Losing Faith: Arguing for a New Way to Think About Therapy

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The Taxi Ride

When I finally made my way to the curb, my taxi was nowhere to be found. Luckily, a group of attendees kindly offered to let me squeeze into the back seat of their already overly cramped cab. I jumped in and we sped off, weaving our way through downtown traffic to Washington Reagan Airport.

From the lively conversation, I surmised that the people in the cab worked together or at least knew one another. I wasn’t paying close attention to what was being said—still thinking about whether or not I would catch my flight—but their sense of enthusiasm was so infectious that to not listen quickly became a chore.

The topic was the diagnosis of Post Traumatic Stress Disorder (PTSD) that had enjoyed a renaissance of popular and professional interest in the wake of 9-11. A new theory about the condition had been presented in one of the breakout sessions at the symposium. Something about how humans deal with trauma differently to animals and how this accounted for why our species developed PTSD and animals did not.

“Yeah,” one of the people went on to explain, “The presenter showed these excerpts from National Geographic films. You know, animals in Africa, on the Serengeti and stuff….” Eager to participate, another chimed in before the first could finish his thought, “Most of those animals are under constant threat by larger predators. But, even though they are hunted and chased relentlessly they don’t get post-traumatic stress disorder!”

Something about that last statement piqued my attention. I was feeling skeptical already and wondered, how do they, or the workshop leader for that matter, know that animals did or did not have PTSD? Anyone familiar with the literature knows that the diagnosis of the disorder in humans is tricky, with agreement between clinicians notoriously low. How could it be otherwise? There are 175 combinations of symptoms by which PTSD can be diagnosed. In fact, using the DSM criteria, it is possible for two people who have no symptoms in common to receive the same diagnosis!

“No, they don’t,” the first continued butting his way back into the conversation, “Because they shake it off.”

“Shake it off?” one of the others asked without a hint of skepticism in her voice.

“Yeah, they don’t repress their natural physiological response to traumatizing events the way we humans have been conditioned to.”

I could feel myself becoming agitated. “Here we go again, I mused, that old Freudian bogeyman, repression, dug up and represented in different words.” It was easy to see that I was the odd man out.

My mind raced back to lazy Sunday afternoons spent with my family watching Mutual of Omaha’s Wild Kingdom. I wondered, Had none of these people ever watched that program? Most of the animals on that and every other nature show I’d ever seen were so jittery from life on the plains it made me want to take medication.

Heads up and heads down, constantly checking, first here and then there, always on the lookout for the thing that might eat them. If anyone on the planet suffered from PTSD, it was those animals.

I turned back to the window, distracted by my inability to recall the name of the host of Wild Kingdom.

“So, what did he say you should do?” one of the group asked, and the second speaker began describing the treatment. To me, it sounded like a variation of the old abreaction technique. You know, helping people “discharge strangulated affects” by having them revisit unresolved traumas. The only difference was the shaking that followed the recollection or reliving of a traumatic event.

At this point, I started shaking—my head that is, from left to right, and back again. No, no, no, no, NO, I was thinking to myself with each turn. And if my response was any indication, it was clear that the “shaking” theory was bogus. I certainly didn’t feel any better. In fact, I was feeling more agitated.

Are you all daft? I wanted to scream. Use your heads, think critically for Heaven’s sake! Instead, looking out the window of the cab, I started imagining these well-intentioned practitioners trying out this new technique. Let me see if I understand your new approach, the sarcasm now dripping from my thoughts, you are working on a disorder that no one can diagnose with any reliability, using a method for which there is no evidence of effectiveness, based on an animal analog that in all likelihood does not happen in nature, and organized around an old Freudian idea that was discredited years ago. I was on a roll now, the invective flowing out of me. Hmm. Sounds great. Sounds like the history of “psycho” therapy…a never ending list of ephemeral fads applied to unspecified problems with unpredictable outcomes for which rigorous training is required. Great. Give it a go.

The intensity of my reaction took me by surprise. What was the matter with me? I wondered. It’s not as if I’d never heard such things before. Our field was full of this stuff: lay on this couch, talk to an empty chair, sit on this person’s lap, watch my finger wave back and forth, or one of my own contributions to the kooky cacophony, “Pretend a miracle happens….”

Where I was cynical, however, my fellow travelers were inspired. In response to any objection I might raise, I could hear them say, Well, maybe you just don’t work with enough of these people to see the value of the treatment. Then they would continue with the typical citation of the evidence used by clinicians to mute all such criticism: the much vaunted “personal experience.” Have you tried it? I did, and it works. At least that had been my experience whenever I made my doubts public.

We pulled up to the curb at the airport. After paying my fare, I muttered a quick “Thank you,” and bolted for the terminal. Sure, my connection was tight but I also wanted to escape. Believe me, it was nothing personal. Of late, I’d been avoiding conversations about therapy whenever I could.

The Epiphany

Before I knew it the pilot was announcing our final approach into O’Hare. And that’s when it hit me.

I could feel my chest tighten at the thought. I wasn’t burned out, depressed, or in the grips of a midlife crisis. It was something much worse. I’d lost my faith. I no longer believed in therapy….

The weeks and months following my epiphany were particularly bleak.

If I hadn’t been depressed before, I was certainly on the verge now. I’d been in love with the field. Now, the passion and commitment that had sustained me for nearly two decades of work as a therapist was gone. I had no energy, no zest. I felt completely adrift, purposeless.

Looking Back, Moving Forward

“Just stick with it,” my clinical supervisor, Bern Vetter, would say whenever I voiced my uncertainty, “everybody feels that way in the beginning.” At that point in my career the little experience I had made it abundantly clear that the practice of psychotherapy was a highly nuanced and complicated affair, requiring years of dedication and study to master. In short, it was not a profession for the impatient. The learning curve was long and steep. Given time, experience and, of course, further training, I had faith that the mountain could be scaled. Once on top, I’d be able to reach out with confidence and offer a helping hand to those struggling on their way up to a better, happier and more fulfilling life.

Looking back, I don’t believe my work as a beginning therapist was necessarily bad. I made a concerted effort to do all the appropriate therapist-like things I’d been taught—maintaining an “open” posture, reflecting feelings, avoiding advice giving, and so on.

I arranged my office to resemble those of experienced therapists I knew and admired, adding warmth and ambiance to the room.

For their part, my clients didn’t complain. Still, I wondered, Could they tell that I didn’t really know what I was doing? Did other therapists feel this way? If so, then why the hell didn’t they talk about it? Was their seeming self-assurance merely a confidence game? If not, then what was the matter with me? Why didn’t I get "it" the way others seemed to?

Bern would always counter, “This is a time to experiment,” in a reassuring voice. “Try some things on for size, see what fits, what the client likes and doesn’t like. In time, it’ll come.” I appreciated Bern’s patience and openness as my experience with other therapists wasn’t always as sympathetic.

I continued to explore, reading books and combing through the research literature. I also went to see everybody who was anybody on the lecture circuit: Barber, Ellis, Haley, Satir, Minuchin, Meichenbaum, Yalom, and Zeig—the entire therapeutic alphabet. As hard as I tried, however, my own work never seemed to equal that of these clinicians. Sometimes what I learned worked and other times it did not. On a few occasions, the new stuff I tried ended in unmitigated disaster.

Why wasn’t I getting “it” the way others—my co-workers, supervisors, book authors and workshop presenters—appeared to? Having always had a strong work ethic, I resolved to continue, reasoning that persistence would, as it often had in my life, eventually win the day. I still had faith.

I thought I’d died and gone to heaven when, shortly out of graduate school, I landed a job at the Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin. I’d been dreaming about working at the small, inner-city clinic ever since I read Steve de Shazer’s Keys to Solution in Brief Therapy in one of the supervision groups I’d attended. In the first chapter of that book, de Shazer described being “plagued” by the same question I struggled with, “how do you know what to do?” Seeking to answer that question was his stated raison d’etre, the focus of his career and work at the center. I couldn’t imagine a better workplace.

Forget what you know or have come to believe about solution-focused therapy. The mechanical version that exists today bears precious little resemblance to the work being done at the time I joined the staff. On the contrary, the process at BFTC was fluid and dynamic, the atmosphere positively electric. We spent hours watching each other’s work, staying late most evenings, and even showing up on the weekends to record, review and discuss sessions.

As time passed, the confidence I had long sought gradually began to build. I thought about my old supervisor, Bern. Now I recognized, or thought at least, he’d been right all along. With experience, it’d become easier to see patterns in the process, markers that helped me to understand what was going on, told me what would be best to say and do. Together with Insoo Berg, the co-director of BFTC, I even wrote about what I had learned in my first book, Working with the Problem Drinker: A Solution-Focused Approach. In what would become a pattern for me, I used the writing process to “work through” and clarify my feelings about and understanding of the work.

I can still remember one of the first cases I watched at the Center. Brother Joel, a capuchin living and working with the downtrodden in Milwaukee, brought a thirty-something homeless man in for a session. The guy was so high that several team members and I actually had to come out from behind the one-way mirror and walk him around the room in order to keep him awake. All the while, Insoo continued to work, skillfully and patiently weaving a therapeutic conversation into the client’s brief moments of lucidity.

Two years later, the man returned for a follow up interview. Honestly, we didn’t even recognize him. Gone were the dirty and disheveled clothes, the smell and grime of the streets. In their place was a clean-shaven, even dapper looking, businessman. We learned that he was in a committed relationship and planning to marry in the near future. He was now the owner of a small business, had a home, his own car, and money in the bank. I can remember thinking that our former client was, in many respects, better off than me. And, all in a handful of sessions!

With experiences like these a regular occurrence, you can imagine my surprise when, in 1992, two independent studies failed to provide much empirical support for the work we’d been doing. Mind you, the reports did not say we were ineffective, merely that we were no more effective than any other group or treatment approach. Adding insult to injury, the same studies showed that we were not any more efficient either. In other words, we accomplished what we had in the same amount of time it took everyone else—a major blow, you can imagine, for a group known around the world as the Brief Family Therapy Center.

The bad news continued. “In depth interviews with our successful clients revealed that the therapeutic map we’d spent so much time developing—including interviewing strategies, techniques, and end of session homework assignments and interventions—mattered little in terms of outcome.” Indeed, although not reported in the published study, the only time our clients appeared to remember the technical aspects of our work was when they were experienced as intrusive and ineffective!

Needless to say, the sense of assurance that had been building since I’d joined the team at the Center was badly shaken. For months, I struggled to make sense of the results. The challenge, or so it felt to me at the time, was not to throw the proverbial baby out with the bath water.

I vowed not to let the results obscure the bigger picture. What therapists did worked. I’d seen it myself on numerous occasions. My faith in the process of therapy was not misplaced. The problem was that the particular way we worked appeared to have little or nothing to do with our effectiveness.

In this regard, the two studies at BFTC had left me far from clueless about the ingredients of successful therapy. High on the list of strong predictors of a good outcome were the quality of the therapeutic relationship, the strengths and resources of the client, and the person of the therapist. The latter finding was particularly interesting. Despite the fact that all of the therapists at the center were practicing the same approach, outcomes varied considerably and consistently from one therapist to another. Most surprising of all, the two most effective therapists at the clinic were graduate students!

Revisiting Old Ground

Writing on this very subject back in 1936, Saul Rosenzweig, a psychologist in the same graduating class at Harvard as B.F. Skinner, suggested that the similarities rather than the differences between competing treatment models accounted for their effectiveness. Being a Lewis Carroll scholar, he labeled his findings, “The dodo bird verdict,” borrowing a line from Alice’s Adventures in Wonderland that reads, “All have won and therefore all deserve prizes.”

Picking up where Rosenzweig left off, Jerome Frank argued in 1963 in his highly influential book, Persuasion and Healing: A Comparative Study of Psychotherapy, that Western therapies worked in precisely the same way and for the same reasons as healing rites across a variety of cultures. Whether practicing as a licensed therapist in Milwaukee or a shaman in the jungles of Papua, New Guinea, healers inspired hope, giving people plausible explanations for their pain and rituals to ease their suffering.

By the 1980’s, the quest to identify a group of common factors underlying effective psychotherapy had come full circle. Based on forty years of data, researcher Michael J. Lambert identified and even estimated the contribution of four pantheoretical contributors to success. As we’d found in the studies at BFTC, the therapeutic relationship and client emerged as large contributors to success—accounting for a stunning 70% of the variance in treatment outcome.

Coming in last place—tied for insignificance with placebo factors—was the particular model or technique a therapist happened to use, contributing a paltry 15%.

Early in my training, I’d been exposed to and dismissed the research on the common factors view for a number of reasons. First, it wasn’t sexy. After all, how stimulating is the idea that all models work equally well and for essentially the same reasons? What about transference? The Oedipal complex? Denial? What about defense mechanisms, insight, family structure, systems theory, double binds, indirect suggestions, paradox, self-disclosure, the DSM, confrontation, empathy, congruence, getting in touch with your feelings, talking to an empty chair, dysfunctional thoughts, self sabotage, and the biochemical imbalance? What about all those important things they taught me in school?

Being cast as our culture’s equivalent to a shaman was another reason for dismissing the common factors perspective. Sure, I knew there were those in the field who readily identified their work with native forms of healing, but I didn’t see these people accepting chickens in lieu of cash for their services.

No sir, they were right there alongside all the other therapists, trading on their professional credentials, and filling in their forms in order to receive insurance reimbursement. Anyway, I was a scientist. I’d been to college and I was going to graduate school. When I finished, my diploma would read “Doctor,” not witch doctor.

With each of my professors committed to one model or another—eclecticism was especially disdained—I’d quickly forgotten about the research supporting the common factors. Yet, there I was, some nine years after starting graduate school and three years post PhD, feeling a little like a kid who has just learned that his parents bought and placed all those presents under the Christmas tree. Sure, the end results were the same but Santa was dead, better said a fiction. In short, there simply was no magic in the method, no missing ingredient, no right way to do therapy.

The Comfort of Companions

We talked about the problems and challenges facing the field, including the rapid proliferation of new methods and techniques, claims about the effectiveness of particular approaches, and the ever-widening number of behaviors and concerns cast as problems requiring treatment. We also talked about the field’s flagging fortunes. By this time, many therapists were feeling the pinch, struggling to make ends meet. The golden age of reimbursement had vaporized in the mushroom cloud of managed care. As a result, psychotherapists were fast becoming what Nicholas Cummings had predicted nearly a decade earlier, that is “poorly paid and little respected employees of giant healthcare corporations.”

The public’s appetite for mental health services also appeared to be changing. For example, the self-help section at local bookstores—once jammed with latte-sipping, self-help junkies—suddenly dwindled, within a short period going from several aisles to one frequently disorganized and poorly stocked shelf. Meanwhile, average Americans were trading away their mental health benefits at alarming rates during contract negotiations with employers.

Apparently, change in the pocket is worth two therapists in the bush. In relatively short measure, the discussion shifted. We were not cynics. We were pragmatists who believed in therapy, so we were talking about solutions. All agreed that the field did not need another model of therapy. Depending on how one counted, anywhere from 250 to 1,000 approaches already existed. What clinicians from differing therapeutic orientations might benefit from, we reasoned, was a way of speaking with each other about the critical ingredients—about what works—in helping relationships. Our different cultures and languages had left us Balkanized as a field, unable to share, fearful of crossing theoretical boundaries, even distrustful of one another.

Notes scribbled on a cocktail napkin turned into a flurry of articles and three books, including Escape from Babel, Psychotherapy with “Impossible” Cases, and The Heart and Soul of Change. To be sure, all were works in progress, as much statements about our development as clinicians, as they were summaries of the research about “what works in treatment.”

Using the common factors as a bridge between treatment approaches, we spelled out a basic vocabulary for “a unifying language for psychotherapy practice.” In essence, we were advocating for a kind of informed eclecticism. Rather than being dedicated to a single model or approach, we argued that therapists could avail themselves of any technique, strategy, or theory as long as it empowered one or more of common factors and, importantly, made sense to the client. With regard to the latter, the research was clear: therapy was much more likely to be successful when it was congruent with the client’s goals for treatment, ideas about how change occurs, and view of and hopes for the therapeutic relationship.

Our message apparently struck a chord with clinicians. The books sold very well. In fact, The Heart and Soul of Change became one of the publisher’s best selling volumes ever—going on to win the Menninger prize for scientific writing. Feedback at workshops was also positive—glowing even. Heady stuff.

On reflection, however, I decided that the response was not all that surprising. After all, figuring out how to use the knowledge and skills one had to meet the needs of individual clients was what practicing therapists did. If nothing else, it was good business practice.

In my own work, I was making a concerted effort to follow the advice we were giving to others: literally, to put the client in the driver’s seat of treatment. More than ever before, I worked hard at setting aside my own ideas and objectives, purposefully attempting to organize the treatment around the client’s goals and beliefs. I spent more time listening and less time talking or asking “purposeful” questions. I also made sure that the suggestions I gave, and any interventions I used, were derived from the interaction.

The Illusion of Progress

Of course, we’d hoped that presenting the factors as principles rather than mandates would circumvent the problem, providing therapists with a flexible framework for tailoring treatment to the needs of the individual client without creating yet another model of treatment. After all, the research showed that clinicians believe that their skill in selecting therapeutic techniques and applying them to the individual client is responsible for outcome. Unfortunately, the data indicate otherwise. Confidence in our ability to choose the right approach for a given client is simply misguided. Indeed, when combined with other studies showing little or no effect for training or experience on treatment outcome, the hope we’d felt at the outset of our work began to feel painfully naïve.

Around this time, I stumbled across an article I’d read a few years earlier while preparing to write Escape from Babel. A psychologist named Paul Clement had collected and published a quantitative analysis of outcomes from his 26 years of work in private practice. The results had alternately intrigued and frightened me. The good news was that 75% of his clients rated improved at the end of treatment, and quickly. The median number of sessions over the course of his long practice was 12. The bad news, however, was particularly bad in my opinion. In spite of believing—in fact “knowing” that he’d “gotten better and better over the years”—the cold, hard fact of the matter was that he was no more effective at the end of his career than he’d been at the beginning.

At this point, I recognize some readers might be thinking, “Hey, Scott, don’t miss the big picture here! What Clement did with his clients not only worked, but also worked in a relatively short period. So what if this clinician did not improve over time?” Who can argue with success? However, if we are to move forward to better, more effective practices, we need to understand why therapy works. The devil or for that matter, the saint, is in the details. The tradition of the field to pile model upon model and technique upon technique, year after year, has not answered the question. It deceives all of us into believing, as did Clement, that we are getting better when in fact we are not. An illusion of progress, in the end, is hardly progress.

And then the cab ride. The lightening rod. The flashpoint. The final straw that broke this therapist’s back. Alas, it seemed that we therapists would believe almost anything. The “shaking treatment” notwithstanding, the entire history of our field was proof.

Fashions of the Field

Just as studies were beginning to show a high casualty rate among clients in some of these popular experiential treatments, the field’s interest in “letting it all hang out” was reigned in and zipped up. From feelings, the field switched to behaviors and thoughts, then to dysfunctional families. Skinner, Beck, Minuchin, Palazolli, and Beatty among others, became icons; systematic desensitization, confrontation of dysfunctional thoughts, and self-help groups the best practice. The process only continues, morphing most recently from the “decade of the brain,” into a “greatest hits of the field” version known as the “biopsychosocial” approach. The so-called “energy therapies” are all the rage; drugs plus evidence-based psychotherapies now considered the “brew that is true.”

With the speed of therapeutic “developments” rivaling changing skirt lengths and lapel widths on a French fashion runway, who could trust anything the field said? We were like the weather. If you didn’t like the way things were, all you needed to do was wait five minutes. Chances are we’d be saying something different. Remember the multiple personality disorder craze? Where have they all gone anyway?

I’d completed one of my first clinical placements at a hospital that had an entire wing of an inpatient unit dedicated to treating people with “Dissociative Disorders.” The “multiples” were coming out of the woodwork. It seemed like an epidemic with the average daily census at the unit exceeding the total number of cases reported in the literature over the last 100 years!

