When East Doesn’t Meet West: Buddhism and Psychotherapy

Posted on by Psychotherapy.net Team

Two statements from the Dalai Lama suggest a conflict between meditation and the type of self-awareness we develop in psychotherapy. The first statement has fascinated and puzzled me for decades. A friend, who meditates regularly, told me that the Dalai Lama said the following in conversation with an American psychiatrist: “When someone has been shot with an arrow you psychologists ask how the arrow got there, who shot it, how long ago, with what intent. We, on the other hand, reach over and pull the arrow out.”

Another statement from the Dalai Lama, suggesting an incompatibility between Western psychotherapy and Eastern meditation, used to cause me sleepless nights: “In the Buddhist tradition, compassion and love are seen as two aspects of the same thing: compassion is the wish for another being to be free from suffering; love is wanting them to have happiness. Self-centeredness inhibits our love for others, and we are all afflicted by it to one degree or another.”

Back then, when I had been in psychoanalysis for many years and I had also been meditating, I had the impression that my meditation practice and my psychoanalytic sessions were antagonistic and that sooner or later I would have to choose between them. Was individual psychotherapy, in its attempt to understand “how the arrow got there,” a form of self-centeredness? Shantideva, an eminent 8th century Buddhist scholar, wrote: “Cherishing the self is the cause of all suffering. Cherishing others is the source of all happiness.” Does psychotherapy amount to a “cherishing of the self?”

This critique of the self runs consistently through Eastern thought. I also found it in the I Ching: “Through hardness and selfishness the heart grows rigid. This rigidity leads to separation from all others. Egotism isolates people.”

Three or four times a week lying around, rambling on about my self. That was egotism. What else could I call it? I mentioned this concern to my psychoanalyst who pointed out that the question was very likely a form of resistance. Maybe it was, but it was also a concern that needed discussion.

A number of Eastern traditions also come down hard on suffering. Shantideva wrote: “The Sanskrit word for suffering is dukkha. The root word kha means sky, or space. The prefix du means unhealthy. So dukkha, suffering, is a condition in which our relationship to space is unhealthy. We suffer when we feel disconnected and alone. An experience of emotional trauma may cause us to retreat into a ‘fortress self.’ We unconsciously imprison ourselves in a state of psychic solitary confinement.”

One thing I knew about myself was that I suffered; I went into psychotherapy to address this suffering. Over the years I found a great depth of self and self-knowledge, a hidden treasure of the self I would not have found but for the suffering. Could the uncovering of this treasure be considered a retreat into a “fortress self?” An imprisonment in a state of “psychic solitary confinement?”

In those years I was always looking for some reconciliation between East and West and especially between these two traditions. One day I came across something promising. I had just discovered that the Sanskrit word for bliss was sukha. Sukha, I read, connotes a healthy relationship to space. We are open. We feel related to others. We are connected to our own embodied selves, to others and to spirit. The key to the transformation of suffering into bliss is to open our hearts. And what do we find when our heart is open? We find love. An open heart is a heart filled with love, yes love. The very thing I had become more capable of feeling as I explored the reasons for my suffering.

Would this settle my worry about selfishness, self-centeredness, egotism, arrows that stay stuck until we understand who shot them? I think it did. Perhaps, in both meditation and in self-reflective work, in our spiritual inclinations and through our inner broodings, we are embarked upon the self-same path. I don’t know that psychotherapy in its many schools would think of its goal as the liberation of love from a heart twisted in on itself by suffering. But I have found, in my self-work, and now for many years in my work with others, that as suffering retreats love enters; as self-pain diminishes, care and concern for others ripens. Maybe it is as natural to love as for a cherry seed to ripen into a cherry, and we psychological workers need only provide the right circumstance for this to happen.

I once read about a seed that had been wrapped away for thousands of years in an Egyptian mummy. Unearthed, brought into the light and planted, it shot out its roots, sent forth its branches, unfurled its leaves. I can’t remember the name of the plant it became but perhaps, whatever it was, it will help us in our work to imagine that love is like that, a mighty seed, often hidden away and hard to reach, but ready to thrive given the right conditions.

Michael Lambert on Preventing Treatment Failures (and Why You’re Not as Good as You Think)

Posted on by rezendevknowfully.com

The Blind Spot

Tony Rousmaniere: Let’s jump right in. You’re a leading researcher in the field of helping clinicians track their clients’ outcomes.
Michael Lambert: Right.
TR: Despite a quickly growing body of evidence that tracking outcomes can really help clinical practice, there are still many clinicians who don’t do it or who don’t want to do it. How would you make the case to these clinicians that tracking outcomes can be beneficial for their practice and for their clients?
ML: Well, the system we developed, the OQ (outcome questionnaire) Analyst, essentially monitors people’s mental health by asking 45 questions about their mental health. Clinicians can’t do that on a weekly basis because it takes too much time to do it, so the best way to do it is through a client self-report measure that asks very specific questions about different areas of functioning. It’s important to use a self-report measure and to tap into a broad range of symptoms that wouldn’t normally come up in a session, since sessions usually focus on what happened last week. It’s like taking a patient’s blood pressure and checking their vital signs for each visit. It gives you a much more precise measure of how they’re doing over time.

We developed the measure essentially to reduce treatment failure. It came out of the problem of managed care bothering clinicians with management bureaucracy around cases they knew nothing about. And so the idea was to stop managed care from managing all the patients in the clinician’s caseload and to focus on the management of patients not responding to treatment. So it’s not for all patients. It’s not necessary for the majority of the patients, actually—but it is necessary for patients who are not progressing or are getting worse. 
About 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started.


Our estimate is that about 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started, which doesn’t include people who simply aren’t improving. But in our survey with clinicians we asked what percent of their patients were improving in psychotherapy, and they estimated 85 percent. This is a major blind spot for clinicians. They’re not good at identifying cases where patients are not progressing or are getting worse. Even in clinical trials where you’re delivering evidenced based psychotherapy and get well trained clinicians who are following protocol, etc., you’re only getting about two-thirds of those patients responding to treatment. And then in routine care, the percentage of responders is closer to one-third. So clinicians’ estimates are way overstated.

In many ways, I think it’s a necessary distortion for clinicians; in order for us to remain optimistic and dedicated and committed and engaged, we have to look for the silver lining even when patients are overall not changing or outright worsening. It’s kind of a defensive posture, and it serves clients well generally and it serves clinicians well generally because the more success we see in our patients the happier we are in our jobs. But the downside is for the subset of patients who are not on track for a positive outcome. The distortion doesn’t work in their favor.
 

We Are the 90 Percent

TR: So are you saying that therapists are kind of inherently optimistic and positive, which helps them with most clients, but creates a blind spot for clients who are possibly deteriorating?
ML: Exactly. The evidence for that comes from a few studies we’ve done. It’s been true since it was first studied in the 1970s that individual private practice clinicians are overestimating treatment effects. This has been going on for 40 or 50 years that we know of and probably forever and it goes on today.


So if you’re in that world of overestimating the successes, then you’re not going to be motivated to adopt what we’ve developed because you can just stay in the happy world of optimism. But if you actually measure people’s symptoms and their interpersonal relationships and their functioning at work or homemaking or study, then the patients aren’t reporting the same thing that clinicians are reporting. That’s a problem.

Another related problem is just how good clinicians think they are at having success compared to other clinicians. Ninety percent of us who practice—I’m one of those 90 percent—think our patients’ outcomes are better than our peers outcomes. So
90 percent of us think we’re above the 75th percentile.
90 percent of us think we’re above the 75th percentile. And none of us in our survey saw any clinician who rated themselves below average compared to their peers; whereas, 50 percent of us have to be below average because it’s normally distributed. So we live in this world where we not only think our patients are having excellent success, but we think we’re having greater success than our peers.
 
That’s one line of evidence to support formal measurement. Another one is a guy named Hatfield in Pennsylvania, who did a study where he compared patients’ mental health with clinicians case notes, and clinicians missed 75 percent of people who were getting worse.

In the study we did we asked 20 clinicians, doctoral level psychologists, and 20 trainees getting doctorate degrees to identify the cases they were treating where patients were getting worse and who they predicted would leave treatment worse off. The patients answered a questionnaire at the end of every session and we identified 40 out of about 350 patients who got worse over the course of their treatment. Of the clinicians in the study, one trainee identified one of those 40 as being worse at the end of the treatment. The licensed professionals didn’t identify a single case.
We live in this world where we not only think our patients are having excellent success, but we think we’re having greater success than our peers.



They did identify about 16 people who were worse off in a particular session than they were when they entered treatment, so if they had just used that information alone, they would have increased their predictability a lot. We thought maybe licensed professionals would be better than trainees, but there was absolutely no difference. It’s a blind spot. We’re just ignoring it.
 

The Moneyball Approach to Therapy

TR: This reminds me of that movie, “Moneyball,” where they talk about using statistics to improve baseball outcomes. It’s like a Moneyball approach to therapy.
ML: Exactly. And if you listen to any recent talks by Bill Gates about improving the health of kids in underdeveloped nations and teaching in the U.S., he’s advocating essentially the same thing we’re advocating. You’ve got to measure it. You’ve got to identify the problems because you can’t solve the problem unless you can identify the problem.
Our clinicians are no better now than they were before we started doing this research. They actually have to use the data.
The way to identify it is not to ask clinicians. We are optimistic. We have to be. I want clinicians to continue thinking that they’re better than their peers. I want them to continue to have huge impacts on their patients. But there are some patients for whom it just isn’t true. So clinicians can’t do it with their intuition.

In our statistical algorithms, we look for the 10 percent of clients that are furthest off track and then we tell clinicians, “This patient is not on track.” That’s what clinicians can't do on their own. That’s information they need. They don’t actually get better at this over time. Our clinicians are no better now than they were before we started doing this research. They actually have to use the data.
TR: So this isn’t something that therapists should hope to improve, like getting rid of this blind spot?
ML: No. All our data suggests they don’t improve. 

But Therapy is So Complicated and Nuanced…

TR: We use the OQ Analyst here at my clinic and we find it really helpful. When I talk about it with other clinicians, one thing I hear a lot is, “Therapy is so complicated and nuanced and subtle. How could a computer program possibly understand that?” What would you say to them?
ML: I’d say that computers weigh evidence properly and clinicians don’t. Clinicians don’t know what evidence is relevant to predicting failure and they don’t weigh it. A statistical system actually gives things weight. 
TR: Are you a practicing therapist yourself?
ML: Yes, and I think I’m better than 90 percent of other therapists [laughs].
TR: I’m sure you are! So how has using the OQ affected your personal practice?
ML: Well, I pay attention to it. I realize that it’s much more accurate than I am. So when somebody goes off track I take that seriously. I say, “Well, whatever is causing this—whether it’s something about our therapy or something in the outside world—something is making them deviate from the usual course to recovery.”

The second part in what we developed was a clinical support tool for identifying what might be going on that’s causing the deterioration. We have a 40-item measure, the ASC, the Assessment for Single Cases, that measures generic problems in psychotherapy like the therapeutic alliance, negative life events, social support outside of therapy and motivation. And there’s a prompt to consider referral for medication. If a patient is getting worse and we’re working hard in therapy, then maybe they need to consider being on a medication. And there’s a prompt for change in therapy tactics, like delivering a more structured psychotherapy—you start increasing the directiveness of the therapy for the off track cases. If you’ve ever read any of Luborsky’s stuff, they do brief psychodynamic psychotherapy of about 20-25 sessions and they divide what they’re doing into supportive tactics and expressive tactics. One goes into deeper exploration of a person and the other one offers a more supportive environment. So you might shift from an expressive tactic to a supportive tactic when people go off track instead of pushing harder to break down fences. You start to try to strengthen the defenses that are there.
When clients are interviewed about the course of therapy, they lie to protect their therapists. But when they take a self-report measure, they're inclined to give a more honest appraisal.



For example, if I were treating a posttraumatic stress disorder patient and we were doing exposure and I was tracking their mental health status and they were going off track, I’d think about giving them coping strategies to deal with their anxiety. We might back off from exposure and make sure they have the tools they need to deal with the anxiety that’s provoked by the exposure. Because they should get more anxious, they should become more disturbed, but it shouldn’t last every day of the week after an exposure session. So you might think you’ve got them in the habit of breathing, but they’re actually not breathing and you have to go back to basics and make sure they’re taking some time to breathe when they get panicked. So the problem could be anything from a technique that’s being misapplied, like exposure therapy, or the need for medication because they’re not really able to make use of the therapy and they’re decompensating.

Another blind spot for clinicians is the therapeutic alliance. Clinicians tend to overrate it as positive, but it really does correlate with outcome if it’s based on client self-report. We’ve looked at studies where clients are interviewed about the course of therapy and in that case they lie to protect their therapists. But when they take a self-report measure, they’re inclined to give a more honest appraisal. 

My Therapist Was Glad to See Me

TR: What do you use to measure the alliance?
ML: We use the ASC for that, too. Eleven of the 40 items are alliance items and they’re based on traditional conceptions of therapeutic alliance, but with 11 specific items like “my therapist was glad to see me.”
It would be nice if therapists knew when patients didn’t think they were glad to see them.
It would be nice if therapists knew when patients didn’t think they were glad to see them. That’s something that therapists can take action on pretty fast unless there’s strong countertransference problems, in which case they probably need to seek supervision and figure out why they don’t like a client.

It might be the time of day, for example. If you see somebody at 5:00, you may not be as perky as at 4:00. Or it may be certain client characteristics like they’re intellectualizing and boring. So we just try to provide clinicians with individual item feedback on items of the 11 that are below average. But it’s only for the 20 percent or so of clients who go off track.
TR: What about dropouts? That’s a pretty chronic, widespread problem in our field that we generally don’t like to talk about. Did OQ help clinicians with that at all?
ML: Yes. What it tends to do in our feedback studies is it keeps the patients who go off track in treatment longer with much better outcomes at the end. And it tends to shorten the treatment with people who are responding well to treatment because it presumably facilitates the discussion of ending treatment. So overall you get about the same treatment lengths, but you’ve got more treatment aimed at people who are having a problematic response and less treatment than people who are responding. We actually find that about half the dropouts are completely satisfied with treatment. So they quit because they felt better. And that can happen really fast, so not all dropouts are a bad thing; about half of them are.

Suicide and Substance Abuse

TR: You mentioned earlier that the OQ assesses for suicide and drinking and other red flags. Maybe you could just speak to that and how it can help clinicians dealing with these issues.
ML: Well, there are three subscales. There’s the symptom distress subscale that’s mainly anxiety and depression with some physical anxiety symptoms. Then there’s one on interpersonal relations and one on social role functioning. The role of adults is often to go to work and do their job and get raises and advance their careers. If you’re a student, it’s succeeding in college or some training program. You can look at those different areas and sort of calibrate problem areas in those three areas. Is it across the board or is it one of the three? And then you can focus your treatment based on where the problems are. And then there are critical items that go into those subscales that are substance abuse and suicide.

We find clinicians tend to underestimate the problems people have with substances.
We find clinicians tend to underestimate the problems people have with substances. They’re under reported, but when they are reported it’s often not addressed because people underestimate the negative consequences of substance use. With suicide, no clinician asks patients at every session how suicidal they were this last week, but that can spike quickly. A patient can go from not thinking of suicide much at all to thinking of it almost daily over the last week. One item on suicide isn’t a predictor of suicide, but, of course, predicting suicide is sort of beyond us generally speaking. So it’s important to ask more questions about It more frequently.

When I see a client and I give them the OQ45, it gives me right off the bat a gauge of just how unhappy they are, but I don’t find it a rich diagnostic instrument. It’s more like a blood pressure test. Some people come in with a really high score. If they score a 100 then I’m really alert because if that doesn’t come down, they’re going to do something stupid. They’re going to try suicide, or drink too much or be too promiscuous or they’re going to end up in the hospital. So for me, if I was tracking somebody that has a score of 100 and we had three weeks of therapy and their score didn’t come down, I’d be thinking about medication if they were depressed more than if somebody had a score of 70, which is moderately or mildly disturbed.

