Author: rezendevknowfully.com

Embracing Your Demons: An Overview of Acceptance and Commitment Therapy

Posted on by rezendevknowfully.com

Imagine a therapy that makes no attempt to reduce symptoms, but gets symptom reduction as a by-product. A therapy firmly based in the tradition of empirical science, yet has a major emphasis on values, forgiveness, acceptance, compassion, living in the present moment, and accessing a transcendent sense of self. A therapy so hard to classify that it has been described as an “existential humanistic cognitive behavioral therapy.”

Acceptance and Commitment Therapy, known as “ACT” (pronounced as the word “act”) is a mindfulness-based behavioral therapy that challenges the ground rules of most Western psychology. It utilizes an eclectic mix of metaphor, paradox, and mindfulness skills, along with a wide range of experiential exercises and values-guided behavioral interventions. ACT has proven effective with a diverse range of clinical conditions: depression, OCD, workplace stress, chronic pain, the stress of terminal cancer, anxiety, PTSD, anorexia, heroin abuse, marijuana abuse, and even schizophrenia.¹ A study by Bach & Hayes² showed that with only four hours of ACT, hospital re-admission rates for schizophrenic patients dropped by 50% over the next six months.

The Goal of ACT

The goal of ACT is to create a rich and meaningful life, while accepting the pain that inevitably goes with it. “ACT” is a good abbreviation, because this therapy is about taking effective action guided by our deepest values and in which we are fully present and engaged. It is only through mindful action that we can create a meaningful life. Of course, as we attempt to create such a life, we will encounter all sorts of barriers, in the form of unpleasant and unwanted "private experiences" (thoughts, images, feelings, sensations, urges, and memories.) ACT teaches mindfulness skills as an effective way to handle these private experiences.
 

What is Mindfulness?

When I discuss mindfulness with clients, I define it as: “Consciously bringing awareness to your here-and-now experience with openness, interest and receptiveness. There are many facets to mindfulness, including living in the present moment; engaging fully in what you are doing rather than “getting lost” in your thoughts; and allowing your feelings to be as they are, letting them come and go rather than trying to control them. When we observe our private experiences with openness and receptiveness, even the most painful thoughts, feelings, sensations and memories can seem less threatening or unbearable. In this way mindfulness can help us to transform our relationship with painful thoughts and feelings in a way that reduces their impact and influence over our life.

How Does ACT Differ from Other Mindfulness-based Approaches?

ACT is one of the so-called “third wave” of behavioral therapies—along with Dialectical Behavior Therapy (DBT), Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR)—all of which place a major emphasis on the development of mindfulness skills.

Created in 1986 by Steve Hayes, ACT was the first of these "third wave” therapies, and currently has a considerable body of empirical data to support its effectiveness. The “first wave” of behavioral therapies, in the fifties and sixties, focused on overt behavioral change and utilized techniques linked to operant and classical conditioning principles. The “second wave” in the seventies included cognitive interventions as a key strategy. Cognitive-behavior therapy (CBT) eventually came to dominate this “second wave”

ACT differs from DBT, MBCT, and MBSR in many ways. For a start, MBSR and MBCT are essentially manualized treatment protocols, designed for use with groups for treatment of stress and depression. DBT is typically a combination of group skills training and individual therapy, designed primarily for group treatment of Borderline Personality Disorder. In contrast, ACT can be used with individuals, couples and groups, both as brief therapy or long term therapy, in a wide range of clinical populations. Furthermore, rather than following a manualized protocol, ACT allows the therapist to create and individualize their own mindfulness techniques, or even to co-create them with clients.

Another primary difference is that ACT sees formal mindfulness meditation as only one way of many to teach mindfulness skills. Mindfulness skills are “divided” into four subsets:

  • Acceptance
  • Cognitive defusion
  • Contact with the present moment
  • The Observing Self

The range of ACT interventions to develop these skills is vast and continues to grow, ranging from traditional meditations on the breath through to cognitive defusion techniques.

What is Unique to Act?

ACT is the only Western psychotherapy developed in conjunction with its own basic research program into human language and cognition—Relational Frame Theory (RFT). It is beyond the scope of this article to go into RFT in detail, however, for more information see https://contextualscience.org/rft 

In stark contrast to most Western psychotherapy, “ACT does not have symptom reduction as a goal.” This is based on the view that the ongoing attempt to get rid of “symptoms” actually creates a clinical disorder in the first place. As soon as a private experience is labeled a “symptom,” a struggle with the “symptom” is created. A “symptom” is by definition something “pathological” and something we should try to get rid of. In ACT, the aim is to transform our relationship with our difficult thoughts and feelings, so that we no longer perceive them as “symptoms.” Instead, we learn to perceive them as harmless, even if uncomfortable, transient psychological events. Ironically, it is through this process that ACT actually achieves symptom reduction—but as a by-product and not the goal.

Healthy Normality

Another way in which ACT is unique, is that it doesn't rest on the assumption of “healthy normality.” Western psychology is founded on the assumption of healthy normality: that by their nature, humans are psychologically healthy, and given a healthy environment, lifestyle, and social context (with opportunities for “self-actualization”), humans will naturally be happy and content. From this perspective, psychological suffering is seen as abnormal; a disease or syndrome driven by unusual pathological processes.

Why does ACT suspect this assumption to be false? If we examine the statistics we find that in any year almost 30 percent or the adult population will suffer from a recognized psychiatric disorder.³ “The World Health Organization estimates that depression is currently the fourth biggest, most costly, and most debilitating disease in the world, and by the year 2020 it will be the second biggest.” In any week, one-tenth of the adult population is suffering from clinical depression, and one in five people will suffer from it at some point in their lifetime?. Furthermore, one in four adults, at some stage in their lifetime, will suffer from drug or alcohol addiction. There are now over twenty million alcoholics in the United States alone.? 

More startling and sobering is the finding that almost one in two people will go through a stage in life when they consider suicide seriously, and will struggle with it for a period of two weeks or more. Scarier still, one in ten people at some point attempt to kill themselves?.

In addition, consider the many forms of psychological suffering that do not constitute “clinical disorders”—loneliness, boredom, alienation, meaninglessness, low self-esteem, existential angst, and pain associated with issues such as racism, bullying, sexism, domestic violence, and divorce. Clearly, even though our standard of living is higher than ever before in recorded history, psychological suffering is all around us. 

Destructive Normality

ACT assumes that the psychological processes of a normal human mind are often destructive, and create psychological suffering for us all, sooner or later. Furthermore, ACT postulates that the root of this suffering is human language itself. Human language is a highly complex system of symbols, which includes words, images, sounds, facial expressions and physical gestures. We use this language in two domains: public and private. The public use of language includes speaking, talking, miming, gesturing, writing, painting, singing, dancing and so on. The private use of language includes thinking, imagining, daydreaming, planning, visualizing and so on. A more technical term for the private use of language is “cognition.”

Now clearly the mind is not a “thing” or an “object.” Rather, it is a complex set of cognitive processes—such as analyzing, comparing, evaluating, planning, remembering, visualizing—and all of these processes rely on human language. Thus in ACT, the word “mind” is used as a metaphor for human language itself.

Unfortunately, human language is a double-edged sword. On the positive it helps us make maps and models of the world; predict and plan for the future; share knowledge; learn from the past; imagine things that have never existed, and go on to create them; develop rules that guide our behavior effectively, and help us to thrive as a community; communicate with people who are far away; and learn from people who are no longer alive.

The dark side of language is that we use it to lie, manipulate and deceive; to spread libel, slander and ignorance; to incite hatred, prejudice and violence; to make weapons of mass destruction, and industries of mass pollution; to dwell on and “relive” painful events from the past; to scare ourselves by imagining unpleasant futures; to compare, judge, criticize and condemn both ourselves and others; and to create rules for ourselves that can often be life-constricting or destructive.

Experiential Avoidance

ACT rests on the assumption that human language naturally creates psychological suffering for us all. One way it does this is through setting us up for a struggle with our own thoughts and feelings, through a process called experiential avoidance.

Probably the single biggest evolutionary advantage of human language was the ability to anticipate and solve problems. It has enabled us not only to change the face of the planet, but to travel outside it. The essence of problem-solving is this:

Problem = something we don't want. 
Solution = figure out how to get rid of it, or avoid it. 

This approach obviously works well in the material world. A wolf outside your door? Get rid of it. Throw rocks at it, or spears, or shoot it. Snow, rain, hail? Well, you can't get rid of those things, but you can avoid them by hiding in a cave, or building a shelter. Dry, arid ground? You can get rid of it by irrigation and fertilization, or you can avoid it by moving to a better location. Problem solving strategies are therefore highly adaptive for us as humans (and indeed, teaching such skills has proven to be effective in the treatment of depression.) Given this problem-solving approach works well in the outside world, it's only natural that we would tend to apply it to our interior world; the psychological world of thoughts, feelings, memories, sensations, and urges. Unfortunately, all too often when we try to avoid or get rid of unwanted private experiences, we simply create extra suffering for ourselves. For example, virtually every addiction known to mankind begins as an attempt to avoid or get rid of unwanted thoughts and feelings, such as boredom, loneliness, anxiety, depression and so on. The addictive behavior then becomes self-sustaining, because it provides a quick and easy way to get rid of cravings or withdrawal symptoms.

The more time and energy we spend trying to avoid or get rid of unwanted private experiences, the more we are likely to suffer psychologically in the long term. Anxiety disorders provide a good example. It is not the presence of anxiety that comprises the essence of an anxiety disorder. After all, anxiety is a normal human emotion that we all experience. At the core of any anxiety disorder lies a major preoccupation with trying to avoid or get rid of anxiety. OCD provides a florid example; l never cease to be amazed by the elaborate rituals that OCD sufferers devise, in vain attempts to get rid or anxiety-provoking thoughts and images. Sadly, the more importance we place on avoiding anxiety, the more we develop anxiety about our anxiety—thereby exacerbating it. It's a vicious cycle found at the center of any anxiety disorder. (What is a panic attack if not anxiety about anxiety?)

A large body of research shows that higher experiential avoidance is associated with anxiety disorders, depression, poorer work performance, higher levels of substance abuse, lower quality of life, high-risk sexual behavior, borderline personality disorder, greater severity of PTSD, long-term disability and alexithymia.