I could go on and on. In fact, all the way back to Benjamin Rush’s time more than 300 years ago. With the same aplomb that we modern helpers tout the benefits of passing fingers back and forth in front of peoples eyes at regular intervals—don’t forget the “cognitive weave” now or it won’t work—the experts of the day were reporting “significant improvement” and “a return to normal life” in the majority of sufferers tied to a wooden plank and spun into unconsciousness, or blindfolded and dropped unexpectedly through a trap door into a tank of freezing water. Of course, we’d like to think that we’re different, that we’ve come along way since then, are more advanced now. And yet, that has been the claim of every generation to come along. Simply put, it is an illusion. “The same research that proves therapy works shows no improvement in outcomes over the last 30 or so years.” In short, we keep inventing the wheel; each era framing the causes and cure within the popular language and science of the day.

More Placebo Than Panacea?

Initially, I was hesitant about sharing my experience with other clinicians. I’m glad I eventually did as I quickly learned I was not alone. A few were even more discouraged than I was. Others still believed in therapy, but had grown weary of the hype attached to it. To these experienced therapists, the field lacked a memory. The old and forgotten frequently passed as new and the new just wasn’t that different. For many, what had started out as much a calling as a vocation had in time become drudgery, just another job.

The Therapist’s View

Sadly, for all the competition, genuflecting, and moaning about what therapy is, precious little attention has been paid to the client’s experience. No one in the cab that day, for example, asked, or even considered, what a client might feel about shaking like a wild animal. Would it be humiliating? Degrading? Helpful? Or, just plain nonsensical? Neither was there any discussion of what the client wanted, what they might like. No, it was all about us. Now, we knew what to do, what they needed. Even all the recent talk about client strengths and collaborating with clients smacks of “us.” Again, we are in charge, this time liberating client strengths and deciding that collaboration is a good idea. In fact, that’s what my journey as a therapist had been about from the outset: me, me, me.

Frankly, shifting my attention, changing the focus of my search away from me and toward the client, is what kept me from abandoning the field.

Is Client Feedback the Key?

Our own work is based on two consistent findings from the research literature:

1. Clients’ ratings of the therapeutic relationship have a higher correlation with engagement in and outcome from psychotherapy, than the ratings of therapists;

2. A client’s subjective experience of change early in the treatment process is one of the best predictors of outcome between any pairing of client and therapist, or client and treatment program.

Given these results, we simply ask clients to complete two very brief, but formal scales at some point during each session—one, a measure of the client’s experience of change or progress between visits, the other an assessment of the relationship. The entire process takes about 2-3 minutes per visit.

At this point, we’ve collected client feedback on some 12,000 cases—significantly more when our data is combined with that of other researchers following a similar line of inquiry using different measures. Consistent with the results from previous studies, we’ve found that the particular approach a clinician employs makes no difference in terms of outcome, including medication. On the other hand, providing real time feedback to clinicians has had a dramatic effect. Over a six-month period, success rates skyrocketed, improving by 60%. More important, these results were obtained without training therapists in any new therapeutic modalities, treatment techniques, or diagnostic procedures. In fact, the individual clinicians were completely free to engage their individual clients in the manner they saw fit, limited only by their own creativity and ethics.

Two large healthcare companies have moved in this direction and have eliminated the “paper curtain” that has been drawn over modern clinical practice. All I can say is, “It’s about time,” as none of these time-consuming activities have any impact on either the quality or the outcome of treatment.

Other intriguing results emerged. Recall the study cited earlier about the superior outcomes of the two novice therapists at the Brief Family Therapy Center? Combing through our own data looking for factors accounting for success, we noticed dramatic differences in outcome between therapists. Most, by definition, were average. A smaller number consistently achieved better results and a handful accounted for a significant percentage of most of the negative outcomes.

Similar differences were observed between treatment settings. Clinics that were in every way comparable—same type and severity of cases, clientele with similar economic, cultural, and treatment backgrounds, staff with equivalent training and the like—differed significantly in terms of outcome. When it comes to psychological services, it appears that unlike medicine, “who” and “where” are much more important determinants of success than what treatment is being provided.

If you are wondering what accounts for the variation in outcome between therapists and treatment settings, you’re not alone.

We did too. Yet, after parsing the data in every conceivable way, we came up largely empty handed. We did notice that therapists who were the slowest to adopt and use the scales had the worst outcomes of the lot. If the feedback tools are viewed as a “hearing aid,” this may mean that such clinicians didn’t listen, in fact were not interested in listening to the client. One therapist claimed that his “unconditional empathic reception” made the forms redundant.

Truth is, however, we really do not know what accounts for the difference. And frankly, our clients, the consumers of therapeutic services, don’t care—not a wit. They just want to feel better. For them, outcome is all that matters. It’s what they are paying for.

Intriguingly, our experience, and that of other researchers such as Michael Lambert and Jeb Brown, indicates that client feedback may be the key.

Does the client think that the therapeutic relationship is a good fit? Do they feel heard, understood, and respected? Does the treatment being offered make sense to them? Does the type, level, or amount of intervention feel right? Do any modifications made by the therapist in response to feedback make a difference in the client’s experience of the treatment? If so, is the client improving? If not, then who or where would be a better choice?

Let me say just say that I am not selling our scales. You can download the measures for free from our website; however, I’d be cautious about doing even that, as finding the “right” set of scales for a given context and population of clients requires time and experimentation.

The Future

It just doesn’t. Rather, one-by-one, clients and therapists pair up to see whether this relationship at this time and this place will, in the eyes of the client, make that all important difference. Sometimes it’ll sizzle, other times it’ll fizzle. Sometimes we’ll both want and be able to make the adjustments necessary to connect, other times we won’t. In some instances, a perfect match on paper will simply lack the chemistry needed to sustain it in reality. That is the nature of relationships. In the end, no amount of training or experience will enable us to “marry everyone we date.”

It’s true. I’ve lost my faith in therapy. Better said, my faith was misplaced from the outset. In part, because of my training, in part because of the broader “assembly line” culture in which we all live, I’d thought that day would come when, equipped with the tools of the trade, I’d finally be able to execute my job safely and effectively. We were like any other profession. Where physicians had a scalpel and prescription pad, we had insight and interventions; where a carpenter used a hammer and nails, I would use interviewing strategies, homework assignments, and the alliance to build my clients more satisfying lives. When that didn’t work, having never found solace in attributing treatment failures to client resistance or pathology, I would wonder as any good journeyman, what critical skill I lacked.

At length, I’ve come to accept that I cannot know ahead of time whether my interaction with a particular person on a given day in my office will result in a good outcome. Neither is all my knowhow, years of training and experience any guarantee. Our grand theories, clever techniques, even our best efforts to relate to and connect with others are empty—full of potential, yes, but devoid of any power or significance save that given to them by the person or people sitting opposite us in the consulting room. Thinking otherwise is not a demonstration of our faith, but actually conceit. The promises and potential notwithstanding, we simply have to start meeting and then ask, can they relate to us, to what we’re doing together at the moment? I know they will tell us. I now also have faith that, no matter the answer, the facts will always be friendly.

Acknowledgments

  The author wishes to thank his colleague and friend Mark A. Hubble, Ph.D. for his tireless and invaluable assistance in the preparation of this article. This article was originally published in Psychotherapy in Australia and is reproduced here by kind permission of the author.

References

Berg, I.K. & Miller, S.D., (1992) Working with the Problem Drinker: A Solution-Focused Approach, Norton.

Clement, P. W. (1994), Quantitative evaluation of more than 26 years of private practice. Professional Psychology: Research and Practice, 25 (2), 173-176.

Cummings, N.A. (1986). The dismantling of our health system: Strategies for the survival of psychological practice. American Psychologist, 41(4), 426-431.

Duncan, B.L., Hubble, M.A. & Miller, S.D., (1997), Psychotherapy with Impossible Cases: the Efficient Treatment of Therapy Veterans, Norton.

Fancher, R. T. (1995), Cultures of Healing: Correcting The Image Of American Mental Health Care: W H Freeman & Co.

W.H. Freeman. Frank, J. D. (1973), Persuasion and Healing: a Comparative Study of Psychotherapy: John Hopkins University Press.

Hubble, M. A.,Duncan, B.L. & Miller, S.D. (1999) The Heart and Soul of Change: What Works in Therapy: American Psychological Association.

Miller, S.D., Duncan, B.L. & Hubble, M.A., (1997) Escape from Babel: Norton.

Rosenzweig, S. (1936), Some implicit common factors in diverse methods in psychotherapy, American Journal of Orthopsychiatry, 6, 412-415.

 

Our Psychological Crisis: Making Sense of the American Psychological Associations Collusion with Torture

Posted on by Psychotherapy.net Team

The recently released Hoffman Report, the independent investigation conducted by former Inspector General of Chicago David Hoffman into the American Psychological Association's (APA) collusion in the torture of prisoners at Guantanamo and other CIA "black sites," has sent shock waves through the psychology profession, whose members are not at all happy to be the public face of torture in America. Listservs around the country are erupting with consternation and outrage, with demands for accountability and justice and reform and cries of betrayal. Our profession is in a full-blown crisis and psychologists around the country are confused, embarrassed, unsure of how to respond in a meaningful way.

What shocks me is how shocked my professional community suddenly seems to be, since much of the information in the Hoffman report has been available to the public for many years, thanks to the ceaseless work of activist psychologists like Steven Reisner, Stephen Soldz, and Jean Maria Arrigo, who first blew the whistle on the APA's cover up back in 2006. Arrigo had participated in APA's bogus Presidential Task Force on Psychological Ethics and National Security, known as the PENS Task Force, which sought to investigate the ethics of "enhanced interrogation" (torture) by appointing a panel made up almost entirely of military personnel who had direct experience with torture at one or more of the various CIA black sites. They, and a small handful of other psychologists out on the frontlines of this battle have been intimidated, publicly maligned, and marginalized by the APA in their attempt to discredit their critics and deflect attention from their dirty secrets.

I was a doctoral student in clinical psychology when news first broke about psychologists' involvement in torture. I had entered my studies with such optimism and hope about my career, feeling that I had finally found my home in the world–a vocation, not just a job–where I might make good use of my deep love and empathy for people and my desire to do some good in the world. It was shocking, then, to hear in my second year of training that people in my new profession were torturing people. I couldn't fathom how those people could be psychologists. Weren't we healers? Weren't we Carl Rogers and Virginia Satir and Freud and Carol Gilligan and…torturers? I couldn't wrap my head around it at all, so I decided to write my dissertation about it in order to get to the bottom of this incongruous debacle.

As I began to research the events around the torture of prisoners at CIA black sites, I discovered that financial embeddedness and collusion between the APA, the CIA and the Department of Defense spanned half of the last century, beginning with mind-control research at the start of the Cold War, then onto the torture of Vietnamese prisoners of war, CIA-backed training of torturers throughout Central and South America (at venues like the School of the Americas), and in a natural progression to the war on terror. The degree of entanglement between the military and the psychology profession, it turned out, was so longstanding, broad and deep that it would have been shocking had psychologists not been enlisted to prop up our latest war. (For more information on this sordid history, read Alfred McCoy's A Question of Torture: CIA Interrogation from The Cold War to the War on Terror.)

Though people are utterly enraged at the actions of the American Psychological Association, let's remember the context in which these unscrupulous actions unfolded. Our President—no our entire government save one dissenter, Congressman Barbara Lee—decided that bombing, kidnapping, torturing and killing the civilian population of Afghanistan was an appropriate response to a terrorist attack on American soil. But much worse, our government decided that a "shock and awe" mass-murder approach to deposing Saddam Hussein, who had no connection to 9/11, was an appropriate sequel. Bush's legal counsel at the Department of Justice rewrote American law to circumvent constitutional and international law regarding treatment of prisoners of war. In short, this was a time of collective national insanity—not a diagnosis covered by insurance, mind you—and the APA was, for the first time, at the seat of absolute power.

Let's also remember that one of President Obama's first acts in office, besides not closing Guantanamo as he had promised, was to summarily reject the notion of investigating, much less prosecuting, the Bush Administration's crimes during the war on terror. This was a powerful signal to those at the APA that they could simply "look forward, not back," without fear of punishment. If our former President, and all of the president's men (and Condoleeza), could get away with lies, deception, torture and the murdering of civilians, why would these psychologists, this professional organization, bother to reckon with itself and its past?

What I struggle with today, as the "shocking" revelations finally seem to have penetrated the psychology profession and the public at large in a way they simply haven't over the last decade, is how to reckon with the intensity of our denial–as a nation, as a profession, as a collection of individuals struggling to make our way in the world. Even my socially progressive little graduate school in Berkeley, CA, received my research with indifference, with one administrator dismissing it as "totally insignificant," the concern of a couple of "ultra-lefties" with no relevance to our profession. This is Berkeley. We're supposed to be cultural revolutionaries in this town, and yet even here, the fact that the association that accredits and determines the curriculum for our training institutions was providing professional and legal cover for an illegal and deeply immoral torture program was deemed irrelevant. If that doesn't suggest a need for a radical overhaul of this profession, then this is not a profession I want to be a part of.

But I'm not turning in my shingle. What I know from this work is that crises of this nature open up the possibility of radical transformation. We psychologists–most of us at least–are loving people with big hearts and empathic natures and a desire to be instruments of healing and change. We are imaginative and inquisitive and have the capacity to hold many (sometimes too many) truths at once. But as we sort through the crisis in our midst, we must break free from thinking we are either confined or defined by this terribly dysfunctional professional organization. A change in leadership, changes to the ethics code, prosecution for those involved in illegalities, democratic checks and balances–these are essential acts of reparation. But to truly find our moral grounding again, nay to find our passion again, we must turn our sights beyond the APA and remember what it means to be healers, not just of individuals, but of society and the planet. If we put love of humanity at the center of our agenda, and reorganize our leadership, our ethics codes, our research and our training institutions around social, economic and ecological justice, putting aside once and for all the advancement of profession over people, we are sure to find our way.

Brian McNeill on the Art of Supervision

Posted on by rezendevknowfully.com

What is Effective Supervision?

Greg Arnold: Brian you’ve been in the field of psychotherapy for over thirty years and you’ve done a great deal of research and work in the area of supervision. My first question is kind of a big one. It seems to me there’s more disagreement than ever in the field about what works in psychotherapy. How do we know what effective supervision is if we can’t even agree on what effective therapy is?
Brian McNeill: That’s a very good question. I think my reading of the psychotherapy literature might be a little bit different from yours, in that I see research on effectiveness of psychotherapy converging into what’s known as the “common factors” across divergent therapies. Wampold and his colleagues did a great deal of research on these factors in his most recent edition of the Great Psychotherapy Debate. Their research suggests primarily that we need to get away from the idea of manualized treatments, especially for training programs, where there’s way too much emphasis on it. I know it’s easy, I know it gives students something to get a handle on, but it discounts those common factors that account for so much of the variance across diverging approaches—relationship building skills, therapist qualities, world view—things that are now consistent with what APA has adopted as evidence-based psychology practice.
GA: So if you focused on the common factors you’d be well in the wheelhouse of accepted clinical science?
BM: Yes
GA: But you said it’s harder than just teaching a manualized treatment. Why do you think there is such a strong pull to fall back on a mechanistic view of the work that we do and to teach it through memorization of knowledge. Why is that so attractive and easy?
BM: I think it’s very attractive particularly for beginning counselors, because it provides a template for what to do in a given session. For example, for many cognitive behavioral approaches we set the agenda in the first 10 minutes; the next 10 to 15 minutes we review homework, and then we get into the agenda for the session.

It has its place at times, but I think it’s overused because it helps reduce a lot of that initial anxiety in beginning therapists, which comes from not knowing what to do if a session doesn’t go as planned. If the client stops talking, for example, it gives them something to fall back on. It’s harder to go in and listen very closely, very carefully—to really attempt to understand what your clients are saying as well as what’s not said and what the meaning is behind non-verbal behaviors, voice inflection. In other words, what a client is not saying, but trying to communicate nonetheless.
GA: Is there an attraction to the manualized approach from the supervisor’s point of view?
BM:
A manualized approach is easier than trying to train your students to be more reflective, or to examine themselves in terms of who they are as a person how that impacts their professional practice.
I think it gives supervisors a break in the sense that if you’re promoting a treatment manual approach, it’s much easier to go in there and say, “Okay, you followed these directions correctly. You could maybe have included these items on your agenda, or reviewed things in a different way, or implemented these particular kinds of cognitive challenges, or engaged in more of a Socratic dialogue.” A manualized approach is easier than trying to train your students to be more reflective, or to examine themselves in terms of who they are as a person how that impacts their professional practice.
GA: Easier in terms of the supervisor’s anxiety?
BM: Yes, absolutely.
GA: So it’s more comfortable for each party—the supervisee and supervisor—to presume this mechanistic view of a manualized treatment and technical rationality, but they’re missing so much juicy, nutritious, formative development. What are they missing there?
BM: From the model that I work from, I believe that what they’re missing are the personal aspects that really play a large part in this journey to becoming an effective psychotherapist. I like the idea of competencies and the competency movement, and I think it provides good kinds of behavioral anchors for various stages of therapist development, but what they’re missing is the journey and the process of what it takes to become an effective therapist. That’s where therapists need to integrate their personal identity with their professional identity. To look at who they are as a person, how that impacts their work in this field, how it impacts their relationships with their clients, how they can engage in reflective practice and be self aware in their interactions with their clients.

Especially from an interpersonal process orientation, how they can use their self-reflections, their feelings in the session, in the moment, in a way that’s effective and helpful for clients, by sharing their perceptions, by giving clients feedback in the moment—those kinds of interactions.

Are Counselors Selected or Grown?

GA: Congruence, immediacy, using their human instrument, being a real person, being integrated—that’s hard work. What is the process of that journey you’ve identified through your research. Since it needs to be personal, and folks can’t hide behind their manuals, isn’t the success of the work tied to the actual person of the therapist? In other words, are counselors selected or grown? Who do we keep and who do we kick out? Are they a tomato plant or are they a diamond in the rough?
BM: Well, to me they’re grown. I know a lot of people gravitate to our field because they believe that they have some natural helping abilities or skills; they’ve maybe been told by friends that they’re good listeners and whatnot, but I think while that can be a nice start for folks, we still need skills and abilities that only training can provide. Becoming a therapist is different than becoming a biologist, or an engineer, in that it requires self-examination and a very high level of self-awareness.
GA: Can anyone undergo that process successfully?
BM:
I do believe that people who are motivated to really want to help others can learn the skills to be effective in this field.
Yeah, if you’re willing. If you are motivated enough, then just about anyone can go through that process. People who are resistant to self-examination are definitely going to struggle in this field. If you’re suffering from a personality disorder, it’s going to be much harder to engage in that kind of self-examination and be insightful. But for the most part, I do believe that people who are motivated to really want to help others can learn the skills to be effective in this field
GA: So barring real outliers, if you engage in this process of self-reflection and vulnerable, non-defensive engagement with training, you’re going to develop these capacities for using yourself and therapy in a way that is effective?
BM: Yes
GA: What does it say about the field that many doctoral programs in psychology are harder to get into than medical school? I’ve seen one spot per 360 applicants at certain programs and there are all these aptitude requirements to set you apart.
BM: I think that is where we’re still very far behind. I never have believed that the traditional selection variables of college GPA and GRE scores have ever been predictive of someone’s interpersonal skills or abilities to interact personally on the level that we do as clinicians and therapists.

With my program, and I know others out there as well, we try to expand those selection variables a bit, but it’s still very difficult. We try to read into what could be some of those qualities through letters of recommendations or statements of purpose, or past life experiences, a kind of outlook—variables that just aren’t very easy to quantify.