For people scoring really high, they’ll likely have a better outcome if they’re not just relying on psychotherapy. So it could prompt a referral, but certainly it’s going to prompt you to be very alert. I usually have a good sense in the first session without the OQ45 of how disturbed people are—unless they’re that exceptional person that doesn’t want to admit to anything, but has plenty of problems. They may not trust you and they may not trust the system and they may not want to report stuff. You find that a lot in the military. When they start to trust you they’re more open.

I saw a borderline patient who didn’t look very borderline on the surface, and it took six months for me to learn that she was cutting herself. I gave her the MMPI as well and she scored quite normally on the MMPI and then was within the average range with OQ45. She presented herself with a simple phobia, a driving phobia. So we were concentrating on the phobia, but there was all kinds of stuff that came out once she felt more trusting. So if there’s a discrepancy between the score on the test and your own intuition, then that tells you the patient may be too ashamed or distrustful to tell you.
 

When Confidence Hinders Us

TR: It seems that a real crux of this is therapists being willing to acknowledge their own limits or blind spots. I came across the outcome measurement before I was licensed. I was a beginner, so it was pretty easy for me to acknowledge. Do you find that more experienced clinicians have a harder time acknowledging that they have blind spots and might need something like the OQ45 to help find them?
ML: I think people trained in CBT and behavior therapies would be open to measurement. Although, in routine practice, they don’t really do it the way it’s supposed to be done and start relying on their intuition. But CBT therapists generally are more open to it. If you get somebody who’s psychodynamic, they’re very, very resistant. I’ve found that it does depend on theoretical orientation. I think also in certain community mental health settings where the patients are so disturbed it can be quite disheartening to see the slow rate of change if there’s any change at all.So you’d just rather not see the bad news because you’re kind of used to people not responding very much.

So it’s a lot harder to sell with psychodynamic therapists and maybe post-modern therapy. Even though client-centered approaches have a long history of studying the effects of psychotherapy and the process of psychotherapy, they still see simple self-report measures as easily faked.
Psychodynamic therapists are usually overly confident in their clinical judgment, so they see defenses at work everywhere and don’t trust self-report measures.
Psychodynamic therapists are usually overly confident in their clinical judgment, so they see defenses at work everywhere and don’t trust self-report measures. But I think underneath all of that is that once we get into a routine and we develop confidence, we think there is no reason to give new interventions a try. You just hear all kinds of excuses for why people can’t do this and they usually don’t hold water. For example, patients don’t mind doing it at all. They like it.

It’s true across all of medicine, where people are really slow to take advantage of innovations. They only adopt new innovations when the gal in the office adopts it. So you’ve got to get people doing it around you before you decide you’ll give it a try. In our very first study, we only got half the therapists to participate. And then by the time we did our third study, all but one participated. And now if the computer system goes down, people get really upset. They don’t want to work without it. But it took two or three years to get all of them into it.

Innovations are a hard sell. Unfortunately, the way most clinicians get exposed to this is through administrators who make them do it, and then their general attitude is distrust of the way the information is being used. Clinicians passively-aggressively don’t participate, and as a result they sabotage the whole effort. It ends up being a power struggle between clinicians and administrators.
 
TR: This brings up a question I wanted to ask you, which is about using the OQ to compare therapists. I think I’ve heard you say that you don’t think it or other outcome measures should be used to compare therapists. Is that accurate?
ML: Yes. I think you end up being on thin ice in settings where patients are assigned randomly. In most settings, like private practice settings, they’re not assigned randomly but you can’t assume that clinicians have equivalent caseloads. Plus we find most clinicians are in the middle. But you can see a big difference between clinicians at the extremes. The average deterioration rate at the institute is about two to three percent, and then we’ll find a clinician that has a deterioration rate of 17 percent. We had one clinician in our center whose patients on average got worse. So I think you can do something with that data. But you wouldn’t want to make too much of it because most of us can’t be distinguished. Our patients do well. And our student therapists do as well as our licensed, supervising professionals. That’s very disturbing [laughs].
Our student therapists do as well as our licensed, supervising professionals. That’s very disturbing.


The only thing we can find is that when you see somebody with a lot of experience, their patients get better faster. But the overall outcome is the same. Even the stuff on paraprofessionals doesn’t show a huge difference between professionals and paraprofessionals.

If you go to a conference where people present outcome data on borderlines, they spend half their time arguing that the patients in their setting are real borderlines and the patients in the other people’s settings are mild borderlines or not real borderlines. Everybody always wants to say, “I have tougher cases,” but it’s not true all that often.
 
TR: Well, that’s how I personally know them in the top 10 percent of therapists, because I’m getting average results, but with really tough cases [laughs].
ML: But the really tough cases, from the point of view of measuring outcomes, are patients who aren’t disturbed. If I was going to fill my caseload to make my data look good, I’d go for the moderately disturbed patients. I would not want a patients who were close to the norm because those people are not going to change. They have nowhere to go. Whereas, the people that are admitting a lot of disturbance, it’s harder for them to get worse and there’s a lot of room for them to improve. Does that make sense?
TR: Absolutely.
ML: They would change a lot. They may never enter the ranks of normal functioning, but they would definitely improve.

The Fact is, We're All About Average

TR: There’s a handful of therapists, including myself, who have been making our outcome data available to the general public, to prospective clients. Do you think that’s a legitimate use of the outcome data?
ML: I have some concerns about it, so I guess it depends on how it’s used. Because in some ways you don’t want patients to know the truth that they have, say, a 50 percent chance of recovering. And if it’s in comparison to other therapists, then you’ve got to make sure there’s some way of making the cases equivalent. Individual clinicians can’t do this, unless they’re gifted with statistics. What we’re doing in managed care is we can calculate the expected level of success for a clinician based on their mix of clients. So if you had one kind of mix, the expectations would be higher than if you had a different mix. And then you can see how they perform in relation to the expected treatment response for their mix.
You don’t want patients to know the truth that they have, say, a 50 percent chance of recovering.
 

The fact is we’re all just about average. So we have no unique claim to effectiveness unless we’re the outlier. So it might be good for outliers on the positive side. For the average clinician you are just able to say, “my outcomes are as good as others.”
 
TR: Our outcomes, as a field, are pretty good, though, especially when you compare it to medical outcomes.
ML: Yes, I think we have a lot to be proud of. 
TR: So your average clinic therapist is actually pretty good.
ML: Yes, I think so. But knowing routine care clinics, the average number of sessions is three or four. So that’s a dose of therapy that’s good for 25 percent of people, not 75 percent. 
TR: What about for therapists who do want to get better? I know a lot of the Psychotherapy.net readers are there to learn new techniques and broaden their skills and knowledge. Can the OQ help people become better therapists?
ML: Maybe in the long, long run, but I don’t think there’s any evidence for it. I think you’ve got to go through the procedures, get the feedback and figure out a way to make it work for the patient. But if they don’t get feedback, they’re not going to be able to identify problem cases and make appropriate adjustments.

What’s true is you need to be measuring patients on an ongoing basis and get feedback when client’s are failing. I don’t think there’s too much effect for giving feedback to clinicians whose patients are progressing well. They may like it, but as far as improving their outcomes, most of the bang for the buck is when the therapy has gone off track. That’s the novel information.
Feedback helps when it’s novel, when it’s giving you information that you didn’t know about.
Feedback helps when it’s novel, when it’s giving you information that you didn’t know about.
 
TR: It sound like what you are saying is the way that we improve is by really recognizing our blind spots and finding tools to help us there rather than thinking we’re going to overcome them.
ML: Yes. The practice of medicine is a good analogy. I don’t think my doctor is any better at guessing my blood pressure after measuring everybody’s blood pressure and getting feedback. I just don’t think he can operate without a lab test. I don’t think we want people managing medical illnesses without lab tests. And they don’t feel any shame at all. They feel like they really get good information and they wouldn’t dream of managing a disease without that information. They don’t expect themselves to be able to do it or learn from it.

If you look at the psychoactive medications—I’m just shocked at how poorly it’s managed. If you work at UCLA, you believe one thing’s the best practice and if you work at NYU, you’ve got a completely different set of practices. And it’s not like it’s based on how your patients are responding to the drugs because it’s very poorly monitored.

I hope this is not too disappointing.
 
TR: How so?
ML: Well just that the feedback is absolutely essential. Therapists can’t just “get good.”
TR: I actually find it liberating because it means I don’t have to try to become good at something that I’m just inherently not good at. So it kind of takes the load off. I just hope we can find more things like this in the future to point out our blind spots and help us so we don’t have to run around pretending they’re not there.
ML: We’ve confirmed our findings in study after study—and now there are more studies coming out of Europe—but it’s really hard to get clinicians to do it. There are people who adopt this early in their careers, but many people are pretty closed and defensive.
TR: Well I’m a psycho dynamic therapist—I do short-term dynamic work and I’m part of a psychodynamic community—and I have found that newer therapists are just a lot more open to it and are kind of growing up with it. 
ML: And they’re not so afraid of technology.
TR: Yeah, that too. So I’m really hoping that the psychodynamic community can start to embrace this instead of resisting it.
ML: It’s not an easy sell, but we’ll see.
TR: Well, it’s been a really fascinating conversation. Thank you so much for taking the time to talk about your work. 
ML: : It was my pleasure.

The God of Psychoanalysis

Posted on by Psychotherapy.net Team

In The Beginning…

Twenty-five years ago, I was part of a psychoanalytic group that met once a week. A dozen or so mostly Jewish and mostly well-to-do urbanites and their psychoanalyst would sit together in a large room on the ground floor of a pre-war apartment building on the Upper West Side and talk to each other for 90 minutes.

Here, in the span of an hour and a half, marriages were made and broken, grand and passionate affairs were embarked upon only to be rescinded before they started, even plots to murder were hatched and committed—in fantasy only of course. Religions too were swapped and dumped with abandon and new ones were taken on with fervor.

In the beginning I paid them no mind mostly, but was amused by the goings-on, almost as if it were street theater. What business did these things have with me? I was the son of a rabbi who had his troubles with his father, his god and women. Someone had suggested being part of this “theater troupe” would benefit me and so I went coughing into my fist.

The Forbidden Apple

Once, an astoundingly beautiful woman entered the group. She was the kind of woman that made men purple with passion and women green with envy. Blonde and lithe with legs that stretched to the Adirondacks, she was the classic femme fatale. And smart like a whip too.

She came to the group because she wanted to get married—and now, she said.

“Get her married,” the analyst gently commanded the group. 

There was a small hubbub. 

“Who do you want to marry?” asked one middle-aged matron.

“I can’t believe a girl like you would ever have a problem,” some Joe quipped.

“Is this a love problem?” another woman asked.

The beautiful young woman turned to the analyst: “This is what I mean! I attract attention, but I don’t get what I want.”

“I’ll marry you,” one good-looking but roguish man blurted out. 

What if one does actually fall in love in the group, I wondered? Is it like falling in love with your analyst—permitted to feel and talk about, but forbidden to act? It was as if psychoanalysis had taken a page from Genesis and said: Of all the fruit trees in the garden you may eat, but of this one….

I quickly learned that one had to take certain things on faith that certain restraints were for the best. If you were running away from religion to look for anarchy, psychoanalysis was not the place. 

“Why don’t you tell her how you feel?” the analyst suggested. “That would be far more helpful to her.”

“I love the way you look,” the man said abashedly. The comely young woman first rolled her eyes and then squirmed in her chair. “I don’t want to have this conversation. I feel totally uncomfortable.”

““You know,” the analyst said firmly, “it is your job to be uncomfortable—and to keep talking anyway.”” 

“But I don’t want to,” she protested.

But others encouraged her. “You could drop the subject if you want to, but this is an opportunity to say anything you want,” another woman in the group told her. “Tell him and us exactly what you think and feel,” she urged.

The woman looked at the analyst and then at the group. “Okay,” she said hesitantly. “I don’t like him! And what’s more is that he’s going to give me all this syrupy talk and I am going to feel I have to give him something that I don’t want to. I am going to feel obligated to him. He reminds me of so many of the men I know. It’s like he just want to put his tongue down my throat…”

“Why live in the future?” the analyst interrupted. “Why not hear his words and then tell him how much you don’t like him? In fact, tell him how much you hate him.”

“Okay,” she said, now intrigued.

The man continued. “Is it my fault I like her?” he said, turning to the group as a whole. “She’s beautiful!”

“What’s beautiful about her?” the analyst asked. 

“Her face, her hair…” and then he trailed off. 

But the analyst would not let it go at that. He pushed further.

“What about her face, what about her hair? Is there anything else beautiful? Tell her for crying out loud. Tell the group, tell the entire New York City for that matter!”

“Yes,” said the man gathering strength from the group. “She has the most beautiful legs I have ever seen!”

“I agree with you there,” the analyst said. “Michelangelo could not have done a better job.” 

The woman no longer squirmed. She seemed to accept the group member’s words and even complimented him in return. The group breathed the breath of satisfaction. 

Nothing Human is Alien

There was a feeling in the group that nothing human is alien and having been raised in a culture of “holiness” and mild separateness, this was a balm to my soul. There was one area, though, where I did feel separate: I had no money and nearly everyone else in the group did. (I had a social work degree, but floundered in various low-paying and ill-suited jobs before I eventually studied psychoanalysis and started my own practice.) But being young, I laughed this off. It was unimportant, I thought, and I would scrape by. What was happening in the group was far more important than mere money concerns. Or so I reasoned.

Each week I attended the group it became more absorbing and relevant. In fact, no sooner did we finish with one person’s difficulties, than the group would move on to somebody else: here a person was dissatisfied with her work-life; there a man pined for the unavailable lost love; still another longed for an erotic connection. This cycle of needs, longings and wants reminded me of an infant. A moment of satisfaction follows a feeding, followed by sleep and then frustration. Were we tired, hungry, wet, in need of a shower or something?

Such was life. It was neither bad nor good, but simply what was. Irritations were voiced, gripes, complaints, yearnings, desires were expressed. Each was dealt with. Everyone tried their best with each other. We talked and listened and abided by all of the commandments most of the time. 

In the meantime, I made enormous progress with women. I became a different man. “That which my mother and father could not teach me about my worth as a man and my place in the world, my desirability—these precious things, the group taught me.” Save for one thing: my progress around money was stymied; the flow of financial nourishment was painfully uneven at best.

It’s not as if money wasn’t talked about in the group. In fact, one of the big psychoanalytic commandments was about payment: Thou shalt pay the analyst. Thou shalt pay him well and promptly. Always you must remember to pay. 

Most of us went along with it just fine, but one person in the group resisted once. “I’m sorry I missed our session, but I don’t feel I should have to pay for that. It was an emergency. I thought I was having a heart attack…Should I have to pay for that?”

“I should charge you double,” the analyst retorted. “Once for missing the appointment, second for despising yourself and the group so much that you didn’t even think to call us to let us know that you were having a heart attack.”

To me he often said sternly: “You make money intermittently because that is how you were nourished. You had an intermittently functioning mother and the world functions intermittently for you. You will need to say more about that in group in order for your life to get better.”

Yes, the analyst was brilliant; and daring. He wore $1500 sports jackets, $300 slacks and $500 shoes. In a field unfairly characterized by menschy but nebbishy stereotypes, (think Judd Hirsch) he was a massive force. In fact, he wasn’t afraid to enact each of the cardinal sins (especially greed). They were mostly in the service of life. He modeled for us that it’s not so bad to be bad, maybe it’s even good to be bad. And if he was greedy, what of it? A little bit of greed can be good. 