Of course, not all forms of experiential avoidance are unhealthy. For example, drinking a glass of wine to unwind at night is experiential avoidance, but it's not likely to be harmful. However, drinking an entire bottle of wine a night is likely to be extremely harmful in the long term. ACT targets experiential avoidance strategies only when client use them to such a degree that they become costly, life-distorting, or harmful. ACT calls these “emotional control strategies,” because they are attempts to directly control how we feel. Many of the emotional control strategies that clients use to try to feel good (or to feel “less bad”) may work in the short term, but frequently they are costly and self-destructive in the long term. For example, depressed clients often withdraw from socializing in order to avoid uncomfortable thoughts—“I’m a burden,” “I have nothing to say,” “I won’t enjoy myself”—and unpleasant feelings such as anxiety, fatigue and fear of rejection. In the short term, canceling a social engagement may give rise to a short-lived sense of relief, but in the long term, the increasing social isolation makes them more depressed.
 

Therapeutic Interventions

ACT offers clients an alternative to experiential avoidance through a variety of therapeutic interventions. In general, clients come to therapy with an agenda of emotional control. They want to get rid of their depression, anxiety, urges to drink, traumatic memories, low self-esteem, fear of rejection, anger, grief and so on. In ACT, there is no attempt to try to reduce, change, avoid, suppress or control these private experiences. Instead, clients learn to reduce the impact and influence of unwanted thoughts and feelings through the effective use of mindfulness. Clients learn to stop fighting with their private experiences—to open up to them, make room for them, and allow them to come and go without a struggle. The time, energy, and money that they wasted previously on trying to control how they feel is then invested in taking effective action (guided by their values) to change their life for the better.

The ACT interventions focus around two main processes:

  1. Developing acceptance of unwanted private experiences which are out of personal control. 
  2. Commitment and action toward living a valued life. 

What follows is a brief summary of some core ACT interventions, illustrated with vignettes of clinical work with a client called “Michael.”
 

Confronting the Agenda

In this step, the client's agenda of emotional control is gently and respectfully undermined through a process similar to motivational interviewing. Clients identify the ways they have tried to get rid of or avoid unwanted private experiences. They are then asked to assess for each method: “Did this reduce your symptoms in the long term? What did this strategy cost you in terms of time, energy, health, vitality, relationships? Did it bring you closer to the life you want?”

Michael was a 35-year-old accountant who suffered from significant social anxiety, and had seen a number of therapists to no avail. In the first session we ran through the many strategies he had used to avoid or get rid of his social anxiety. They included: drinking alcohol, taking Valium, being a “good listener” (asking lots of questions, but sharing little of himself), arriving late, leaving early, avoiding social events altogether, deep breathing, relaxation techniques, using positive affirmations, disputing negative thoughts, analyzing his childhood, blaming his parents (who were both socially avoidant), telling himself to “get over it,” self-hypnosis and so on. Michael realized that none of these strategies had reduced his anxiety in the long term. Although strategies such as taking Valium, drinking alcohol, and avoiding social events had reduced his anxiety in the short term, they had created significant costs to his quality of life. His “homework” was to notice and write down other emotional control strategies, and to assess their long-term effectiveness and costs to his quality of life.

Control is the Problem, Not the Solution

In this phase, we increase clients' awareness that emotional control strategies are largely responsible for their problems; that as long as they're fixated on trying to control how they feel, they're trapped in a vicious cycle of increasing suffering. Useful metaphors here include “quicksand,” “the struggle switch,” and the concepts of “clean discomfort” and “dirty discomfort.” We might deliver these metaphors like this:

Remember those old movies where the bad guy falls into a pool of quicksand, and the more he struggles, the faster it sucks him under? In quicksand, struggling is the worst thing you can possibly do. The way to survive is to lie back, spread out your arms, and float on the surface. It's tricky, because every instinct tells you to struggle; but if you do so, you'll drown.

The same principle applies to difficult feelings: the more we try to fight them, the more they overwhelm us. Imagine that at the back of our mind is a “struggle switch.” When it's switched on, it means we're going to struggle against any physical or emotional pain that comes our way; whatever discomfort experienced, we'll try our best to get rid of it or avoid it.

Suppose the emotion that shows up is anxiety. If our struggle switch is ON, then that feeling is completely unacceptable. This means we could end up with anger about our anxiety: “How dare they make me feel like this?” Or sadness about our anxiety: “Not again. Why do I always feel like this?” Or anxiety about our anxiety: “What's wrong with me? What's this doing to my body?” Or a mixture of all these feelings. These secondary emotions are useless, unpleasant, and unhelpful, and a drain upon our vitality. In response we get angry, anxious or guilty. Spot the vicious cycle?

But what if our struggle switch is OFF? Whatever emotion shows up, no matter how unpleasant, we don't struggle with it. So if anxiety shows up, it's not a problem. Sure, it's unpleasant. We don't like it, or want it, but at the same time, it's nothing terrible. With the struggle switch OFF, our anxiety levels are free to rise and fall as the situation dictates. Sometimes they'll be high, sometimes low and sometimes there will be no anxiety at all. Far more importantly, we're not wasting our time and energy struggling with it.

“Without struggle, we get a natural level of physical and emotional discomfort, depending on who we are and the situation we're in. In ACT, we call this “clean discomfort.”” There’s no avoiding “clean discomfort.” Life serves it up to all of us in one way or another. However, once we start struggling with it, our discomfort levels increase rapidly. This additional suffering we call “dirty discomfort.” Our struggle switch is like an emotional amplifier—switch it on, and we can have anger about our anxiety, anxiety about our anger, depression about our depression, or guilt about our guilt.

Obviously, these metaphors are tailored to the particular feelings the client struggles with. With the struggle switch ON, not only do we get emotionally distressed by our own feelings, we also do whatever we can to avoid or get rid of them, regardless of the long term costs. We draw clients' attention to the many ways they've tried to do this—through more obvious strategies such as drugs, alcohol, food, TV, gambling, smoking, sex, surfing the net—to less obvious emotional control strategies such as ruminating, chastising themselves, blaming others and so on. (As mentioned earlier, many control strategies are not an issue, as long as they are used in moderation.)

Michael was able to connect with these metaphors readily, especially the idea of the struggle switch. We were able to refer back to this in subsequent sessions whenever he experienced anxiety. “Okay, right now, you're feeling anxious. Is the struggle switch on or off?”
 

Six Core Principles of ACT

Once the emotional control agenda is undermined, we then introduce the six core principles of ACT. ACT uses six core principles to help clients develop psychological flexibility:

  • Defusion
  • Acceptance
  • Contact with the present moment
  • The Observing Self
  • Values
  • Committed action

Each principle has its own specific methodology, exercises, homework and metaphors. Take defusion, for example. In a state of cognitive defusion we are caught up in language. Our thoughts seem to be the literal truth, or rules that must be obeyed, or important events that require our full attention, or threatening events that we must get rid or. In other words, when we fuse with our thoughts, they have enormous in influence over our behavior.

“Cognitive defusion means we are able to “step back” and observe language, without being caught up in it. We can recognize that our thoughts are nothing more or less than transient private events—an ever-changing stream of words, sounds and pictures. As we defuse our thoughts, they have much less impact and influence.”

If you look through the wide variety of writings on ACT, you will find over a hundred different cognitive defusion techniques. For example, to deal with an unpleasant thought, we might simply observe it with detachment; or repeat it over and over, out aloud, until it just becomes a meaningless sound; or imagine it in the voice of a cartoon character; or sing it to the tune of “Happy Birthday”; or silently say “Thanks, mind” in gratitude for such an interesting thought. There is endless room for creativity. In contrast to CBT, not one of these cognitive defusion techniques involves evaluating or disputing unwanted thoughts.

Here’s a simple exercise in cognitive defusion for yourself:

Step 1: Bring to mind an upsetting and recurring negative self-judgment that takes the form “I am X” such as “I am incompetent,” or “I’m stupid.” Hold that thought in your mind for several seconds and believe it as much as you can. Now notice how it affects you.

Step 2: Now take the thought “I am X” and insert this phrase in front of it: “I’m having the thought that….” 'Now run that thought again, this time with the new phrase. Notice what happens.

In step 2, most people notice a “distance” from the thought, such that it has much less impact. Notice there has been no effort to get rid of the thought, nor to change it. Instead the relationship with the thought has changed—it can be seen as just words.

There now follows a brief description or the six core principles, with reference to the case or Michael.
 
1. Cognitive Defusion: learning to perceive thoughts, images, memories and other cognitions as what they are—nothing more than bits of language, words and pictures—as opposed to what they can appear to be—threatening events, rules that must be obeyed, objective truths and facts. 

In session two, Michael said he experienced frequent distress from thoughts such as “I'm boring,” “I have nothing to say,” “No one likes me,” and “I'm a loser.” As the session continued, I had Michael interact with these thoughts in a number or different ways, until they began to lose their impact. For example, I had him bring to mind the thought “I'm a loser,” then close his eyes and notice where it seemed to be located in space. He sensed it was in front of him. I asked him to observe the thought as if he was a curious scientist, and to notice the form of it: whether it was more like something he could see, or something he could hear. He said it was like words that he could see, and he noticed that as he “looked” at it, it became less distressing. “I asked him to imagine the thought as words on a Karaoke screen; then change the font; then change the color; then imagine a bouncing ball jumping from word to word.” By this stage, Michael was chuckling at the very same thought that only a few minutes earlier had brought him to tears. “Homework” included practicing several different defusion techniques with distressing thoughts—not to get rid of them, but simply to learn how to step back and see them for what they are—just “bits of language” passing through.

2. Acceptance: making room for unpleasant feelings, sensations, urges, and other private experiences; allowing them to come and go without struggling with them, running from them, or giving them undue attention.

In session three, I asked Michael to make himself anxious by imagining himself at a forthcoming office party. When I asked him to scan his body and notice where he felt the anxiety most intensely he reported a “huge knot” in his stomach. I asked him to observe this sensation as if he was a curious scientist who had never seen anything like it before; to notice the edges of it, the shape of it, the vibration, weight, temperature, pulsation, and the myriad of other sensations within the sensation. I had him breathe into the sensation, and “make room for it”; to allow it to be there even though he did not like it or want it. Michael soon reported a sense of calmness; a sense of being at ease with his anxiety even though he didn't like it. “Homework” included practicing this technique with his recurrent feelings of anxiety—not to get rid of them, but simply to learn how to let them come and go without a struggle.

3. Contact with the present moment: bringing full awareness to your here-and-now experience, with openness, interest, and receptiveness; focusing on, and engaging fully in whatever you are doing.  

In session four, I took Michael through a simple mindfulness exercise, focused on the experience of eating. I gave him a sultana, and asked him to eat it “in slow motion,” with a total focus on the taste and texture of the fruit, and the sounds, sensations and movements inside his mouth. I told him, “While you're doing this, all sorts of distracting thoughts and feelings may arise. The aim is simply to let your thoughts come and go, and allow your feelings to be there, and keep your attention focused on eating the sultana.”