The Developmental Approach to Supervision

GA: So you’ve expanded the selection criteria, you get the individuals selected for this privilege, then how do you balance the inherent dual relationship built into supervision? If someone is operating on your license, there’s a tension between oversight—where you have to think of client safety and liability and the reputation of your clinic—and the more humanistic, nurturing role of standing behind trainees when they make mistakes, which are essential to learning, but they also pose a liability. So how do you balance your gatekeeping role and your role as a supervisor tasked with nurturing their development?
BM:
We are thankfully moving away from the idea that to be an effective supervisor you just need to be an experienced effective clinician.
We are thankfully moving away from the idea that to be an effective supervisor you just need to be an experienced effective clinician. Over the past 30 years we have come to understand that these are very different domains. It’s taken awhile, as you can see from the just recently published supervisor competencies that the APA put out.

We now have more of a developmental approach to supervision. We know that beginners are going to be exhibiting certain kinds of qualities and have certain needs, versus intermediate or advanced trainees. It takes a skilled supervisor to assess where a given trainee is at developmentally and to provide the appropriate supervision environment that is going to enhance acquisition of skills—not only in terms of interventions, but abilities to be self-reflective, to develop as a therapist personally and professionally.
GA: How does a person go from a lay person, totally uninitiated through the whole journey of maturation to a great clinician?
BM: We look at three levels of psychotherapist development. At the beginning level we have trainees that are obviously just entering the field. It’s a novel situation for them and they’re typically highly invested. In most programs, probably 80% of your students want to be clinicians, even though we do obviously take a scientist practitioner kind of approach.

It’s anxiety producing for beginners, and as supervisors we need to help them reduce that anxiety, to help them take the focus off themselves early on during sessions and give them some structure and support. We focus on formulating relationships with their clients and learning those important listening skills.

Then we look at dependency versus autonomy. Obviously a beginning student is going to be very dependent upon their supervisor for structure, direction, and support. We look at self-awareness, both in the cognitive and affective realms and, again, a beginner is not going to be very self-aware in terms of how they come off in a session.

We believe that if you attend to the appropriate level of structure, direction and support, especially at the beginning level, that helps them progress onto an intermediate level.
GA: Let’s hang out at level one for a second. What could go wrong at that level?
BM:
Students get anxious. They feel like they need to do something, that listening isn’t enough.
Students get anxious. They feel like they need to do something, that listening isn’t enough. And that’s when they want to fall back on a manualized approach, but even a manualized approach, at least in my mind, is not going to be effective unless you have that base of all effective therapeutic intervention and that is the relationship. Things can go awry if students aren’t acculturated to the research about the therapeutic relationship being the basis of all later therapeutic intervention.

That’s the thing that I harp on the most, because I think that that’s what I see going awry the most. The lack of appreciation for developing those basic interpersonal skills early on.
GA: Really believing and internalizing that value, that this relationship is really important to cultivate.
BM: Yes, and that I need to effectively listen and communicate empathy.
GA: What about for the supervisor in this level? What can get in the way of them providing what the student needs at level one?
BM: Well, much like the therapeutic relationship, the supervisory relationship serves as the base of any kind of supervisor effectiveness as well. If for whatever reason the trainee and the supervisor don’t hit it off personally, the supervision isn’t likely to go well. I see that the most where the supervisor is not focusing in on the beginning trainee’s needs; they take an old line perspective that they shouldn’t be providing advice to their supervisees.
GA: Let them squirm. Encourage autonomy.
BM: Yeah, sink or swim. Or we’ll also see supervisors get hung up on their approach to psychotherapy and apply it to supervision. So if they’re very psychodynamic or interpersonally oriented, they want to get in there with the beginning supervisee and start processing with them, whereas the supervisee is really more concerned about what do I do with this client in the next session.

The Adolescent Stage

GA: So assuming all goes well and the supervisor is able to build a great supervisory dyad, attending to the person as an individual in an empathic way that builds a relationship and then providing structure to mitigate their anxiety and then the supervisee is able to get out of their own head, cultivate some self-awareness. They’re starting to be able to balance the focus on the clients, all that stuff. We move into a new intermediate stage.
BM: They then move into second stage or level two. At this point they’ve had some experiences with success in their interventions with clients and they’ve also had some failures. In other words, they’ve been through a couple of semesters of actually seeing clients and engaging in clinical work, so they have a greater sense of the complexity involved in providing psychotherapy. They’ve come to the realization that maybe it’s not as easy as they thought it might be.

It’s hard at times. Clients don’t come back and you’re left asking yourself what happened. Or the client is very resistant. In these cases, the supervisee’s motivation then can fluctuate—they start to question themselves and in some cases they might question whether they’re suited for this field because of some of the failures that they’ve experienced.

At the same time, hopefully they’ve had some success and so they want to develop a sense of autonomy or independence. They are becoming more self-aware. They’re not only able to focus on what they’re experiencing during the session, but they start to be able to focus in and sometimes at this level maybe a little bit too much towards what the client’s experience is.
A pitfall for students in the intermediate stage is that they can get a little bit overly enmeshed in their client’s issues.
A pitfall for students in the intermediate stage is that they can get a little bit overly enmeshed in their client’s issues.

This calls for a different kind of supervisory environment—one where you have to give them a little bit more autonomy. You do have to allow them to try out things that they’re interested in. Let them make some decisions. Of course, overriding all of this is the concern of client welfare, so you constantly have to monitor client welfare and make sure that ultimately your trainees are still following what you would see as required kinds of interventions in the interest of client welfare. But, they want to be able to come up with some more things on their own. They’re less dependent upon the supervisor. And so you’ve got to give them some leeway here.

They’re also more open to some examination of who they are as a person and how that impacts their clinical work. In fact, at this stage they really want that kind of self-examination. They want to look at transference, counter transference kinds of reactions and those kinds of implications because they’re getting a little bit more advanced in their abilities, their skills, their knowledge. So you have to be flexible as a supervisor and be able to assess where your trainee is at.

The analogy we draw is that it’s almost like dealing with an adolescent. They’re gaining some skills and perhaps they want to demonstrate their autonomy.
The analogy we draw is that it’s almost like dealing with an adolescent. They’re gaining some skills and perhaps they want to demonstrate their autonomy. If you can’t lighten up a bit, or deal with that kind of therapeutic adolescence, it’s going to create some resistance, and even some rebellion at this point. If you want to just stay with a completely structured kind of approach of always directing your trainee, we’re saying that that’s not going to work at this stage. You have to help them through stages or periods where they feel like their motivation is low because they’re discouraged with some clients or certain client types. You have to be able to identify that when you’re reviewing recorded sessions.

In that sense it does take a lot of work on the part of the supervisor to accurately assess and intervene with their trainees to foster their continued development as a therapist.
GA: It sounds like it could be a really rewarding time for everyone involved.
BM: Yes, absolutely. It can be very challenging, but ultimately very rewarding.
GA: So take me through level three really quickly.
BM: At this point, we’re probably looking at a trainee at the advanced stage of level two moving off into internship. Typically what we would see as a level three trainee is in my mind developed during that internship year.

They’ve kind of weathered that storm of level two in terms of that dependency/autonomy conflict and they’re able to pretty much operate at an independent level. Motivation is high. They understand the complexities of this endeavor of our field. They go into their work with an understanding that, yeah, there’s going to be successes but there’s going to be some failures, there’s going to be difficult clients. There’s going to be some client types or populations or diagnostic categories that I work best with and others that maybe just push my buttons and that I’ve got to be careful with.
GA: We can’t help everybody all the time.
BM: Exactly. They demonstrate that high level of self-awareness and self-insight on both cognitive as well as affective levels. They’re self-aware enough to know that if there’s something that isn’t working for them, if they need some help on something, or if they don’t have the experience in a given domain—maybe marriage and family therapy as opposed to doing individual therapy—they know and have the awareness to consult with somebody run it past their supervisor.

And they’re not going to be reluctant to do that. They just understand that that’s really part of what they need to do to develop their skills, and that ethically that’s what’s called for. Hopefully that occurs by the end of internship or is fully developed out there with some post-doctoral supervision. That’s what we envision as the advanced psychotherapist and one that hopefully develops into later years as a master psychotherapist.
GA: Talk about post-doctoral supervision, where you’ve got your degree but you’re not yet licensed because you still have 1500 hours to complete [in some states].
BM: Post-doctoral supervision used to be in name only. As long as you had an identified supervisor, it really wasn’t necessary to meet or document. Maybe if you had a problem or some questions you’d go and consult with your post-doc supervisor. It was also the norm that your post-doc supervisor just had to be a clinician with three years of experience.

I think we have made progress on that front, too. For example, APA and our programs now requiring training in supervision.
GA: Many programs still don’t require that, though.
BM: It puzzles me how programs can get accredited by saying that they offer a workshop on supervision, or they implement a module during practicum training. That’s really not enough, but I think that’s the case with the majority of programs.

In that sense I’m happy to see APA publish the supervisor competencies, which I think is going to help a lot. More strictly enforcing that APA requirement that all trainees receive training in supervision is going to help.
GA: What’s the risk of this all-lip-service post-doctoral supervision? What’s the pitfall of someone who says, “Oh, I’m level three, I’m done growing. I don’t need consultation.”
BM: Well, if an advanced trainee has that attitude, that’s definitely problematic. More often than not there are areas where they need to develop and to grow, as well as weaknesses they need to attend to.

We run the risk of just assuming that because someone has completed their coursework and internship and training requirements that that’s all there is. The journey does continue to becoming a master therapist and some of those qualities manifest themselves later down the road. Experience matters and learning doesn’t stop. You can always learn from a mentor at any point in your career.
GA: Forever.
BM: Yes, absolutely.
GA: In closing, pretend I’m your student and I am thinking about what to do with my career and I’m saying, “This supervision stuff is a lot of work. It’s not compensated very well. The field doesn’t seem to value it very much. I’m not sure I’m going to pursue supervision in my career.” How would you talk me into it?
BM: I would say that a lot of clinicians gravitate to training programs at the internship and post-doc level because it’s tough work to just be seeing clients all the time. It’s easy to get burned out just seeing clients.
Supervising can be a nice break, a way to stay current, and also just really enjoyable to have the opportunity to work with trainees.
Supervising can be a nice break, a way to stay current, and also just really enjoyable to have the opportunity to work with trainees. The relationship with trainees can be long-lasting, and you may get calls from them in the future for advice not just about clients, but about their careers or other aspects of their lives. It’s very rewarding to have the wisdom that you’ve developed over a number of years valued later on.
GA: I’m sold. We all must go forth and propagate quality supervision.

Any closing thoughts to share with our readers, your wisdom from these 30 years of studying this and experiencing it personally?
BM: Well, I listen to a lot of music, a lot of jazz. And I draw a lot of parallels for how we operate in the moment as clinicians, as supervisors based on our accumulated experience and skills. One of my idols, a jazz bassist named Charlie Hayden, passed away recently, and I remember reading an interview with him in which he said, “to be a good musician, to really communicate as a good musician, you have to be a good person.” What he meant was a good, humble individual who is willing to look closely at him or herself and implement that humility in their work.

I strongly believe that as clinicians, and by extension trainers and supervisors, that if we work on being a good person—and that can take many forms in terms of personal development, spirituality, etc.—it helps us to be good clinicians, good supervisors, trainers of our students. And it affects our clientele. So I tell my students all the time to be a good clinician, try to do your best to develop yourself as a good person.
GA: It’s been an absolute pleasure. Thank you so much for sitting with me.
BM: Thank you so much for the opportunity.

In Bed With Your Therapist: The Paradoxical Intimacy of Online Psychotherapy

Posted on by Psychotherapy.net Team

Online Therapy

When engaging in psychotherapy by Skype or other video conferencing system, clients will often keep their appointment even when they feel too sick or fragile to attend school or go to work. They reach out to their online therapist from the comfort of home, sometimes wrapped in blankets in a cozy chair, sometimes lying on a couch.

And sometimes, they will have their session from bed, cradling their on-screen therapist in their lap. As an occasional change of locale, it makes sense and is far better than missing the session.

Other clients actually prefer to hold their appointments in bed on a regular basis. Both authors have held continuing weekly sessions with men and women who connected with us from their bedrooms, usually clothed and lying on top of the bedspread, often leaning back against the headboard with pillows. The session venue a client chooses often makes a subtle statement, but our clients who take us to bed instantly get our attention.

Therapists in bed with their clients. It raises so many uncomfortable but fascinating issues. Does it mean we, as therapists, are failing to preserve good boundaries? Are we allowing our professional role to be trivialized? Is the erotic transference (or even more troubling, the erotic counter-transference) at work?

We believe that occasional sessions from bed can be useful, maintaining contact that might otherwise be interrupted by illness or some other factor. We have found that the choice of ongoing sessions from the bedroom provides important information, to be understood and made use of in therapy. Therapists need to pay ongoing attention to boundaries and transference issues, of course; but if we’re mindful, we can also focus on the purpose and meaning of this unusual choice—to take your therapist to bed.

Kyle and Lisa are two clients whose stories show how bed sessions can be both constructive and revealing.

Kyle and the Shame Spiral (Joseph Burgo)

Early in our work together, Kyle used to suffer from what we referred to as the "downward shame spiral." Fearing that he might humiliate himself at some upcoming event such as a job interview, Kyle would postpone that appointment at the last moment; but doing so only filled him with shame and made him dread the rescheduled interview even more, which he would subsequently reschedule once again with another feeble excuse, and so on, until the employer lost interest.

Eventually he would become so overcome with shame about his behavior, feeling himself to be a “total loser,” that he would retreat from the world and retire to his bed, often for days on end. Sometimes he would cancel one of our twice-weekly sessions at the last moment; on other days, he slept right through the hour and emailed me much later. Missing the appointments intensified his sense of shame and failure, which made it even more difficult for him to break out of the downward spiral. Overcome with shame, he couldn’t reach out to me for help.

I came to recognize when Kyle was on the verge of one of these retreats by reading his facial expression … or rather, his complete lack of expression when he appeared on screen. Kyle’s usual manner was quite lively and engaging; he had a good sense of humor and a compelling smile. In the grip of a downward shame spiral, however, his face looked deadened, as if it were numb. While he and I normally had a warm and friendly relationship, at these moments, he gave me an impression of complete indifference, as if he felt nothing about me. He seemed encapsulated and cut off from me. I could usually predict that he would miss the next two or three sessions.

Eventually, Kyle would emerge from his shame retreat, re-engaging with me and the world at large, though we never understood exactly why and how he recovered. It felt almost biological, as if he had to pass through a physiological cycle over which he had no control.

This state of affairs went on for six or seven months, with downward shame spirals kicking in every few weeks or so. As many times as I encouraged him to reach out to me, as warmly as I expressed my concern, nothing seemed to help him withstand the call of bed. I felt frustrated by the many missed appointments and wondered if I was really helping him. During one of our sessions at the end of this period, he came in with the “dead face,” as we referred to it, and I didn’t expect to see him for our second session later that week.

I nonetheless logged onto Skype at the appointed time to wait for him. A few minutes into the session, I received an email from Kyle. Running behind. With you in a few. I sat at my computer and waited. About five minutes later, Skype showed Kyle “online” and he soon initiated the call. My screen came to life. “Usually, Kyle would speak to me while seated at a table in his apartment, or sometimes in a small conference room at his workplace. Today, he was in bed, lying down so that his unshaven face appeared sideways in the screen.” His hair was rumpled. He still wore the dead face expression but at least he had shown up.

“Is this okay?” he asked. “I wasn’t sure if you’d mind my Skypeing you from bed but I couldn’t make myself get up.”

“You’re here,” I assured him. “That’s what matters.”

Kyle filled me in on the last couple of days. He had indeed fallen into a downward shame spiral after our last session and retreated to his bedroom. He’d cancelled some appointments and dropped the ball on some important commitments, but he didn’t want to remain in seclusion any longer. I could feel him searching my face for disapproval or judgment; I told him that I was very glad he had managed to keep our appointment.

Over the course of the session, Kyle shifted to a sitting position, his back against the headboard, with his computer positioned in his lap. Though not exactly lively, his expression no longer seemed completely immobile. By the end of the session, he had resolved to get out of bed after we signed off, and so he did. When he appeared on screen for his next session, he was fully clothed and in work mode.

The in-bed session was a transitional space for Kyle: allowing me into his place of seclusion helped him to bridge the gap and reconnect to his world. I considered it a sign of progress that he had reached out to me and indeed, over the next half-year, the downward shame spirals lessened in both frequency and duration. We conducted one or two more sessions from his bedroom, but eventually, the strength of our emotional connection allowed Kyle to keep his appointments no matter how badly he felt.

Eventually, the downward shame spiral became a thing of the past.

Lisa's Artist's Block (Anastasia Piatakhina Giré)

Lisa was an attractive woman in her late fifties whose marriage to a successful businessman allowed her to pursue her passion for art. The first time we met, Lisa was lying in bed, weak from a recent flu. A bright floral canvas appeared on the wall behind her. She told me she was a painter and proudly announced that she had her own “atelier” in her home. The painting on the wall was one of her own.

I enjoyed meeting with Lisa, even if the décor—the flowery bed linen and a bedside table with a pot of face cream on it—made me feel rather uncomfortable and aware of boundaries being crossed. “Lisa apologized for “receiving me in bed,” but didn’t look uneasy about it.”

At first glance, Lisa seemed to have everything a woman of her age could wish for: two grown children, a supportive husband, and a very exciting hobby. But she acknowledged a feeling of profound sadness and almost physical emptiness, which she could not explain or share with anyone else. In fact, for the past few months she had been unable able to paint and was actively avoiding her studio. Describing her artist’s block, unusual for her, made Lisa blush with shame.

As the weeks went by, she continued connecting for sessions from her bed. She looked perfectly healthy, with no signs of depression or any other debilitating condition. Unable to escape from that bedroom, my uneasiness kept growing and I gradually began to feel trapped.

What was Lisa trying to convey by “keeping me in her bed”?

When I finally shared with her my curiosity about her choice of place for our sessions, she at first seemed surprised. She had always thought that online therapy “was this thing you could do from anywhere.” Then we began to explore what “bed” represented to her. I asked whether it was a space she usually shared with her husband, Charles.

No, they had being living in separate rooms for the last decade as Charles’ sleeping problems kept him awake for most of the night. In the beginning, he used to make frequent visits to her bedroom; they would often stay in bed together, chatting and sometimes making love. Over time, his visits became increasingly rare; now, he would pass by her room with just a quick “hello,” moving on to his own bedroom. Sharing this for the first time, Lisa looked profoundly sad, her usual cheerfulness replaced by tears.

I understood that her bed had become a lonely place where she felt trapped, unwanted, and too old for sex. To express these feelings verbally, either to her husband or to me, her therapist, was far too difficult because she felt so ashamed of this “pathetic and needy” part of herself. Though Lisa couldn’t express her desire for sexual contact with her husband, was she unconsciously making me his replacement by taking me into bed?

I encouraged Lisa to take the risk and tell Charles how she felt. The confession took him by surprise: he had no idea that his wife still desired him and had assumed that she preferred him to keep his distance. Charles soon came back to visiting her bedroom regularly. Now that she had replaced me with a more appropriate “bed” companion, Lisa began connecting for sessions from her atelier, a far more suitable location for therapy.

For our last session, Lisa was dressed in her working outfit—clearly Charles’ old shirt, oversized for her. She was bubbling with a new energy, and announced to me that her artist’s block seemed dissolved, “gone by magic.” She was able to paint again.

Up Close and Personal

These two vignettes illustrate how online psychotherapy can facilitate progress and provide information that in-person sessions cannot, at least not as quickly. No doubt Kyle would eventually have made his way back to the consulting room after a shame attack, but the middle-ground of therapy-in-bed provided a helpful bridge. In all likelihood, Lisa would eventually have communicated her isolation and longing for intimacy to an in-person therapist, but without the visual setting that prompted her online therapist to probe deeper, it likely would have taken much longer.

In discussions of online psychotherapy, professionals and laypeople usually see it as second best to in-person therapy. After practicing in the online setting as well as in person for several years now, the authors have come to believe that it is neither better nor worse, but truly different. Experiences like being “taken to bed” by our online clients often provide a kind of insight that would never be available to a therapist seeing all of his clients in a physical therapy office.