In many ways he was an excellent model for me. But besides that, the truth is that I loved this man terribly, though I didn’t know exactly why. He was not an easy man, nor was he easy to love. Most often he was neutral to sympathetic, but beneath that he could be cold, brutal and unyielding, withholding words and warmth. “I am an analyst,” he would say, “not a social worker.” I sensed that though he justified his coldness and objective stance in the name of “analysis,” this also served as a cover. I was sure that he suffered and he could not metabolize his own pain. What’s more he suffered existentially, I imagined, just like me. I suspected that he too had come from the Jewish barrio. Perhaps beneath his glitz and glamour, the smells of chulent and potato kugel were not alien to his nostrils. Perhaps he too had once struggled over the Talmud and whether or not to run to the synagogue or away from it. When I asked him about this, he would slyly evade the question in the famous manner of nearly all analysts, but he did it in such a way that I knew and he knew that I knew too. 

"Have You Tried Being a Shoeshine Boy?"

People enter psychotherapy when they are in great pain and within a few sessions their symptoms start to abate, but not in psychoanalysis. Here, each of us seemed to be in it for the long haul—not for symptom relief, but for character maturation. For example, I remember one man had lost his job and he was attacking himself for not having yet found another. Bald, short and fat, he worked for one municipality or another in some kind of administrative role and he would recite his bleak story for the benefit of the group. He would come in with heavy sighs, sniff and complain: “I’ve been laid off. I’ve sent hundreds of resumes. I’m 58. No one wants me.”

Finally after several weeks of this, the analyst shouted out: “Have you tried being a shoeshine boy?” (He really did look like a shoeshine boy) “Really, I hear the city needs one. Why don’t you buy one of those kits and you could go on the subway…”

“You’re making fun of me…”

““I am making light of you. I am not making fun. I don’t take you nearly as seriously as you do,” my analyst would say.”

Within a few weeks he had found a good job. You would have thought he would have left the group, but far from it. He stayed, as many others did month after analytic month, year after analytic year, forking over good money. What was going on here in the church of psychoanalysis? What kept people coming?

I too kept coming even as it began to dawn on me that my karma of obtuse struggle and deprivation might continue regardless of how much I knew about mother and father or even how angry I got. Years went by and I had not even the slightest thought of leaving. I wondered if that made me a believer in psychoanalysis. Or perhaps, I thought, the opposite was true: Attending weekly sessions was a way of not having to believe–the same way that some might attend synagogue in order to not have to deal with G-d. Or maybe I stayed because of the love of the people in the group or perhaps the love of the analyst? These questions ran to the core of my being. What was I all about?

Even as I paid attention to these questions other thoughts came to me. “Everything that seemed both right and wrong with religion seemed both right and wrong about psychoanalysis.” For one thing, it was circular. When the analysis was working, and you made progress in life and you felt happy, that was great; when it wasn’t working, well, that meant more analysis and even more commitment. Your prayers have not been answered; well the answer is to pray more and harder.

“You haven’t helped me,” one woman would say. “I am still in the same stupid job and marriage for all these years.”

“Who you are you angry at?”

“All of you…”

“Who most of all?”

She turned and like the wicked witch of the East, pointed a finger at the analyst. 

“I pay you. My life is supposed to get better.” 

“What is better?”

“You know!”

The analyst turned to the group: “Does anyone here know what she means?” 

One woman piped up. “How are we supposed to know what you want? You don’t say anything from week-to-week. You sit in silence, stewing.”

“Why don’t you get rid of that bozo anyway?” another man shouted out.

“Because I love him…?”

“You love him? But you carp about him all the time.”

“He’s the misery I know.”

“Well, are we also the misery you know. You stay with us here in your misery and you don’t let us know minute-to-minute how you feel. You don’t connect with people, you pickle with them. We’re all pickling together with you…in a barrel of misery.”

She stammered and turned pale. “But I both love and hate everyone….”

“Why can’t you tell us?”

“I have terrible thoughts. Sex and violence….” 

“A person must put all of his thoughts and feelings into words…”

And so it went.

The Fall

After many years of faithful group attendance it would seem that I had gained immeasurably. I had found my way in love and work; I had my own thriving practice and had become “wise” to myself and my foibles. I was secure in the Edenic paradise of psychoanalysis and group. Many an energetic afternoon was spent in the womb-like feeling of a pre-war climate-controlled Upper West Side fortress. We listened to each other, yelled at each other, and got better, smarter and wiser.

But my family and expenses grew at a far greater pace than my income. I had never been sufficiently realistic about money and was mortgaged and borrowed to the hilt, all the while thinking magically that I would be saved by psychoanalysis.

While membership in the church of psychoanalysis had always been expensive (and worthwhile) it had become unmanageable. It was 2007 and just ahead of the spectacular mortgage crisis the bank had shut the spigot on my home equity line. I had nothing. The doctrine of “say everything” as a cure to all of life’s ills began to sound tinny. There were realities now to consider—forces like falling real estate prices, recession, that were impervious to even the formidable powers of psychoanalysis in general and to this psychoanalyst in particular who told me, “you should be here twice or three times a week in order to accomplish what you need!”

There was something else too. Something I had to consider. In long relationships one has—in marriages, families, with groups, synagogues, communities, tribes and religions—there is often anger, even hatred, beneath the surface. While one devotedly participates, attends, pays dues, an equal and opposite negative feeling can form—something like what Jung described as the dark or shadow side.

In a flash, this side can get jarred loose from behind the veil—a fire that badly burns and can gut a 20 or even 50-year relationship in an instant. So that’s what you’ve been thinking and feeling about me all along!

Such a thing happened here too. They and the analyst saw my departure from the group as a “resistance”—something without real merit, perhaps even something that I was doing to them. I in turn felt they were in a small way responsible for my financial disaster. After all, had they not sweet-talked me (at least by my recollection) all these years with blandishments on the one hand and psychic fire and brimstone on the other? You need us or you will be forever damned! They, not surprisingly, would have none of it. We had words, terrible words. And these words devolved into name-calling. To the man I had admired and loved for more than a decade I spoke harsh truths. ““You’re a greedy man. You are running a psychoanalytic synagogue—a money-grubbing mill for your own benefit. You’re a disgrace to the profession,” I added for good measure.”

The man whom I had loved and thought loved me became hostile and erupted like a volcano. “You’re a chazir,” he shouted at me, his slip of Yiddish a sign of his rage. “A pig, a pig!” he screamed at the top of his lungs. “You are a disgrace to nineteen years of psychoanalysis.” I gave as good as I got, but I was stunned, traumatized. I paid him one last time and walked out, vowing never to return.

It might be hard for someone who has not experienced the intimacy of psychoanalytic treatment to understand the depth of my feelings of sadness, hurt and betrayal. It is like having biblical-sized curses hurled at you at gale force by your own father. Even as I relived that horrible moment in my mind a million times—of him screaming at me and calling me names—I would never pick up the phone again to call him. I would spit on his grave.

In the meantime, just as Adam became a lot more interesting and productive after having been cast out of the Garden of Eden, I too got to work in high fashion. I built a small empire of psychoanalytic groups in the height of economic Armageddon. Even as I grieved for my analyst, I clearly was able to prosper without him. I was ready to chalk up the relationship to another chimera—a false god.

But a few weeks ago I got a message. “You have proved your point. It’s been five and a half years. It’s time.”

I had thought that the relationship had been murdered, forever relegated to harsh dreams and a raw place in my mind. Words cannot always be retracted. Some things cannot be taken back.

Could it have been for five-and-a-half years we had no contact, but we actually were in communion with each other? How much does this resemble a life where God Himself seems absent and yet every once in a while we feel he has been with us in some form all along? Devout believer or atheist, these may be the very comforting and troubling facts of our existence. Psychoanalysis, like religion, calls us back with its rhythms and vibrations, its gentle waves of thought. How could I not answer its plaintive song?
 

Epilogue: My Return

The day of my return was as beautiful a fall day as there ever was–a day that made a case for life itself. Broadway of Manhattan’s Upper West Side was teeming with people and commercial purpose. I was early and took a walk. New York was like a big friendly courtyard. I stopped by one of the Korean flower market/delis for a handful of lavender orchids.

I walked past the corner of 79th where men sell 20-year-old copies of Playboy along with scarves and old paperbacks, a place where the smell of the subway in summer wafts up through the gratings. That particular corner is a strange nexus of half-hearted commerce that bleats along in a netherworld between handouts, thrift and light industry. 

At 3:25 I knocked on his door and walked past the threshold that I once swore I would never again cross. But here I was. I waited in the waiting room and at the concerted hour and minute we were, once again, analyst and patient, face-to-face.

He was taken aback by the sight of me, I could tell. I had gotten gray. In your late 40s it comes upon you suddenly, like an overnight frost. He was grayer too. Such is life. He was gentle and warm. “How are you? How have you been, you look well, more distinguished,” he put his hand on his chin, miming the growth of gray whiskers.

“Yes, well one becomes gray,” I said. “This can’t be helped. And of course, it’s been 5 and a half years.”

“Too long…”

I sat down.

“Something happened here that hurt you,” was how he began.

“Yes,” I said, and I began to tell him exactly how, but I interrupted myself. I had brought with me a letter—a letter that he had written me after our first meeting exactly 24 years ago. It was in his own handwriting on his letterhead.

“Here, I want you to see something.” I handed him the envelope.

Ever the analyst on guard for booby-traps—real, psychological, symbolic or imagined—he said, “what is it?” He hesitated to take hold of it.

“It’s a letter, from you, dated October 24, 1988. I’ve saved it for 24 years.”

It was a response to a letter that I had written him following our first meeting, which lasted not more than 16 minutes. A quarter of a century ago his office was cross-town, and I remember it was bathed in late afternoon sunlight. He wore a seer-sucker suit with pinstripes the color of the sky.

“What is the first memory of your mother?” he had presciently asked.

“I was two or three years old and standing at the edge of the railing of my crib and she was looking in on me.”

“If you are looking to get married or even to get along better with women, then this is the group for you,” he said. “The most beautiful and wonderful women in New York City are in my group.”

One could scarcely understand what it meant to me at that time to get help from a strong man with women. I needed to connect with women. That I knew, but I scarcely knew how. And I knew he would help me. Nevertheless, I was not quite ready to join the group for various reasons; I was, as he grasped instantly, and I later came to understand, ambivalent.

“Shall I encourage you, discourage you, or let you feel the freedom to be ambivalent for as long as you need to be?”

With that simple line I was hooked on psychoanalysis for a quarter of a century. Here I had come from a background of non-stop commandments, one had to, one must, one should—and now I could be deliciously ambivalent.

“What is the charge for today’s consultation?” I asked him then.

“No charge,” he said.

I took him up on his invitation to be ambivalent, but when I came home I wrote him a letter telling him of the freedom he deftly helped me to experience in his office. I would join him in a few months.

The letter he wrote me in response was now in his hands and carefully, he opened it.

“I too enjoyed our meeting,” he wrote. “It is good for you to take as much time as you need. I look forward to working with you in the right time. I have the idea I can help.”

He held his own letter with evident satisfaction.

“From the day I met you,” I continued, “I knew that you were one of the most significant people I would ever meet in my life.”

He smiled with even greater satisfaction.

We then talked about my understanding of what happened 5 years ago and how he hurt me. At first he seemed to resist, passing my reaction off to transference, but as I quoted his words back to him, he seemed to concede that he erred.

“You were vicious and brutal,” I said. “Was I after all these years, your father, one of your siblings (all of whom I knew)?”

“You were somebody from past, it’s true. Someone I did so much for who took every opportunity to throw it all back in my face.”

“19 years of treatment and I was him?

“I am afraid so.”

“Well, that explains a lot then. My words, my true heart-felt words, things that I told you about yourself then were internalized by you as an attack. But of course, they were said to you out of love—the very first time that I could love and say the truth. What you called a disgrace to psychoanalysis was actually my highest achievement. I was trying to find a way to work with you!”

“At last he nodded. “I hurt you and I apologize.””

“I accept,” I told him.

We spent more time catching up. He remembered every detail of my life and my family. It was a good meeting. Our minds were facing each other not just our bodies. I would be in touch soon to resume our work.

“That would be welcome,” he said.

It seemed deceptively easy. Is that all it took? Were a few minutes of talking and clarification to heal my wounds sufficient to restore our severed relationship?

Yes, it took one session and five-and-a-half years of pain, for both of us. (It was clear to me he had been in pain about it.)

“What will be the charge today?” I asked, with my check already pre-signed. (Modern analysts tend to raise their fees regularly so I anticipated a hefty hike.)

“There is no charge for today’s session,” he said. “It is an acknowledgment of our relationship.”

“It is touching that you acknowledge our relationship that way,” I told him.

We bade farewell. It was two days exactly before the Jewish New Year. “Shana tova,” he said. “A gut yahr,” I replied.

I had gone back to the analyst who hurt me. It wasn’t the first time that I had taken a risk for love, but it was one of those times love was well rewarded.

Psychoanalysis, like religion, calls us and calls us back with its promise to hold our hurts, our wounds, and our grievances. And some of us keep coming back almost as if we can’t help it. Perhaps this is as it should be. One doubts, one hates, one loves, but one forgives too and often one returns. During High Holidays, one is even permitted to return without having to know why and in psychoanalysis, my analyst, once said, it's Yom Kippur every day.
 

The “L” Word

Posted on by Psychotherapy.net Team

Lisa hefts herself heavily up the stairs to my office. She must come up two feet to a stair, like a small child. She is breathless by the time she gets to my office and has to take a few moments to collect herself. As she settles in, I realize she has gained even more weight in the few weeks since I last saw her.

She is huge, solemn, powerful, inert. Once she is seated, nothing moves but her head and hands and her big, expressive eyes. Her pace in therapy has been glacial. I wheedle, nudge, poke, prod, shove, usually with very little effect. My anxiety stimulated by her apparent weight gain, today I shove, for all the good it does me. A boulder slammed into the earth by the gravity of her rage, she is immovable.

During the session, she makes some small, wry, self-aware and self-deprecating joke about her resistance to change. I can’t even remember what she said, but flooded with affection for her—impulse and action melded together, racing along the same neurons in tandem—I burst out with, “Oh Lisa, I love you.” I am a little shocked to hear my own voice saying the words. It is true enough, but I did not expect to say it. Had those synapses fired at any distance from each other, I would not have.
She does not look shocked. She has, in fact, a small smile. I would guess that in her half century of living she has heard these words spoken to her fewer times than I could count on one hand. I can practically hear the tectonic rumble of pack ice shifting.

I have so flustered myself that I just carry on with our conversation, ignoring my own exclamation. As we talk, I ask her a question that I have asked her many, many times. “What do you imagine would happen if you stopped bingeing?”

This time she responds differently. Her eyes widen. She looks so frightened I want to turn and look behind myself. “I can’t,” she says. “You don’t understand.”

“What don’t I understand?”

“I am just like them. I am just the same.” I know exactly what she means. She means she is like her brothers, her mother.

Looking at her, I feel as though I am both seeing and imagining a child in her bed, piled high with blankets of flesh, her big, wide eyes peering out at me from beneath her coverings. She is not fully present—her eyes are shifting rapidly back and forth. She has the terrified look on her face of someone who has received a blow and is expecting another. I have been sitting with one leg crossed under me, but I shift both my feet squarely to the floor in an unconscious effort to ground her.
“No,” I say, “you are not like them. You are afraid of being like them.”

“If I wasn’t bingeing,” she says, her eyes still flicking, one shoulder slightly hunched as if to protect herself, “I could really hurt someone. I could kill someone.” Usually, she talks about how her fatness protects her from others, but she has never before talked about how she believes it protects others from her.

I speak to her in the low, soothing voice that you would use with an injured person or a frightened child. In a few moments, I can see her breaths start to even out. Her eyes stop moving and focus back on me. She smiles shyly, almost in greeting. She has been gone, but not gone. The session moves on and before the end, she commits to what is for her a big step.