Afterwards, Michael said he was amazed that there was so much flavor in one single sultana. I was then able to use this experience to draw an analogy with social situations, where Michael would he so caught up in his thoughts and feelings that he wasn't able to engage fully in conversation, and missed out on the “richness.” “Homework” included practicing full engagement with all the five senses in a number of daily routines (having a shower, brushing his teeth, and washing the dishes) as well as continuing to practice his defusion and acceptance techniques. He agreed also to practice mindful engagement in conversations; i.e. keeping his attention on the other person, rather than on his own thoughts and feelings.

4. The Observing Self: accessing a transcendent sense of self; a continuity of consciousness that is unchanging, ever-present, and impervious to harm. From this perspective, it is possible to experience directly that you are not your thoughts, feelings, memories, urges, sensations, images, roles, or physical body. These phenomena change constantly and are peripheral aspects of you, but they are not the essence of who you are.
 
In session five, I took Michael through a mindfulness exercise designed to have him access this transcendent self. First, I asked him to close his eyes and observe his thoughts: the form they rook, their apparent location in space, the speed with which they were moving. Then I asked him: “Be aware of what you are noticing. There are your thoughts, and there you are noticing them. So there are two processes going on—a process of thinking, and a process of observing that thinking.” Again and again, I drew his attention to the distinction between the thoughts that arise, and the self who observes those thoughts. From the perspective of the Observing Self, no thought is dangerous, threatening, or controlling. 

5. Values: clarifying what is most important, deep in your heart; what sort of person you want to be; what is significant and meaningful to you; and what you want to stand for in this life. 

In session six, Michael identified important values around connecting with others, building meaningful friendships, developing intimacy, and being authentic and genuine. We discussed the concept of willingness. The willingness to feel anxiety doesn't mean you like or want it. Instead it means you allow it to be there in order to do something you value. I asked Michael, “If taking your life in the direction of these values means you need to make room for feelings of anxiety, are you willing to do that?” His reply was, “Yes.” 

6. Committed Action: setting goals, guided by your values, and taking effective action to achieve them. 

Continuing session six, we moved to setting goals in line with Michael's values. Initially, he set the goal of going for lunch with a work colleague every day, and sharing some personal information on each occasion. In subsequent sessions, he set increasingly challenging social goals, and continued to practice mindfulness skills to handle the anxious thoughts and feelings that inevitably arose. At the end of ten sessions, Michael reported that he was socializing a lot more, and more importantly, he was enjoying it. Thoughts of being “a loser” or “boring” or “unlikeable” still occurred, but usually he did not take them seriously or pay them any attention. Likewise, feelings of anxiety still occurred in many social situations, but no longer bothered him or distracted him. Overall, his anxiety levels had diminished considerably. This reduction in anxiety was not the goal of therapy, but was a pleasant by-product.

This illustrates how ACT can result in good symptom reduction without ever aiming for it. First, a lot of exposure took place, as Michael engaged in increasingly challenging social situations. It is well known that exposure frequently can lead to reduced anxiety. Second, the more accepting Michael became of his unwanted thoughts and feelings, the less anxiety he had about those thoughts and feelings. Indeed, practicing mindfulness of unwanted thoughts and feelings is a form of exposure in itself.

The ACT Therapeutic Relationship

ACT training helps therapists to develop the essential qualities of compassion, acceptance, empathy, respect, and the ability to stay psychologically present even in the midst of strong emotions. Furthermore, ACT teaches therapists that, thanks to human language, they are in the same boat as their clients—so they don't need to be enlightened beings or to “have it all together.” In fact, they might say to their clients something like: “I don't want you to think I've got my life completely in order. It's more as if you're climbing your mountain over there and I'm climbing my mountain over here. It's not as if I've reached the top and I'm having a rest. It's just that from where I am on my mountain, I can see obstacles on your mountain that you can’t see. So I can point those out to you, and maybe show you some alternative routes around them.”

Conclusion

The experience of doing therapy becomes vastly different with ACT. It is no longer about getting rid of bad feelings or getting over old trauma. Instead it is about creating a rich, full and meaningful life. This is confirmed by the findings of Strosahl, Hayes, Bergan and Romano? who showed that ACT increases therapist effectiveness, and Hayes et al (2004) who showed that it reduces burnout. If I had to summarize ACT on a t-shirt, it would read: “Embrace your demons, and follow your heart.”


References
 

  1. Bond, F. W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163; Branstetter. A. D., Wilson, K. G., Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment among cancer patients: ACT and CBT. Paper presented at the Association for Advancement of Behavior Therapy, New Orleans; Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802; Twohig, M. P., Hayes, S. C., Masuda, A. (2006). Increasing willingness to experience obsessions: Acceptance and Commitment Therapy as a treatment for obsessive compulsive disorder. Behavior Therapy, 37:1. 3-13; Zettle, R. D., & Raines, J. C. (1989). Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology, 45, 438-445.
  2. Bach, P. & Hayes, Steven C. (2002). The use of Acceptance and Commitment Therapy to prevent the rehospitalisation of psychotic patients: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129-1139.
  3. Kessler, R.C ., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. (1994). Lifetime and 12-month Prevalence of DSM-111-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51 (Jan 1994): 8-19. 
  4. Davies, T. (1997), ABC of Mental Health, British Medical Journal, 314, 27.5.97: 1536-39. 
  5. Kessler, R.C ., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S. (1994). Lifetime and 12-month Prevalence of DSM-111-R Psychiatric Disorders in the United States. Archives of General Psychiatry, 51 (Jan 1994): 8-19. 
  6. Chiles J., and Strosahl, K. (1995), The Suicidal Patient: Principles Of Assessment, Treatment, and Case Management, American Psychiatric Press, Washington, DC. 
  7. Strosahl, K. D., Hayes, S. C., Bergan, J., & Romano, P. (1998). Does field based training in behavior therapy improve clinical effectiveness? Evidence from the Acceptance and Commitment Therapy training project. Behavior Therapy, 29, 35-64; Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., et al. (2004). The impact of acceptance and commitment training on stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-836. 


 

Diana Fosha on Accelerated Experiential-Dynamic Psychotherapy (AEDP)

Posted on by rezendevknowfully.com

“What You Think is Impossible, You're Actually Already Doing”

Polly Ely: Diana, welcome. As a devotee and student of Accelerated Experiential-Dynamic Psychotherapy (AEDP), I’m so happy to have this opportunity to interview you. Because AEDP is still pretty new to the world of psychotherapy, could you begin by explaining a bit about it?
Diana Fosha: Well, to begin with, unlike most models of psychotherapy that proceed from psychopathology—that start from what’s wrong and very reasonably want to go about fixing and healing it—one of the core characteristics of AEDP is that it assumes healing is already there to access from the first contact with the patient, including the most traumatized person that we encounter. It proceeds from the assumption of healing as a process and healing as a phenomenon—something to be entrained and engaged.

And we’re an experiential treatment, so whether we’re working with healing or attachment or emotion or what have you, we’re not so much interested in the narrative or people’s stories about it as much we’re interested in helping people drop down as much as we can into their experience and exploring the experience.
PE: In terms of “dropping down,” are there particular components or interventions that feel most relevant to AEDP that allow for that to occur?
DF: One of the things that’s characteristic of AEDP is to make the most of what’s there before trying to work with what’s not there or what’s maladaptive. So even when dropping down, if we see little glimmers of greater contact with the body, we would try to focus in on that little glimmer and enlarge it. I think more than anything else the stance is, “You’re already doing it so let’s just do more of it.”
PE: So you’re trying to amplify it, stretch it out, do more.
DF: Make you aware that what you think is impossible you’re actually already doing.

“I Don’t Have Any Feelings”

PE: So when you talk about greater contact with the body, how might you proceed with bringing something to life by making contact with the body in some way that traditional psychotherapists or eclectic psychotherapists might not feel as comfortable doing?
DF: Well, I’ll just say what we would do in AEDP and let other people judge whether it’s what they do or don’t do. For instance, the last person that I worked with was a man with a huge trauma history and a lot of disassociation. He walks in and he is telling me about some severe illness in a parent, and I ask him how he feels about it, and he says, “I don’t have any feelings.” So my question to him is, “What are you aware of?” And he becomes aware of a kind of subtle sensation in his chest—and that becomes our entry point. So we stay with that and I ask, “What does it feel like?”

“Well, it’s tense and it’s sort of a little dense.”

“Is it pleasant? Is it unpleasant?”

Over the course of a period of time, we really stay with what’s in his chest, which turns out to have all sorts of qualities of heaviness and pain—it’s a painful sensation. So before you know it, here I am with this incredibly intellectualized, supposedly in-his-head patient, talking completely in the language of sensation.
We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language.
We’re no longer talking content. We’re no longer talking narrative. We’re speaking this kind of right-brain language. He’s touching his chest with his hand as he’s palpating the spot where he’s experiencing this, and he’s starting to notice all these shifts and fluctuations, which are very much occurring in the moment. So within a few minutes, we had sort of “dropped down.”
PE: Dropped down and undone some belief about him not having any feelings?
DF: Right. Or that he’s all in his head or that he has an impossible time accessing his feelings.
PE: I see. So you’re developing capabilities and his belief in those capabilities, too.
DF: Over time, yes, absolutely
PE: So when I think about that—what’s happening in the body—how do we tie that to either the intellect or the story that they’re coming in with about whatever their perceived problem is? How might that be an inroad to the problem?
DF: Oh good question, because, of course, he’s not coming in because he has this subtle sensation in his chest; he’s coming in for a variety of issues and we’re just using it as an example. But really as we’re able to get more body-based and right-brained as a way of speaking about these kinds of phenomena, he and I are also having an interaction and we’re noticing what goes smoothly and flows and what’s difficult; what brings him closer and what makes him more distant?

And as we’re evoking what the pain is about or the sensation and what happens when I empathize, associations start to come up. “Did you ever have this kind of feeling? What comes to your mind about what this feeling may be telling you?” That becomes a way in, a much deeper way than telling the story or narrative. And eventually, the goal is to bring it all together—to bring it to a place where we can integrate experience with narrative, with understanding, with some sense of how his experience is linked to whatever issues he was having in his past.
PE: Sounds almost like you’re bypassing the thinking mind by calling on associations from that place in the chest that you’re talking about.
DF: I think that’s very much the case; or we’re trying to do that in the earlier part of the process, where we want to get experiential, construct something from the bottom up. In other words, not with preset preconceptions, beliefs, narrative coherence, but to let the story emerge from the kinds of experiences that are getting generated in the therapy. And then once we’ve worked with that, then we’re putting together basically a new narrative.