We’ve also discovered a special intimacy that is idiosyncratic to online therapy. Even if both were sitting up, the in-person therapist would never see a client such as Kyle so intensely “up close and personal.” During an online session, the computer image often seems analogous to a movie screen filled up by an actor’s face, conveying high intensity anger or fear or shame to the audience. While in certain respects online sessions are less immediate than in-person psychotherapy, we have found them to be even more intimate, more emotionally evocative in this particular way.

Online sessions also allow a client like Lisa to show rather than to tell, and as any fiction writer will tell you, a vivid and visual scene more effectively engages the reader than straight narrative. Clients who connect from bed often show us something deeply personal and painful that would be much harder to narrate later during an in-person session. Consciously or not, they invite us to witness their personal world first-hand, to enter their story lines, so to speak, rather than hearing about them after the fact. This conveys to the online “here-and-now” a very distinct, moving quality.

Such moments of real intimacy and shared vulnerability are precious, helping us to forge a strong therapeutic relationship with our clients, even ones who may be thousands of miles away on another continent and who we may never actually meet in person.

This essay is condensed and adapted from the authors’ forthcoming book In Bed With Our Clients (and Other Adventures in Online Psychotherapy).

Birthplace

Posted on by Psychotherapy.net Team

There are places I’ll remember all my life.

—I was born in a small Russian town, a very cold and dirty place.

This was one of the first things Anna shared about herself in a long introductory email reaching out to me for online psychotherapy.

In this description of her native town, I could sense her sad childhood: a lack of emotional warmth and possibly some neglect.

The way people describe their early surroundings usually tells something significant about their life story.

We developed early bonds with our caretakers, but also with a place. We end up internalizing the qualities of the landscape or family house where we grew up.

Can we ever detach ourselves from our original place? Does it not persist inside us, long after the physical building has been knocked down?

Anna had left her native town early, to study and work in Moscow, and then she had moved abroad. Her departure had been more of an escape: eager to leave, she had barely said her goodbyes. Since then she had changed countries several times, and finally landed in London. But the original “coldness” and “dirtiness” had followed her, as a malevolent shadow from her past.

It was only our second session, and I was experiencing Anna as frozen and difficult to reach out to. She complained that no town ever felt good enough to her: “too cold” or “too dirty.” Through the videoconferencing, I could have a glimpse of her current London interior, which looked unsurprisingly impersonal and rather messy.

Anna’s restlessness was partly due to her conscious desire to find a more nourishing environment, but this was conflicting with a deeper sense of hopelessness and despair: she believed that such a place did not exist for her.

Even in a warmer and more welcoming country, she would always feel alienated by a feeling of guilt—as if betraying her birthplace, her motherland. That felt deeply wrong.

But at the same time, she could not feel belonging to this new and “better” place, she felt painfully “different.”

Deep inside she kept being “a girl from a dirty and cold place,” her life stained by it forever.

As often happens with expatriates, something shifted when Anna went back home for a holiday. We had an online session whilst she was there. As her face appeared on my screen, I was struck by how different she now looked: instead of her usual impeccable jacket, she was wearing a loose t-shirt; her hair was messy; and without make-up she looked younger.

This was a unique opportunity to accelerate the process.

She was staying at her parents’ flat—the very one where she had grown up, and was certainly getting in touch with some early emotional experiences of her childhood.

Internet connection is always bad here, so maybe we will need to switch-off the video at some point. She warned me, preparing a retreat in case the session triggered too much shame. She was also reminding me how “imperfect” her childhood place was.

Shame was indeed around for the whole hour, but Anna was brave enough to stay with it, and we managed to navigate through this experience together.

Using her laptop’s webcam, Anna finally showed me around. This was a real risk-taking, and I could appreciate how exposed and vulnerable she felt. The place was indeed muddled, and was a testimony of an un-nourishing childhood environment.

Anna’s mother, born just after the war, had been stockpiling all sorts of things, an aversion to discarding possessions which qualified her as a “hoarder.” Understanding her mother’s struggle helped Anna make sense of the level of messiness she grew up with, and the shame she was feeling about it.

That “back home” session actually was a turning point in my work with Anna.

She realized how much she was actually attached to her birthplace, with a painful loyalty that did not let her leave it completely behind.

Making a better sense of her mother’s mental condition, Anna was now able to re-evaluate her own relationship with her family home and her native town. This place was not her. It did not define her; it was rather a sum of her experiences, which had started in that town, but did not have to end there. And the latter was her choice—such an empowering realization.

Maybe a warmer place existed somewhere for her after all…?

Allan Schore on the Science of the Art of Psychotherapy

Posted on by rezendevknowfully.com
David Bullard: Allan, you are known for integrating psychological and biological models of emotional and social development across the lifespan. You’ve done a great deal of research and writing suggesting that the early developing, emotion-processing right brain represents the psychobiological substrate of the human unconscious described by Freud. Your work has been an important catalyst in the ongoing “emotional revolution” now occurring across clinical and scientific disciplines.

I’ve been watching my own process while getting ready for this interview, with a lot of left-brain work: reading, taking copious notes and thinking, and anxiously trying to figure out the structure for this interview. After all, it isn’t everyday one gets to interview a person called “the American Bowlby,” and whom the American Psychoanalytic Association has described as “a monumental figure in psychoanalytic and neuropsychoanalytic studies!” But essentially, this will be a conversation, and
I’d like to begin with a quote attributed to Jung, involving a graduate student who went to him, inquiring as to what he could do to become the best therapist possible. Jung said, —loosely translated—“Well, go to the library and read and study everything good that’s ever been written about the art and science of psychotherapy, and then forget it all before you sit down to peer into the human soul.”

It occurs to me, having followed your work for a while—most recently your writing about right brain communication in psychotherapy—that Jung’s quote may be partly what you’re writing about.
Allan Schore: Absolutely. The title of my book, The Science of the Art of Psychotherapy (2012), attempts to more clearly understand the relationship between the two, because on the one hand, as so much clinically relevant research now shows us, there is a science that underlies the clinical domain. And there is a certain amount of information and knowledge that we as clinicians must have in order to succeed in the particular area of expertise that we’re in—psychotherapeutic change processes.

Yet, at the same time it’s also an art, something that is extremely subjective and personal. For most of the last century it was thought that subjectivity was outside the purview of science. But we now understand psychotherapy changes more than overt behavior and language—it also acts on subjectivity and emotion. As you know, the left hemisphere is dominant for language and overt behavior; the right for emotion and subjectivity. This dichotomy fits nicely with left versus right brain functions. The two cerebral hemispheres process information from the outside—and inside—world in different ways: one from an objective stance, the other from a more subjective perspective. The two brains use different ways of perceiving the world and of being in the world.

Neuroscience has legitimized subjectivity in psychology and in therapy.
Neuroscience has legitimized subjectivity in psychology and in therapy. Both science and clinical theory agree that psychotherapy is basically relational and emotional, and so we now think that emotionally and intersubjectively being with the patient is more important than rationally explaining the patient’s behavior to himself. The core self system is relational and emotional, and lateralized to the right hemisphere, and not the analytical left brain. As we empathically “follow the affect” and facilitate the patient experiencing a “heightened affective moment,” we’re intuitively inhibiting the dominance of the left and “leaning right.”
DB: Can you speak more about how neuroscience is changing our understanding of the art of psychotherapy?
AS: Let me try to give a broad overview. In the critical moments of any session the patient must sense that we’re empathically with them. Research shows a difference between the left brain understanding of cognitive empathy and right brain bodily-based emotional empathy. In other words, we’re experiencing and sharing the patient’s right brain emotional subjective states, being with the patient rather than doing to the patient. In this therapeutic context we have to also be in the right brain to make therapeutic contact, and for the patient to make contact with her deeper emotions. Later we may engage our left brains to more cognitively understand the emotional state, but while we’re attempting to “listen beneath the words” in order to “reach the affect” and work with the affect we must, as Reik said, abandon “sweet reason” and “rigidly rational consciousness” and “abandon yourself” to intuitive hunches that emerge from the unconscious.

Intuition and empathy are right brain functions, and both operate at levels beneath conscious awareness. Bion said we must leave conscious expectation behind in order to really hear the whole patient. So getting back to Jung, he also said “Man’s task is to become conscious of the contents that press upward from the unconscious.”

These two different brains, the conscious mind and the unconscious mind, must work together. As my colleague Iain McGilchrist has shown, we are currently out of hemispheric balance. I think psychology has placed too great an emphasis on the conscious mind, and we are now challenging the long-held idea that reason must overcome bodily-based emotion. That the conscious mind needs to control and suppress the unconscious mind, that science and art are always in conflict, and that they would never mesh together. As I’ve written, with the ongoing interdisciplinary paradigm shift our perspective has changed, and not incidentally the gap between the practice and the theory of psychotherapy has really collapsed in the last two decades.

Getting back to your Jung citation, at the very beginning of our clinical education we’re learning techniques, and we’re learning the psychological science of psychotherapy. But as we learn our craft and gain clinical experience, ultimately the bulk of our learning comes from being with and learning from our patients—about them as well as self-knowledge. As I see it, our growing clinical expertise expands within the psychotherapeutic relationships we share with our patients. It’s what our patients are teaching us, if we are open to it. It’s not just about them and the deeper psychological realms within them. It’s at the same time becoming more familiar with the deeper core of our own self system. Being psychodynamically focused, this involves the use of both our conscious left and especially the unconscious “right mind.”

I believe that we’ve overvalued the analytic left mind. So lately I’ve looked more carefully at the neuroscience for the overt and subtle difference between the left and right brain/mind. This has shifted my clinical focus from the explicit to the implicit, from cognitive mental content to affective psychobiological process. I now see the change mechanism acting beneath the words—in process more than content. We now have a better idea what this process is about, and how relational interactions literally can change that process and thereby change character structure.

My idea about science is that we need to update ourselves about what is objectively known about the brain and what is known about the body, as well as “knowing” more about our own subjectivity. And that’s a continual journey. Fundamentally, our psychotherapeutic exploration of somebody else’s subjectivity, which is bodily-based subjectivity, is also an exploration of our own subjectivity. So, there are two types of knowledge here that really underlie psychotherapy change processes: the explicit knowledge of the broader biological and psychological scientific theories, and the “implicit relational knowledge of self and other.”
DB: Before we go any further, as a psychodynamic therapist, even a “neuropsychoanalytic” one, what might you say about your work to therapists who are using more directive methods, such as CBT and EMDR?
AS: The neurobiologically informed psychodynamic perspective that I use emphasizes a clinical focus on not only explicit conscious but implicit unconscious processes. All schools of psychotherapy are now interested in these essential functions that take place beneath awareness. And all are accessing attachment internal working models, which Bowlby said operate at unconscious levels and can be changed by therapy. So I’m interested in not only the patient’s overt behavior, but also her internal world, what cognitive scientists call internal schemas.

My work is fundamentally about how to work with affect, and so clinically I’m exploring with the patient not only conscious but unconscious cognition and, importantly, unconscious affect. The patient may have no awareness of what neuroscience is now describing as “unconscious negative emotion.” Research has now established that fear isn’t necessarily conscious; you can experience it without being aware that you’re experiencing it. So how do we detect these unconscious affects?

And then there’s the matter of the communication of emotions within the therapeutic alliance that are so rapid that they occur beneath conscious awareness. The alliance is a central mechanism in not only psychodynamic therapy but CBT, EMDR, experiential, body psychotherapy, etc. This gets to what used to be called the common factors that impact all forms of treatment. I’m interested in the change mechanisms that occur in all psychotherapeutic modalities, but especially in the right brain, which is dominant for emotional and social functions and stress regulation.
DB: But let me get in a question for the people who may not have had much exposure to the kind of neuroscience and the neuropsychoanalytic approach that you’ve written so much about over the last two decades. At basic levels, you say that right brain development is much more rapid in the newborn, or in the developing fetus even. Can you address those implications?
AS: Let me just go wide for a second and then we can kind of dive in here, because the truth of it is that the last two decades have been remarkable in terms of the changes in the field of psychology across the board. I’m thinking about the early ‘90s when there was a huge split between researchers and clinicians, where there were divisions within the different schools of psychotherapy, and where the focus was very much on verbal content of the session. Although there were breaks away from classical psychoanalytic theory, the focus was still on undoing repression, making the unconscious conscious, and with interpretations being the major vectors of the treatment. Emotion really had not come into the forefront. But that’s the key to the change.

Over the ‘70s we had been moving into a behavioral psychology and from that to a behavioral psychotherapy. Then it transitioned into a cognitive psychology where suddenly, we went beyond just overt behavior and into covert cognition, which became a legitimate field of study. Out of that came cognitive behavioral therapy and then in the ‘90s the emotional revolution, as it’s been called, began, which posited that affect is primary, as well as affect regulation. And that’s where my studies really began, in the early 1990’s.

The Reemergence of Psychoanalysis

DB: Did you have much contact with psychoanalysts Joe Weiss and Hal Sampson in San Francisco who founded a psychotherapy research group and developed Control Mastery Theory?
AS: Not contact, but I was well aware of them and I’m pretty sure they were aware of me.
DB: They were.
AS: Their work has held up, and its impact continues. There’s now an intense interest in gaining a deeper understanding of what used to be called the non-specific mechanisms of change, in all forms of psychotherapy. They were onto that really early.

My first book, Affect Regulation and the Origin of the Self, tied together the social-emotional change processes in early development and in psychotherapy. This was in 1994 and, incidentally, the term “self” was not being used that much back then. Psychodynamic people were still more or less using the term “ego” rather than “self.” As I’m sure you’re well aware, Jung had put his money on “self” and was much closer to describing the core system than Freud’s “ego.”

The early developmental models of the time were dominated by the cognitive models of Piaget.
Everyone had been attempting to try to squeeze Piaget into a psychotherapeutic mechanism. It proved to be kind of an awkward fit.
Everyone had been attempting to try to squeeze Piaget into a psychotherapeutic mechanism. It proved to be kind of an awkward fit. Emotion was the key to attachment.

And so the subtitle of my book was The Neurobiology of Early Emotional Development. That same year Antonio Damasio had come out with his book Descartes' Error, and the whole idea of emotion, which had been ignored by science, began to come out of the closet.

Twenty years later it’s well established that emotion is primary in early human development, that affect dysregulation lies at the core of psychopathology, and that affective communications are essential in all forms of psychotherapy.

The second area of basic change is the matter of the interpersonal neurobiology of attachment—a shift from the intrapsychic to the interpersonal. Many people had been looking at attachment theory, but even attachment theory was hard to anchor clinical process in. That had to be worked out: other than the “strange situation” and the AAI [Adult Attachment Interview], how were clinicians going to use Bowlby’s attachment theory and information about early development? That has been a remarkable change. Now just about every clinician has some understanding of the centrality of early development and how that interpersonal developmental mechanism plays out in the therapeutic relationship.

Indeed, early development really has come into the fore in all forms of psychotherapy, with all patient populations.
Interpersonal neurobiology—how early relationships shape the brain—has transformed attachment theory.
Interpersonal neurobiology—how early relationships shape the brain—has transformed attachment theory. This transformation from what I call “classical attachment theory” to “modern attachment theory” focuses on not only regulation but also dysregulation and ideas of psychopathogenesis, which have also been major themes of my work. My efforts have been to generate a more integrated theory of mind and body, of psychology and biology. In essence I’ve attempted to synthesize these fields in order to create a coherent psychobiological model of how the self develops, how dysregulation and disorders evolve, and then ultimately how to treat these disorders.

A couple of other things to mention: another change over the last two decades has been the reemergence of psychodynamic theory and the revitalization of psychoanalysis, the science of unconscious processes. It took a while, because as you know, classical psychoanalysis was seen as apart from science, and was cast out of academia for a long period of time.

But this reemergence has paradoxically been fostered by neuroscience, and its interest in rapid implicit processes. Neuroimaging research has established that most essential adaptive processes are so rapid that they take place beneath conscious awareness. I’ve suggested that the self system is located in the right brain, the biological substrate of the human unconscious. This differs from Freud’s dynamic unconscious, which mainly contains repressed material, banished from consciousness. At any rate there is now great interest in implicit unconscious processes, and I think we’re now coming back to a modern expression of psychodynamic theory. Indeed all forms of therapy are now looking at right brain to right brain transference and countertransference communications, and how these are expressed in the therapeutic alliance, beneath the words.
All forms of therapy are now looking at right brain to right brain transference and countertransference communications, and how these are expressed in the therapeutic alliance, beneath the words.



One other major change has been the rediscovery of brain lateralization, and the appreciation of the different structural organizations of the right and left brain. Each has different critical periods and growth spurts, and ultimately different specialized functions. For me the terra incognita literally has always been the early developing right brain, the unconscious. More so than the surface conscious mind my interest has been in deeper early forming nonverbal bodily-based survival processes. I became especially interested in how we could bring these survival processes into the open, and how these could be studied. As a clinician-scientist, everything that I’ve authored has had to be clinically relevant. It has to fit the way that I work with my patients, as well as scientifically grounded. My theories are heuristic, and not only open to research but able to generate experimental hypotheses that can be tested.

Hemisphericity

DB: You’ve spoken of the left brain being verbal, rational, and logical, but of the right brain actually having verbal aspects also. How would you describe the verbal capacities of the right brain?
AS: The first person to bring up the idea that all language is not only in the left hemisphere, just for the record, was Freud in 1891 in On Aphasia, which still is studied by neurologists.
Right hemispheric language creates the intimate feeling of “being with.”
But the idea that everything that is verbal has to, by definition, reside in the left brain is still held by many people. Current neuroscience shows this is not the case. The right also has language. The right stores our own names, and processes emotional words. Prosody, the emotional tone of the voice, is right lateralized, as well as novel metaphors, and making thematic inferences. So when a patient all of a sudden is in an emotional state and is using an emotional word, the right is tracking that also. Right hemispheric language creates the intimate feeling of “being with.”
DB: And humor is known to be more right brain?
AS: Absolutely!
DB: And it kind of “wakes up” our left brain with recognition?
AS: Yes. Because the processing of what is familiar is left and the processing of novelty is right. Essentially we’re looking for, not the bottom line preexisting truth, but for the ability to process novelty, especially novelty in social emotional interactions. And for many patients intimacy is novelty. So, yes, anything that is new pops into the right brain first, and you actually get bursts of noradrenaline in the right hemisphere, the hemisphere that is dominant for attention. In fact, I’m now citing studies which indicate that the highest levels of human cognition—the “aha” moment of insight, intuition, creativity, indeed love, are all expressions of the right and not left brain.
DB: It’s in the right, but we don’t know about it until it shows up in the left. The right brain lets us know what’s actually going on, especially in the body, and in the deeper core of the self.
AS: Correct. Essentially, the left has the illusion that it has just discovered something new, but the truth of it is the right has discovered it, and now the left is putting into words what the right just found out about the self, especially in relation to other self systems. My colleague Darcia Narvaez is showing that morality is also a very high right brain process. A body of research indicates that the right is dominant for affiliation, the left for power.

This gets into some of the matters that Jung and others were talking about— these very high symbolic mechanisms are in the right hemisphere. Here’s another example of how neuroscience has changed our ideas about the human experience. It used to be thought that all symbolic processes are a product of the verbal left brain, so the goal was to get the patient to use words, and once there was conscious verbalization, then the patient can understand, and then the unconscious becomes conscious and change occurs. We’re now saying that’s not quite the case. The ultimate expression of the right brain is a conscious emotion. The ultimate expression of the left brain is a conscious thought.
Becoming aware of our bodily-based emotions is more essential than becoming aware of our thoughts.
Becoming aware of our bodily-based emotions is more essential than becoming aware of our thoughts.

The right brain and the unconscious mind are more connected into the visceral body. As you know the body has been rediscovered in the last couple of decades. And that’s been an enormous change for psychology and psychiatry.

