychic. This parallels the movement from an intrapsychic and individual model to the interpersonal or intersubjective understandings of relational psychotherapy. You also mentioned that the way Joseph Goldstein taught you to observe your own mind in meditation is how you had always tried to listen to your patients. You wrote:

“This does not mean that I do not respond, that I am not myself when I work, that I do not care, or that I do not sometimes need to probe. But by not having a personal agenda in my therapeutic interactions, by putting my self on hold, I can make room for whatever appears on its own. We practice meditation when we listen to the feelings of another, to their pain, their distress, and their suffering. In this sense, psychotherapy and meditation are one.”
ME: Joseph always says it's not what you're experiencing that matters, it's how you relate it. I always try to remember that.
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The Joy of Meditation and of Psychotherapeutic Work

DB: Is there any additional question or issue you would like to address in this brief interview?
ME: It is a little hard to talk about, because I haven't thought it through completely, but what I have been exploring a lot lately is the Buddha's understanding of joy or happiness that is derived not from seeking after sensual pleasures but from non-sensual or non-worldly experiences. The Buddha, in that language, was talking specifically about experiences that come in meditation, when the usual seeking after pleasure or rejecting of unpleasure is suspended and one's experience can withdraw, though that might not be the best word—that one's experience can relax into the nature of mind. There's an inherent joyfulness, an inherent balance, one could say loving or shining nature, to the mind that becomes available through the deliberate renunciation of the usual attempts at maximizing pleasure.

So taking that seriously, I've been thinking about how some aspect of that is actualized in the psychotherapeutic relationship, as well. Which also involves a tremendous amount of renunciation, both on the part of the therapist and the person in therapy.
Joy, I think, is a good word to describe the feeling tones that can be opened up in the psychotherapeutic relationship...
Joy, I think, is a good word to describe the feeling tones that can be opened up in the psychotherapeutic relationship, which I think therapists have been aware of since the time of Freud but have been scared of, and which people have continually tripped over because it can lead to the suspension of renunciation and the acting out of the feelings that are evoked. But one dimension that the Buddha's world gives to us is this sense: not of the unconscious being only a whirlpool or cesspool of destructive feelings, but also a background of joyful and loving energy that is here if we are willing to look for it, or is even here if we are receptive to it.
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The Courage To Create

DB: It sounds like another book is percolating: The Joy of Therapy, perhaps!

Non-therapist acquaintances of mine sometimes remark: "Oh, I could never listen to people's problems all day!" I often reply that, although I certainly hear painful, difficult and tragic life issues, I also hear of the courage in people's struggles, and they also share their joyful moments of delight, aliveness, and triumph. It is a privilege to be able to learn deeply about the astonishing varieties of human experience. And at times, at its best, it is a form of I-Thou relationship.

I also wonder if you would feel it appropriate to describe your current personal meditation practice, if it can be so described, other than the meditation-like experience of psychotherapy?
ME: My current meditation practice? I try to sit whenever I have time for it. In the morning if I can, in the evening before bed if the time is available. After reading the New York Times. And I try to go away on retreat (for a week if I am lucky) every year or two.
DB: In ending this talk with you, I am remembering Rollo May, who was another much-admired author I was honored to talk with many years ago. Of his many books, one of my favorites was The Courage to Create. So on behalf of all of your readers and all of the people who have been touched by you and your writing, I want to thank you for being willing to put all of these compassionate, thoughtful and wise explorations out there for us to read because it really does take courage to create.
ME: Thank you.

Copyright © 2010 David Bullard. All rights reserved. Published November 2010.
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Mark EpsteinMark Epstein, MD, is a psychiatrist in private practice in New York City and author of five books and many articles on Buddhism and Psychotherapy. His first book, Thoughts without a thinker: Psychotherapy from a Buddhist perspective has a welcoming forward by His Holiness the Dalai Lama, and has been described as a landmark in the fields of Buddhism and psychotherapy. Next was Going to pieces without falling apart: A Buddhist perspective on wholeness; followed by Going on being: Life at the crossroads of Buddhism and psychotherapy; and Open to Desire: The truth about what the Buddha taught (2005, New York: Gotham). His most recent contribution is Psychotherapy without the self, a compilation of more academic essays from the past 25 years. He received his undergraduate and medical degrees from Harvard University and is currently Clinical Assistant Professor in the Postdoctoral Program in Psychotherapy and Psychoanalysis at New York University.
David Bullard, Ph.D., David has had a private practice of individual psychotherapy and couples therapy in San Francisco since 1976. He is a clinical professor in departments of medicine and psychiatry and a member of the professional advisory group of Spiritual Care Services at the University of California, San Francisco, and is a consultant for the Symptom Management Service (outpatient palliative care) at UCSF’s Helen Diller Family Cancer Center. His latest professional publication is the chapter “Sexual Problems” (co-authored with the late Harvey Caplan, M.D., and with Christine Derzko, M.D.) in Behavioral Medicine: A Guide for Clinical Practice, 4th edition (2014; McGraw-Hill). He has previously published interviews for psychotherapy.net with Allan Schore, Ph.D.; Bessel van der Kolk, M.D.; Mark Epstein, M.D.; Ida Gorbis, Ph.D.; George Silberschatz, Ph.D.; and Lonnie Barbach, Ph.D.; and also has written about conversations with Tibetan Buddhist scholar Robert Thurman, Ph.D.
Excellent chance to listen to Mark discuss his points of view. I especially love the way he burrows awareness practice into the intimacy of the psychotherapeutic relationship. How true! How true! Thanks for the nice read.
Connie Hills
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CE credits: 1
Learning objectives:

  • Learn how Buddhism can enhance psychotherapy.
  • Describe Epstein's view on the role of the psychotherapist.
  • Identify ways in which Buddhist psychology and psychoanalytic psychology complement each other.
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