The Origins of AEDP

PE: What are the origins of AEDP? Did it spring forth from another model or did it come from your own curiosities about psychotherapy and what works?
DF: That’s an excellent question. I think the easiest way to answer that question is to tell you a little bit about my personal trajectory. My own training and development as a clinician was very psychoanalytic, psychodynamic and also developmental.
At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results.
At the time I felt uncomfortable with the length of traditional psychoanalysis and its relatively cavalier attitude towards effectiveness and results. So when I came across short-term dynamic psychotherapy in the work of David Malan and others, I was very excited because it seemed to be a way of working that preserved some of the depth. The analytic way of working, but at the same time, it was short-term, it was intensive. And the effectiveness of the treatment was one of the measures.

So I trained in a particular form of short-term dynamic psychotherapy developed by a clinician named Habib Davanloo, who developed a very intensive and very confrontational model of short-term dynamic psychotherapy. That was my early training and the first exposure I had to viscerally-based, deep feelings and emotions being systematically accessed in a relatively short period of time.

However, that way of working was confrontational; there’s a fair amount of stuff around aggression, which was not ideally suited to my personality or my way of understanding what’s needed in treatment. So from that point forth it became my personal goal to access the phenomena that I witnessed and learned in short-term dynamic psychotherapy and have things that are as visceral and as powerful and as transformative, but proceed from a place of being with the patient, rather than from a place of confrontation.

My other goal was to have a coherent theory for these amazing transformative phenomena. And I thought psychoanalysis, as marvelous as it is, didn’t have a good explanation of why the hell these phenomena were transformative in the moment.

You know, you start a session, you access this experiential phenomena, and 15 minutes later or half an hour later you’re in a, very different, transformed place. So it became important for me to try to have a theory that really reflected the phenomena of experiential psychotherapy. And over time AEDP, with both its theory and its practice, started to develop.

Resistance vs. Transformance

PE: You talk a lot of about transformation and for me, as a student, transformation is a word that was fairly new to me in the context of psychotherapy until I came upon AEDP. It just wasn’t a term that I ran across in my own training. I’m thinking about the word “transformance,” which is a term that you coined. It’s an important term and concept in the language of AEDP. Would you be willing to share a bit about its meaning?
DF: Well, it’s this idea of healing from the get-go—of healing not just being an outcome but a process that exists within each person that emerges in conditions of safety. That idea is not new to AEDP; it exists in spiritual traditions; it exists in humanistic therapies; it exists in some other existential therapies.
Whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.
But still, our language tends to be very psychopathology-based, so that it seemed to me that a term was needed in our therapeutic lexicon to capture this notion of healing from within that we’re trying to tap. I coined the word “transformance” to capture that force and to have it be in counterpoint with resistance. So, whereas resistance is the conservative force in the psyche that causes us to resist changes or challenges, transformance is the force in the psyche that’s moving towards growth and expansion and transformation.
PE: I know for myself that one of the key elements of being an AEDP therapist is videotaping our work. What feels most important to you about that? It has some obvious teaching potential but I wonder if there’s more to it that you believe contributes to the process?
DF: I think it’s very much this emphasis on experience and phenomena and being able to witness firsthand the actual, live interaction. When a student comes to me for supervision, I’m not hearing his or her rendition of what happened. We’re having an experience together, witnessing what happened on video. It’s a huge help for the therapist because there’s no way that one can, in the moment, have access to the multiplicity of things that are happening in any given moment. So there’s this component of being able, after the fact, to look and look again and again and again, which is a beautiful way of learning about the richness that’s there.

Meta Processing

PE: Going back and looking at my work has been a huge place of growth for me as a therapist, and layers of new understanding emerge each time I watch a session. As I become more sophisticated in my understanding of what I’m doing, I’m able to notice more about the experience in the moment with my patients.

One area that is very key to AEDP that has been a struggle for me and where I’ve stretched a lot is around the idea of doing meta processing with the patient. Could you talk some about how you define meta processing and its value and why we, as therapists, may want to consider doing meta processing with our patients?
DF: Meta processing is huge and I think it’s one of the more important contributions that AEDP has made to the field of psychotherapy. I can explain it best by using a scenario. Let’s take somebody who comes in with depression and is feeling sort of sluggish or hopeless or whatever aspect of depression they have. And as a result of doing a piece of work—maybe it involves mourning—30 minutes later the depression lifts. They have a somewhat new perspective. They start to have a little bit of confidence in their own capacity to be effective in the world, right?
PE: Okay.
DF: So the depression lifts and the person starts to feel some efficacy. Well, at that point for us, what we want to do is process
PE: In that session.
DF: Right there in that session. What happened that allowed them to come in feeling lousy and now, half an hour later, they’re feeling more energized or more effective? So we then go through the experience.

The reason it’s called meta processing is that we’re processing the experience of what’s therapeutic about therapy. So—meta therapy. We might start to explore with the patient, “So you’re saying that you’re feeling better. And you have a sense that maybe you can be more effective. What’s that like? What does that feel like?” In the same way that we would explore what the sadness felt like or what grief feels like or what heaviness feels like. Now we’re beginning to explore what does energy feel like? What does vitality feel like? What’s it like that you and I, through talking together and doing this piece of work together, ended up here when we started back there? So that all these experiences that are quite implicit start to become more explicit, and then we’re doing another round of experiential exploration.
PE: So the next round is kind of concretizing what was learned in those first 40 minutes?
DF: Yeah. That’s a beautiful way of saying it. Concretizing, solidifying, increasing awareness, and consolidating it.
PE: And is that something that you expect your therapists to do every session?
DF: Well, we think about it in the following way: we have “Big-M” meta processing and “Small-M” meta processing. And “Big-M” meta processing is when you’ve had an experience like the one we’ve talked about—a very definite change for the better as a result of doing a piece of psychotherapeutic work. Whereas “Small M” meta processing is when there is a tiny little shift. The patient says something, you make a remark, and maybe tears come to their eyes because they feel understood. It’s not that you’ve worked for half an hour and you’ve done a whole process; it’s been one little exchange. “When I said that, it seemed to have moved you. What’s that like for you? What happened?” That’s a little meta processing. But it doesn’t have to be positive. It can be negative. Let’s say you say something and you see the patient sort of turn away or advert their eyes. So there’s been a very specific moment, a little change. We want to zero in on that and not have preconceived ideas about what it means. It doesn’t matter. The point is for the therapist to really get inside the patient’s experience, in a precise way.

So that’s how we use the meta processing and it’s probably accurate to say that rarely does an AEDP session go by without several instances of either “Small-M” or “Big-M” meta processing.

Existing in the Heart and Mind of Another

PE: I’ve been asked a few times if there’s any research that supports the accelerated outcomes of AEDP. How do you answer that question?
DF: That’s a very good question. There are about five research projects that are currently in the works on various aspects of AEDP—on outcome, meta processing, the nature of the changes that people experience as a result of AEDP training—but there are many, many components of AEDP that have been researched in the context of other experiential models. So while we have no research on meta processing or on dyadic affect regulation—because nobody else has done it—there’s infancy research that shows that mother/baby dyads where there’s effective affect regulation are the dyads that produce the most resilient babies. We have developmental research that shows that working with the feeling of existing in the heart and mind of another, which is a phrase we use that relates to attachment, is a huge aspects of resilience in the face of trauma.

There’s a lot of experiential research in the field of trauma that shows that processing previously unbearable emotions through to completion in a safe environment is one of the factors that leads patients to both stay in treatment and have better outcomes on some of the interpersonal measures. So many pieces of AEDP have quite strong empirical validation. The last piece comes from what AEDP shares with short-term dynamic psychotherapy, which shows that when you get past defenses and when patients and therapists are in close contact with core emotions, that contributes significantly to good outcomes. There’s a whole literature on that.
PE: You mentioned a few minutes ago how therapists report being impacted by working with this model. Can you say more about how their lives changed or their own personal processes changed?
DF: That’s a beautiful question. I would actually love to turn it back around and hear what your experience has been.
PE: Well, it has sort of paralleled my own deepening and ability to understand myself and where my defenses lie and where breakthroughs occur for me. It’s such a big question because, as I deepen in my understanding of AEDP, I see a natural transformation in who I am as a human being with other people; how I do in relationships with other people. How much vitality and life I feel within myself on a moment-to-moment basis and just how well I recover and how resilient I become. Without sounding like I’m proselytizing, I feel pretty transformed by it, to be perfectly honest.
DF: I appreciate your saying that. It’s a beautiful answer and people often speak of the parallel process in terms of their own transformation and deepening. I think that one of the other aspects is the gratitude that people experience at the generosity of the community. In the same way that we do therapy with affirmation and empathy and focusing on what people already do, the AEDP community is a very affirming, supportive community.

Especially for people who have had a lot of experience having to steel themselves against criticisms. You can certainly learn with a lot of harsh feedback, but I think the sense of learning through deepening, while being held and being in resonance with others; learning to pay attention to what gives you energy and vitality and what saps your energy and vitality and bringing that into the work—these are things that people are profoundly grateful for.

People have often said that they have a sense of coming home, which is very moving to me.
Way before they became professionals trained in fancy models and systems of interventions, there was just some intuitive sense of wanting to be with people and help them—some sense of hope and generativity that very often gets trained out of people in graduate school.
Way before they became professionals trained in fancy models and systems of interventions, there was just some intuitive sense of wanting to be with people and help them—some sense of hope and generativity that very often gets trained out of people in graduate school. People learn techniques and learn models and become very competent, but lose contact with some of that kind of naïve but very core sense of what it takes to heal in the presence of another. There’s something about AEDP that really draws on those innate processes by which we connect and heal and need to be with one another that lets people feel more alive.
PE: The word that comes to mind for me is “sustainable.”
DF: Yes, something about it allows you to sustain rather than burn out, and feel actually fed by it.

Men Get a Bum Rap

PE: I know recently you did some work around the differences between working with men and women and I’m wondering if there’s anything about that you’re excited about and would like to share.
DF: You know, I’ve really felt that men, to be perfectly honest, were getting sort of a bum rap in the world of emotion focused therapy. I have a colleague who sees couples and the typical set up was that the woman dragged their male partners in and they came because they didn’t want to lose the relationship. But they would always be revealed in the therapy as cut off from their emotions and not therefore able to use the couple’s therapy, so my colleague would send the men to me for individual therapy. These men would come in with their tails between their legs and feeling sort of sheepish or defensive or alienated. And when, in AEDP fashion, I’d look for the glimmer of what’s resilient or what’s healing or what’s transformance based and reflect back to them sensitivity or care or empathy, it was such a mind-blowing experience because they were so used to being told everything that they do wrong.