I have never said “I love you” to a client before. I do not understand what unconscious imperative drew those words out of me. It felt as if I had no choice at all. I am as easily blinded to myself as the next person, but I can think of nothing in my life or day, no need of my own, that drove me to share those words with her in that moment. If my assessment of myself is correct, what then in her impelled those words from me, and what did they mean to her? Did I frighten her into a dissociated state, given that her experience of love is so deeply intertwined with violence? Did my expression of love for her provide her with some increased security so she could reveal more about her experience of herself? Did she want to warn me what a dangerous person she is to love? I am inclined to believe all of the above are true. Clinical error or simple human caring, countertransference enactment or empathy, I believe that in the session our separate continents shifted just a little, perhaps even measurably, toward each other.
 

Seeing Medusa in Every Client

Posted on by Psychotherapy.net Team

In Greek traditions, Medusa is the notorious stone-cold killer who was well known for turning people into statues. Her reputation became so brutal that she was often depicted as evil itself. However, like everyone who eventually comes to hurt others, Medusa had a life before she was the snake-haired statue-maker, but few seem to remember that. This is that story:

Medusa was a stunningly beautiful young woman. She was so striking, in fact, that everyone around her pursued her and longed to be her husband. Medusa had thick, gorgeous hair that men longed to see, and even be near. Suitor after suitor came and presented himself to her, transfixed by her beauty.

Medusa’s magnificence was so great that the gods themselves not only took notice of her, but also could not control their impulses to be with her. One of the gods, the ruler of the sea, Poseidon, became obsessed with Medusa. He sought her out while she was in Athena’s temple. There, in the midst of the holy place, beautiful, innocent Medusa sat praying to the goddess.

Poseidon did not attempt to hold back his urges, and sweeping in with a terrible ferocity, he raped Medusa on the altar of the temple. In an instant, he was gone. The deed was done. Medusa lay shattered on the floor of Athena’s house. “Why?” she thought. But she hardly had time to think. Athena was appalled that such a sacrilege would take place in her hallowed temple, and she swept in with almost the same speed with which Poseidon left.

Medusa, turning to the divine being with a look of desperation, did not receive the compassionate look in return for which she hoped. Instead, a fury overcame Athena. “How dare this take place in my temple!” she thought. Athena was enraged at Poseidon for defiling her sanctuary, but she could not punish a fellow immortal, so she turned with hatred and viciousness to Medusa.

Someone had to suffer for the atrocity to the goddess, and the victim was the target. With unquenchable anger, Athena blamed Medusa for her carelessness, for “enticing men,” and used her deific power to transform Medusa’s hair into snakes. As though the pain of serpent-hair were not enough to repel the sons of the world, she further cursed her in a way that ensured men would stay far away from her from that day forward. In a rage, Athena proclaimed, “He who looks on you will be turned to stone!”

And so a victim of rape, misdirected rage and hatred—and all for being nothing more than beautiful—Medusa, came to be known as she is today: the face of evil itself. The wrath and disgust for others that Medusa became known for were taught to her by the very figures she trusted.

There is no violent offender, no person who hurts another, and no villain in this world who does not have a story of how and why she or he came to be. We must learn to see Medusa. We must learn to see beyond the snakes and the curse that holds others at bay, and look into her deep, tragic history to get a fuller understanding of who she is… and we must also and equally do that with every client we encounter.

As therapists, we need to consistently evaluate our own personal judgments of others—not just in lip service, but in actual, in-depth explorations of who we are, and why we might hold the judgments that we do. Medusa had reasons for hurting others as she did, and so does everyone else. Our job as therapists is to assess, understand, and explain human behavior, without judgment or bias. The more we know about the past (others’ and our own), the more feasible that task becomes.

If we do not learn to see Medusa, we run the risk of remaining transfixed in our own sculptured, static mind-set: a place from which we will forever stand as judge, jury, and executioners in our own minds.
 

Christian Conte on Anger Management

Posted on by rezendevknowfully.com

"People Don’t Just Wake Up One Day and Become Violent'

Victor Yalom: Dr. Christian Conte, we’re here today to talk with you about your work with violent offenders, with anger management, and so on. You’ve chosen to work with a rather unusual and, most therapists might think, a difficult, challenging population. What got you interested in this kind of work in the first place?
Christian Conte: When I was an intern in a master’s program, I had an opportunity to co-run a group for sex offenders. The first group I ran was an adolescent sex offender group, and the way the person who was running the group started each group was that everybody had to introduce themselves by saying what they had done to offend on someone else. And then they had to follow it up with anything had ever been done to them.

So at the time I went in, my energy was pretty high because this was my first experience. I didn’t know what to expect. The guy who was training me said, “Look. They’re going to tell you about raping little kids. You’re going to hear all kinds of stuff.” So I sat down and the person to my left started. And, he talked about what he had done to someone else and then he said, “I, myself, have been physically, mentally, and sexually abused.”

So I thought, “Okay. I can see that.”

So then the next person goes, and same thing. “I, myself, have been physically, mentally, sexually abused.” As they went around the group, my energy started to calm down as I realized that everybody had had something happen to them. And over the last 14 or 15 years since then, I found that to be true for everybody I’m working with. People just don’t wake up one day and become violent. They don’t just wake up one day and hurt somebody. They’ve had past history that leads them to do what they’ve done. So that really got me interested.
 
VY: Other than your energy going down, can you recall what other kind of initial reactions you had, thrust into that group for the first time?
CC: I was studying CBT heavily at the time, so one thing I was doing was recognizing what my thoughts were. I think I was fairly judgmental in my thoughts when I started. And then my thoughts started to shift into thinking, “What would it be like to have to introduce yourself and say, ‘This is what I’ve done’?” Because that was the very first thing that struck me, is that someone would talk about their offenses so freely.
When you live in shame, you act out of shame.


I thought, “Well this is interesting. I’ve never had this experience before.” So I think my thoughts ranged from, “How could you?” to “Wow. How difficult would it be to actually be saying this?” That was my initial experience and I left feeling like I wanted to do more work with sex offenders. I worked at a mental health institution and I volunteered extra days of the week, so I was there 40 hours a week and it was just a practicum. I was doing that much time because I was so invested in it and I had the opportunity to do it.
VY: You said you were aware of some judgmental thoughts—which, of course, is natural. But how did you handle that? What did you do with that?
CC: Well I still look back on that very first session and I was really struck by the moment—I think it was the third person that went and I remember his face getting really red as he talked about what he did. This kid was about 15 and had forced his brother to give him oral sex and his brother was very, very young, like 5. And I thought, “My gosh. What would that be like to have to sit and tell these people that? How much shame must be coming up for him?” And I still reflect on that when I think about how I’ve tried to make getting beyond shame central to my work. Because when you live in shame, you act out of shame. 

"Oh Yeah? I’m Dr. Conte Too"

VY: How did your work progress over the years, in terms of the type of population and your ideas about it?
CC: I remember a guy came in who was straight out of prison, much bigger than I was, solid as a rock. And I just had a really good connection with this guy, I could really relate to him. When I talked to my colleague about how well things were going, he said, “Well look at you.” This might be a silly thing but I had just recently shaved my head—you know, I was losing my hair anyways so I started shaving my head—and I guess I didn’t even see myself in that way, but I think other people could see me in that way. 
VY: It’s not just your hair but you’re a big, muscular, stocky guy, and you sport tattoos to boot!
CC: All of that. I think I realized my persona fits, so I started running a group to see if my approach could be effective, which it turned out to be, and I ended up running groups for violent offenders.

On my first day there the guys were in line to sign in and, as they were getting in line to sign in, a guy said, “Hey go ahead, man.” I just had a t-shirt on so I had tattoos out and everything, and he said, “Go ahead, man.”

I said, “No, you go ahead. I’m Dr. Conte.”

He said, “Oh, yeah? I’m Dr. Conte, too. Go ahead.”

I said, “No. I really am. Go ahead and get in line.” So I learned early on that my persona does help. It certainly helps me to connect with people. And I don’t feel the same types of judgments that I hear other people feel about these guys. I really don’t. I look at people and I realize, “How do I know that I wouldn’t have been different if I didn’t grow up in their world and see the things that they saw and have their cognitive functioning?” I’ve thought that for a long time. And when I started to integrate into my personal life what I believed about counseling and psychology, and I really started to integrate it through meditation, it just became a part of who I am.

One thing that my clients have always reported is that they don’t feel judgment from me. I’m going to accept you. I’m not going to accept the behavior. I mean, guys knew I was not for violence. I wasn’t even a proponent of spanking. I don’t even spank my daughter. I’m not for violence in any way. But I’ll accept you as who you are. You may have messed up. That behavior is not acceptable, we’ve got to work to change it, but I accept the essence of who you are.
 

Yield Theory

VY: That speaks to the central theory you’ve developed—you refer to as “Yield Theory.” Can you describe that in a nutshell?
CC: In a nutshell the essence of Yield Theory is based on the fundamental assumption that if I lived every day as the other person, with that person’s cognitive functioning, with that person’s ability to experience emotions, and with that person’s life experiences, I believe I would have made every single decision that that person made in life. My experience is, when I throw that on the classroom, that causes a discussion right there.

People tend to respond with, “Well I had a hard life, but I didn’t do that,” but that is not what I’m talking about. You had a hard life, but you also had your cognitive functioning and your life experiences. You had your whole perspective. So it’s just a hypothetical assumption but what it helps me see is, I don’t know that I would have done this differently. That’s just radical empathy, I think, but what it allows me to do is if a person comes in and says, “That’s it. I’m going to kill that guy“—I don’t know how many tapes I’ve watched through the years of training counselors, the first thing they’ll say is, “Let’s just calm down. Let’s not do that.” Or somehow try to stop the person.

Where I go with the person, no matter how intense it is—if they’re saying, “I’m going to kill him,” I’ll respond in kind: “You kill him then. You need to kill him. All we need to do is sit here and talk. We’ll talk for a minute, then you go kill him.” And I really let them get out everything that they’re going to get out.

The analogy is like you’re driving down the road and you come to a merge sign and you yield with somebody, and your car’s driving along next to their car. After a while in this little hypothetical experiment, they say, “You know, we’re driving the same direction. I’m going to invite you into my car.” So you get into the other car with them and now you’re a passenger, but you’re starting to see things out of their window. And after you drive on a trip long enough with someone, they start to trust you and allow you to drive, then you can steer them down a different path.
 
VY: So that’s where the name “Yield Theory” comes from?
CC: That’s where the name Yield Theory came from. You give it up to join them.
VY: So philosophically you could get into a debate about free will and whether you would make the exact same choices they do, but what I hear you saying is, it’s a useful assumption in really deeply being empathic, understanding, and trying to see things from their point of view.
CC: Exactly. The very first time—this is just coming to me right now—the very first time I ever used it, after I really thought about it and wrote about it in a little journal exercise in a master’s program, I went into this group home to work and this adolescent female came down and she talked about how she stole this other girl’s shorts. And she was laughing about how she got away with it. So I completely went with it and even laughed with her: “that’s hilarious, and she didn’t even see that coming!”

And she said, “She’s so stupid.”

And I just kept joining with her: “I can’t believe how dumb she would be to let that happen.” And it went on like this for a while. By the end of the time that we were together, she said, “You know what? That was kind of messed up what I did.” And she gave the girl her shorts back. I went with her so much and then I would pose a questions like, “You know, I wonder though, as funny as it is, if there’s a point where, if she sees that, or if somebody finds out you’re stealing from them, if people aren’t going to start stealing from you? And I wonder what that’s going to be like?” And then she started to think about it.

So the point is that once people really believe and feel that you’re with them, then they don’t have to fight any more. So it’s a work around—getting around people’s fight-or-flight responses. That’s huge.
 
VY: Whose fight-or flight-response?
CC: The client’s. I know that’s a question for people because I think that’s what happens with violent offenders. Every time I’ve ever had an intern come in and sit with me doing my groups with violent offenders, they say, “Well that wasn’t anything like I thought it would be.” 

"I Picture These Giant Guys Sitting There with Knives"

VY: In what way was it different than they expected?
CC: They say, “Well some of these guys were like normal people. They just got really angry.”

And I say, “What did you expect them to look like?” I work with some gang members who have tattoos on their heads and everything else and on their faces and in that sense, that might be a little different for some people who go to school and train to become counselors. But for the most part, you see normal human beings who have issues. And I always say, ““There are two kinds of people in the world: people with issues and dead people.””] So if you’re alive, you got issues.

When people would walk out of the group, they’d say, “Wow, that guy was a normal guy,” or, “I could relate to that guy.” So I started to survey my interns before they went into a group for the first time, to see what they were expecting. They’d say, “I just picture these giant guys who are all like sitting there with knives.” That’s what their projections would be. And they’d get in there and say, “Well this is totally different.” I think if you’re not checking those assumptions, if you’re not checking those fears and projections, then you’re going to spew them all over your clients.
VY: You were saying earlier that you became aware that your physicality, your presence, helped you connect with the clients and helped them relate with you, but what about your more typical counselor, who might be rather bookish, and probably not at all physically imposing—can they do this work just as well?
CC: Anybody can do this work. Think of Aikido. You can take someone who weighs 80 pounds and they can throw me, because basically you’re taking the person’s own body weight and throwing them. If I push, they pull. If I pull, they push. I was trained in Akido, so I thought, well, this is the same thing mentally. I’m aware I’m 6 feet, 260lbs—I’d like to say 250 for the interview, but I’m at 260…
VY: Well, it’s right after New Year’s so hope springs eternal…
CC: Right, but I know I’m a big guy and that I can take care of myself physically, but I don’t put that out there. You can watch former cops come in and they’ll run groups or work with other cops and they talk in a tough way—I don’t do that. My intention is not to say, “Look at me. Look how tough I am. If it really comes down to it, I could kick your ass.” I always maintain that “you guys are tougher than I am.” I have no attachment to that.
VY: But have you noticed any differences or any particular struggles female therapists have working with violent or sexual offenders?
CC: The person I co-founded “Balanced Life” with in South Lake Tahoe, Lacey Noonan, was amazing. What she would do is she would handle herself extraordinarily well and then in supervision, she’d come in and say, “You know what? When so and so was standing over me, I felt all kinds of fear but I pushed through it.” She would step back and look at the person and say,
“You know, I wonder if you’re aware that you’re standing over me in an aggressive way?”
“You know, I wonder if you’re aware that you’re standing over me in an aggressive way?” She said that internally she had fear but realized that, through the years, she could trust the process, that she had to stay open and genuinely compassionate.

I would kind of stand in front of people and say, “Look. It’s me. I’m the person that’s stopping you from trying to get yourself locked up. So what I say to you when I give you this direct feedback, this is to help you.” And Lacey took on that approach, too. She’d say, “I’m not here to hurt you. I’m simply telling you the stuff that’s a little bit more direct because I want to help you.” She is a smaller female and she was tremendous at this. 
VY: But she did feel fear.
CC: Sure.
VY: So how do you help therapists that are new to working with this population handle that fear and not let it get in the way of being compassionate?
CC: Lao Tzu, the founder of Taoism, said, “ If you treat the people as though they are trustworthy, then they will be trustworthy.” If I look at you and I’m exuding peace and I’m trying to talk to that center in you that I know that you can exude peace as well, I think a transformation happens. I realize as I say it out loud, it can sound out there. 
VY: Well, it can, yeah. Just to play devil’s advocate, I have not worked with that population so I don’t have that direct experience, but it can certainly sound naive. These are people that have done some terrible things and just by being compassionate, you’re going to change that?
CC: I totally agree. I think it does sound naive. Except that I’ve seen it for thousands and thousands of hours of working with people. So it’s a matter of saying, “Look, I’m validating why you’re angry at something. You’re angry at something. You have a right to be angry. Just because you grew up in a certain area, because you look a certain way, because you look physically tough, I’m validating—hey, this is what you’ve done. But the question is, do you want the results of what you’re going to do?”

I mean, there are certainly moments when things get really intense. I had a guy one time—about 6’7”, 270 lbs—and he came his fourth time late to group. He was late by two minutes. And guess what? If you’re late by one minute, I’m calling your parole officer. I wasn’t attached to that. I didn’t have emotion around it.