Trauma and Development

DB: Would you say that has been driven through the clinical work, research and writing on trauma?
AS: Partly that. But also the developmental work on attachment theory and attachment trauma. Clearly, modern trauma theory, which did not really exist until around the late ‘90s, has also been one of the important transformations of the last two decades—the idea that “the body keeps the score,” as Bessel van der Kolk put it. But even beyond that, I would suggest it’s the re-discovery of the autonomic nervous system that is the major player here. It’s now an accepted principle that in order to understand the human experience it’s not just the voluntary behavior of the central nervous system, but also the involuntary behavior of the autonomic nervous system—mind and body. And that’s why much of my bodily-based attachment model involves the autonomic nervous system. The mother is literally a regulator of crescendos and de-crescendos of the baby’s developing autonomic nervous system.

These same bodily-based processes are also involved in the therapist’s right brain psychobiological attunement to and regulation of the patient’s emotional states. So the body has now embedded itself into the core of models of subjectivity—an embodied subjectivity which is not just an abstraction of the left brain, but right brain processes. The body is now seen as essential to right brain to right brain intersubjectivity. In my own work I’ve argued that this conceptual advance has impacted clinical models, such as somatic countertransference—the therapists’ own bodily reactions to patients’ conscious and especially unconscious communications. Also, there is the idea that a major function of the therapist is to regulate the patient’s autonomic arousal, a clinical concept that has challenged the older idea of neutrality, and that expands the previous concept of containment. This perspective attends more to right brain unconscious process than left brain conscious content. Once again, these scientific advances have transformed our clinical models.
DB: Wouldn’t another major transformation be what I heard you saying in a recent workshop: that the very disruptions of intensive therapy allow the repressed traumatic developmental relational issues to come to the surface, and if they’re dealt with properly, there then is healing?
AS: Absolutely the case. Except not “repressed,” but dissociated. There’s also been a shift in defenses, from an earlier clinical model that emphasized insight and the undoing of repression, a model of therapeutic action based on bringing to the patient’s consciousness repressed unconscious material.
Trauma theory emphasizes working with the deadening of affective consciousness by this other bodily-based survival defense, dissociation.
Trauma theory emphasizes working with the deadening of affective consciousness by this other bodily-based survival defense, dissociation. Clinicians are learning to differentiate the two and recognize the latter.

But, yes, the idea about disruptions and repairs came out of the developmental data and was incorporated into my modern attachment theory. My writings emphasize that rupture and repair, both in the developmental and psychotherapeutic contexts, involve important opportunities for interactive regulation of dysregulated affective states.

At the most fundamental level I’m interested in the mechanisms of change, especially in the early developing right brain self system. To use an earlier language, what I’m exploring is how the object relational sequences between the mother and the infant shape emerging psychic structure. In more modern terms these are investigations of interpersonal neurobiology. An interpersonal neurobiology of human development enables us to understand that the structure and function of the mind and brain are shaped by experiences, especially those involving emotional relationships, and to understand how brains align their neural activities in social interactions.

The tie in from my developmental work to my clinical work is that the same right brain to right brain social emotional processes that are setting up between the mother and the infant later play out in the therapeutic alliance. The model links the right brain growth in early development with later changes in the social/emotional context. And as you pointed out rupture and repair are potential contexts of emotional growth. So I’ve paid attention to the work of other developmental psychoanalytic researchers like Beatrice Beebe and Ed Tronick and Karlen Lyons-Ruth, who are also studying ruptures and repairs.

In my most recent writings I’ve focused on the essential role of these repairs in re-enactments of attachment trauma, which really is at the heart of the therapeutic change mechanism. I’m describing how both patient and therapist co-construct both the rupture and the repair, and that these ruptures are not technical mistakes, but literally—
DB: —the universal disappointments that are part of human relationships, and the repairs being the paths of healing?
AS: Beautifully put. Enactments represent communications of previous ruptures that triggered negative affects so intense and so painful that they were dissociated and banished from consciousness. As the therapy progresses and the attachment bond in the therapeutic alliance strengthens, there is enough safety for the patient to dis-assemble the dissociative defenses and let the affects come online more frequently. And then, what has been buried and packed down underneath dissociation surges into bodily awareness in the presence of a regulating other, now offering a possibility of interactive repair.
What has been buried and packed down underneath dissociation surges into bodily awareness in the presence of a regulating other, now offering a possibility of interactive repair.
Jung, who studied dissociation, described how the enduring emotional impact of childhood trauma “remains hidden all along from the patient, so that not reaching consciousness, the emotion never wears itself out, it is never used up.” He also stated the trauma may suddenly return: “it forces itself tyrannically upon the conscious mind. The explosion of affect is a complete invasion of the individual. It pounces upon him like an enemy or a wild animal.”

In my model of “relational trauma” I’ve suggested that it’s not just misattunements that lead to the traumatic predisposition. It’s also the lack of the repair, and that repair and interactive regulation requires a very personal, authentic response on the part of the therapist. Attachment trauma was originally relational, and so the healing must be relational, a mutual process. In Sullivan’s words, the therapist is not neutral and detached, but a “participant observer.”

Love, Repair, and Deepening Love

DB: Okay, can you take what we are talking about and even apply it beyond therapy to other intimate relationships? Could you actually say to a couple that it’s in the very upsets that they have that, if they could approach it in the right way, they’ll have a window into learning about some of their earlier wounds or traumas, and be able to heal them?
AS: Obviously the original context of attachment trauma was a very intimate context. I mean the relationship between the mother and the infant defined an intimate context. Her ability to down regulate negative affect in rupture and repair and up-regulate positive affect in mutual play shaped the attachment bond and the infant’s developing right brain. In a secure attachment the intimate context is characterized by mutual love, and over the course of my studies I’m increasingly using the term love to describe the intensity of the emotional bond. This is more than just pleasant affect. This is intense emotion.

And that love, incidentally, between the mother and the infant also is the mother’s ability to pick up communications that are not only joy but also distress and to be able to hold and to feel that in herself, and then to regulate that and communicate back to the baby.

The idea about being able to hold the pleasure and the pain really is the key to this. In the cases of other intimate dyads, this also applies. A number of clinicians are now focusing on the same right brain psychobiological mechanisms in couple’s work. The couples’ therapist who is working with attachment is able to hold the dyad, to regulate each member of the dyad. She’s also facilitating and reading nonverbal emotional communications within the dyad, and bringing to awareness affective moments in which they are engaging and disengaging, and switching between various emotional states.

The therapeutic action with couples is to allow each member to become more aware of these rapid automatic processes, and how each is communicating or blocking transmissions from the other. As always the clinical principle is to follow the affect, especially authentic affect, whether positive or negative. And again, rupture and repair are important contexts for right brain development and emotional growth. But even beyond couples therapy, interpersonal neurobiology and affective neuroscience are now being incorporated into group psychotherapy. The focus is on what group members are communicating beneath the words, at conscious and unconscious levels, and how right brain emotional communications and regulatory transactions are occurring in the group relational context.

So, although the emotional contact between humans originates in the mother-infant dyad, it ultimately becomes the way in which individual human beings communicate with other human beings. These deeper communications and miscommunications have little to do with left-brain language functions. They have more to do with right-brain abilities to nonconsciously read the spontaneous facial expression, tone of voice, and gestures of other humans.

Self-Regulation, Co-Regulation, and Buddhism

DB: Are Buddhist ideas of the self/nonself of interest to you? Or do you get all you need from psychoanalytic thought and neuroscience?
AS: Most of my ideas about the self come from neuroscience and psychoanalysis, including Jung and others. But the idea of self/nonself and multiple self states have been a focus. In current relational psychoanalytic writings the concept that comes closest to my own is Philip Bromberg’s idea about multiplicity of self-states: that we all have a variety of self states associated with different affects and motivations. Some of these are operating on a conscious level, others of these on unconscious levels. He calls these latter states “not-me” states as opposed to “me” states (a concept he borrowed from Harry Stack Sullivan).

Depending upon context we nonconsciously switch through these states. Each of these self states is tied into a motivational system (fear, aggression, shame, depression, joy etc.). In other words, when threatened, the fear motivational system is triggered. My right brain is attending to and tracking the external threat outside. In that self state noradrenaline and adrenaline is higher, cortisol is elevated, the physiology and attentional systems are altered. The memory system is also altered. When the threat passes or I’ve regulated and coped with it, I become relieved and switch into another self state, say a quiet alert state or a positively valenced exploratory state. So due to self regulating mechanisms we switch through these self-states. Resilience and flexibility is the adaptive ability to fluidly switch depending upon what is occurring in the context and what is meaningful at that point in time.

On the matter of Buddhism’s concept of self—that self state of consciousness that is associated with meditation, as I understand the concept, aims to control and still the fluctuations of the mind. The self (mind, awareness) identifies itself with fluctuating patterns of consciousness. Yoga, for example, is a form of mastering or eliminating such fluctuations and the attainment of stable concentration of attention and non-attachment to sensory experiences. With practice a change from evaluative to non-evaluative self-monitoring occurs during meditation. That said, neuroscience studies show that “compassionate meditation” does have more of a right brain, limbic focus.

I’ve written that self regulation can take two forms: interactive regulation in affiliative interconnected contexts, and autoregulation in autonomous contexts. In yoga the meditating self is acting as an autoregulatory system. My interests in development and in psychotherapy are relational, so I’ve been more interested in interactive regulation that occurs between human beings.

That said, the key is being able to switch between these two modes of self regulation. Both of these derive from the early interactive regulation of the attachment relationship. Going inward to control emotion is different from reaching outwards to others at moments of loss or joy. The inability to emotionally connect with others is at the core of any relational affect focused psychotherapy.
As I look at the significant problems of the larger world I’m convinced that we need more connection, not separation and autonomy.
As I look at the significant problems of the larger world I’m convinced that we need more connection, not separation and autonomy. For me, where we are in this world right now, really what we desperately need, what’s being thinned down on a daily basis, is this capacity for interactive regulation.

We also have the problem that the US and Western cultures emphasize the value of autonomous and independent personalities; they are highly valued over interdependent ones. As I mentioned, the left hemisphere is associated with power and competitiveness, the right with affiliation and pro-social motivations. So, again, that’s the reason why I’ve been more interested in the higher right hemisphere, which processes not only emotional states and higher cognitive functions, but spiritual and moral experiences. It is here in the right where the self is transcended, where the self becomes larger and expanded. In these states the grandiosity of the self literally is collapsed down and there is some understanding that one is part of a much larger organism, a much larger sense of being alive. This sounds like the Buddhist autoregulatory self state.

But let me repeat, interactive regulation is the key to the therapeutic alliance. There is now a push into the relational trend in all forms of psychotherapy. Actually in psychoanalysis the relational emphasis has always been there. I’m thinking of Ferenzci, Jung, Kohut and more recently relational intersubjective psychoanalysis. This relational trend now is coming into mainstream psychology, and is seen as the central mechanism of psychotherapy.

I point this out because psychologists on the one hand can be teaching meditative skills, but can also be accessing relational expertise in the therapeutic alliance.
DB: But they better also have those mindfulness skills themselves so they can be present to receive all of what’s coming in the interaction rather than kind of stereotypically looking through these variety of theories or thinking of what to do next or how to be.
AS: Right. But I suggested that a certain form of mindfulness, including a bodily awareness, must take place in a relational context. The idea being that there are certain parts of the self that cannot be discovered, that cannot come into awareness, unless they are being mirrored by another human being.
DB: Ah! So it’s not just that the relational trauma that gets dissociated can be healed through the relational—there’s a Yiddish term "fargin" that means, “joining someone’s joy.” I love that concept.
AS: That’s a great cultural metaphor—sharing someone’s joy as well as pain.

A Third Subjectivity

DB: So there may be feelings that you are not going to fully experience until you see them mirrored in a reciprocal emotional interaction.
AS: Exactly. One of the central concepts that I’ve written about is resonance. In physics, a property of resonance is the tendency of one resonance system to enlarge and amplify through matching the resonance frequency pattern of another resonance system.
It’s more than mirroring, it’s an intensification of positive arousal and thereby an energetic mechanism, which is a form of interactive regulation.
In psychology, a state of resonance exists when one person’s subjectivity is empathically attuned to another’s inner state, and this resonance then interactively amplifies, in both intensity and duration, the affective state in both members of the dyad. This resonance can occur rapidly at levels beneath conscious awareness, and it generates what has been called “a third subjectivity.” For example, in mutual play states dyadic resonance ultimately permits the inter-coordination of positive affective brain states, shared joy, which increase curiosity and exploration.
DB: What you just described might also be related to what my Zen friends call “one mind.” There’s a great quote sometimes attributed to e.e. cummings about this: "We do not believe in ourselves until someone reveals that something deep inside us is valuable, worth listening to, worthy of our trust, sacred to our touch. Once we believe in ourselves we can risk curiosity, wonder, spontaneous delight or any experience that reveals the human spirit.”
AS: Yes, again, it’s more than mirroring, it’s an intensification of positive arousal and thereby an energetic mechanism, which is a form of interactive regulation.
DB: And it’s also accounting for my increasing enjoyment of this interview versus a little bit of anticipatory anxiety about talking with you in the very beginning. But it quickly became exceedingly enjoyable.

Can you discuss the variability of people in terms of quiet versus very active internal experiences—either auditory and verbal, some other form of thought, or visually active consciousness in contrast to people who have a naturally occurring or developed quiet mind?
AS: Sure. The first thing that comes to mind is what has been termed as “the quiet alert state.” This is the flexible state that the mother accesses to pick up her infant’s varying emotional expressions. It’s associated with a state of autonomic balance between the energy expending sympathetic and energy conserving parasympathetic branches of the autonomic nervous system. Within attachment communications the caregiver sets the ranges of arousal, the set points of the infant’s resting quiet alert state. It’s relationally tuned, and later affects the individual brain’s default state. In other words, regulation is the key to the quiet mind.

But I’m also thinking about right and left hemispheric balance, and individual differences in “hemisphericity.”
There are individuals for whom that chatter is always so intense, so continuous, and even so loud they cannot quietly be with themselves. They can’t tolerate internal silence, and so they can’t monitor what’s coming from the body and from deeper strata of the unconscious.
For example, in a resting state greater right hemisphericity is associated with a history of more frequent negative affect, lower self esteem and difficulties in affect regulation. Greater left hemisphericity, on the other hand, is associated with heavy inhibition of the right brain, repression of emotions, and over-regulation of disturbances. Consciousness is dominated by continuous left brain chatter, and thereby an inability to be emotionally present, to be “in the moment.” There are individuals for whom that chatter is always so intense, so continuous, and even so loud they cannot quietly be with themselves. They can’t tolerate internal silence, and so they can’t monitor what’s coming from the body and from deeper strata of the unconscious. They’re always in a state of “doing” rather than “being.”
DB: And they have difficulty experiencing their bodies and can’t even tell you what they’re sensing, or maybe even how they’re feeling because it’s just pure thought.
AS: Right. When it comes to emotion and emotion dysregulation, for a long time people were thinking only about under-regulation, that the emotions are so powerful and so strong that they interfere with the logical and rational capacities of the left hemisphere. But there is also another problematic state—where it’s over-regulated. In that case the person is habitually packing down emotions, out of awareness, and whose left hemisphere is so dominant that it’s always “in control.” They “live in the left,” and use words to move away from affect. They’re talking about rather than experiencing emotion, from the other side of the callosal divide, not actually allowing themselves to disinhibit the right and to feel what is in the body. And yet, “the body keeps the score.” In the most extreme cases they’re dissociative and alexithymic.

These are patients who use words in order not to feel; they are over-inhibited and susceptible to over-regulation disturbances. Think about overly rational, insecure, avoidant personalities who overemphasize verbal cognition and dismiss emotion. Returning to our earlier discussions of recent changes in the science of affect, dysregulation can be either under-regulation or over-regulation, an avoidance strategy versus an anxious strategy.

Imagery

DB: Coincidental with that, I’ve noticed there are people, such as myself, who are minimally or not at all visual in their memory. Aldous Huxley described this about himself in Doors of Perception. If I were trying to visualize my living room, I would say it’s like 10% clear.

Other people I know are eidetic or photographic in their imagery. People who have that kind of visual memory can also have vivid imagery intrusively interfere in the present, where a person would be walking downtown and, instead of having a thought or worry that a bus might hit a particular woman, he would see the bus hitting her. Or he would visualize a building falling down—all-intruding upon his peace of mind, as you can imagine.
AS: A few things come to mind from your observations. The classical idea of brain laterality is that the right processes visual and spatial images while the left is involved in language.

But when it comes to imagery, the truth is we forget much of the time that imagery can be in any modality. We usually think about the visual image, as in your example of someone having an image of a bus hitting a pedestrian, or a building falling. Or a patient will come up with metaphors that are loaded with visual images. Also think of visual images of faces, especially emotionally expressive faces. But imagery can also be auditory—as when our consciousness becomes aware of a song melody or olfactory images, of an emotionally evocative smell or odor.

So, for those of us who are highly auditory, like both of us, we used to think that was verbal. But as you know, there are nonverbal auditory cues. Aside from the verbal content the voice itself is communicating essential information, even more important in an intimate moment than the verbal. Most psychotherapists are highly auditory and attuned and very sensitive to even slight changes in the prosodic tone of voice of the patient. It’s at that point where we will lean in, so to speak. But we also use our voice as a regulatory tool. In a well-timed moment we intuitively and spontaneously express our calming and soothing voice, or at other times we’ll come in with a more energizing voice, or even a limit-setting voice. Or we’re expressing an auditory metaphorical image.

So I think that when we talk about imagery, especially emotional imagery, we’re usually thinking of visual images. But there also are tactile images. As in an image of what it feels like at this moment, including what it feels like in your body and in my body, because I can pick this up and put that together with another’s facial expression.

But also there’s a difference between implicit visual recognition and explicit visual recall. I may not be able to have a conscious memory of a visual representation. But if there’s a subtle change in an emotional expression on a patient’s face, I can pick it up quickly. And let’s remember that when it comes to processing the meaning of nonverbal facial and auditory expressions, this is not occurring at conscious awareness. These interpersonal cues that denote changes in affects and subjectivity are detected and tracked by the right amygdala, at levels beneath awareness. Again, we’re listening beneath the words, and these signals are triggering unconscious memory systems of various sensory modalities—auditory and tactile, as well as vision.
DB: Hmmm, it just struck me that I often say that I’m not visual. But I must be visual in my right hemisphere because I have these wonderful, clear, visual dreams.
AS: I agree. Remember with the right brain, you’re talking about not only long-term visual memory, but also ultra-short working memory, what has been called the visuo-spatial sketchpad. We hold a momentary image in consciousness long enough to see if it matches with our memory of affectively charged personally meaningful experiences. At a reunion, when you emotionally see your daughter’s face your right brain can immediately detect that there’s something wrong, or that she’s experiencing shame or joy. That right brain function is essential to our ability to be in close relationships. Someone who is mind-blind to facial expressions will have problems with intimacy.

Alone in the Presence of Another

DB: I think back to your former student and couples therapist Stan Tatkin, who has made the point that our partner often knows things about us by looking at our face before we’re aware of what we are feeling, which brings us back to the reasonableness of trying to grow with affect co-regulation versus only self-soothing and all of that through meditation. But is there a name for something that would be like co-meditating? I know we’re talking about co-regulation.
AS: Well now I’m thinking about Winnicott’s idea about being alone in the presence of the other. Remember?
DB: No!
AS: Winnicott talked about the child in the second year achieving a complex developmental advance—the adaptive ability to be alone, and the creation of true autonomy. That is, to be separate, to be processing one’s own individuality and one’s own self system in the presence of another. The other is a background presence, so it doesn’t get swept into the child. But they’re literally both individuating in their presence together. And this is a kind of silent being together without having a need to take care of the other or support the other, of literally that kind of comfort.