It was in that kind of informal way that I got interested in what happens to men in psychotherapy, especially in emotion- or relationally-based psychotherapy, because AEDP is so attachment- and emotion-based. So I actually went to do some neuroscience research and there’s a tremendous amount of the neuroscience research on sex difference and affect regulation.

And surprise, surprise, all the stuff that standup comics and guys in bars and girlfriends speaking to each other talk about—you know, everybody’s so-called stereotypes of the other gender—have some bearing in neuroscience.

PE: Which ones stand out to you?
DF: Well there are some real differences in how male and female brains process emotion. One of the main characteristics of male brains is that they’re actually more emotional—counter to stereotype—and have more right-brain activation than women, but that more visceral, raw sense of emotion is not as linked with language, so that modulation of emotion is much more problematic in men. Whereas connectivity in the brains of women is much more evenly distributed in the left and right brain, so that everything is much more connected for women. Under extreme emotional activation, language sort of goes off screen for men.
So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different.
So it’s not that men don’t have feelings; they have tremendous, tremendous emotion, but the capacity to articulate is different. And then there’s all this backlash in terms of shame and feeling inadequate for not being able to have an emotional conversation.
PE: That’s such an empathic way to be with men who are experiencing some trouble with expressing themselves.
DF: Yes, and I’ll tell you one other fascinating one, which has to do with face recognition. There’s an area in the brain that’s devoted to face recognition and women are superior to men in face recognition in all conditions, across the board. Under stress, women’s face recognition gets better and men’s face recognition gets worse. In stress-based literature they say that under stress, men’s sympathetic nervous system—the fight-flight response—is activated. For women, what’s activated under the same kind of threatening conditions is the limbic system and what’s been called the “tend and befriend.”

We women reach out, seek, and offer care. Reaching out to others means better face recognition, right? Presumably, evolutionarily speaking, the more you can recognize a face, you can recognize friend, foe, nurturer, etc. Whereas under stress, men sort of go inside, get strong, get into fight or flight, and are more isolated. It’s like the focus is on action and the face recognition drops off. So those are two things that seemed to me to bear very directly on our work, whether we’re working with individuals or couples.

PE: What are your suggestions for people who are interested in learning about or getting involved in AEDP?
DF: The first thing would be to visit the website, www.AEDPinstitute.com which is a focal point for the community and a way to just find out something about the model. We’ve got videos, presentations, downloadable articles, and trainings with different members of the faculty. You can also find out where trainings in various parts of the country are.
PE: Thank you so much for taking the time to discuss your work.
DF: Thank you.

Transforming War Trauma: The Healing Power of Community

Posted on by rezendevknowfully.com

"What's the matter? The war's over," someone said to a veteran. "Yeah, over and over and over," he replied.

Coming Home

It’s January, 2007, the first moments of the Coming Home Project’s first retreat for veterans and their families. Kenny Sargent and Rory Dunn are Iraq veterans who both sustained traumatic brain injuries (TBI). One was shot in the head, one was hit by an improvised explosive device (IED); both suffer from post-traumatic stress. As people mill around, Ken and Rory meet for the first time, up close and personal. Since neither can see very well, they touch each other’s wounds, comparing scars and experiences. They are like long-lost brothers. The process of making palpable emotional connections has begun.

We gather for our first circle—33 vets and family members from seven states, with four facilitators. In the opening moment of silence, as we remember those unable to be with us, Stefanie and Michael’s three-year-old son, Ben, is playing around the edges of our circle with Isaiah, his new three-year-old friend. Amidst the reverent quiet, we all hear Ben say, “My daddy died in Iraq.” We learn later from Stephanie that “Michael committed suicide six months after returning from Iraq.” Out of the mouth of babes, the first words spoken at a retreat have their own truth: something inside Michael died in Iraq.

We go around the circle, introducing ourselves. Stephanie, Ben’s mom, feels isolated in Houston, where she lives with the heavy legacy of Michael’s suicide. Her church has ostracized her. The group’s reaction is palpable: Stephanie is taken in like a family by a swarm of other spouses and parents.

At the end of the workshop, as we are saying our goodbyes, Rory gets up, makes his way over and we hug. He was angry and bitter at the outset, not just about his injury, but about failures in leadership and his friends who died in the IED attack and. “No one but a vet can understand another vet” were his first words. I am not a vet myself but a Zen master, psychologist-psychoanalyst, and the son of a combat vet.

After we hug, Rory says, “You’re alright.” Near his seat I notice a scrap of paper on the floor, pick it up and ask if it’s his. “Yeah, it’s nothing,” he says. I look at it and see quite a legible note, with three family trees. I ask him about it. “It’s all the people blown away by my buddies’ dying,” he replies. I ponder it: girlfriend, baby, church members, mother, father, sister, and so on—three little stories, three little family trees radiating impacts that eat at him. I offer him the scrap of paper and he gently reclaims it.

Love is a Force for Change

After the attacks of September 11, like so many others I felt that if we, individually and as a country, could withstand and reflect on the dreadful trauma we were experiencing, and not react in a blind knee-jerk fashion, we could bring the perpetrators to justice and at the same time forge alliances and communities of nations that would provide a strong foundation for genuine security for all going forward. Many were thirsty for revenge, but many in the peace community were calling for love. I gave some talks that presented love as a force for change, not some naive fantasy that ignored the powerful forces that had been unleashed. I was disheartened and frustrated that, despite the voices of millions here and around the world, and the counsel of seasoned military leaders, the drumbeats to war were impermeable to reflection, forethought, and considered wise action. Knowing the carnage that was to come, I felt helpless and angry thinking of the great damage our country would inflict not only on this generation, but on generations to come.

Rather than stew in this state, it dawned on me that, given my experience with meditation, healing communities, and trauma, I could join with others and make a difference. It was 2006. Troops were returning stateside in droves and, along with their family members, they were falling through the cracks of the unprepared, overtaxed and outmoded healthcare systems of the Veterans Administration (VA) and the Department of Defense (DoD). If we waited for the government to do something, anguish would only intensify and tens of thousands would fail to receive the care they desperately needed and had earned. Most service members who needed treatment, especially for unseen injuries such as post-traumatic stress and mild to moderate closed head traumatic brain injuries (TBIs) were loathe to come forward—afraid of losing their security clearances, their promotions, and, most of all, the respect of their buddies. I sensed that a compassionate, non-judgmental and welcoming community that included families could be an inviting and healing resource for them.

I gathered a cadre of San Francisco Bay Area therapists who began to provide free, confidential therapy for veterans and their families. We soon began offering retreats for veterans and their families—which we distinguished from psychotherapy so as to counteract the stigma of mental illness—that provided small peer support groups, expressive arts, wellness practices such as meditation and qigong, and vigorous recreational activities in the great outdoors. After a few retreats, we began to incorporate secular rituals into the program, and I enjoyed the dawning realization that the five elements that organically came to comprise the retreats were not a new “quick fix,” but were instead rooted in how we humans have, since time immemorial, worked to transform overwhelming trauma: Sharing stories in a safe environment (healing dialogue), resilience exercises such as meditation, yoga and qiqong (spiritual practice), expressive arts, being active in beautiful places (the healing power of nature), and secular ritual (adapted from reverent religious experience). Four core human capacities also emerged from these retreats—aliveness, bonding and closeness, self-regulation, and a sense of meaning and purpose—elements that help create a life worth living.

For veterans, the stigma of needing help is a major obstacle to getting help, but we noticed it evaporate by the end of our retreats, as isolation lifted and they experienced a sense of being in this together, of belonging. We knew we were onto something when, during the closing circles, participants’ comments began to echo across retreats. They said they’d never experienced an environment this safe, this trusting, where they could be real and reconnect with their fellow vets, their families, and themselves—where they could experience the belonging and camaraderie of service again, and feel free to open up, as much or as little as they were ready for.

Since beginning in 2007, the Coming Home Project has offered 25 retreats and workshops for families, male and female veterans, student veterans, and caregivers. We have brought in local health, education, employment, housing, legal, financial and other services so participants can connect with needed resources, and we recruited local volunteers to be part of our logistics team, enabling the veterans and civilian communities to get to know one another better. In their 2012 review of post-deployment reintegration programs, The Defense Centers of Excellence, a joint VA-DoD agency mandated by Congress to identify, study, and disseminate best practices for psychological health and traumatic brain injury, stated that “the Coming Home Project helps rebuild the connectivity of mind, body, heart and spirit that combat trauma can unravel; renew relationships with loved ones and create new support networks.” We were the only reintegration program of thousands studied that met all their criteria (successfully integrating psychological, behavioral, social-family and spiritual dimensions) that also had significant outcome data and whose pioneering research on post-traumatic growth with veterans and their families and caregivers was published in a peer reviewed journal of the American Psychological Association.

Stephanie
It’s March, 2007, and we’re preparing for our second retreat. Former Marine officer and Zen priest, Colin, and I pick up the van and await the arrival of several families in a Hawaiian barbecue restaurant near the Oakland airport. Fifty people from twelve states gather. 

Later in the day, in the safety of the small veterans group, 15 vets meet. Stephanie tearfully shares how she feels like a failure: as a soldier (she served as a Captain in the Army herself), as a wife, as a mother, as a person—in every way. She didn’t appreciate the gravity of her husband’s distress and couldn’t prevent him from killing himself. Sadness and self-reproach run deep. Several jump in to reassure her: “You have not failed.” They offer good points: God had other plans for you; you now can be of help in ways you couldn’t have before, and so on. But Stephanie’s expressiveness and emotion dry up as she seems to compliantly agree. When a third person prefaces his remarks by saying that he will offer something to lift the mood, I say, “That’s okay,” trying to keep alive the space for acceptance and disclosure that reassuring and uplifting comments often unintentionally foreclose.

Rory
In a pre-retreat roundtable Rory expresses how betrayed by the government he felt after he was injured—by their lack of responsiveness and accountability. His anger is powerful, but rather than being transformative, it seems to progress into a loop of escalating rage. The more angry he gets, the more the energy of the group intensifies, amplifies. Two people leave the room—one takes issue with Rory’s facts, another feels his comments are too polarizing. Rory, of course, has every right to express his outrage and sense of betrayal, and yet as his complaints become increasingly politicized, he alienates himself from the group. His TBI makes it especially difficult for him to regulate his emotions.