But I remember going up, thinking to myself, “This guy’s bigger than I am. This could be interesting.” I went up to him and I said, “Look. I can understand you’re going to be really frustrated and will probably direct some of this anger at me, but you recognize that this is your fourth time late, and that your PO has to be contacted, and you’re likely going to go back to jail.” And he turned, and for a moment when he turned, and put his head off to the side, I thought, “Okay. Well he could turn around and swing right here. I’m aware of that.” But I said, “Look, I understand. I can understand you’re fired up. If you’re pissed off, you’re pissed off.”

And, he said, “No. I know. I want to be pissed at you guys but the truth is, I know I did it. I knew I did it.”

And I just jumped on it. I was like, “That’s huge. That’s huge for you to have that realization.” I just kind of praised that part before anything happened.
 

Avert Your Eyes

VY: Have you or anyone you’ve worked with or supervised ever been physically attacked?
CC: No. No, we have not. And we’ve have worked with a lot of people who have struggled with anger. One thing I’ll do is I also teach students about turning your body so that your body language isn’t inviting that. You know, if males sustain eye contact for too long, their testosterone actually increases, so I tell people to avert their eyes. You don’t have act tough and be like, “Let me stare you down.”
If males sustain eye contact for too long, their testosterone actually increases.


I turn to the side and make sure that I’m not in a threatening pose. I’ll put my hands in my pockets. I’ll do something to make somebody feel secure, that I’m not trying to threaten them in any way. The closest I think I’ve ever come—I had a guy who came in really high. He was really high on drugs and he wasn’t necessarily that big but he was just an angry guy and he was really high. So I was just very careful with how I approached him in regard to my body language and was very respectful that he was very pissed off and said, “You have a right to be pissed off.”
 
VY: We’ve been talking about underlying assumptions, the spirit of your work, you know, countertransference—if you want to put it in that language—but let’s back up a bit and get into some nuts and bolts. Have you worked with this population mainly in a group setting?
CC: Mainly in a group setting, yes.
VY: So how do these groups work? How are they structured? Are they mandated clients primarily?
CC: For the groups that I ran out there in California for six years, they were mandated by the State of California. If you committed a violent crime, you would be mandated to 52 weeks of anger management.
VY: And this is people that have gone to prison? Or doing this in lieu of going to prison?
CC: The majority of them went to prison. Every once in a while, you get somebody who, if they had no priors and depending on the nature of what they did, they would just get mandated to group therapy. That was few and far between.
VY: So they come out of jail and….
CC: They come out of jail or prison, and they’re mandated to spend 52 weeks in this two-hour anger management group. There were specific rules, obviously, that they had to follow for our program to maintain certification. So they had to be there at a certain time, they had to be two-hour groups, you get a 10-minute break. It was an open group so people were coming in all the time.
VY: About how many members?
CC: We would have 25 people in groups, which is way over the standard recommendation for group counseling which is eight to ten group members. But even though the groups were open and really big, we would get people sharing as though it was a closed group. I thought that was profound, the way that people would share, and I believe it was due to the atmosphere that was created for them. They were going to be accepted no matter what. I always said, “Whatever thoughts about what you want to do, talk about them. I don’t care what you want to do, let’s talk about it. I’d rather you talk about it then pretend like you’re not having these thoughts.”

So over the course of my career I developed over 100 exercises I would do with these groups at various times and I’m actually about to publish a workbook on anger management that includes all of them. So I’d take something like Gestalt therapy, the five phases of psychopathology—the phony, the phobic, the impasse, the implosive and the explosive—and I’d turn that into an exercise.

The Phony Phase

VY: What would an exercise look like, for example?
CC: So I’d start out by describing what the idea was—I’d tell them about what each layer was, but I would try to use the language that worked for them. So instead of saying, “there’s a phony layer,” I might say, “This guy, Fritz, called it a phony layer. It just kind of means that we’re superficial, we’re fake sometimes.” So then I’d teach this idea to them, and then I would give them a worksheet where they would detail, “How have I been phony in the past? How have I been phobic in the past?” I always asked, “How have you been this way in the past?” Rather than, “Were you this way?” Because if we say, “Were you?” they’re going to say, “No. Not me. I was never that way.”

Or I might take a Johari Window—I would take that and then I’d make a worksheet out of it. “So how are you in each one of those blocks?”
 
VY: So you do exercises like that where people would do some reflection, share with the group as a whole?
CC: Everyone would have something written down and then we would process what was going on. So I would give whatever topic I was going to do, and I’d talk about it for a little bit, and then they’d fill it out. If I had a particularly quiet member for a long enough period of time, and I wanted to draw that person out I could say, “What did you have there for that one?” And they’d feel confident to have something to look at. But basically we’d morph it into a process group at that point. Very powerful. Then I’d always end groups by asking them what they were taking away from the session.
VY: So when you say “a process group,” would you do much interpersonal here-and-now work, where people would give each other feedback in the moment?
CC: Absolutely. Right there in the moment, what was going on then, what was happening inside of them. Sometimes I would let things get heated, because I felt confident I could handle it. And there were one or two times where I would step in and say, “Okay. Now we’re going to step back for a minute and let’s talk about what just happened.” But again, it wouldn’t be judging them or scared or “break it up.” It would just be, “Okay. Let’s talk about this. Let’s stop right here for a second. Let’s hold on.” I tried to create an atmosphere of respect for one another by giving them respect, so they would listen when each other talked. There were 25 people in the room, so if somebody started a side conversation, I would say, “Hey, let’s stay focused right here. We’re always giving somebody respect, whoever’s speaking.” And they would. It was a very respectful atmosphere.
VY: Do any examples pop into your mind? Any recollections of heated moments that kind of stand out to you that you were able to use in a therapeutic manner?
CC: Well one time this guy was talking about how he beat this guy up, which ended with him kicking the guy in the head. He wasn’t proud of this moment, and his face started to get flushed as he told it. He said,
“I was kicking him in the head and I just, when they pulled me off, I was just, like, ‘What’s wrong with me? What did I just do?
“I was kicking him in the head and I just, when they pulled me off, I was just, like, ‘What’s wrong with me? What did I just do? I don’t understand what I just did.’”

And then, in the back of the room—boom, boom—this guy just started pounding on the floor, really loudly, with his foot, stomping on it. And it kind of echoed through you. And he said, “What the fuck is wrong with a human being that would step on somebody’s face?” He didn’t realize that, not only was he putting that guy down who finally owned up to what he did, but he was intimidating everybody in the room because he was getting so fired up, his testosterone’s flowing, as he’s pounding his foot.

I let it get heated and then somebody else defended the other guy: “Man, he just said he felt so bad about it, he couldn’t believe he did it. And look at you!” And he responded, “Look at me? I can’t believe you would do something like this.” Meanwhile, this guy himself had done some horrific stuff, so it was shadow projection.

And that was one of those times when I stepped in and I said, “Alright, now listen. Let me say something. Let me just say something. I don’t know if you’re aware of this, but as you were pounding your foot on the floor, the rest of the group members—and even me, I was feeling, ‘Whoa, this is some heavy energy.” He didn’t get it at first, so I switched it over to the other guy and said, “That was huge for you. I think he misheard what you were saying, because I saw your face and I saw how you finally had that feeling of, ‘Wow. I can’t believe I did that.’ And I really appreciate that you even got to that spot or that you would share that with us.”

So I’m trying to validate him. And then I said, “Now what else happened here? Do you notice how the group divided? Some people who happened to be sitting by him were were agreeing with him—let me ask you guys, were you really in agreement with him or was it because of where you were sitting?” So then we started to talk about how they would just naturally come to somebody’s defense just because they’re sitting right next to them.

It ended up being super powerful. We took a break—and I didn’t take a break until we had moved the energy in a different direction—but when we came back, I used humor to get it going at first, which was very helpful. And then we started to talk about it again, and the guy who had been pounding his foot said, “Man, I’m sorry, I just got so into that story.” And then he admitted, “I’m having a bad day.” So he was able to kind of work through it. That was one of the most powerful experiences; it was intense.
 
VY: Do you ever physically stand up?
CC: Most of the time I was standing already, but there were times that I would walk forward, just use my energy to cut somebody off or to say, “Okay, let me stop you right there for a second.” I definitely have used that energy in that way. I get that from being a professor. If somebody started to have a side conversation in class, I just walked over to that direction and, all of a sudden, there’s no side conversation.
VY: It sounds like to be effective, you need to feel in control.
CC: I think so.

Motivating Mandated Clients

VY: Would there be voluntary clients and mandated clients in the same group?
CC: Yes.
VY: So what was the difference? A lot of therapists think it’s hard to do treatment with mandated clients, that they don’t have the motivation. What are your thoughts?
CC: I’ve made a career out of working with mandated clients, so I don’t believe that at all. I think it’s our job to find out what their motivation is, and a lot of times people’s motivation, especially with this population, is, “I don’t want to be in prison. I don’t want to be sitting in this cell.” At the end of the day,
I’ve sat down with enough big, strong, tough people, who one-on-one will break down and cry and tell me how they don’t want to be sitting in that cell.
I’ve sat down with enough big, strong, tough people, who one-on-one will break down and cry and tell me how they don’t want to be sitting in that cell. That is a huge motivator.

I’ll say, “I’m going to make a wild guess that you don’t like rules. So why are you going to make decisions to put yourself in a place where they have tons of rules for you?” So I use that as a motivator for any mandated client, from adolescents all the way up. I had a new adolescent male in my practice the other day, it was my first time seeing him. His mother made him come, and I said, “Well that’s pretty shitty. She’s making you come sit across from this dude, a crazy bald-headed dude.”

And he kind of smiled and looked away. And I was like, “Man, I can’t believe she’s making you do that. It’s messed up. What do you need to do to not have to come here anymore?” And then we kind of worked through the goals that way.
VY: Any other general strategies, principles, to work with violent offenders, sexual offenders, that differ from standard therapeutic practice?
CC: Something that was a typical approach for anger management for the longest time was that people would have to write letters and read them out loud to the group about what they did and why they felt so bad. I strongly disagree with this type of perspective, forcing people to take accountability when they’re not ready to. All they do is learn how to say whatever needs to be said in front of the official people, without actually working to change.

So I never force people to take accountability. I never say, “You need to say this,” or “You need to feel shame about what you did.” Never. Because if you shame people, they’re just going to act out again. If you think you’re a no-good son-of-a-whatever, you’re going to keep doing it.
 

No More Letters of Apology

VY: So that first group that you led, where people had to start out saying what they had done, really made an impact on you.
CC: It did, but even more than that when I started to work with violent offenders because they had to read letters of apology for what they did, and the very first time I sat in on a group with violent offenders, I listened to what people really said: “No this is horse shit.” “You’re supposed to say this in it.” “No, no, hurry up, man, get an eraser. You’ve got to say this.” “Just say this word right here, you’ll make that dude happy.” They just said what they were supposed to say.

Since that time, all these years later, I’ve visited people in prisons and talked to people, and that’s still what they do. They’ll say in their writings whatever the therapist tells them they’re supposed to say so they can check the box and say they took accountability, but it’s not actually happening. So I threw that out before I started. There was no way I was doing that.

The first week I took over the groups I said, “No more of those letters. Those are out the window. We’re not doing that anymore.” Of course people would come in and think, “I did nothing. I didn’t do anything. I shouldn’t be here. I shouldn’t have to be experiencing this.” But over time, in accepting them and showing them and teaching them…Look if you meet one asshole in a day—what is the saying?
“You meet one asshole a day, that person might be an asshole. But if you meet five in the same day, you’re probably the asshole.”
“You meet one asshole a day, that person might be an asshole. But if you meet five in the same day, you’re probably the asshole.”

If you keep going to jail over and over again, you’ve got to be doing something wrong. So maybe everybody in the world’s messed up, or maybe it’s you. Maybe you need to start working on yourself. A statement I often said was, “Look, we’re all human beings. If a human being does it, it’s human nature. So if you do it, let’s just explain it. Let’s figure it out.” A lot of guys would comment that it helped them when I talked about it that way, “That’s just human behavior. So you got pissed off. So you hit somebody that you wish you hadn’t hit. Let’s learn from it; let’s move from here.”
 
VY: You’re passionate about what you do, and you take an optimistic and hopeful approach, which is certainly a good thing. I mean, if we can’t be hopeful about the clients we’re working with then probably we shouldn’t be doing it. But there’s certainly some thought in the field that there are certain people—we often label them “sociopaths”—that are just untreatable, unreachable. What are your thoughts on that?
CC: In all my years, I had only one person who I said was not right for the group setting. He was really locked into his worldview. He was intimidating physically and would get people to kind of join. I thought he was detrimental to the group setting, so I recommended him for individual treatment. I remember talking to his probation officer and he said, “In 30 years, he’s the only person who, when he goes to the bathroom, I have my hand on my holster on my gun.” He said, “My hairs on the back of my neck stand up.” The guy was an imposing figure, for sure. And I do think that some people probably need to stay locked up. I understand that that probably is that way for some people.

But I believe everyone can change. I still think human beings are worth it.
What I don’t see is how we’re not spending more time and more effort on trying to genuinely rehabilitate people.
What I don’t see is how we’re not spending more time and more effort on trying to genuinely rehabilitate people. Not make people write accountability letters that they’re faking, but genuinely change. Because if they’re going to come back out in society, why not have more intense programs that are really life-changing and affecting their whole psychology? Not just saying, “you’re angry,” but looking at their whole being. There are people that probably have a much more limited chance to change than others but I still want to remain hopeful that it’s possible for anybody to change
 
VY: Are there major mistakes or pitfalls that you’ve made or that you would caution other therapists about who are new to this population?
CC: Hmmm. Which ones do I want in print is the question?

I made a huge mistake one time with an adolescent male who told me about his drinking. I used Yield Theory, kind of went with him, validated him. I was a school counselor at the time and I ran out of time to talk to him, so all he got was validated about his drinking. He left and that was it. And I thought, “What the hell did I just do?” I validated his perspective, let him think it was okay, and I didn’t give myself enough time to actually complete what I was going to do.”

You Can Definitely Kill This Person, but…

VY: Yeah, you mentioned before that you validated this person’s desire to want to kill someone. So once you validate that, what do you do after that?
CC: You have to have the time to know that you’re going to finish the interaction. But what I can do faster now is I can move more quickly into options for people. So what I wasn’t able to do back then and what I can do now is within a statement or two, get into the options. “You can definitely kill this person but let’s think, let’s play it out real quick: If you do it, what’s going to happen?”

I’m kind of like a coach and I’ll use that metaphor a lot with men I work with—“You’re the pro. I’m just here to run some options by you. You can run this play and here’s the likely results; you run this play, here’s your results.”
 
VY: This reminds me a bit of Motivational Interviewing. We just did a video series and an interview on Motivational Interviewing, and I know that was an approach originally developed for addictions. It’s now been applied to healthcare and criminal justice. And it’s ultimately about respecting that the client—it’s their life and they’re ultimately going to make their own decisions. But given the challenges of your clients, when you’re discussing options with them do you really stay neutral? Because there’s a risk of just telling them what to do, which they’ve heard all their life; but it seems that there is also a risk of supporting, empathizing, validating them, and not taking a stand about, “Hey, maybe it’s not a good idea to kill someone.” What are your thoughts about that?
CC: That’s a really good question. It’s tough, especially when you watch yourself on tape, to say that your voice doesn’t go a certain way when you provide the option that you hope they’ll choose.
VY: Right.
CC: So I can say that I stay neutral, but I’m sure if I saw myself on tape, I make some options sound a bit more enticing than others. And not killing somebody—I want to make that sound good, so I probably end with it. I start with the option that they’ve been thinking of and I go with it. But I really play it out. “So you go kill him. Let’s play it out. So, you get arrested, or maybe you’re on the run for a little bit. What’s that like, when you’re on the run? Tell me about that.” My experience has been that when people do that, it’s almost like learning from experience in the future—now—by playing out their options.
VY: So your hope is that by doing that, they’ll make the right decision, but without pounding them over the head with it.
CC: Right.