So, on the one hand there is the joining of joy, which would be more active so to speak. And on the other hand there is this idea about being alone in the presence of the other, which is more passive. The self-system has stability at that point in time. It can shift out of that state if it needs to, but again, I would suggest to you that comes close to what you’re talking about. And that gets into the importance of solitude, the importance of privacy, which in this day and age is being completely forgotten. The poet Rilke said so eloquently, “For one human being to love another, that is perhaps the most difficult of all our tasks, the ultimate, the last test and proof, the work for which all other is but preparation. I hold this to be the highest task for a bond between two people: that each protects the solitude of the other.”

Repair in Relationship, and Returning to the Matter of Love

DB: I wonder if you would agree with a quote from Kierkegaard when he said "perfect love is learning to love the very one that has made you unhappy.” Does that resonate with you at all?
AS: Absolutely the case.
DB: Anything that you would modify?
AS: In my recent lectures I’m describing the interpersonal neurobiological emergence of mutual love between the mother and infant. Studies on the functional neuroanatomy of maternal love document that the loving mother is capable of empathizing and feeling in her own body what the baby feels in his body, whether it be a joy state as well as a pain state. When the securely attached mother is in the fMRI scanner viewing emotional videos of her infant in a joy state or in a cry state, positive emotions such as love and motherly feeling coexisted with negative ones such as anxious feeling and worry in the mother herself.

Other studies show that insecure dismissive-avoidant mothers cannot hold the distressed baby’s painful negative states. The narcissistic mother only stays connected when the baby is mirroring back a positive state, and is unable to tolerate and repair shame states. So this ability to hold onto both positive and negative affect, and not engage in splitting is essential. In fact, in developmental studies, Ed Tronick has shown that even the secure mother is only attuned about 30 percent of the time. The key is not only the misattunement, but the interactive repair. These misattunements are common—my colleague Philip Bromberg describes frequent collisions of subjectivities within an intimate dyad.

Returning to our earlier discussion, it’s the ability to interactively repair these collisions that allows for the strengthening of an emotional connection between an intimate couple. Clinically, it’s the emerging ability of the therapeutic dyad to co-create and co-regulate ruptures that allows us to tolerate the negative transference and strengthen the positive transference—to move together from positive to negative and back to positive affective states. That really strengthens the bond and it leads to resilience. For me that’s what Kierkegaard’s intuition is describing.
DB: Ah.
AS: But while the moments of emotional connection are important, so are the moments of shared solitude, of being alone in the presence of the other, moments of shared silence. It’s very limiting to think that everything has to be filled with words or interpretations.
For some therapists, when there’s too much silence they’ll start to fill it up with words, for their own regulatory needs.
For some therapists, when there’s too much silence they’ll start to fill it up with words, for their own regulatory needs.You know, for some therapists, when there’s too much silence they’ll start to fill it up with words, for their own regulatory needs. The matter that I’m raising here is that attachment is about the capacity for intimacy. Are intimacy and the capacity for mutual love expanded in long-term psychotherapy? Can patients use what they’ve experienced in therapy to expand the abilities for forming close and personally meaningful bonds with others, as in deep friendships and long term romantic relationships? Can they use these relationships as a source of more intense brain/mind body interactive regulation and autoregulation, and therefore have both interdependence and autonomy?

Both clinical theory and interpersonal neurobiology agree that in optimal social emotional environments the self-system evolves to more and more complexity. Not only the growth of the left brain conscious mind but also the right brain unconscious mind can be enriched and expanded in deep psychotherapy. By emotionally interacting with other right brains, a secure right brain self can continue to grow and develop to more complexity over the later Eriksonian stages of the life span. The secure self is not a static end state but a continuously expanding dynamic system that is capable of both stability and change.

Freud said that, in the end, therapy, and indeed life, was about love and work. Today we might think about that in terms of the expression of the development of the affiliative right and agentic left brains. My work has been an exploration of the primacy of the emotional development of the right brain, over the life span. In The Art of Loving, Eric Fromm described the intense emotional experience of love as “the experience of union with another being” and proposed that “beloved people can be incorporated into the self.” Here’s an example of self expansion that occurs within and between two people.
DB: Well, that’s all a lovely way to end. I’ll respect your own need for solitude by finishing up this conversation, but I would like to close with asking about your current activities. You’re still meeting in several cities with students?
AS: Yes. For almost two decades I’ve continued to meet with study groups here in Los Angeles. I also have ongoing groups in Berkeley-Alameda, as well as Boulder, and in the Northwest.
DB: In Seattle?
AS: Yes, I Skype with clinicians and researchers in Seattle, Vancouver, and Portland. I’m about to start a Skype group in Australia, also.
DB: Well, all of this time with you, at both a personal and professional level has been delightful. So, thank you so much. I’m sure people are going to enjoy what you brought to today’s discussion.
AS: Same on my side, and thanks for today, David. I also greatly enjoyed this back and forth dialogue. As you said at the beginning the key was to have a spontaneous conversation.

What Remains: The Aftermath of Patient Suicide

Posted on by rezendevknowfully.com

Note: Clinical material in this article is taken across various venues and years of treatments. Identities are disguised to protect confidentiality. References used in writing this article, as well as resources for clinicians, can be found at the bottom of this page.

Silent Mourners

The memory is quite clear: several years ago, early one morning checking my voicemail, two messages in I came upon a message from my patient, Jill. The message was date-stamped the evening before. She said she would miss today’s session due to a need to find new housing; she thanked me for our work thus far (as she frequently did, sometimes out of social politeness or her fears of abandonment, other times out of sincere heartfelt gratitude, something we frequently explored). This time her gratitude sounded heartfelt in tone. Her message also left me perplexed, as we had not talked of housing, and I saved it. Another message, left moments before I checked my voicemail, was from Jill’s psychiatrist, Brian, asking me to give him a call when I got in the office. Brian and I spoke frequently of Jill, her ongoing medical decline at a relatively young age, and her persistent depression and posttraumatic stress. We followed her carefully, exchanged perspectives, and possessed mutual respect for one another’s clinical skills.

I called him immediately. “Are you in your office?” he asked, his voice ominous.

“Yes,” I replied, feeling my stomach tightening.

“Are you aware of the events related to Jill?”

“No,” my heart now pounded from my chest into my throat.

“Jill killed herself by handgun . . . “

I do not remember what he said next, just that he was still talking. I gasped, crying, while simultaneously attempting to hide my upset.

“Margaret, there was nothing, nothing you could have done to prevent this,” Brian continued, his voice clear and emphatic, speaking from his decades of experience, his knowledge of Jill, and his knowledge of our work together.

We talked for some time, and I could feel myself wanting to hang up the phone and be alone, but Brian insistently kept me on the line, wisely, for forty-five minutes. That was enough time for both of us to begin feeling the immensity of Jill’s death, and to begin the longer process of inquiry and reflection into her suicide and its after-effects. It was a process that would continue for a few months between us, and for more than a year for me.

Clinicians who lose patients to suicide are sometimes referred to as “silent mourners.” Some describe this kind of grief as disenfranchised. For me, I think of this grief as a kind of lived experience that catapults you into another environment which is foreign and therefore scary; a kind of grief that is uniquely solitary to bear and therefore devoid of larger community to bear it with you; a kind of grief that is intensely intertwined with shame; and a traumatic grief that possesses all the hallmarks of interpersonal trauma, whose impacts often continue reverberating long after the initial shattering experience has occurred. All of these facets and more underscore the particular experience of clinicians grieving suicide loss.

The differences are rather key in understanding how to be with our selves and also how to respond to colleagues who experience this kind of loss personally or professionally. My hope in writing this article is to buoy understanding, widen the circles of support for clinicians who have experienced suicide loss, and to offer some guideposts along the way of grieving. This topic and these aims are one of my life-long passions in my career. I have had the unfortunate experience of surviving two siblings’ suicides, the sudden death of a third sibling that suggested passive suicide, and the deaths of both parents from organic causes that were informed by these traumatic losses. My terrain of grief and traumatic loss was quite familiar to me by the time I met Jill, having traversed its intricacies in feeling, thought, and body using psychotherapy, meditation, long-distance hiking, body work, and writing, for many years. My experience served me well in working with Jill while she was alive, as well as holding what remained after her death. I was and am, after all, a wounded healer, meeting her suffering in life and in death.

Our Privileged Intimacy, Our Private Mourning

By its very nature, psychotherapy is a privileged space. The therapeutic relationship is characterized by a unique emotional intimacy with each patient. As therapists we are honored by our patients’ presence, the trust that is hard won, and the growing capacities through the course of psychotherapy we witness. We accompany and guide, inquire and curiously explore in a most particular way with each patient. With each patient, a slightly different relationship forms. We are slightly different therapists with each patient we encounter.

The extent to which we as therapists may deny the singular relationship with and presence of our patients in our lives contributes to the complications of grieving their departure in any form—from treatment termination to physical death. In her article, “Necessary and unnecessary losses: the analyst’s mourning” (2000) Sandra Buechler reflects that, because our work asks us to cultivate objectivity, and objectivity is often (over) emphasized in the work (and in training), it becomes a norm without critical thinking or reflection. This clinical cultural norm may also encourage a sense that we can (or should, perhaps) simply “move-on” when a patient departs. A therapist’s stance of distance may additionally complicate the grieving picture, especially in the case of loss by suicide. That stance may feed defenses of denial, encourage guilt, and amplify feelings of shame.

The great Jungian, James Hillman, stated that the suicide of patients is a “wrenching agony of therapeutic practice.” It is also a reality of practice that we fantasize will not touch us, despite the statistics. Depending upon the research reviewed, approximately fifty per cent of psychiatrists and thirty per cent of psychologists experience patient suicide. The statistics are incomplete and varied, often reflective of response rates to inquiry. Further, we do not, to my knowledge, have statistics on the numbers of mental health professionals who have experienced suicide loss within their personal circles of close family-friend relations, but it is fair to consider the percentages may be slightly higher if these were included.

For clinicians, suicide challenges every value we place in the therapeutic endeavor. It can raise fears of litigation, cloud clinical decision-making, and spark feelings of professional isolation. Suicide of a patient can challenge personal and professional identities, career trajectory, and sense of professional security. In its wake, patient suicide can leave posttraumatic stress symptoms behind as well as complicated grief. Interestingly, in my work with therapists who have experienced suicide loss of family or other close relations, they experience similar dilemmas. The sense that as a clinician he or she did not serve their family member or friend well, the questioning of clinical acumen, the guilt of feeling as though he or she should have done something to be of help and more, are common. As clinicians, suicide loss in any arena of our lives is experienced through the lens of our clinical knowledge, expertise, and experience.

There is little personal discussion on how therapists weather such a loss. Lay survivors of suicide are in an unknown country, inhabiting a strange landscape. Therapists surviving the suicide of a patient are in a similar land and yet there are important differences: there is no institutionalized ritual, no community of mourners, no one, really, who knew the patient as the clinician knew the patient. There is no one who witnessed first-hand (as best anyone can) the relationship between a certain patient and a certain therapist, yet the specific dyadic relationship is never to be experienced again. It is never to be remembered by anyone else but the therapist. In specific ways, we are the only one who holds our patient in mind. Even in the case of Jill, Brian held one particular relationship with her, and I another. Although Jill sometimes spoke of us to one another, the bulk of our memories of her are solitary, and the texture of our relationship with her singular.

Therapists are usually left alone with what remains in the aftermath of patient suicide. These remnants include all that was unsaid, unprocessed within the therapeutic relationship—both the regrets of what was not named and processed that are possibly linked to the suicide, and certainly all that had no chance to be felt and spoken of together that more time would have provided. Additionally, all that the therapist retains of his or her patient remains inside the therapist’s memory.

Further, who the therapist was with this particular patient is lost. This leaves open the question of who we are as therapist now. The process of mourning for therapist-survivors asks that we delve into the question of who we are now that our patient has left in this self-destructive way. And who are we, as therapist, the one here to facilitate healing—to engender life, if we have that kind of perspective—in the face of chosen death?

It can be alluring as the therapist-survivor for all these reasons to move far from the confusing thicket of feelings left by patient suicide. The cultural context and identity as therapist can encourage this moving away from honest reflection and processing too. Yet as we know with our patients, moving away from the real experience of the here and now can lead to a dulling of living, a numbing. In our work, moving away from our feelings can feed psychotherapeutic cynicism, burnout, and depression. It can also lead to problematic clinical decision-making and ethical lapses in judgment.

Our willingness to open, receive, and make contact with our patients within the therapeutic work is an offering toward healing—if we choose to risk it. From a relational perspective, certainly, our willingness in these ways is a vital vehicle in the process of transformation found within the therapeutic endeavor. Upon the suicide of a patient, it is tempting to shut down in response to profound relational loss and loss of the therapeutic framework upon which we rely.

Being with Groundlessness

“The dead leave us starving with mouths full of love,” the poet Anne Michaels writes. Jill left me starving and full. Her message to me left me full. The timing of her departure left me starving, questioning. She left me loving her, yes, but also left me with a myriad of other feelings including meaninglessness, impotence, frustration, and raw sadness. I was, because of my life experiences, immediately aware that I needed to take seriously the particular kind of loss I was experiencing—the loss of an incomplete, torn-apart relationship, the loss of who Jill was to me, a loss of clinical voice, and the loss of who I was as a psychotherapist with Jill.

There is ineffability—an unspoken quality— in this kind of traumatic loss. Psychoanalyst Ghislaine Boulanger distinguishes between child and adult onset trauma, noting how core self experience and self-in-relation experiences are undermined. Adult onset trauma shatters illusions of omnipotent control, ever-shaking the normative expectation of personal agency and healthful denial of omnipresent mortality. The suicide of a patient shatters illusions of therapist omnipotence, shaking expectations of potential positive influence upon patients, and calls into question core identity as well as identity-in-relationship to other patients and colleagues.

Western psychology rests within a worldview of personal agency. It is a worldview imbued with Euro-American, individualistic, educated, and moneyed values—all of which are crushed in the face of adult onset trauma. It is the very nature of this kind of traumatic loss that it rocks our assumptive world as therapists: questioning whether our endeavors are life giving, whether our efforts possess meaning and influence; and whether our chosen profession is worthwhile.

There was Todd, a patient-therapist in my practice who came to me after his long-term patient completed suicide. Todd had fifteen years of clinical experience and before that eight as a university professor. He was well versed in suicide prevention and intervention. “After his patient’s death, he refused to ever work with a patient again who even mentioned suicidal feeling states; he would refer them.” His stance is maintained to this day, six years later. His way of coping is not unusual among therapist-patients in my practice or across the profession. Whenever I present a paper on this topic, I hear stories of mental health professionals at all levels responding similarly. So understandably haunted, they desire to avoid any chance of experiencing a suicide loss again; some believe they can no longer objectively assess risk; and others feel traumatized, unable to clinically engage with a patient experiencing suicidal ideation or self-harm.

There are some other common coping approaches among therapist-survivors. They include all the ways we may become vigilant in our practice: taking numerous, even if repetitive, trainings on ethics and suicide prevention; developing a rigid stance in responding to patients expressing suicidal thoughts or intent; and intervening in overly-conservative ways that communicate anxiety to the patient rather than clinical engagement. In her essay for the collection, The Therapist in Mourning: From the Faraway Nearby (2013), Catherine Anderson describes these kinds of responses as part of the working through process with “a desperate need to understand what had happened and a magical wish to protect [oneself] against any future vulnerability.”

Another common response is to avoid examining clinical missed opportunities and errors, to defend against the pain, shame, and perhaps guilt that are simmering. Gina, a patient-clinician of mine, experienced a patient suicide after two sessions. When the patient did not show to the third session, Gina called. Subsequently, the patient’s father contacted Gina. He told her his son killed himself the day after the second session. It was excruciating for Gina to slowly begin to examine her state of mind during the sessions. She came to realize that she was, due to many factors, defending against making genuine a connection with this patient, and was more distant than usual. Her past clinical experience told her that when she has that kind of response, she hesitates exploring avenues that would be productive, and that she overlooks what later, when less defensive, was there all along. That was her missed opportunity. Of course, there is no telling if Gina had been less defended if that would have made a difference—given her a vital piece of clinical information that she could capitalize upon to then help the patient. It was crucially important, however, to Gina’s healing process to bring into consciousness what she already actually knew about herself in her brief work with the patient.

The ground of my being was continually moving beneath me after Jill’s suicide. Because of my life history and my working with it in therapeutic ways, I knew my footing could be regained, but I questioned when that would happen. I returned to writings that reminded me about how vulnerable groundlessness really is and how inevitable it is as well. Pema Chodron, in When Things Fall Apart, writes:

“[T]hings don’t really get solved. They come together and they fall apart. Then they come together again and fall apart again. It's just like that. The healing comes from letting there be room for all of this to happen: room for grief, for relief, for misery, for joy."

Her perspective, for me, reflects what I believe and practice in my private and professional life, but can easily forget in times of great tumult. It is a kind of perspective that provides me refuge.

I knew from my history that if I refused to directly experience what was present within me I would only harden my heart. Cutting myself off by armoring my heart would negatively impact my relationships with other patients, let alone the relationships in my personal circle and my relationship to life itself.

The practice of mindfulness meditation is one way I engage my direct experience, and it had been a practice of mine for many years before I began my clinical work. I returned to intensive practice after sustaining the many family deaths in quick succession aforementioned; I spent a month on a silent meditation retreat as well. The amount of silence offered was an integral experience for my body, heart, and mind to begin having room to feel through those traumatic losses. With Jill’s death, I returned to steady meditation practice again, in order to create room inside myself for the range of feelings I was experiencing. It sounds, perhaps, so simple, so easy, and yet it is not. Silently meditating twice daily confronted me with every vulnerability, every feeling, body sensation, and thought I possessed. Profound shame, futility, anger, banality, and sorrow as well as heartache and headache were some of the many storms I weathered sitting quietly on my meditation cushion. Yet it was the silence and the generous observing accompaniment to myself that were central in my finding footing again.

Ritual as Scaffolding

James Hillman suggests that in the face of patient suicide the clinician go into the context of the death—not to stay on the surface. His advice speaks to delving into our interior world, and grieving, but also something more. He suggests lending all of our knowledge of our patient to the endeavor as well, exploring as thoroughly as possible nuances of our patient’s suicide.

With Jill, intuitively I knew I needed rituals as a frame in my quest to deeply understand her suicide to the best of my abilities, as well as to mourn her death and all of the losses accompanying it. One ritual that was obvious was the therapy itself. There are the set days and times of sessions; the usual pattern of entering and exiting sessions with some of their inevitable variability; the parameters of the relationship.

Keenly aware of how groundless I felt, I longed for grounding in the ritual of my sessions with Jill. “I could not fathom scheduling another patient in Jill’s session times. I realized what I wanted was to keep my appointment with Jill. So I did just that: I kept my appointments with Jill for one year.” Sometimes I went to a meditation space near my office for the appointment; sometimes I was in a natural setting. Other times, I spent it in my office. Wherever I chose to spend the sessions, I also was with Jill. Sometimes reading a book of poetry that evoked Jill, or intentionally recollecting parts of sessions.

By the second week of appointments with Jill, I began writing during the time. I used poetry as a companion. Sometimes I wrote to Jill, sometimes extemporaneously to the Reader with a capital R. An excerpt follows of one of my writings:

I reviewed notes on Jill I came across; process notes. Notes when Brian spoke with me several weeks ago. There is much that remains unsolved in my heart. And it’s in my heart, especially, that time takes its own rhythm, a time that doesn’t match up with the clocks and the calendars.

It’s sorrow or poignancy, both, being touched by Jill—I’m feeling right now. Knowing I’m not alone, really, in such an experience ultimately—like anyone grieving anything how universal and connected to the everyday human experience this actually is. Paradoxically how alone and singular I feel. Alien among colleagues who have not experienced such a violent loss. A lone mourner.

Jill suffered in body and mind, physical and emotional pain. Her physicality used to be a route to survival as a child and a young adult. Her physicality was already failing her. The grief she felt was so layered and frequently linked to all the losses felt trans-generationally across her family history. And even this doesn’t say all she felt and lived with.

I can and do write circles of theory or case formulation but that is not what I’m desiring here. I feel almost desperate to continue delving into this process with her in this kind of way, unsure of where it is leading.