Over the course of the retreat, however, Rory begins to shift in a way I’ve never seen. Through frequent, long conversations with a high-ranking officer and fellow vet, one of the facilitators, he becomes noticeably lighter, more open to hearing others’ stories. He begins to share his experiences with a sense of measure, calibrating his impact, modulating it and bringing it to a close. The recognition and containment that his fellow vets give him is deeply moving to witness. Maybe Rory doesn’t have to repudiate everything about his military experience after all.

Claudia
Claudia is a female Iraq veteran who came with her 18-month-old daughter and her sister from Tucson. She had met Tonia and Ken, fellow veterans on the retreat, while on the TBI ward at the Palo Alto VA. She is friendly and sincere but appears vacant and taciturn. During a breakout group she stands around the perimeter, but toward the end she beings to speak, tentatively. Although she says she doesn’t want to read what she had written earlier during a journaling exercise, it seems that a part of her longs to do so. With a little encouragement, she begins to read: “My world has narrowed from what it was….” Her voice trails off. She describes her TBI and the difficulty she has remembering simple but important elements of her past. She feels that a crucial piece of who she was has been taken from her: she can’t even remember her daughter’s birth. She needs her sister’s help with tasks of daily living, as her short-term memory is also impaired. She is battling to retain custody of her daughter. Claudia’s reading has a palpably catalytic effect on everyone. When families gather later, the aliveness of her young daughter, the glimmer in her eyes, juxtaposed with Claudia’s memory impairment, her sense of vacancy and helplessness are striking, poignant and sad.

Mauricio 
At the big morning group early in the day, Mauricio provides comic relief when he states that of the two master sergeants in the group, he is on top of Ken. Everyone laughs about who is on top and who on bottom. He kids us about status and rank and we all laugh harder. In the smaller vets group, however, he is quiet. After Claudia reads, Mauricio opens up about how difficult it is to not be himself in mind and body. He can’t remember important parts of his childhood and it is a continuing blow to his esteem and to his view of himself, particularly given his role as master sergeant of the men under his command. It is an identity crisis of a different order from the normal developmental kind. It isn’t what he says as much as how he says it that makes an impression. He speaks slowly, with an undercurrent of deep emotion, but shows few visible signs of feeling, save a slight crack in his voice.

Jessie
Jessie was a sergeant major in the Army, blinded in an IED blast while serving in Iraq. He speaks with gravity and conviction, conveying a deep sense of betrayal that, after all he’s endured, offered, and sacrificed, he’s had to do it all himself, become his own advocate, find the services and the help he needs. A covenant has been broken. He asks if I will request that folks say their names before they speak. I invite him to make the request himself. He speaks simply and with dignity. After that, when people begin to speak they stop, remember his request, and say, “Sergeant Major, this is Jim,” addressing Jessie by his title.

We usually leave rank and degrees at the door, but this is different: it is an expression of deep respect. When people forget to identify themselves, Jessie gently reminds them, and later on, when Jessie begins sharing, someone says, “You forgot to say your name.” Jessie laughs and everyone cracks up, the role reversal incongruous, funny and poignant all at once.

“There are times during the day when we laugh until we cry, and laugh and cry both, sometimes not knowing which is which.” Our laughter helps us bear the pain and is good for the soul. Everyone knows that by asking people to say their names, Jessie wants to communicate and feel part of the group, wants to hear and recognize everyone, and in turn be recognized by all of us. Though he feels invisible to the institutions entrusted with his care, here among friends his desire for mutual recognition comes across loud and clear. And he is seen.

Paul
Paul comes in toward the end; he’s been resting. Given their brain injuries, some tend to get tired and nap in the afternoon. Paul had been feeling things out around the edges, beginning with the roundtable on Friday. He became upset with the figures Rory quoted during the roundtable, thought they were inaccurate, misrepresentative and needlessly polarizing. He struggled to stay open, thought about leaving, but finally decided to stay. When Paul and I first met, it was difficult to follow what he was saying since the injuries he sustained affected not just his appearance but also his speech. But by now, after two days, I and others can hone in and understand most of his words as well as his feelings. In the small group, he pours out feelings about how he was treated upon his return, and his struggles with physical, emotional and relationship challenges. We hear him.
 
The Children
In the small teen group, Mark, a Marine helicopter pilot during the first Gulf War, now Buddhist priest and facilitator, began begins with a moment of silence and then asks, “How are you doing?” Tasha is quick to respond, “You really want to know?” and immediately starts to cry. Her sister Alishya, strong like their mom, warns Tashsa not to open things up, but when they share their drawings in the closing circle, they also share how isolated they feel and how hard it is to speak their thoughts and feelings to their parents. With some difficulty, their parents, Tonia and Ken, listen and take in what they hear.

When the workshop ends, Tonia and Ken renew their wedding vows. Her eyes reach out for Ken’s, while Ken strains to respond and to make eye contact with Tonia, in spite of being unable to see much. It is heart-wrenching and heart-warming. After the ceremony, outside the room in the hallway, Tasha begins to cry. As Mary Ellen, a family friend and service provider, holds her, Tasha sobs and cries it all out. What is striking is that no one interrupts the pair; everyone recognizes the outpouring of feeling and lets it be.

Jesse’s daughter, Brittney, is feeling isolated, has no one to talk to, and doesn’t want to burden her suffering parents with her own feelings. “Brittney mentions that her father can’t see her face and therefore doesn’t know if she is sad or happy.” His blindness allows her to hide her feelings, but she feels guilty about doing so. She is afraid that expressing her true feelings will be too upsetting for her father.

At dinner on Saturday, Ben, now four, looks my way; he’s restless. I suggest we trace one another’s hands with crayon. He quiets for a while. I give him my drawing of his hand and he gives me his drawing of mine. We take them with us as we part. Claudia’s 18-month-old girl is dancing with exuberance. Paul’s son, Sebastian, three, calls my name several times. Each time I respond. He wants the give and take. I enjoy the call and response. Two days earlier I was an as-yet-unknown quantity, not safe.

As the retreat comes to a close, everyone is so thankful for the opportunity to meet one another in safety, trust and acceptance. I think about the flexibility of roles: now sharing one’s anguish and small triumphs; now helping another with his. And the humor—it rises up in a flash and fades again, sustaining us as we delve more deeply. Laughing and weeping at the same time. These qualities—flexibility, range of emotion, and sense of safety and trust—reflect the health and healing nature of the community. Such a community brings out the best in us, helping us grow emotionally, interpersonally and spiritually, as it offers a collective space to transform trauma.

We Become That Village

Claudia’s little girl, without her father; Ben without his; Sebastian without his mother. And the teenagers, Brittney, Tasha and Alishya, with loving parents both present, yet struggling with the dramatic and rippling impacts of their fathers’ injuries. Mothers, fathers, sisters, brothers; we all step in to fill the gaps. If it takes a village, we become that village.

What drives this remarkable opening to connection? It is the power of compassion that creates a field of unconditional acceptance and love—each of us supporting and being supported. That field becomes the vehicle, the “bigger container” that holds the grief, the loss, the anger, the powerlessness, the damage. And the precious shards of hope. Everyone can feel its power: the trust, the safety, the deep care. This collective field of compassion grows capacities for withstanding, regulating, expressing, and representing inner anguish. “The dynamic beloved community helps transform trauma, turning inner demons, ghosts that haunt the present and foreclose the future, into ancestors.” Real people and real inner capacities we can access when we need them. We take in and make our own the comrades, the camaraderie, and their beneficial qualities. We enjoy being and learning together. New possibilities for being alive open up. All this is the activity of healing.

As children we are taught to be aware of the consequences of our actions. Actions have impacts that ripple out in many dimensions and last a long time. These effects manifest in ways we did not anticipate. Being aware of and anticipating the consequences of our actions is a developmental achievement. Being responsible for the web of impacts that has ensued from our actions, intended or not, is, likewise, an ongoing achievement.

As a society, we don’t take very good care of one another. Our children, our elders, our natural resources are often ignored, overlooked, forgotten or mistreated. Ours is a disposable culture. But what we do not include, recognize and care for does not go away. The impacts last for ages, and they affect everyone. The web of life is our connective tissue: human, animal, mineral and vegetable. What we discard or fail to adequately care for, we do so at our own peril. Our veterans and their families unfortunately have too often fallen into this category. Their suffering, their humanity, their dignity and their sacrifice often go unrecognized.

Since we are interconnected at the core, what happens here impacts what happens there; even if there is no visible or logical link. Almost three million service members have been deployed to Iraq and Afghanistan. Factor in the children, parents, partners, grandparents, brothers, sisters and so on, and that’s a lot of people who have been directly impacted by these wars. As we learned from Vietnam, unattended to, the wounds of war fester and deepen, wreaking havoc on individuals, families, and communities.

"When the Hair Grows Over"

The impacts of war are legend. Some are visible but many are not. There are injuries we can see and injuries that are invisible to the eye but nonetheless radiate deep and wide into a person’s life, health and web of relationships. TBI patients and their families have a saying: “When the hair grows over.” When the visible injuries heal, the unseen wounds to mind, heart, soul and spirit often go ignored. I am not only referring to post-traumatic stress. There are many veterans whose problems do not meet the criteria for a diagnosis of PTSD, but who nonetheless experience profound disturbances in functioning and well-being, as do their families. The ever-present traumatic past crowds out the open present, collapsing hope and possibility. I don’t believe that post-traumatic stress should be classified as a “disorder,” although our inner experience does become disordered, and we ourselves can be temporarily disabled. But I see the loose constellation of clustered symptoms organized by psychiatry manual-makers as the psyche’s means of trying to recover from the shock and chronic helplessness of unimaginably overwhelming circumstances.

Post-traumatic stress and war’s other wounds are not just stress and anxiety problems; they impact our identity, our self-regard, sense of purpose, and our entire worldview. Sometimes war shatters it all. “Rebuilding damaged connectivity among body and mind, heart and soul, among thoughts, feelings, actions, beliefs, and relationships is critical.” There is also a cultural dimension to healing the unseen wounds of war. Although it is important to learn skills to reduce stress and anxiety and rebuild the brain’s capacities to modulate and manage strong emotions—to rebuild internal connections—it is equally important to rebuild connectivity among family members and within communities.

What we cannot hold, we cannot process. What we cannot process, we cannot transform. What we cannot transform haunts us. It takes another mind to help us heal ours. It takes other minds and hearts to help us grow and regrow the capacities we need to transform suffering. This is done in concert, reweaving the web of connective emotional, relational and spiritual tissue that cumulative trauma tears asunder. With another mind and heart, and an informed, compassionate culture, it is possible, to transform ghosts into ancestors.