Yield Theory for All

VY: So you’ve been talking mainly about your work in groups. What pointers would you have for a therapist who doesn’t have a particular focus or experience with this, but encounters in their private practice, a patient—maybe you’d call them “borderline” or whatever—but who really struggles with rage, aggression, acting impulsively and self-destructively. What advice would you have for them?
CC: Let’s say you’re struggling with someone with a borderline personality disorder, and you want to teach them a new skill, and you’re getting wound up in so much resistance and feeling stuck. That’s the moment to implement Yield Theory and really get into their worldview, and watch—just try it on, something as simple as that and watch how that will shift things for you.

And then it’s a matter of skill, of teaching the options. So for somebody struggling with borderline personality disorder, it would be about helping them become aware of what they’re doing, with mindfulness, and kind of going with them, yielding with them in a way that allows them to feel safe enough to become aware of themselves, and then helping them become aware of what’s happening in interactions between them and others.
VY: What would you advise students or beginning or experienced therapists who are wanting to work with this population or have the opportunity to work with them?
CC: As you said, I’m super passionate. I’m really an intense person and I’m really passionate about what I do. I was really passionate about students looking at their own lives, just like I’m passionate about looking at my own life and looking at mistakes I’ve made. I’m pretty effective at not repeating mistakes, but I’m really creative at making new mistakes every day. So I really try to look at my own life every day and ask myself, “Am I living according to what I’m trying to preach and what I’m teaching?”

But the reality is, as a supervisor for the last decade in this field, watching people’s tapes, listening to students, the bottom line is, the majority of people in our field are fairly judgmental. They’re opinionated, they try to get their opinions across in therapy sessions, and I see that a ton.
The bottom line is, the majority of people in our field are fairly judgmental.


One exercise I would do in class is, I would draw a normal bell curve, and I’d say, “This bell curve says that the majority of you, in this room right now, are going to fall right here. You’re going to be average counselors. That means when people come see you with their emotions, trusting you with their lives and telling you about their life, you’re going to give them an average response. You tell me where you want to be.”

Of course, every student would go and mark the top and say, “I’m going to be this elite counselor.” And I’d say, “Well what’s it going to take to be there? You have to read incessantly. You have to learn about your life incessantly. You have to be passionate about saying ‘What am I doing in my personal life?’ You can’t be super judgmental in your personal life and then walk into a session and just think all of a sudden you’re not going to be super judgmental.” So I really try to get people to practice what they preach. 

Let’s learn more. What are our biases? What do we think? What do we really believe? What are we attached to? I teach a lot about confirmation bias and the idea that people get so locked into, “This is my religion. This is my politics,” that kind of stuff. They hate the other side or don’t like the other side and then go into a counseling session and can’t separate themselves from that.

 
VY: Really attending to our own growth, our own biases, is a refreshing perspective, especially in this day of “empirically validated treatments,” where it’s all about the technique and not about the therapist. So I really appreciate your passion about that.
CC: I like the way you’ve rephrased it. That’s much more concisely said than what I said. I like the idea of counseling as an art, and it’s never which martial art can win, it’s which artist, as a counselor, can be effective? And so we’ve really got to learn about ourselves. I think we’re charged with doing that. I think we have an oath with saying that we’ll do that in our personal lives. People who do that become very effective counselors.
VY: Right. Well I think that’s a wonderful note to end on, so I want to thank you for taking the time to share this with us. For readers who want to get more of a sense of who you are and the spirit of your approach, we’re delighted that we’ll be releasing a video of you coinciding with the publication of this interview. I would urge people to take a look at that, as well.

The Tao of Anger Management: A Yield Theory Approach

Posted on by rezendevknowfully.com

“The gentlest thing in the world overcomes the hardest thing in the world.” —Lao Tzu

Brian had been incarcerated for taking a baseball bat to his girlfriend’s truck with her inside of it; he then pulled her out and beat her unconscious. He was out of prison and in my anger management group for two weeks when he reported, “What I did may have been too much, but she deserved it because she stole my money.” He claimed that he shouldn’t have gotten in that much trouble because it was “my truck anyway,” and besides, she “slipped and hit her head on the ice.” Brian was still in the precontemplation stage of change: he didn’t think he had a problem.

Things got worse before they got better. The following week Brian was furious when he came to group, complaining that he had been called in by his probation officer two days in a row to be drug-tested. The only reason for this, he claimed, was that his ex was “sleeping with a cop.” In a state of rage, his face flushed, his fists and feet pounding wildly, he shouted about police corruption and denounced his ex-girlfriend, the “whore” who was just out to get him. 

Instead of asking him to calm down, take a breath, or do anything other than be where he was in the moment, I simply validated him. I imagined what the world would look like from Brian’s perspective as I said, “Man, that’s just plain messed up.” I knew that Brian didn’t know anything other than what he knew in that moment, and he needed someone to see what he saw, so I went with him further: “You know, it sucks that you work so hard to be sober, and then people go and pull this shit, and test you even more.” I paused briefly, made a projection about what he might be thinking and added, “I mean, they tested you literally, but they’re also testing your limits too. It’s like they’re trying to set you back.”

He responded emphatically, “Exactly! They’re pushing me!”

“You know what?” I said, “this was kind of messed up, so I’m not even going to ask you to calm down right now.” I paused, shook my head, and waited for a moment before continuing. “In fact, even if this is supposed to be anger management, it would be stupid for someone to think you need to learn from this right now, because you have a right to be pissed off.”

He nodded his head in agreement, and he was visibly calmer, so I went on.

“I’m not going to tell you to learn anything from this right now, but let’s say this was tomorrow at this time, what do you think you might say about this experience?”

“I don’t know.” He paused. I waited. “I guess I would say that I probably overreacted.”

I then said, “I’m not going to say that you overreacted because it was really messed up, but, I don’t know—I wonder if this was like a week later… I wonder what you’d say about this experience then?”

 “I don’t know,” he said. “I guess I’d say that probation has a right to test me two days in a row in case I’m using or something.” He was calming down more, and moving more and more into his frontal lobes.

So I said finally, “Look, I know you’re pissed off, and I see you’re hurting about this, and we don’t need to talk about this tonight—but if this were a month from now, I wonder what you might say about this whole night?”

Almost completely calm now, Brian replied, “I guess if this were a month from now, I would probably look back on this night and see that I was still doing the same thing I always did: blaming her for me not wanting to be drug tested.” 

The shift occurred. The door was open to future work. 

Behind the Mask

"Treat the people as trustworthy, and they will be trustworthy." —Lao Tzu


When Brian came in furious and outraged, it could have elicited fear in me—he was, after all, an imposing figure—but I knew that Brian wasn’t angry at the world or at me; he was angry at having to take responsibility for something unpleasant. When that happens, people are usually blinded with rage, but not likely to hurt someone they don’t know. Brian was scared to face the world without what he had come to depend on: drugs to alter his state of mind. He was not ready in that moment to genuinely be accountable for what he did—so that was not the time to get on a soapbox and criticize his actions. 

More importantly, Brian didn’t scare me because I am armed with the knowledge that anger masks fear. Just as you wouldn’t walk into a costume party and believe that goblins and monsters are suddenly alive and dancing with each other because you would know it was people dressed in costumes, so too do I see that when people are angry, they are wearing a mask to hide what is really going on inside them. It was important for me to trust the deepest part of Brian’s essence: the part that is, in my view, inherently good. 

As a therapist, my goal is to facilitate people’s journey through the depths of their undiscovered psyches in a way that helps them move beyond the battle of the ego/true-self dynamic so that they can find, hold, and live in expanded consciousness. My working assumption is that the essence of people is much deeper than what we can see on the surface. This assumption helps me view people as vastly greater than their actions, and infinitely more than any pain and suffering they have caused or experienced. 

I specialize in working with people who have been convicted of violent crimes: murder, rape, and the abuse of others. The work is not easy, but it is some of the most rewarding work that I have ever done, due in part to the amazing transformations that I’ve witnessed throughout the years. I’ve watched gang members gain awareness and perspective enough to walk away from their gangs; I’ve seen people who train as fighters walk away from street fights; I’ve seen people who have spent their lives believing that life is about getting “respect,” make incredible changes and learn to more deeply respect themselves and the world around them. 

“No one sets out to be defined by his or her worst moment in life, yet almost every violent offender is judged, convicted, and defined by his or her worst moment.” Just imagine if everyone in your life defined you by your worst moment, that this moment accompanied you like a badge of shame throughout your life, limiting all future possibilities, including your hopes and dreams. It would seem terribly unjust; and yet this is what we do with violent offenders. They carry the burden of our shadow projections and are left believing that they are terrible people because they have done terrible things. And because they lose hope about the possibility of breaking free from these deeply internalized expectations, they live up to their self-fulfilling prophecies by continuing to do terrible things. 

The startling recidivism rates in our country (close to 70% of violent offenders return to a life of crime after imprisonment) should be all the evidence we need to understand that our system of rehabilitation-by-incarceration alone simply doesn’t work, but it’s not. The “more shame, more guilt, and more punishment” approach—though it has a long history among treatment of violent offenders—has led to 7 out of 10 people returning to lock-up. It’s clear that it is time for a new approach to this problem, and it requires a change in consciousness, not only among violent offenders, but also among the population at large. 

Yield Theory

“Knowing how to yield is strength.” —Lao Tzu


My approach to working with clients who have committed the most heinous of crimes is grounded in what I call “Yield Theory,” a powerful and compassionate approach to communication that essentially boils down to radical empathy delivered with intentionality. Taoism is a spiritual tradition—the core of which is seeing beyond the black and white world of either/or, good/bad, and recognizing balance through the single essence of everything. Founded by the legendary Lao Tzu more than 2,500 years ago, “Tao” means the way. For me, the journey that clients take to personal growth is the same as what we all undertake along the way in life.

Yield Theory differs from radical empathy in that in addition to attempting to think and feel entirely from clients’ perspectives, therapists also go with or literally yield to what clients are saying in the moment, with the intention of guiding them to new insight on situations. This approach involves more than simply understanding that multiple factors contribute to violent interactions—you must cultivate the ability to not resist even the angriest outbursts. Yielding entails both joining with the essence of who clients are, and “going with” clients to circumambulate their fight-or-flight responses so they will be more open to the possibility of healthier options.

The underlying assumption of Yield Theory is this: If we lived every day as another human being—not just walked a metaphorical mile in that person’s shoes, but actually had the exact same cognitive functioning, affective range, and life experiences—then we would make every single decision that that person has ever made. Every single decision. This goes beyond simple empathy: it is the capacity to truly recognize the essence of others, and non-judgmentally accept who people are, regardless of their choices and actions—including violence. 

By yielding with others and genuinely trying to understand why they have done what they’ve done rather than judging them, I have found that people are more than just willing to open up and talk—they are also much more open to the possibility of change. I have found that by accepting the essence of people, I have an easier time approaching violence with compassion. The Yield Theory framework has allowed me to rid myself of judgment and do the job I was intended to do: assess people accurately and help them change and lead lives directed by their true selves (their essence), rather than by their egos (introjected identities). 

My anger management program is predicated on respecting all human beings who enter treatment, regardless of their actions, and strives to meet every person where he or she actually is. I call it, “conscious education rooted in compassion.” Even the most resistant clients who ardently deny any accountability for significantly harming others are accepted as readily as those who are actively seeking change. Everyone has a story, and people’s cognitive functioning, ability to process emotions, and life experiences shape and continually influence them.

“Though many therapists and counselors may claim to “accept all people,” in practice, most struggle in their work with people who have violent tendencies.” It could be that the natural fight-or-flight response triggers their survival fears and causes them to write off violent offenders as incapable of change, dangerous, and hence deserving of judgment; but it could also be because human beings tend to value their own standards of living, beliefs, and ideas over those of others and in subtle and often unconscious ways judge people who are different—particularly when those differences appear threatening. 

It is hard for most people to grasp that fully accepting a person who commits a violent crime has absolutely nothing to do with condoning that person’s actions. Truly understanding this, however, makes all the difference in our work with those who are pushed the margins of society. 

Components of Yield Theory

Vulnerability takes courage—especially amongst people who define themselves by how “tough” they are—and yet I have found in my anger management groups (which are open, so there always new people coming in) that people share with the same level of vulnerability and honesty as any therapy group I’ve ever witnessed. I believe this is due to the key components of Yield Theory that I apply in my groups: acceptance, the elimination of shame, mindfulness, creativity, conscious education, non-attachment and authenticity.

Acceptance
The potential for everything great and everything terrible resides inside all human beings. If a human being has performed an act, then it is accurate to say that it is “human nature.” If we can accept the nature of human beings (that we will at times be loving and kind, at other times hurtful and cruel, and everything in between and beyond), then we can evaluate others, as well as ourselves, in terms of trying to simply understand human behavior. Furthermore, if we accept the premise that we cannot do one single thing to change the past, and we merely have the ability to impact the present to shape the future, then we can see that pejorative, judgmental approaches do little to impact the present or future in positive ways; whereas acceptance of what is, along with acceptance of the essence of people, can set the stage for conscious learning and change.

With Brian, it was important to accept him for the essence of who he is, and from there to accept where he was cognitively and emotionally in that moment. From his perspective, after all, things were unjust and unfair, so acknowledging that was an important first step.
 
Shame
Years of studying people who commit violent crimes has led me to the conclusion that people who live in shame act out of shame.Eliminating shame, therefore, has become central to my work. At first glance, it may seem difficult to swallow the idea of not shaming someone who has committed a violent act; however, as David Hawkins (2002) suggested in his “map of consciousness,” shame is the lowest form of consciousness that human beings experience. What I have learned is that it is difficult for human beings to make highly conscious choices from low levels of consciousness, so helping people have expanded consciousness becomes paramount to changing their actions.

It would have shamed Brian to try to get him to see what he did wrong while he was in a state of fear and anger. It was not the time to have him acknowledge responsibility or even awareness of anything he did that was hurtful. Instead, it was important to work with what was available for him cognitively and emotionally in the present moment.

Mindfulness
Mindfulness was first described in the Dhammapada as a way that the Buddha taught others to observe and keep constant watch over their thoughts. Engaging in “right mindfulness” entails expanding the awareness that we have not only for ourselves, but also for the world around us. The more mindful we can be in every moment, the more likely we are to consider alternative ways of interacting with others. Mindfulness begins with self-awareness, but it also extends to an awareness of the environment and what is going on inside other people as well. As a group leader, I both practice and teach mindfulness. Though it is fairly easy for therapists to learn how to teach or simply read a basic mindfulness exercise in a group setting, it is the role modeling of mindfulness (i.e., the therapist’s constant awareness of present moment intra and interpersonal experiences) that seems to make the biggest impact on clients. As many people who teach mindfulness would explain: mindfulness must be lived to be understood. 

It was important for me to be mindful and aware of my own thoughts when Brian began railing against his parole officer and his ex, and to be careful not to get caught up by them. I tried to be as aware as possible about what might be going on inside of him, based on what I was seeing in him and my own internal reactions, but ultimately the best we can do as therapists is project what we imagine others are thinking, and then check those projections. In this instance, my projection appeared to be accurate. But mindfulness goes much deeper than just awareness of my thoughts and his; it is also an awareness of the environment in the moment, and a willingness to stay present with whatever unfolds without reverting into a reactive or defensive posture.

Creativity
In my experience, having the ability to genuinely meet a diverse group of clients where they are separates average therapists from very good ones. If we are charged with meeting people where they are, then we must consider that people have varied learning styles, and forcing clients to only get information in the way that we think works is, in my view, irresponsible. To implement creativity in therapy is to constantly evaluate one’s own communication style, and to be open to adjusting it accordingly to what people need. I believe the onus of communicating effectively rests with the therapist, so when clients are not getting what we are communicating, I believe it is our responsibility to find creative ways to meet them where they are. Creativity can come in the form of analogies, metaphors, techniques, or even just in the openness to develop new ways to say things in ways clients can fully hear. 