Strange, I guess, to feel the shock, still, that she is dead. I just know the only way to move with this, through this, to be with it all, is to do what I’m doing. Let it come in words or feelings. Let it come through me, in silence.

Of course, the questions remaining in the aftermath of suicide usually cannot be fully answered, but answering all the questions is not the point of such a process. If there is an aim, it is the recognition that the clinician continues in relationship without her (or his) partner in the dyad. Feeling and thinking alongside that recognition is the heart of the process. Psychologist Robert Gaines would call this the stitching together of continuity our relationship to the dead. Finding a relational home once again. Finding one’s clinical and human voice again.

Other rituals also occurred to me related to mourning, whether a formal memorial or an informal honoring, as well as creating continuity. By the end of the second week of appointments with the spirit of Jill, I realized I needed two additional things: to visit where she died, and to create some kind of memorial. There was no funeral service for Jill; she had no family or close community. Something of our process together needed representation. Something of her treasured symbols shared with me needed representation. And something of our relationship needed representation too.

Brian drew me a virtual map in verbal description as to where she died. Over the next four appointments with the spirit of Jill, I developed a memorial. A colleague accompanied me on the day that I set, and we drove to the place close to where Brian described. We walked the remainder of the way. Although Jill chose a place where she surely would be discovered, it was not an overly exposed public place. When I got there, I wept. I wept not because of her death in that moment but because of the purposefulness of the place. I recognized it, immediately, based on our work together. Based on what Jill shared with me. I could see how Jill, with her particular perspective, felt beauty in this place. The place fit into the story of her life, the story she shared with me. The story we made sense of together. The place symbolized what she would frequently discuss and feel, the existentials of existence, and the evolution of her life.

The ritual included flowers, some writing I read to commemorate Jill, and a prayer combined with poetry I put together to reflect our relationship. My colleague and I sat in silence afterward, listening to the sounds around us. I felt close to Jill in the moment. Through the scaffolding of this ritual, as well as the ritual of appointments with her, I began to understand some meanings in her death, and I regained my voice once again.

Jill genuinely affected me—her life as well as her death. Destruction, and particularly self-destruction, surrounded her in the history of her life yet she developed into a highly deliberate, aesthetically-minded, symbolically-attuned woman who struggled with looming thoughts that dragged her into familiar mire she was accustomed to escaping by vigorously and creatively using her body, no longer available to her. Her suicide was equally aesthetically minded—if you forgive the stretch of the word in this context but rather feel into the contour of its meaning. I noticed this in numerous ways from the evidence she left behind, the chosen place of her death, the timing of her death, to her message left for me.

I was acutely aware in working with Jill of my family standing with me, for they are there, always, in the background of my mind and heart, like a luminous shawl. How the experience of their tragic, violent, and sorrowful deaths created, initially, a nuclear-sized crater within me that since healed—and continues to evolve in healing—with scarred but incredibly strong layers. Layers of capacity and depth for ambiguity, curiosity, and love in the face of enormous challenge, rejection, and destruction. I never revealed to Jill my personal history, yet I felt it was these very experiences and my working with them, through them, that enabled me to meet Jill in the dark and light of her psyche without collapsing. All of these details and their meaning that I came to understand over time enabled me to continue to serve fully in my life in all ways professionally and personally with openness.

Relational Home for One Another

Clinician-survivors come in contact with the real attachment felt for the person who died in the process of mourning. Regardless of theoretical orientation or therapeutic stance, there was (and is) a relationship. The basis of the relationship is connection, care, and likely love. Therapists may have difficulty admitting they love their patients; some secretly do so with shame as if caring were untoward. When working in my practice with therapists mourning a suicide, moving through the shame of caring to the healing and human quality of caring is vital.

Clinician-survivors ask me to be their therapist initially because they find my contact information from the American Association of Suicidology’s website. There, among numerous resources, is a link to resources for clinician-survivors. Clinicians who contact me often gingerly express their desire for support, understandably fearing an amplification of shame they already are carrying. Shame demolishes a person’s sense of self. Shame isolates and evicts us from our relational home.

Some studies have explored the ubiquitousness with which clinician-survivors are met with judgment and shaming from colleagues. It has been found that clinicians who have not experienced a suicide loss professionally or personally are more likely to assume that there must have been something the treating clinician had done wrong. One way to understand this is to consider the nature of trauma. People involved in the traumatic event, either directly or indirectly (hearing of it, etc.), hold parts of the experience and defend against the emotional enormity of it. Blame, shame, grandiosity, omnipotence, and guilt are often convoluted in the mix. Unbearable feelings are projected or disavowed. Most of us “know” this, but when we are in the midst of it ourselves we can forget.

Before I entered my contact information on the clinician-survivor network, I carefully considered this act—a public acknowledgment of an aspect of my history. Before I agreed to write this article, which is drawn from a public presentation I gave to two different professional organizations, I considered how my history in print felt quite different than speaking it. I sensed the risk I felt in both instances. For me the risk is primarily located in relationship to colleagues unfamiliar with suicide loss. My feeling of risk among the professional community is not singular—it is cited repeatedly as a way that therapists feel shame for their grief in relation to patients generally, and most especially the shame felt when a patient completes suicide.

Coming out, so to speak, on the website and in this article are acts of advocacy for other therapists in a direct way, and ultimately also, I believe, advocacy for patients. Coming out in these ways are antidotes to shame as well, although revealing oneself carries with it a chance of being judged or shamed. Hiding when feeling shame, after all, is a protective solution to those risks—albeit risks that are generalized. Two anecdotes may elucidate.

When a psychologist-colleague found out that I publicly acknowledged my identity as a suicide survivor, he questioned me. He wondered if I were exposing something that “should” be hidden. His sense of hiding was initially justified by the importance of neutral stance and limited self-disclosure. With further exploration between us, however, my colleague came to realize that he felt anxious and even dissociated when hearing about my experiences. His shaming reaction toward me was a coping mechanism for his anxieties.

Another colleague responded quite differently to finding out about my public acknowledgment as a suicide survivor. Her response: There but before the grace of God go I. She too felt anxious hearing my experience, but she remained in communion with me. She shared her anxiety and her wishful fantasy that she would never experience this kind of trauma. Through our discussion, we created a relational home for one another.

In therapy, we create, with our patients, a relational home. While this home is focused on the patient’s needs, it is irrevocably the particular home we live in with our patient. That home continues to live inside of the therapist-survivor after the patient dies. In Trauma and Human Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections (2007), Robert Stolorow writes, “The mangling and the darkness can be enduringly borne, not in solitude, but in relational contexts of deep emotional attunement and understanding.” The loss of a patient or a loved one by suicide is unfathomable, though we know it happens. It is nothing short of a cataclysmic trauma, one that is enormous to digest. The impact of it on clinicians has been compared to the traumatic loss of a parent. It is a leveling experience for it takes us out of our protected role as therapist and throws us into the most humble, bare experience of our own humanity.

Brian, the psychiatrist, only learned of my family history after Jill’s death. He wondered, “Perhaps there is some unconscious way Jill knew you could make meaning of and bear her death.” It is curious whatever Jill may have implicitly known of me—but ultimately that is something I will never know. Importantly, it was not lost on me, her therapist, the relevance of the place she chose to die. What it meant to her, what she communicated to me in her final message, and what she communicated in her choice of place. It was not lost on me, her therapist, the layered meanings in the timing of death. The curious exploration of these among other unspoken aspects of our work together was what I gave voice to in my year of kept appointments. A year of rediscovering meaning. A year of regaining clarity, ground, and clinical voice. A year of examining the soul of the process between us, and what lived on within me.

***

Following is a list of readings and resources for clinicians and clinician-survivors who wish to learn more about, and seek support for, the grief of losing a client to suicide.

The clinician-survivor network of the American Association of Suicidiology provides consultation, resources, support, and education to mental health professionals in the aftermath of suicide loss, personally and/or professionally. The website includes nationwide clinicians available as resources, as well as an extensive bibliography.

Anderson, C. (2013). "When what we have to offer isn’t enough" in Malawista, K. and Adelmari, A., Eds. The therapist in mourning: from the faraway nearby. New York: Columbia University.

Boulanger, G. (2002). Wounded by Reality: understanding and treating adult onset trauma. New Jersey: Analytic Press.

Buechler, S. (2000). "Necessary and unnecessary losses: the analyst’s mourning." Contemporary Psychoanalysis 36: 77-90.

Chodron, P. (2000). When things fall apart: heart advice for difficult times. Boston: Shambhala Publications.

DeYoung, P., (2015). Understanding and treating chronic shame: a relational/neurobiological approach. New York: Routledge.

Gaines, R. (1997). "Detachment and continuity: the two tasks of mourning." Contemporary Psychoanalysis 33(4): 549-571.

Hillman, J. (1997). Suicide and the soul. Connecticut: Spring Publications.

Michaels, A. (1997). Memoriam in The Weight of Oranges / Miner’s Pond. Toronto: McClelland & Stewart.

Plakun, E. & Tillman, J. (2005). "Responding to clinicians after loss of a patient to suicide." Retrieved December 2013 from http://www.austenriggs.org.

Stolorow, R. (2011). "Portkeys, eternal recurrence, and the phenomenology of traumatic temporality." International Journal of Psychoanalytic Self Psychology, 6:433-436.

Stolorow, R. (2007). Trauma and human existence: autobiographical, psychoanalytic, and philosophical reflections. New York: Routledge.

Tillman, J. (2006). "When a patient commits suicide: an empirical study of psychoanalytic clinicians." The International Journal of Psychoanalysis, 87(1), 159-177.

 

Je Taime…Me Neither

Posted on by Psychotherapy.net Team

This couple therapy session was the last chance before Anna and Guy’s upcoming wedding in Paris. They had reached out to me for a premarital counselling session via Skype, knowing that I was working with mixed couples.

Their situation, as Anna exposed it to me in her short email, needed to be addressed with some urgency: they were due to get married in the town hall of Guy’s native Paris within two weeks, and Anna still had serious doubts about her final “yes.”

Their two faces appeared on my screen, one next to each other, cramped into the frame of the Skype window. From the start, I mentioned one of our challenges: neither of us was using our native language here. Anna is Polish, Guy is French, and I am Russian. From my experience, this multilingual field would be played out at some point during this session, but how?

Their respective English was fluent, even though Guy had a strong French accent, which made him sound like an odd TV-series character. In the first minutes, I learnt that they had started dating online, and now Anna had finally moved in with Guy in Paris. Since then, their respective lifestyles had been drastically altered: Anna had an 8-years old daughter from her first marriage, and Guy had an autistic sister who lived in the same building. Those two were constantly challenging their shared existence. They were their respective “burdens,” as Guy shared.

When he pronounced this word, Anna’s face hardened with pain. She was clearly hurt by the reference to her daughter as a “burden,” and was getting defensive. Their typical argument then started to unfold. These fights happened on a daily basis, leading inevitably to door- slamming and painful silences.

Now their faces were flushing with all kinds of emotions.

“You are so slow and uninterested!” she stated, bitterly.

“You always sound so aggressive and impatient!” he responded, defensively.

I could clearly see what both of them meant. Anna did sound irritated; her aggressive facade seemed to hide a deep insecurity. Guy did come out as a bit slow and detached. He was carefully looking for his words, avoiding eye contact, and every time, before speaking, he would make a pause, recollecting and revaluating his thoughts. This habit of his could be easily taken for a lack of interest or passion. In Anna’s view he simply did not feel enough love for her, or enough acceptance for her daughter, to become a good husband and father.

And yet, they were really willing to look at their relationship, ready to fight for its survival, avoid its ending. I was starting to wonder how I could be of any use, when I heard the sound of a distant doorbell. They both jumped on their chairs. Anna smiled badly; Guy shivered and disappeared from my sight.

“See?! This is what happens. She comes in and out when she wants, uninvited.”

I understood that Anna was talking about Guy’s sister, and I invited her to pause and wait for Guy’s return.

Such interruptions of the sessions are frequent in my online practice. They are somehow an unexpected gift of this particular setting. I always endeavour to make the most of them. In this virtual space, silences are tougher to tolerate, even for the psychotherapist.

Anna and I were staring at each other, hearing their voices at a distance, and I could sense her disappointment and growing anger. She looked lonely and lost, with the other half of my screen left empty by Guy’s absence.

When he finally came back, she had that look of resignation. They are not going to make it, I thought.

Guy, clearly shaken by this sudden illustration of “his side of the problem,” muttered some excuses in French (he knew I understand it well). In his native language, he sounded surprisingly fast and emotional.

We had only half an hour left in the session, and a few days until the big day, so I decided to risk something, and suggested an experiment: would Guy be willing to repeat what he had said earlier about their “respective burdens” in French? I knew Anna could understand most of it.

“Je t’aime…”—this is how Guy started his difficult speech. He talked about sharing their respective pains and responsibilities: his sister but also her daughter. He talked passionately. His body animated (at least the upper part which I could see). He seemed to almost forget about me.

Anna was listening, and this time she did not seem impatient.

That was the midpoint of the session, and such a precious opening! I felt blessed.

We then explored how using his native French had changed their common experience. Guy was finding it difficult to understand all the details when Anna spoke English quickly (which she did naturally). So his mind wandered, he looked uninterested. It reminded Anna of her first husband, who was distant and absorbed by his own activities.

As for Guy, he would see his role as a protector of his autistic sister. In his speech in French he said something valuable, which became an anchor for the rest of our session:

"Elles vont être maintenant notre fille et notre sœur."

I made sure Anna understood this: “they will now be our daughter and our sister.”

That felt manageable for both, and Guy was here to protect them all. It switched the whole perspective.

I cannot know for sure whether Anna and Guy will stay together, but I know that they did try hard to understand each other better…

Losing the Couch: Finding the “Sacred Place” in Online Therapy

Posted on by Psychotherapy.net Team

I clearly remember my very first visit to my British psychotherapist. She used to receive her patients in her conservatory. Her dogs sometimes got impatient and produced considerable clatter, which I could clearly hear from inside the house. The front door would be unlocked. Clients just had to push the gate to get through an unkempt garden into the peculiar therapy room. She would be already comfortably sitting there in the same old chair, and a flowery cup of tea would be ready; weak for her, and strong for me. When I was late, my tea was cold. Maybe it was her subtle way of punishing me…

I actually loved this place. Years later I can still recall its particular smell of wet dogs and a damp garden. That therapy room had become an anchor for me, which safely attached me to the Island that was then my temporary home; I was in the midst of yet another international move.

Now that I use the online setting for my psychotherapy practice, I sometimes wonder what my clients will remember of our encounters. No particular smell of madeleines will ever be attached to a virtual space.

Any therapist, myself included, hopes that his therapy room can become some sort of “sacred place” to his clients, a place for individual growth. We all work towards this goal, creating small rituals and paying careful attention to the boundaries of the therapeutic relationship.

With the current expansion of online counseling, therapists and their clients are seeing this sacred element of therapy being taken away. Our cherished therapy rooms are disappearing, replaced by a simple desk and a computer.

I have kept a traditional face-to-face practice in Madrid, on top of my online work, so when I connect with a client on Skype, he can always spot behind me the background of a traditional therapy room decorum: two large armchairs, a box of Kleenex, a smiling Buddha statue… a pale reminder of the physical space where our encounter would have had to take place just a few years ago.

A couch, a bookshelf, and a coffee table… we have been familiar with these traditional attributes of a therapy room for ages. Anybody coming to a therapist for the first time knew what to expect, and rarely got surprised. In a space, tightly bound by walls, boundaries tended to be clear: the therapist had his own chair, the client might have a choice between two chairs and a couch. In this place both the therapist and the client felt safe. This space seemed eternal… until the online option emerged, bringing confusion.

Now online therapy is practiced within a no-place space. The couch is gone. And each of us therapists responds to this loss in different ways, which vary as in any grief—from denial and anger to acceptance.

During an online session, two people stare at their respective computer screens, without sharing a common place. This becomes an opportunity to build their own space together. It is very much like coming to a new empty area, and building from a green field a house here or there, then eventually a village.

In my experience, this lack of a physical place actually fosters creativity.

Many people I meet in my practice live very mobile lives, geographically unsettled; so the perceived neutrality of the no-place becomes a real asset in addressing the displacement-related issues.

Amélie’s story is one such case. She was back to Paris after 10 years in Korea for her husband’s career. There, Amélie had felt isolated and disoriented in her vast house, while her husband was travelling extensively. She had had to leave behind her music teacher job, and after several years of this expatriate life, she was feeling lost. Now back to her native Paris, she was feeling depressed. Her first panic attack happened in a shopping mall. She did not know where she was and was not able to get out of this unfamiliar place crowded with strangers. She was struck by an acute sense of derealisation. She reached out to me, in addition to her local psychiatrist.

“How is it for you to tell me your story here, online?” I asked.

Actually, Amélie felt safe, her anxiety was stepping back. She was relieved, as she could meet with me from the only place that still felt familiar—her parents’ Parisian flat. Driving to a therapist’s office would have been too much for her at that point. The online space we shared became in this case a way of dealing with her confusion without re-introduction of another different place.

Every time I connect with a client, especially for the first time, I am ready to get surprised. Those who seek therapy online generally use and abuse the flexibility allowed by the technology, so I “meet” them (virtually) in their holiday house, hotel room, office, kitchen, or lounge.

Without moving from my desk, I am then able to spot small samples of their physical realm. I always feel touched by the trust involved in this “letting me in.”

The whole situation has now been reversed: it is not the therapist who lets his client in, but the client who is choosing which of his sceneries to share with his therapist.
These “unexpected gifts” somehow make up for the lost couch.

In any successful therapy there is a time when the client ends up internalising the reparative relationship with his therapist, creating the “safe place” within, that anchoring gift I received from my first therapist. When this happens, the concrete place does not matter as much as the “virtual” place discovered. And the person is able to go anywhere, feeling safe enough to further explore the world.

As in the case of Amélie, the placeless reality of the online setting accelerates this natural shift from place towards relationship.

I enjoy both my online and my face-to-face practices. When connecting with a client, I always attempt to recreate the ever-important “sacred place” of a therapy room, together with my client, in this ethereal space offered to us by technology.

Ronald Siegel on Integrating Mindfulness into Psychotherapy

Posted on by rezendevknowfully.com

Mindfulness is an Attitude Toward Experience

Deb Kory: Ronald Siegel, you’re an assistant professor of psychology at Harvard Medical School, a longtime student and teacher of mindfulness meditation, on the faculty of the Institute for Psychotherapy and Meditation and in private practice as a psychotherapist. You’ve done a great deal of work in bringing mindfulness to chronic pain patients and co-wrote a book called Back Sense: A Revolutionary Approach to Halting the Cycle of Chronic Back Pain as well as one for therapists, Sitting Together: Essential Skills for Mindfulness-based Psychotherapy. Most exciting of all—for us at least—you are the star of a new video we produced and are releasing this month called Integrating Mindfulness into Counseling and Psychotherapy, which features you doing mindfulness-based psychotherapy with real clients. In it, you go into great detail about the theory and practice of mindfulness-based psychotherapy, and also do four different therapy sessions with clients each presenting different issues. For our readers who haven’t yet had a chance to watch it, let’s start with the basics: What is mindfulness?
Ronald D. Siegel:
Mindfulness is an attitude toward experience—approaching any moment of our lives with both awareness and acceptance.
Mindfulness is an attitude toward experience—approaching any moment of our lives with both awareness and acceptance. Many people mistake mindfulness for mindfulness meditation, which is actually an umbrella term for many different practices that are designed to cultivate mindfulness, some of which involve following an object of awareness, like the breath, others of which involve things like loving kindness practice or equanimity practices. Those are practices designed to cultivate mindfulness, but mindfulness itself is an attitude toward moment-to-moment experience.
DK: Is it possible to practice mindfulness without having some experience with meditation?
RS: Absolutely. We all have moments in which we’re mindful, in which our minds and bodies show up for an experience. In fact, you might take a minute just now, while reading this, to think of a meaningful moment you’ve had. People will often say, the birth of a child or a graduation or getting married or a particular sunset or a conversation with a friend—all of those moments are essentially moments in which our attention is in the present. We’re accepting of what’s happening and we’re not lost in fantasies of the past that we call memories, nor fantasies of the future. We’re actually present.