Concealed within damage often lies great strength. Resilience runs deep but its resources need to be nurtured. It is like a seed that has been buried in a disaster; it needs tending, attending. When the great redwoods are damaged in a fire, their seedpods are not destroyed—there is devastation, but often the forest can return to health, with protection, care and skill. If we cultivate the intention to be of help, if we take the time and energy, if we realize that the responsibility for healing the impacts of war is collective, the seeds of renewal and transformation await us just beneath the charred wounds of war. It takes a village and it begins with each of us.

Irrespective of political or religious beliefs, each veteran, each partner, child, sibling, parent and grandparent, deserves our loving, skillful, attentive care for the visible and invisible injuries from serving in Iraq and Afghanistan. They don’t only need a new set of techniques or new understandings. They need us to harness our own humanity—head, heart, body and spirit—our native connectivity and capacity to respond, in order to make a difference. They need us to participate in creating a culture in which the wounds of war are lovingly and skillfully enveloped as part of a welcoming community, where they can heal and be transformed. Fundamental interconnectivity takes the form of a responsive community that holds the vets and their families in its attentive, loving embrace.
 

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.

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



 

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.

Tara Brach on Mindfulness, Psychotherapy and Awakening

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What is Mindfulness

Deb Kory: In this day and age a lot of people are throwing around the term mindfulness. Many therapists—particularly in the Bay Area—describe their approach as “mindfulness-based,” but I have a feeling that most people don’t actually know what that means. What exactly is mindfulness? What does it mean to be a mindfulness-based therapist?
Tara Brach: Mindfulness is a way of paying attention moment-to-moment to what’s happening within and around us without judgment.

Mindfulness is a way of paying attention moment-to-moment to what’s happening within and around us without judgment. So, said differently, when we attend to the moment-to-moment flow of experience, and recognize what’s happening…fully allowing it, not adding judgment or commentary, then we are cultivating a mindful awareness.

DK: So, it’s non-judgmental awareness of the present moment?
TB: That’s another way to say it, yes.
DK: How does that relate to being a mindfulness-based psychotherapist? What does that mean?
TB: It means that intrinsic to the psychotherapy is a valuing of cultivating that kind of attention, and an encouragement of the person you’re working with to cultivate it, and a use of it yourself. It can be sometimes formally woven into the therapy, but sometimes it’s just implicit.

Meditation and Psychotherapy

DK: Where does meditation come in? Is that a necessary part of mindfulness work?
TB: Meditation is the deliberate training of attention. So, when you do a mindfulness meditation, you are deliberately cultivating mindfulness by using strategies to enter the present moment and to let go of judgment and so on.
DK: So, it’s a way to help cultivate awareness of the present moment, and I would imagine that’s especially important for therapists. Does that mean that you actually do meditation in your sessions with people?
TB: Well, some people do, and some people don’t. I’m not in active clinical practice right now. I was, for several decades, seeing clients regularly and then turned to mostly writing and teaching and training therapists in how to weave mindfulness into their practice. So, I’m no longer seeing clients myself, but when I did see clients and when I work with people and do sessions that are related to meditation training—I would often, as part of a process of them getting in touch with what was going on inside them, invite them to pause and just simply use a period of time to quiet the mind, to just notice the changing flow of experience, or maybe to do a particular compassion practice. So, I would weave particular styles of meditation into a therapy session.
DK: Would you suggest that people do it in their day-to-day lives also?
TB: It very much depends on the client that you’re working with. For some people, talking about meditation, suggesting that they meditate, is a set-up for failure and shame. They’ll try to comply because they think, “Oh, Tara is this well known meditation teacher and this is what she’s into, so I should do it,” and so on; whereas it’s not a fit for them at that particular time.

Many therapists already, just by the nature of who they are, have a natural sense of coming into presence and a deep sensitivity to other people, but all of us get help by training.

So there were many people I would see where it would be much more of an implicit part of the process. I’d be encouraging attention to what was going on in the moment, encouraging them to just notice their experience without adding any story—all things that we would associate with meditation practice without saying, “Hey, we’re meditating.” What makes meditation meditation is that it’s an intentional process of paying attention on purpose to the present moment.

DK: And it doesn’t necessarily mean sitting in the lotus pose, right? It’s something that you can do in your daily life walking out in the world?
TB: Absolutely. Meditation is a training of attention that you can do in any posture, at any moment, doing anything that you’re doing on the planet. In fact, for us to have the fruits of meditation, we have to be able to take it out of a compartment or a particular context and have it just be, you know, here’s Deborah and Tara doing a Skype call. So, we’re not leaving meditation behind just because we’re in the midst of an activity.
DK: Thanks, that helps me relax a little bit!
TB: Yeah, it helps to name what we’re doing. I think psychotherapy and meditation are incredibly synergistic and they fill in for each other in some important domains. There are many things that come up when we’re meditating that we really actually don’t have the resilience or the focus to untangle, and a therapist can help us do that. The relationship itself, a trusting respectful relationship, creates a sense of safety that can enable us to unpack things that we might not be able to work on when we’re on our own, especially if there’s trauma.There are increasing numbers of people who are recognizing they have trauma in their bodies, and when they start to meditate and feel like they’re kind of coming close to that, they can get flooded, overwhelmed. In therapy it’s possible for people to establish safety and stability so that they can just begin to put their toe in the water and go back and forth between being with the therapist and touching into their resourcefulness and then dipping a little into the places in their body and their heart where they’re feeling this more traumatic wounding. That kind of a process, if we tried it on our own just in a meditation setting, could potentially re-traumatize us.

DK: So the therapist offers a safe container for the traumatic feelings.
TB: Yes, and the relationship that really enables a person to have the support in untangling. What meditation offers to therapy is a systematic way of training the attention. Where the therapist might help a person focus and stay focused on the present moment when encountering a painful issue, meditation training teaches us to do it on our own. It builds that muscle of being able to come back to this moment, even if it connects us with something we have habitually resisted.Meditation also trains us to, on our own, get the knack of offering ourselves compassion or forgiveness so that we can leave the therapy setting and continue in a kind of transformational way to be with the contents of our own psyche and wake up from limiting beliefs and the painful emotions.

DK: It seems at least as important for the therapist to have that ability to stay present, because there’s a transmission that happens. There is an energetic quality to what we do.
TB: Exactly right. Many therapists already, just by the nature of who they are, have a natural sense of coming into presence and a deep sensitivity to other people, but all of us get help by training. All of us.

The Alive Zone

DK: One of the things I was going to ask you was about how you differentiated your roles as psychotherapist and spiritual teacher, but you’ve said you actually are no longer in clinical practice. What led to that decision to leave that particular role and go more into teaching and writing?
TB: Well, I had done clinical practice for many years and, I think, the place where I felt most needed and most alive is in the process of teaching people how to wake up their hearts and minds, and with that I mean both the practices and the whole inquiry about what really serves freedom. That realm was much more alive for me. For many, many people—most of us I’d say—meditation and therapy are incredibly juicy. They weave together beautifully. So it wasn’t that I was thinking therapy wasn’t an alive zone—it was just that I had put my energies really into the teaching side of things, and I was writing and that took a lot of time.
DK: Aren’t there some areas of the profession that are a little bit deadening though? I’m just about to get licensed myself after an 8-year-long process, and I have been somewhat disheartened at times by the way the profession is organized—its restrictions, the whole 50-minute-hour, the billing and diagnosing, the legal and ethical structures that can at times seem very fear-based and a bit paranoid. I’m curious about what might have felt restricting to you.
TB: Well, the culture does not support the kind of processes of transformation that I’m most excited about, and they take time and immersion. I love retreat settings where people can really give themselves to a very deep attention. I like working with people when there is a longer period of time for people to be together and really have the inquiry and the experience, have the time to unfold. So, as you mentioned, with the slot of a 50-minute-hour, there’s a kind of rigidity that is necessary in some ways, but not so much to my liking.
DK: In my experience—and I live in Berkeley, CA, which is considered progressive and rather “woo woo”—spirituality and religion were not incorporated into our professional training. We aren’t taught to value it except in a kind of multicultural, “let’s be tolerant of other points of view” kind of way. There’s an emphasis on scientific methodology, assessment, empirically validated research, etc., that feels very split off from what you’re talking about. I wonder if that was your experience at all?
TB: Well, what’s alive about therapy is the therapeutic relationship and, like any other two humans connecting, nothing can really flatten that. If you know you want to show up and be with somebody and really know that you’re there to see the goodness in the other person, you’re there to help recognize the patterns that are getting in the way, you’re there to hold a container moving through difficult material—that all is beautiful, and that can happen regardless of the structure around it.That said, I find that I do that more effectively with people in sessions that are more focused on how to bring meditation to difficult experiences. My interest is not so much to do with coping strategies or too much emphasis on the storyline;

I’m more interested in our potential to realize the full truth of who we are beyond the story of a separate self. Most therapy is not geared in that direction. People that end up working with me, or working individually with me doing what I might call spiritual counseling, are kind of a self-selected group of people that are interested in a more transpersonal kind of work–not in any way to ignore the issues of the personal self, but to have the personal be a portal to the universal, and an expression of our awake heart and awareness.

DK: Where did you go to get your degree in clinical psychology?
TB: I did my undergraduate work at Clarke University, and I did my graduate degree at Fielding Institute, which is out on the West Coast in Santa Barbara.
DK: What was your plan at the time?
TB: Well, even then—I had lived in an ashram for 10 years—I was approaching psychotherapy in a very holistic way. I was doing yoga, teaching yoga, and weaving yoga and meditation into any work I did with people. So I’ve always been blending East and West together, right from the get-go.My plan was to keep doing this, to be able to have a degree so I could afford to have this as a profession. I have a fascination with the psyche. I mean, I’m totally interested in how we create limiting realities about ourselves, and our capacity to see beyond the veil to the vastness and mystery of who we are. So my plan was just to keep on weaving these worlds together in whatever way would be most alive.

The Trance of Bad Personhood

DK: I read somewhere that you wrote your dissertation on eating disorders?
TB: Yeah. I had struggled with an eating disorder for a good number of years—probably 5 years—and meditation was really helpful; basically, it taught me how to pause. There’s a wonderful saying that between the stimulus and the response there is a space, and in that space is our power and our freedom. That’s Viktor Frankl. So the practice of meditation taught me how to pause and open mindfully to the space so that there’d be a craving or fear, but there would be some space between that and action.It also taught me a lot about self-compassion. I found that addiction is fueled by blaming ourselves. In Buddhism, they call it “the second arrow.”