In the heated moment with Brian, I chose to use a future-self technique with him. I have found that in working with a largely angry population, being able to think quickly and creatively is not only a bonus, but a necessity. 

Conscious Education

“What is a good man, but a bad man’s teacher? What is a bad man, but a good man’s job?” —Lao Tzu

In my view, it is the responsibility of therapists to offer something more than just listening to their clients. Teaching skills is essential to helping people who are struggling with anger. We cannot expect people to respond differently to the world until we teach them different options. For counselors to implement conscious education, they must be willing to teach concepts patiently and compassionately until clients understand the ideas. This is quite different than simply relating concepts and assuming that clients understand them. In conscious education, therapists do not assume their clients should already have specific information; instead, they make the effort to teach in compassionate ways that meet diverse learners where they are.

As a former tenured professor, I know all too well how lengthy the discussions can be over the semantics of what does and does not constitute teaching. Outside of the world of academia, however, I would argue that we are always teaching others—even if the lesson is about how we are likely to respond in a given situation. I know from further interactions with Brian that he learned that day how to implement the future-self technique. He subsequently reported using it several times and even taught it to another group member during an anger management session.

Non-attachment
The idea of non-attachment is at the foundation of healthy learning. Whereas it is fairly easy for most Westerners to understand the idea of attachment to material goods through identification (“I’m a homeowner” or “This is my car” or “I am a good person because I have a high-paying job”), the notion that we are equally attached to our ideas seems far less widespread. “As long as our ideas are a part of who we are, we become defensive when people disagree with us.” When we can separate ourselves from our things, as well as from our very ideas, we are engaged in the process of non-attachment. As therapists model this concept, they create a safe path for clients to learn to express themselves openly, knowing they will not offend their therapist in any way. 

As a caution to those becoming too attached to the idea of non-attachment, Zen practitioners offer the concept of the “soap of the teachings.” Consider that to clean a shirt, it is necessary to use soap; but if the suds are not rinsed out, the garment will not truly be clean. In this same way, non-attachment to the idea of non-attachment becomes central to practicing the concept. 

In the case of Brian, I was not attached to his response, and would have been content with being off base had he told me that was the case. I was also not attached to the technique I was using with him; had it not helped, I was ready to readjust my technique to something more useful. 

Authenticity
People can spot disingenuousness easily. Mirror neurons are not only the root of vicarious learning, but are also the key part of our neurology that helps us identify when people are being authentic with us or not. It is well known in our field that clients will use the inauthenticity of their therapists as a reason they cannot or should not have to change. On the other hand, when people experience authenticity and know that we sincerely have their best interest at heart, they are much more open to learning about themselves.

The most pragmatic way therapists can convey authenticity is to regularly practice the ideas that they are teaching in their personal lives. It is paramount to practice what we preach. We do not have all the answers, nor should we purport to. We make mistakes as equally as our clients: not better or worse mistakes, just different mistakes, and we are all in this process of experiencing what it is like to be fully human. 

Conclusion

“Can you love the people and lead them without imposing your will?” —Lao Tzu

To understand people’s stories is, in a sense, to journey with them to the depths of their psyches. As a modern journeyman, I like to use vehicles as an analogy for journeying. Here’s my analogy for using Yield Theory to work with clients: Imagine that you are riding in a car and you come to a merge point (a yield sign). You merge with another car until you are side-by-side. Suspend what you know about reality, and imagine that as you travel beside the car long enough, the other driver sees that you are going in the same direction, so he invites you into his car. 

As a passenger now in this person’s metaphorical car, you have a better opportunity to see the road as he sees it, through his windshield. As the trip goes on, perhaps the driver gets tired and is ready to rest for a bit. You are now trusted enough to take the wheel. When you do, you can help steer the car down a more effective path. 

Lao Tzu said, “What is painted on these scrolls today will appear in different forms in many generations to come.” Similarly, the words of all therapies emerge at different times and come in different forms, but they are always essentially the same. For Yield Theorists, accepting the core of who people are, finding creative ways to communicate so that we are actually heard, teaching in some form, modeling openness, facilitating awareness and being authentic are therapeutic concepts that are simultaneously a way of life. 

The first practice of the Tao is something called undiscriminating virtue. It means taking care of those who are deserving and also—and equally—taking care of those who are not. When therapists practice Yield Theory, they are practicing undiscriminating virtue by immersing themselves into the psyches of others—regardless of anything they have done up to that point. Violence as a human construct probably cannot be eliminated; however, people—even those with the most violent backgrounds and intense struggles with anger—can learn a different way. 

We can continue to stand on our soapboxes and preach against violence and against the people who perpetrate it, but violence will always exist and shaming people simply doesn’t work. If we truly want to help people overcome their violent tendencies, we must work from a place of consciousness, choose to merge with others—see the world as they see it, attempt to understand what they understand, and help support them in their journey to new levels of awareness and peace. 

“To the highly evolved being, there is no such thing as tolerance, because there is no such thing as other.” —Lao Tzu



 

Treating a Couple After an Affair

Posted on by Psychotherapy.net Team

The couple in my office is connected mostly by the spaces they hold between them. Sitting on the loveseat in my office, they do not touch, although their arms, legs, and elbows and hands shift in an unconscious echo of each other’s movements. They are not so much mirroring each other as performing an elaborate dance of avoidance and retreat, their bodies’ dialogue spoken even through their many silences. On a larger scale, the same thing happens where they live: he comes home, she goes upstairs; she comes downstairs, he goes up; he enters a room, she leaves. They know if one of them tries to bridge the gap, something even worse will happen. There will be a wordless rejection, a sharp reminder of loneliness like a slap, or there will be a spark that will catch, flaring up hot and mean between them.

She can’t imagine how she is going to get over the affair. She is all the things anyone would expect: angry, hurt, shamed, frightened. He is torn between the grief of losing his wife and the grief of losing his lover. He has given up his lover in that he no longer sees her, and hasn’t for months, but he still has this backwards kind of feeling that if he re-engages with his wife—has fun with her, makes love to her, creates pleasant memories with her—that he is somehow being unfaithful to the lover he has renounced and, most importantly, all that she represented to him. To maintain what remains of his honor and fidelity he feels he must remain distant from his lover, his wife, and himself.

Today she is angry, but instead of the usual sullen acceptance on his part, he flares up in anger, and then, just as suddenly, bursts into tears. They are both startled by his emotion.

He gasps out the words, “I can’t believe how much I miss her” and I think, oh boy, she is going to explode.

I take a breath, preparing to intervene, but I hesitate when I see her face. There is anger there, but also something more like confusion or doubt. I wait.

“I don’t know what to do,” she says, “I want to kill him, but my heart goes out to him at the same time. What am I supposed to do?” In other circumstances, the bewilderment in her expression would be comical.

I would have said, if he had given me the opportunity to offer advice, that it would not be helpful for him to share this grief with her, that it would only inflame her anger and hurt and sense of betrayal, but there is no going back now. His grief is intense and visceral. He is holding his head in his hands and almost wailing.

Still looking at me, she holds her palms up and shrugs her shoulders in a mute gesture of helplessness, then turns to look at him. I have no idea what will happen next.

Slowly, she reaches across the couch for his hand and twines her fingers through his. He grasps her hand like a lifeline and clings to her as he sobs.

He chokes out his guilt—“I’m so sorry, so sorry”—but at the same time his relief is palpable. He seems more present than he has at any time since they started coming for sessions. There is no sense of anything secret or held back. He gathers her closer to him and they lean into each other in a tight embrace, both crying.

They leave, and I find I am near tears myself. What I am feeling is mostly the kind of surprised awe I feel sometimes in nature—what I feel in those rare moments, a dawn, or a sunset, when I am completely outside myself, bearing witness to beauty. His unvarnished honesty, her generosity, their mutual capacity to express love in what has been an atmosphere of despair and anger were acts of tremendous courage. Certainly it may have been, like a particular sunset, a fleeting moment, perhaps unrecoverable. But I hope—and I realize that I don’t need to go much further than that one word: hope. I hope, and I believe they will hope, that this moment of meeting holds a promise that other such meetings are possible.

Why Its Time to Take Mobile Seriously

Posted on by Psychotherapy.net Team

I was looking over my Google Analytics stats last month, and was shocked to see that 19% of my clicks in Google AdWords for psychotherapy searches were done on smartphones. People of all ages are now looking for a therapist on their phones, with almost all of the searches being done on iPhone and Android devices. And while Google owns about 2/3 of the search results on desktops and laptops, they command an astonishing 97% of all searches on mobile devices.

What's driving this trend, and what does it mean for marketing your psychotherapy practice?

Three things are driving the trend toward increased searching on smartphones:

1) Larger Screens—the recently-released iPhone 5 stretched to 4.87 inches high, while the most recent Android phones (especially those from Samsung, such as the Galaxy S3 and Note) are well over 5 inches high and almost half an inch wider than the latest iPhone. Larger screens mean more information can be displayed, so the phone becomes a viable alternative to the laptop or desktop computer.

2) Faster Input Options—with faster processors and better software, both Apple and Google have made significant gains in the speed and accuracy of inputting text into the search box. Both offer very accurate voice input, and in Google's latest operating system, Jelly Bean, they offer a rapid "swiping" option that allows users to keep their fingers on the screen while rapidly moving around the virtual keyboard. The virtual keyboard is less of a limitation than ever before in using your smartphone for search.

3) Faster, More Accurate Search Results—Apple offers Siri, who despite her limitations, can respond to many natural language inquiries with accurate search results. Google’s search software is even better, offering remarkably fast and accurate information in response to voice or keyboard input.

There are six important implications of these trends for marketing your practice online:

1. You now need to make sure your website displays properly on a wide range of devices, from smartphones to 7-inch tablets to full-size 10 inch tablets. The good news is that almost all websites look fine on full-size tablets, and most look okay on the 7-inch tablets. But most of the action is in smartphones, and that's where your website might not display properly. 

There are several ways to address this issue. The best way is to hire a programmer who will program your site to dynamically reconfigure based on the size of the screen. This way you don’t have to have two separate sites that need to be optimized for search.

Another option is to use a service such as dudamobile, which will walk you through a step-by-step process to create a mobile version of your existing site. They have a free version, but to get unlimited pages and your own URL, you need to pay $9/month. Google offers a free mobile site creator (with an awful user interface), but it does not integrate with your main website; for details click here.

2. When you send out email responses to potential client inquiries, you need to be sensitive to how they will format on a smartphone screen, since over half of all emails are now first read on a smartphone. It’s a good idea to have a short subject line. The last words of a long subject line may not be visible in the mobile phone's display. Also, consider sending plain text emails instead of HTML. The line width in text is almost always adapted to the display width.

3. Search Engine Optimization (SEO) is different for mobile searching. According to Google, a typical mobile search is only 15 characters long. Google will compensate for this short entry to using “predictive search”—when you type in only 1 or 2 characters, Google will offer suggestions based on the most frequent searches which start with those characters.

For example, someone may search for "individual counseling in San Francisco" on their desktop or laptop, but on their smartphone it might be "counseling SF." What are the most common “predictive search phrases” that are related to your practice and location? Test this out by searching for your practice on a smartphone, and see which predictive phrases Google offers as suggestions, since these are the ones people are likely to click on first. Be sure those phrases are on your site and in your meta tags.

One huge bonus to Mobile SEO on smartphones is that your phone number can be clicked on, which places a direct call to your office. This is a tremendous advantage over someone visiting your website, since on average it will usually take over sixty visits to your site to trigger one phone call.

4. Google Places Profiles—be sure you have a free Google Places profile, because they often show up near the top of a mobile search results page. You can create or edit a profile at www.google.com/placesforbusiness

5. Yelp Profile—as part of Apple's competition with Google, the Siri program will initially search for services on Yelp, not Google. Many iPhone users choose Siri over Google search. To take advantage of this, get a free Yelp business profile at biz.yelp.com

6. Consider a Mobile-only Google AdWords Pay Per Click Campaign—this may be the highest return on investment of any advertising available to private practitioners today, because of the high number of direct calls to your office it will generate for very little cost. If you do this, make the “Call” button very large and prominent on the first page of your mobile Landing Page, to be seen without scrolling.

The move to mobile is accelerating every month, so the practitioner who takes advantage of these trends will have a great advantage over those who wait. The time to act is now.

True Refuge: Finding Peace and Freedom in Your Own Awakened Heart

Posted on by rezendevknowfully.com

Editors Note: The following is adapted from Tara Brach’s forthcoming book, True Refuge: Finding Peace and Freedom in Your Own Awakened Heart (Bantam, January 22, 2013). 

My earliest memories of being happy are of playing in the ocean. When our family began going to Cape Cod in the summer, the low piney woods, high dunes, and wide sweep of white sand felt like a true home. We spent hours at the beach, diving into the waves, bodysurfing, practicing somersaults underwater. Summer after summer, our house filled with friends and family—and later, with spouses and new children. It was a shared heaven. The smell of the air, the open sky, the ever-inviting sea made room for everything in my life—including whatever difficulties I was carrying in my heart.

Then came the morning not so long ago when two carloads of friends and family members took off for the beach without me. From the girl who had to be pulled from the water at suppertime, I’d become a woman who was no longer able to walk on sand or swim in the ocean. After two decades of mysteriously declining health, I’d finally gotten a diagnosis: “I had a genetic disease with no cure, and the primary treatment was painkillers.” As I sat on the deck of our summer house and watched the cars pull out of the driveway, I felt ripped apart by grief and loneliness. In the midst of my tears, I was aware of a single longing. “Please, please, may I find a way to peace, may I love life no matter what.”

This place of peace, connectedness, and inner freedom, even in the face of life’s greatest challenges is what I call “true refuge.” It does not depend on anything outside ourselves—a certain situation, a person, a cure, even a particular mood or emotion. The yearning for such refuge is universal. It is what lies beneath all our wants and fears. We long to know we can handle what’s coming. We want to trust ourselves, to trust this life. We want to live from the fullness of who we are.

RAIN
The pathway to true refuge is presence, the courage to meet even our most challenging inner experiences with a mindful awareness. About twelve years ago, a number of Buddhist teachers began to share a new mindfulness tool that offers in-the-trenches support for working with intense and difficult emotions. Called RAIN (an acronym for the four steps of the process), it can be accessed in almost any place or situation. It directs our attention in a clear, systematic way that cuts through confusion and stress. The steps give us somewhere to turn in a painful moment, and as we call on them more regularly, they strengthen our capacity to come home to our deepest truth. Like the clear sky and clean air after a cooling rain, this mindfulness practice brings a new openness and calm to our daily lives.

I have now taught RAIN to thousands of students, clients, and mental health professionals, and have made it a core practice in my own life. Here are the four steps of RAIN presented in the way I’ve found most helpful:

R    Recognize what is happening
A    Allow life to be just as it is
I      Investigate inner experience with kindness
N    Non-identification

Recognize What is Happening
Recognition is seeing what is true in your inner life. It starts the minute you focus your attention on whatever thoughts, emotions, feelings, or sensations are arising right here and now. As your attention settles and opens, you will discover that some parts of your experience are easier to connect with than others. For example, you might recognize anxiety right away, but if you focus on your worried thoughts, you might not notice the actual sensations of squeezing, pressure, or tightness arising in the body. You can awaken recognition simply by asking yourself: “What is happening inside me right now?” Call on your natural curiosity as you focus inward.

Try to let go of any preconceived ideas and instead listen in a kind, receptive way to your body and heart.

Allow Life to Be Just as it Is
Allowing means “letting be” the thoughts, emotions, feelings, or sensations you discover. You may feel a natural sense of aversion, of wishing that unpleasant feelings would go away, but as you become more willing to be present with “what is,” a different quality of attention will emerge. Allowing is intrinsic to healing, and realizing this can give rise to a conscious intention to “let be.”