We have many moments of this kind of mindful presence in the course of our lives, it’s just that once we start to be attentive to various states of consciousness, we notice that they’re the exception, rather than the rule. They’re relatively rare. So we do mindfulness practices to cultivate more of these moments in our lives.
DK: A sunset or being with a loved one—those are positive experiences. Do we tend to be more mindful in positive moments?
RS: I think instinctually we are, because when we’re experiencing painful moments, we recoil from them. We try to change them or get them to stop, and it takes some practice to open to unpleasant experiences as well. That is a central part of mindfulness practices, particularly in the therapeutic arena, where we understand one aspect of psychopathology as a tendency to resist experience, to try to make it stop.
DK: You are considered a mindfulness expert of sorts and you’re also a psychologist. Have you always brought mindfulness into your psychotherapy practice?
RS: Well, I’d like to challenge that designation first. I’m certainly not a poster child for the practice, given my experience with my own unruly mind. However, I first started practicing mindfulness back in high school, so I have been at it for some time and the principles associated with mindfulness have always infused my psychotherapy practice. In fact, when I learned more conventional psychotherapeutic techniques like cognitive behavior therapy, psychodynamic techniques, systems techniques, humanistic psychological techniques, it was always against the backdrop of Buddhist psychology, which is really the ground out of which mindfulness practices grew.

Our Relentless Tendency Toward "Selfing"

DK: How do therapists actually bring mindfulness into therapy?
RS:
Experienced psychotherapists are perfectly capable of having a full session, making reflective comments, insightful interpretations, all while planning a 12-course meal and having our attention quite divided.
Mindfulness can infuse psychotherapy on many different levels. It can infuse psychotherapy simply on the level of the practicing psychotherapist—what happens to us as the tool or instrument of treatment when we start practicing ourselves. For example, we start to actually show up in the room more fully. Experienced psychotherapists are perfectly capable of having a full session, making reflective comments, insightful interpretations, all while planning a 12-course meal and having our attention quite divided.
DK: Shhhh, that’s supposed to be a secret!
RS: Yeah, don’t tell people outside of the field! But the more we practice mindfulness, the more we’re able to be present. The other thing that happens is our capacity to be with and bear difficult emotions increases a great deal as we take up these practices. As therapists, we tend to hear about painful matters all day long, and sometimes it feels like too much, so we start to shut down our feelings; that can get in the way of being present. Mindfulness practices can help us to remain open in a fresh way to those painful feelings.

At the next level, there’s what we might call mindfulness-informed psychotherapy, which involves gaining insights into how the mind creates suffering for itself—through our own mindfulness practice and through the experience of longtime practitioners. As we gain some of those insights, we start to see certain patterns of mind that begin to inform our models of psychotherapy. For example, our relentless tendency toward “selfing”— creating narratives in our minds, starring me. These narratives are often quite distorted and create a tremendous amount of tension and suffering as we try to hold on to one self image and abort another.

As we see this through our own mindfulness practice, we start to notice that our clients or patients seem to be struggling with the same thing and we can help them with that by drawing upon our own insights and practices. Similarly, noticing the tendency to resist experience and how that multiplies difficulty. In psychotherapy, regardless of what sort of treatment we’re doing, we try to help people move toward, rather than away from, painful experience. To be more present, rather than to be lost in the thought stream involving narratives about the past and the future. That’s a mindfulness-informed psychotherapy.

Finally, there’s the option that comes out of our own experience of doing meditation and realizing that it helps us be more present, clear, have greater affect tolerance, more perspective, and more wisdom in on our lives, as well as more compassion for others. We think, “Hmm, maybe this could help my clients or patients to do this same. Perhaps I’ll teach it to some of them.” I should underscore that it’s about teaching it to some of them and having a map or an understanding of what sort of people might respond well to which sorts of mindfulness practices, at what stages in treatment or stages in life development. It’s not a one-size-fits-all practice.

When Mindfulness is Contraindicated

DK: Isn’t it actually contraindicated for some people?
RS: It’s absolutely contraindicated for many people. For example, for folks who have a lot of unresolved trauma, meaning they’ve experienced painful events in their lives that were too difficult to fully let into awareness at the time, so some aspect of them has been blocked. Maybe it’s the narrative historical memory of the event that’s blocked, maybe it’s the affect associated with the experience that’s blocked, but in some way, the experience has been disavowed. Folks like that, if they start doing certain mindfulness practices, such as spending time following the breath, tend to become quite overwhelmed with the rush of previously blocked material that comes into awareness.

The most problematic adverse effect is due to “derepression,” or the rushing into awareness of things which defensively have been held out of awareness.
A colleague of mine at Brown University named Willoughby Britain is doing a large study on the adverse effects of mindfulness practices, and the most problematic adverse effect is due to what she calls “derepression,” which is this rushing into awareness of things which defensively have been held out of awareness up until the start of mindfulness practices. So, much as we wouldn’t in psychotherapy start talking about material in a vivid way that someone’s not ready to talk about, we don’t want to start doing mindfulness practices that might be premature for various people.
DK: Is Britton against using mindfulness at all in psychotherapy?
RS: No, she’s a mindfulness practitioner herself, a research psychologist who is very enthusiastic about these things and is trying to map this territory. What many meditation teachers know from observation is that these adverse effects are much more likely when somebody attends an intensive silent retreat over the course of many days. But I’ve lead countless groups of psychotherapists through mindfulness practices that are as short as 20-30 minutes and it’s not unusual for one or two members of the group to become overwhelmed by the experience, either by the emotions that comes up or by bodily sensations that they tend to keep out of awareness with constant activity and entertainment. Many, many people are vulnerable to reconnecting with split-off contents.
DK: Let’s say someone comes in to see you for psychotherapy and they haven’t done much psychotherapy and they seem somewhat fragile in this way. How might you work with them?
RS: What’s interesting is there are many mindfulness practices that actually help to create a sense of safety, that create a sense of holding, as Winnicott would say. There are mindfulness practices that are akin to guided imagery or have aspects that feel like hypnosis, and if they’re done in the context of a trusting therapeutic relationship, bring the safety of the therapeutic alliance into the experience of the mindfulness practice.

There are also practices that ground us in the safe aspects of moment-to-moment experience. Walking meditation, where we’re feeling the sensations of the feet touching the ground, or listening meditation, where we’re listening to the sounds of nature or the ambient sounds in the city. Or nature meditation, where we’re looking at clouds and trees and sky. Those objects, since they tend to be safe for most people and bring our awareness away from the core of the body—away from where we tend to identify emotion as happening and toward a safe outer environment—can be very stabilizing. In fact, many of those practices are conventionally in trauma treatment called “grounding” practices because they create safety.

A Transtheoretical Mechanism

DK: It seems to me like everybody in our profession is talking about mindfulness these days. And approaches that I would assume are kind of strange bedfellows—CBT and mindfulness, psychoanalysis and mindfulness—are being paired together. If you go to Psychology Today and look at the profiles of psychotherapists, mindfulness is now a little bullet-point you can select as an orientation. I often wonder if most practitioners actually know what they’re talking about when they claim to work within a mindfulness framework. Like, are they saying that because they’ve been to a one-day meditation retreat or are they actually genuinely skilled in this approach?
RS: Well, I think it’s the same as with any psychotherapeutic model, theory or treatment system—people have very variable levels of understanding of what they’re doing. There are some people who have a great deal of wisdom, compassion and knowledge, who are saying that they’re doing mindfulness-oriented treatments, and there are other people who have a much more cursory exposure to it and may not have much depth of personal experience, but are intrigued by the idea or see it as a useful concept to identify with because other people may be interested in it and looking for a therapist who has some expertise.

But I do think that the field is still in its infancy in terms of really understanding the psychological, as well as the neurobiological, effects of these practices.
The field is still in its infancy in terms of really understanding the psychological, as well as the neurobiological, effects of these practices.
It’s quite a complex field, with many different practices, each one affecting the mind, the brain and the body in different ways and in different ways for different individuals. So while we can make some generalizations and have some guidelines, I think clinicians are best served to see it as very complex.

To the other point that you made about various forms of treatment being incongruent with mindfulness, I actually don’t think most are. I think of mindfulness as a transtheoretical mechanism that is operating in virtually any effective psychotherapy, because virtually any effective psychotherapy is going to help people step out of irrational, unhelpful cognitive patterns. Virtually any effective psychotherapy is going to help people connect with, feel and embrace an increasingly wide range of emotions. Virtually any psychotherapy is going to try to help people to engage more fully moment-to-moment in their lives. Since these are cardinal features of mindfulness practice, you can see them as being helpful in virtually any form of treatment.
DK: So you don’t see it as its own model or approach, but more an attitude and set of practices that are brought into all approaches.
RS: Very much so. While we might choose to actually teach a mindfulness practice to a given client or a patient in a given psychotherapy, that could be done within the context of a cognitive behavioral treatment, a systemic treatment, a humanistic treatment, a psychodynamic treatment and many others as well.

When graduate students come to me and say, “I want to get trained as a mindfulness therapist. Where should I go to school? What kind of training should I have?” I tend to implore them, “Please don’t get trained as a mindfulness therapist. Please get trained as a therapist, first and foremost. Have some understanding of the complexities of the human mind and body, some understanding of the myriad forms of psychopathology that we can get stuck in, a good introspective understanding of your own issues and conflicts and how they get in the way of relating to other people, and get supervision from people who’ve been working with troubled folks for a long time; once you develop that foundation, then integrate mindfulness practices into psychotherapy.”
When graduate students come to me and say, “I want to get trained as a mindfulness therapist. Where should I go to school? What kind of training should I have?” I tend to implore them, “Please don’t get trained as a mindfulness therapist.”


Of course it’s very valuable all along in your training to be doing your own mindfulness practice, to maybe even have a meditation teacher that you turn to for advice. Extremely useful. But if I had a friend who was struggling psychologically and I had the choice of either sending them to a brilliant mindfulness practitioner with very limited clinical training or a reasonably good clinician with reasonably good training as a clinician, but who’d never heard of mindfulness, I would send that person to the clinician in a heartbeat.

We Are Hardwired for Misery

DK: That’s an interesting point. I live in the Bay Area, and there are a lot of people who are really into Buddhism and mindfulness practices, who kind of eschew psychotherapy for more spiritual practices of meditation and yoga. But at the same time, I know that the Buddhist teachers around here are often imploring people to get therapy, to not do the “spiritual bypass” thing and avoid the work of getting into the muck of our psyches and how they impact our relationships and lives.
RS: Yes, absolutely. Jack Kornfield, who teaches at Spirit Rock in the Bay Area and has written many books on the subject of integrating psychology and Buddhism, recently wrote an article about highly experienced mindfulness meditation teachers, Buddhist teachers, who needed to go into psychotherapy. Ultimately, it’s not that one is better than the other—they are both pathways toward sanity. There are so many pathways to insanity that we actually need a variety of tools to work toward sanity.

I would argue that our natural evolutionarily determined predilection is to be quite nuts and quite miserable.
I would argue that our natural evolutionarily determined predilection is to be quite nuts and quite miserable. As Rick Hanson, who wrote Buddha’s Brain: The Practical Neuroscience of Happiness, Love & Wisdom, puts it, “Our brains are like velcro for bad experiences and teflon for good ones.” It’s a total setup for human misery, not to mention the hardwired tendency toward self-preservation that makes us concerned with how we rank compared to the other primates in our troop, which results in endless self-esteem concerns.

We are hardwired for misery. It is a good thing that we have both Western psychotherapeutic techniques that can help us untangle our narratives and get in touch with our feelings and do that in a healing, interpersonal context, and also have access to mindfulness and compassion practices that can help us transcend our personal story to see existential reality, to face the reality of change and death, to face the reality of sickness and old age, and develop sanity through those practices as well.
DK: As mindfulness practices are becoming more mainstream in the psychotherapy community and the medical community, it’s also becoming more secularized. People might go to their primary care physician and be prescribed a mindfulness-based stress reduction (MBSR) class for high blood pressure, and never even hear the word “Buddhism.” Is there a downside to that?
RS: Let me talk about the upside first and then the downside. The Dalai Lama was talking to a group of clinicians and researchers at Emory University about depression, and toward the end of the conference, I remember being quite moved when he said, “If you folks discover that some elements of Buddhist meditation practices are useful for alleviating depression, I really have only one request for you: please, please don’t tell people that it comes from Buddhism. My tradition is about alleviating suffering, and if you tell people that these are Buddhist practices, you’re going to miss huge numbers of people whose suffering could be alleviated. Don’t get hung up on that. Express this in whatever form is going to be useful in alleviating suffering.”

So my inclination is to tailor our psychotherapy practices to the cultural background, needs, and proclivities of whoever we’re working with. There’s no need to present mindfulness in a way that is going to be alienating. Not only do you not need to mention Buddhism, you don’t need to mention meditation. These practices can be presented simply as attentional control training. When we train our attention differently, we have very different psychological experiences and it helps us both gain insight and cut through all sorts of forms of suffering.

The first rule of psychotherapy is to meet the client or patient where he or she is, and this should not be forced upon people as some alien cultural system, and nor should people be forced to consider the implications of these practices for developing wisdom and compassion if all they’re hoping for at the moment is a little bit less anxiety. That may come later down the road, but we can help them with that anxiety first.

That being said, there are potentials to these practices that are very deep, very wide, and very rich. If a clinician learns mindfulness-based stress reduction and sees these practices primarily as a tool for helping people to relax, they will miss some of the depth and some of the breadth of what these practices can offer. I think it’s useful for clinicians to practice with some intensity themselves, so they can see personally how transformative these practices can be, in a way that goes far, far beyond any benefits that come from relaxation training. It can be very useful for clinicians to learn about Buddhist psychology. It is a very profound and helpful way to understand the mind and how we get caught in suffering.
DK: I think that there’s a lot of mystery and mystification around what mindfulness is, and one of the great things about this new video with you we’re releasing is that we get to see you doing meditation with clients, and modulating it to the specific needs of each client. In real life you don’t do meditation with everyone, but this gives psychotherapists a chance to see what it looks like to bring it into a session.

I think a lot of people are kind of scared to do it and I know that when I first started doing it in my therapy sessions—and I only do it occasionally—I was actually surprised at how profound an experience it was for people and that it had the capacity to stir up some really intense memories. It’s a powerful tool that we have to learn how to use. Can you say a little bit about how you modulate and decide to use meditation in therapy sessions?
RS: First I’d like to pick up on one thing you said.
Many people in our society are involved in states of distraction all day long. Google says we check our cell phone on average 125 times a day.
Many people in our society are involved in states of distraction all day long. Google says we check our cell phone on average 125 times a day. We spend hours watching television. We spend a lot of time chatting with friends. There’s nothing with that—all of these things can have wholesome aspects to them and can make for a rich and interesting life, but for many of us, they keep us from really noticing what’s happening in our minds and in our hearts in each moment. They help to insulate us from the hundreds of micro-traumas that most of us experience just going through the day. The little disappointments, the “I wonder what she meant by that,” the “I didn’t do that as skillfully as I would have,” or “I haven’t quite achieved what I wanted in my life.” Endless, endless reflections, each of which has a bit of pain in it and each of which we want to distract ourselves from with various forms of entertainment and engagement. When people start taking up these practices, all of the pain of those micro-traumas start to come into awareness, and they can indeed be unsettling. Of course they also offer the opportunity to integrate all of that, which is a wonderful potential. So I think we have to be very judicious about it.

My main criteria for whether to actually teach mindfulness practice in a session are twofold; one is, what’s the person’s cultural background and how weird are they going to think it is to choose an object of attention and bring attention to that and return to that object when the mind wanders? Because for some people, it’s like, “forget it, man, that’s not me.”
DK: Yeah, on of the clients in the video, Julia, is a bit like that.
RS: For folks like that, I’m going to be very judicious about it, but one can bring mindfulness into psychotherapy in many, many ways that don’t involve teaching meditation. I already spoke about the shift in our attitude and our capacity for presence as psychotherapists that occurs, as well as the shifts in our models for psychopathology and for what might help people out of psychopathology that might come from our own practice.

Let’s say we’re sitting with somebody and it’s clear that some feeling got triggered. The conventional way to respond to that in therapy is, “What are you feeling now?” A slightly different way to ask the question might be, “what did you notice happening in the body and the mind right now?” That little shift in phrasing starts to shift the conversation from the normal narrative about “my life starring me,” to an observational stance—to what the CBT folks would call “metacognitive awareness,” or what the analysts would call “observing ego.”

To begin to watch and to identify a little bit with awareness itself, rather than the contents of the process. Of course it might be skillful or it might be unskillful in any given moment. For one person at one moment, what they need is to feel your empathic connection to them and saying, “What were you feeling at that moment?” might feel more empathically connected. But for somebody else, they might need to develop some of this observing ego or metacognitive awareness, and if we’re phrasing it in a slightly more objective way, it might serve that purpose. That begins to develop a little bit of mindfulness, even though we’re not doing anything that looks like meditation.

The second criterion I use is, “What’s their capacity to be with their experience?” If they have very little capacity to be with their experience, I want to start with very small doses and very non-threatening contents. If they have more capacity to be with their experience, we can dive into larger doses and get at whatever arises in consciousness right now. It really depends on the person.

Lighten Up

DK: You mentioned CBT and metacognition and it seems like a lot of what’s happening in mindfulness interventions is “noticing.” In CBT, I tend to think of it more as not just noticing, but blocking or counteracting thoughts. Is there also a methodology within mindfulness training where you’re being more directive with the material that comes up in the brain, or is that off limits?
RS: That’s a very interesting question. Let me correct one thing. There’s noticing, and there’s also feeling in a wholehearted way. I think one mistake people make is they assume that this is a very cognitive kind of endeavor and that’s only one part of it. The other part is really opening to what’s happening on a heart level, in terms of really feeling feelings, as well as noticing what’s happening in the interpersonal field and our relationships and connecting in an alive and juicy way to experience. So I just want to mention that first.

Secondly, CBT folks have described it as the third wave of behavior therapy. The first wave was Skinner on one hand and Pavlov and Watson on the other hand. Operant and classical conditioning and working with modifying behavior. Then came the very important insight that human beings, unlike other laboratory animals, think a lot and our thoughts have tremendous impact on both our emotions and on our behavior. So maybe what we should be doing is using behavioral principles, learning theory, to modify thoughts.

The third wave is coming from a different direction:
What if we start to see all thought as essentially fluid, suspect, unreliable, and based on emotion?
What if we start to see all thought as essentially fluid, suspect, unreliable, and based on emotion? These acceptance and mindfulness-based approaches are all about lightening up in relation to thought, rather than trying to get rid of the bad and hold onto the good.

In my experience, that can be quite powerful, but it takes a while. It’s a much more subtle and in some ways sophisticated way to work with the mind than just replacing maladaptive irrational thoughts with adaptive rational ones. After all, one person’s adaptive, rational thought, is another person’s insanity. We all may agree about our zip code and whether it’s raining at the moment, but as soon as we get into more complex matters, humans differ a great deal and I think we’d do better to have a more relativistic approach toward different thoughts.
DK: So the third wave basically posits that we are all insane.
RS: Yes, we’re all insane. This is a little bit of a bold summary, but my impression of the last 15 or 20 years of advances in cognitive science is basically the realization that all the processes that we’ve thought of as rational are irrational, that bias, desire, cultural proclivity, those kinds of factors are really what determine how and what we think. The idea that we are rational organisms analyzing data for positive goals—yeah, occasionally, but that’s not mostly how we tick. So if we can lighten up generally in our approach to thinking, I think that’s quite helpful.
DK: That is a perfect place to end. Thank you so much for sharing the insights of your otherwise unruly mind.
RS: It’s been a pleasure.