Many students I work with support their resolve to “let be” by mentally whispering an encouraging word or phrase. For instance, you might feel the grip of fear and whisper “yes,” or experience the swelling of deep grief and whisper “yes.” You might use the words “this too” or “I consent.”

At first you might feel you’re just putting up with unpleasant emotions or sensations. Or you might say yes to shame and hope that it will magically disappear. In reality, we have to consent again and again. Yet even the first gesture of allowing, simply whispering a phrase like “yes” or “I consent,” begins to soften the harsh edges of your pain. Your entire being is not so rallied in resistance. Offer the phrase gently and patiently, and in time your defenses will relax, and you may feel a physical sense of yielding or opening to waves of experience.

Investigate with Kindness
At times, simply working through the first two steps of RAIN is enough to provide relief and reconnect you with presence. In other cases, however, the simple intention to recognize and allow is not enough. For instance, if you are in the thick of a divorce, about to lose a job, or dealing with a life-threatening illness, you may be easily overwhelmed by intense feelings. Because these feelings are triggered over and over again—you get a phone call from your soon-to-be ex, your bank statement comes, you wake up to pain in the morning—your reactions can become very entrenched. In such situations, you may need to further awaken and strengthen mindful awareness with the I of RAIN.

Investigation means calling on your natural interest—the desire to know truth—and directing a more focused attention to your present experience. Simply pausing to ask, “What is happening inside me?” might initiate recognition, but with investigation you engage in a more active and pointed kind of inquiry. You might ask yourself: “What most wants attention?” “How am I experiencing this in my body?” or “What am I believing?” or “What does this feeling want from me?” You might contact sensations of hollowness or shakiness, and then find a sense of unworthiness and shame buried in these feelings. Unless they are brought into consciousness, these beliefs and emotions will control your experience and perpetuate your identification with a limited, deficient self.

In order for investigation to be healing and freeing, we need to approach our experience with an intimate quality of attention. We need to offer a gentle welcome to whatever surfaces. This is why I use the phrase “Investigate with kindness.” Without this heart energy, investigation cannot penetrate; there is not enough safety and openness for real contact. Imagine that your child comes home in tears after being bullied at school. In order to find out what happened and how your child is feeling, you have to offer a kind, receptive, gentle attention. Bringing that same kindness to your inner life makes inquiry, and ultimately healing, possible.

Non-Identification: Rest in Natural Awareness
The lucid, open, and kind presence evoked in the R, A, and I of RAIN leads to the N: the freedom of non- identification, and the realization of what I call natural awareness or natural presence. Non-identification means that your sense of who you are is not fused with or defined by any limited set of emotions, sensations, or stories. When identification with the small self is loosened, we begin to intuit and live from the openness and love that express our natural awareness. The first three steps of RAIN require some intentional activity. In contrast, the N of RAIN expresses the result: a liberating realization of your natural awareness. There’s nothing to do for this last part of RAIN—realization arises spontaneously, on its own. We simply rest in natural awareness.

Bringing RAIN to Obsessive Thinking

Jim was a law student who had been attending my Wednesday night meditation class for a year and a half. He made an appointment to see me privately, telling me that he had a compelling obsession that he wanted to address. When he arrived at my office he walked quickly to one of the chairs, seated himself, and jumped in. “I don’t know if you work with this kind of thing,” he said, “but I’m having sexual problems and I really need some help.” He stopped abruptly, and blinked nervously. I could feel his courage in pushing himself to be so direct, and I wanted to set him at ease. “How about telling me more,” I said, nodding a bit to encourage him. “If I’m not the best person to help, we can figure out a good next step.”

Jim gave me a grim smile. “Okay, then,” he said, “here’s what’s going on. I’m in a new relationship, one that has some real potential. She . . .Beth . . . has so much that I’m looking for. She’s smart, fun, kind. And very attractive.” Jim paused, as if acknowledging to himself the realness of her appeal. When he continued, his voice was a defeated monotone: “The problem is, I’m afraid I’m going to blow it with her.” “Jim’s fear was of performing poorly during sex. He said the problem had ruined several prior relationships.” He’d obsess longingly about having sex, and he’d obsess anxiously about premature ejaculation. Then, when he started to make love, he’d either climax quickly, or he’d shut down and lose his erection. Ashamed, over a period of weeks or months he’d become increasingly distant from his partner until she reacted with hurt or anger. Then he’d call it quits.

“I don’t want to do this to Beth, or to me,” he stated bitterly. “I hate how I obsess about sex—wanting it, fearing what will happen—it’s my mind that’s ruining my sex life . . . and it’s also screwing with my ability to study.” Sitting back, he shook his head in disgust. “We’ve slept together a couple of times, and the same old thing is happening . . . What to do?” he asked, not really expecting an answer.

I suggested that while we could talk some more, we could also use RAIN to explore what was going on. Jim had heard about RAIN in class but had not yet tried it on his own. “Let’s go for it,” Jim said. “I’ve talked this to death in my own head already.”

When we practiced RAIN together, Jim noted the fear and shame underlying his thoughts, but he quickly shifted from connecting with the feelings to analyzing what was happening. “I’m fixated on the past,” he said scathingly, “and can’t get it that now is now!” Drawing his attention to his harsh attitude toward both the feelings and the obsessing, I suggested that as he continued this investigation on his own, he might intentionally offer some message of acceptance or care to whatever felt painful or unwanted.

This turned out to be a real sticking point for Jim. At our next meeting several weeks later, he confessed that whenever he’d tried to work with RAIN on his own, he could acknowledge his feelings, but he definitely couldn’t allow or accept them. Instead, within moments of recognizing his shame and fear, he’d flip right back again into the stories of past embarrassment and the anticipation of future humiliation. Then he’d judge himself. “No matter what was going on, I was doing something wrong,” he told me.

Finally, after more than a week of this, Jim realized he had lost confidence that RAIN could help him. The crisis came late one evening. Craving relief, he cast about for anything that might distract him and subdue his mental fixation. He focused on his breath, he tried substituting other thoughts, he put on his favorite music, and then he finally picked up a novel. When he realized he wasn’t taking in the words on the page, Jim threw the book aside in desperation. “I knew I was running away,” he told me, “and that it was making things worse.”

Then he finally surrendered to what was happening inside him. “There was a mix of bad porn and dumb soaps dominating my mental screen . . . with nobody controlling the remote,” he recalled. “It was obvious that ‘I’ couldn’t do anything. So something in me stopped fighting and softened.” As the charged thoughts kept playing through his mind, Jim mindfully noted them as “obsessing.” Soon he recognized the familiar undercurrents of fear and shame. But this time, he spoke to them with a gentle inner whisper: “It’s okay, it’s okay.” To his surprise, the fear and shame gave way to a deep loneliness. Again he offered the message “It’s okay,” and he felt his eyes well up with tears. When his mind lurched back into sexual fantasy, and then into judgment, he noted that, and remembered to whisper “It’s okay.” He was accepting both the fantasy and his aversion to it.

Gradually, as he continued to make room for what was arising, Jim realized he was utterly sad. But it was okay. He felt real and, as he put it, “fully present in my skin.” Jim had found his way to the accepting presence that is key to RAIN. I encouraged him to continue to pause whenever he realized he was feeling stuck and reactive, to give himself time to come back and be here, and then inquire with interest into whatever was going on inside him. “Try to be patient,” I told him. “It can take a while to decondition our emotional looping . . . but you can trust it’s happening!”

In the weeks that followed, “Jim discovered that whenever he could stop the war and offer an unconditional presence to his experience, the circling of obsessive thoughts and unpleasant feelings began to dissipate.” The more he mindfully named and accepted his scenarios of future failure, the more he could see them as thoughts, not reality. He didn’t have to believe their story line. And by opening without resistance to the fear in his body, he reconnected with a mindful presence that included the fear, but was not possessed by it. Jim was more at home with himself, but when I asked him about his relationship with Beth, he shifted uncomfortably in his seat and looked down at the floor. “We’ve got a ways to go,” he said, “but I’m working on it.”

Our next session was a month later. Jim told me that the week before, he and Beth had been on the verge of breaking up. On several occasions during the past weeks the sex had been what he called passable. “It worked,” he said flatly. But there were other times when he had avoided being intimate because he felt the old insecurities lurking in the background. Beth too had pulled away a few times after they had begun hugging or kissing. One night after dinner she tried to break the tense silence, asking him if they could talk about what was going on between them. Jim felt himself shut down completely. He gave her a tired look and attributed everything to the pressures of law school. When he left early, saying he needed to study, she didn’t even walk him to the door.

When he was back at home, Jim did some honest soul-searching. He asked himself what really wanted his attention, and the response in his body was immediate. An ache of sadness filled his chest and strangled his throat. “It was a lifelong loneliness . . . and it felt unbearable,” he said. “When I asked that place of loneliness and sadness what it wanted from me, the response was ‘acceptance,’ but that was not all.” Jim waited, listening inwardly as he relived his experience. “It wanted me to be as real with Beth as I was being with myself.” He looked at me with a self-effacing mile and shook his head. “I was scared shitless!” His mind raced forward to the moment when he would confess his shame about falling short sexually. He could see her being polite and kind, but having to mask the pity and disgust she was feeling. “Impossible. Forget it,” he told himself. “I might as well break it off now.”

But when he imagined losing Beth, something cracked open. ““Tara,” he said, looking at me with tears in his eyes, “I had to take the chance.”” He called her on the spot and asked if he could come back over that night. “She agreed . . . it was almost like she was expecting the call.” Initially Beth sat on the other end of the couch, frosty and quiet. But as soon as Jim started talking, she realized that he wasn’t there to break up with her. “Beth shocked me, because she just started crying. That’s when I realized how much our relationship mattered to her.” From that point on, he said, their conversation was nothing like what he had imagined.

The more he told her about his embarrassment and fear, the more he realized that his feelings were in the safest, most caring hands possible. “Beth was hurt that I hadn’t trusted her enough to tell her,” Jim told me. “She had thought I was losing interest . . . we were both afraid of rejection.” Jim was quiet for a few moments as if weighing what he wanted to say next. “That night was the first time I could really say I made love with someone.”

The adage “what we resist, persists” is a deep truth. If we try to fight obsession and the raw emotions that underlie it, we end up reinforcing them. For some people this might lead to acting out in rage or taking drugs. In Jim’s case, it meant being unable to maintain a sexually intimate relationship. Even without acting out, resisting our obsessive thoughts or feelings traps us in the suffering of a small, deficient, separate self.

As Jim was discovering, the best medicine for obsession is taking refuge in the truth of the present moment. We learn to recognize what’s going on, and accept the fact that it’s happening. When we become mindful of a thought as a thought, our sense of identity is not unconsciously fused with its content and felt sense. Thoughts and feelings can come and go without disconnecting us from our natural openness, intelligence, and warmth. For Jim, this homecoming freed him to be intimate with another person. He could contact and accept his own inner life without believing limiting stories about himself. And he could see past the veil of stories about Beth that had been keeping him separate from her. She became an authentic, vulnerable human, and that allowed true loving to flower.

Meeting Our Edge and Softening

The Buddha taught that we spend most of our life like children in a burning house, so entranced by our games that we don’t notice the flames, the crumbling walls, the collapsing foundation, the smoke all around us. The games are our false refuges, our unconscious attempts to trick and control life, to sidestep its inevitable pain. We do not want to face the raw experience of losing the life we love.

“When we distract ourselves from the reality of loss, we also distract ourselves from the beauty, creativity, and mystery of this ever-changing world.” There are times that stepping away from the full pain of loss can be an intelligent and compassionate response—it gives us space and time to regain some energy, perspective, and balance. It may not be a false refuge to keep ourselves occupied after a fresh loss—to bury ourselves in work, books, movies, or to surround ourselves with company. The same is true if we need to withdraw from regular activities and social engagements. But our ways of seeking relief are often neither healthy nor temporary. Instead, they become ongoing attempts to control our experience so that we don’t have to open to our grief. For me, relating wisely to what I call “the controller” was a pivotal step in finding refuge in the face of loss.

I was scheduled to teach a meditation retreat one winter, when my body really crashed. I landed in the hospital, unable to teach, or for that matter to read, walk around, or go to the bathroom without trailing an IV. I remember lying on the hospital bed that first night, unable to sleep. At around 3 a.m., an elderly nurse came in to take my vitals and look at my chart. Seeing me watching her, she leaned over and patted me gently on the shoulder. “Oh dear,” she whispered kindly, “you’re feeling poorly, aren’t you?”

As she walked out tears started streaming down my face. Kindness had opened the door to how vulnerable I felt. How much worse would it get? What if I wasn’t well enough to teach? Should I get off our meditation community’s board? Would I even be able to sit in front of a computer to write? There was nothing about the future I could count on.

Then a verse from Rumi came to mind:

Forget the future . . .
I’d worship someone who could do that . . .
If you can say, “There’s nothing ahead,” there will be nothing there.
The cure for the pain is in the pain.

I began to reflect on this, repeating, “There’s nothing ahead, there’s nothing ahead.” All my ideas about the future receded. In their place was the squeeze of raw fear, the clutching in my heart I had been running from. As I allowed the fear—attended to it, breathed with it—I could feel a deep, cutting grief. “Just be here,” I told myself. “Open to this.” The pain was tugging, tearing at my heart. I sobbed silently (not wanting to disturb my roommate), wracked by surge after surge of grief.

The house was burning and this human self was face-to-face with its fragility, its temporariness, with the inevitability of loss. Yet as my crying subsided, a sense of relief set in. It wasn’t quite peace—I was still afraid of being sick and sidelined from life—but the burden of being the controller, of thinking I could manage the future or fight against loss, was gone for the moment. It was clear that my life was out of my hands.

Those six days in the hospital were a humbling lesson in surrender. A pulse that wouldn’t go above forty-five; doctors who couldn’t figure out what was wrong; food I couldn’t eat; release date extended. Yet what was most amazing to watch was how the controller struggled to remain in charge.

On the third day I was walking around the perimeter of the cardiac unit, jarred by how weak I felt, how uncertain about my future. Then, for the ten thousandth time, my mind lurched forward, anticipating how I might reconfigure my life, what I’d have to cancel, how I could manage this deteriorating body. When I saw that the controller was back in action I returned to my room and wearily collapsed on the raised hospital bed. As I lay there, the circling thoughts collapsed too, and I sank below the surface, into pain.

Tibetan teacher Chögyam Trungpa taught that the essence of a liberating spiritual practice is to “meet our edge and soften.” “My edge was right here: the acute loneliness, the despair about the future, the grip of fear.” I knew I needed to soften, to open. I tried to keep my attention on where the pain was most acute, but the controller was still there, holding back. It was as if I’d fallen into a black hole of grief and died. Gently, tentatively, I started encouraging myself to feel what was there and soften. The more painful the edge of grief was, the more tender my inner voice became. At some point I placed my hand on my heart and said, “Sweetheart, just soften . . . let go, it’s okay.” And as I dropped into that aching hole of grief, I entered a space filled with the tenderness of pure love. It surrounded me, held me, suffused my being. Meeting my edge and softening was a dying into timeless loving presence.

In some ways, the hospital was a great place to practice. So little control, so many hours alone, so many rounds of vulnerability. In the remaining days, I repeated to myself again and again: “Sweetheart, just soften.” Whenever I recognized that I had tightened in anxious planning and worry, I noted it as “my edge.” Then I’d invite myself to soften. I found that kindness made all the difference. When I returned home, the stories and fears about the future were still there. The controller would come and go. But I had deeper trust that I could meet my life with openness, presence and love.

“Each of us has the innate capacity to turn toward true refuge.” We can decide to love life. We can meet our edge and soften. I call this saying yes to life, and often guide students in meditation around this practice. Although we will continue to shut down, we can always start with exactly what we are experiencing and bring kindness to our resistance. We can say yes to our no—to the parts of ourselves that want to ignore, suppress or turn away from pain. As we intentionally deepen our yes, we discover an unconditional acceptance—an open, tender space of awareness—that frees us. We have come home to the refuge of our own awakened heart.