The first arrow is the craving or the fear or whatever; the second arrow is, “I’m a bad person for having these feelings or doing these behaviors.” The “bad person” arrow actually locks us into the very behaviors that are causing suffering. So, in both Radical Acceptance and True Refuge, I emphasize a lot about how to wake up from that trance of bad personhood.

DK: One of the things I like about your work is that it’s very integrative. I get a sense that you’re really open to cognitive science, to philosophy, to various wisdom traditions, to 12-step programs—essentially to whatever seems to work for people. As someone who has benefited a great deal from the twelve-step model, I’m also well aware that it doesn’t work for everyone and that we have to have a big tool box available to help clients—particularly those struggling with powerful addictions. What’s your approach when working with addicts?
TB: Well, my inquiry is always, what have you been exploring and what helps? Humans are really resourceful, so I always try to find out what works for you. Of course, there are so many different approaches. I did my dissertation on binge-eating and meditation practice, but it became very clear to me that without having a relational component, without having a group and people to support you, nothing would hold. Whether it’s a 12-step group or in the Buddhist communities we have the kalyana mitta groups, or spiritual friends groups—the great gift is that we really get that suffering is universal, that we’re not alone in it, that it’s not so personal, that there’s hope, there are ways that we wake up out of it, and that we’re there for each other. We’re kind of in it together.
If there’s any medicine in the whole world, it’s that sense of belonging, of connection with others.I think that on the spiritual path, meditation—learning to be here in the present moment—is critical; but equally essential and interdependent is the domain of sangha, or community. We need to discover who we are in relationship with others. Whether it is addiction or any other form of suffering, a mindful relationship with our inner life and with each other is what de-conditions the contracted beliefs, feelings and resultant behaviors.

What gives hope is described in recent science as neuroplasticity. The patterns in our mind that sustain suffering can be transformed. And how we pay attention is the key agent. A kind and lucid attention untangles the tangles!

Will This Serve?

DK: In your work, you really make a concerted effort to share your own fallibility, and I think that for psychotherapists that’s a really tough one. I feel quite committed to that in my own practice, and yet I notice that I’m often pulled to frame things as, “long, long ago, when I was sick,” you know? But I’m not that old, so it couldn’t have been that long ago.
TB: Right…as long as there’s a 10-year gap between now and when I was really confused…
DK: Exactly. So it’s something I really try to work on, because I know in my own experiences as a client in therapy and in supervision, that I feel safest and most connected when people are willing to share with me not just that they were screwed up in the past, but that they’re still screwed up, because we all are.
TB: Yeah, the vulnerability, the fear, the shame—it all continues to rise throughout life. I’ve made that kind of vulnerable sharing a deliberate practice for a few reasons. One is, it’s the truth. I mean, there’s no way there’s not going to be projection when you’re a teacher or a therapist, but I really feel like mindfully sharing about our personal foibles serves. I regularly get caught up in self-centered thoughts, impatience, irritability, anxiety, the whole neurotic range. And…the truth is that I’ve been blessed to have increasing freedom, you know? That pain and difficulty and stuff keeps arising, but so does a mindful, compassionate way of relating to what’s happening. The result is there’s less and less of a sense that it’s happening to a self or caused by a self. I know how valuable it is for people to see that as a therapist or as a teacher that you have a certain amount of happiness or freedom in your life and that you’re still working on things. It gives hope.
DK: Yes, it’s a fine balance.
TB: It’s a fine balance. I think the inquiry is always, will this serve? We’re not doing it to unload; we’re not doing it to be a certain kind of person. It’s just, will this serve? But, I have found for myself that leaning in that direction is usually beneficial.

What We Talk About When We Talk About Love

DK: You also talk a lot about love. I felt very clearly that I came into the profession in order to practice love—to practice it and to practice it, learn about it. But in my training, I literally never heard the word uttered. I made a point to bring it into discussions at school and at training sites, but in my experience it was a lot easier for people to talk about hate—“hate in the counter-transference” and love as just “positive countertransference.” Obviously there have been terrible abuses of power by therapists in the name of love, but it seems like the response has been an over-correction, and has left us without a proper vocabulary for what we are actually doing.
TB: Well, as you were speaking, I was thinking that it’s beginning to change. That’s the good news, Deborah. I mean, there is so much research now on self-compassion and compassion for others. There are universities like Stanford, which has a whole institute—The Center for Compassion and Altruism Research and Education (CCARE)—dedicated to compassion studies. Compassion is love when we experience another person’s vulnerability or suffering. Love, in terms of loving-kindness, is described as love when we see the goodness in what we cherish. Gratitude and appreciation and love and beauty are all words and places, domains of attention that are actually becoming more common in the psychotherapeutic community.And I feel like it’s really important that we consciously take this one on. For instance, I have made a point of talking about prayer and talking about calling on the beloved and calling on loving presence when I feel very, very separate…really reaching out to that which feels like a source of loving presence and then discovering it wasn’t outside of me, but I first have to go through the motions. So it starts with a dualistic sense, and then it ends up revealing unity. I’ve made a point of talking about that when I’m doing keynotes at professional conferences, because I really want there to be an increasing acceptance and comfort with the language of prayer.

How could it be that we all have these longings? I mean, every one of us longs to belong. Every one of us longs for refuge. We long for feeling embraced. We long to feel bathed in love. We long to touch peace.

That’s prayer. That longing, when conscious and expressed, is the fullness of prayer, and for us to acknowledge the poignancy of it and invite people to recognize it and have it arise from a depth of sincerity, actually is a very powerful part of healing. Prayer is a powerful part of healing. It helps us step out of a small and separate ego kind of sensibility, and recognize a larger belonging.

So I feel like we’re at a very juicy kind of era in psychotherapy where more and more of the profession is opening itself to intentional training and training in self-compassion. It has definitely opened its doors to that. It’s opened the doors to mindfulness in a big way, and when you open those doors, people become more embodied and there’s more creativity, more possibility.

The Squeeze

DK: The title of your new book is True Refuge, and it speaks to, I think, both the longing and the possibility for refuge inside of ourselves that we create in relation to others, as part of the human community. What’s the relationship between this new book and your first book, Radical Acceptance?
TB: Well, I wrote Radical Acceptance because I was aware in my own life and with most everybody I connected with that probably the deepest, most-pervasive suffering is that feeling that something is wrong with me.I called it the “trance of unworthiness,” because most people I know get it that they judge themselves too much and they’re down on themselves, but are not aware of how many moments of their life that assumption of falling short is in some way constricting their behaviors and stopping them from being spontaneous. You know, it could be that here we are doing this interview, but there’s some nagging sense of, “Oh, I should be doing this better,” and how that in some way blocks the heart from being as open and tender. It’s just, we’re not aware of how many parts of our life are squeezed by a sense of deficiency.

I’ve found that until we are aware of that squeeze, we’re caught in the trance. So I wrote the book because I wanted to say, “hey guys, we’re all going around feeling bad about ourselves,” and explore how practices of freedom—cultivating a mindful awareness, cultivating compassion, cultivating a forgiving heart, learning to turn towards awareness itself to begin to recognize its formless presence that’s always here—help to dissolve the trance and reveal who we are. This vastness and this mystery is looking through our eyes right now, even though we’re just looking at a computer screen—there’s this sentience and it’s so cool. So the purpose of Radical Acceptance was to very much draw attention to that trance.

DK: And what was the purpose of writing True Refuge?
TB: In True Refuge, I enlarged the scope because in addition to unworthiness, our basic trance of separateness gives us a very profound sense of uncertainty and loss. I think it becomes more vivid as we age that, “okay, these bodies go, everyone we love goes, these minds go.” Right now, for example, I’m watching my mother lose her memory as dementia is setting in. Just watching that happen is painful and sad.But what directly motivated me to write True Refuge was a period of about 8 years of a steady decline in physical health. There was a time that I had no idea whether I’d regain any of my capacities I had lost. I have a genetic disease that affects my connective tissue, so I had to give up running, give up biking, and give up a lot of the recreational activities I most love. I remember at one point being completely filled with grief at the loss and sensing this deep longing, a very poignant longing, to love no matter what. Really I just wanted to find some refuge, some sense of peace and okay-ness, openheartedness, in the midst of whatever, including dying. That feels important to me. So True Refuge was approaching a broader domain: How do we find an inner sanctuary of peace in the midst of all the different ways that life comes and goes? How do we come home to that?

DK: When the pain of life brings you to your knees…
TB: Exactly. I remember being very struck by William James, who wrote that “all religions start with the cry, ‘help.’” Somehow deep in our psyches there is always some part of us that’s going, “Okay, how am I going to deal with this life? How am I going to deal with what’s around the corner?” What happens for most people—and this is kind of the way I organized True Refuge—is that we develop strategies to try to navigate life that often don’t work. I call these false refuges. This is in all the wisdom traditions. We know that the grasping and the resisting and the overeating and the over-consuming and the distracting ourselves and the proving ourselves and the overachieving… just don’t create that sanctuary of safety and peace and well-being. It just doesn’t work.So in the book I talk about our false refuges and then explore what are really three archetypal gateways to homecoming. You can find them in all the different world religions including Christianity, Judaism, Hinduism, and it’s most clear for me through Buddhism. These three gateways are: truth (arising from mindfulness of the present moment), love and awareness. In Buddhism these are ordered differently and called Buddha (awareness), Dharma (truth) and sangha (love).

So the architecture of the book is based on that, and I used a lot of stories—my own stories, and other people’s stories—to address the pain of feeling deficient, but a lot of other struggles also.

No Mud, No Lotus

DK: The parts of True Refuge that were most moving to me were the descriptions of your struggle with your disease, because there is just no getting around how painful and difficult that must be. You really share your cry for help and the fact that you’ve been able to make some peace with it is both awe-inspiring and hopeful, since all of us, as you say, will face our own physical demise. But it does seem like living with chronic pain that severely limits your mobility is one of the deeper sorts of spiritual challenges that we face. Do you feel grateful for what it’s taught you?
TB: Yeah, I do. You know, I’ve heard many, many people say from the cancer diagnosis or the heart wrenching divorce or whatever it is that they wouldn’t trade it for the world. I feel the same way. “No mud, no lotus,” as the Buddhist saying goes. We wake up through the circumstances of our life, and the gift is that when it gets really hard you have to dig very, very deep into your being to find some sense of where love and peace and freedom are. Our experience of inner freedom is not reliable if it is hitched to life being a certain way. If I’m dependent on my body being able to run to feel good, I’m going to be in trouble. I’m actually better than I was before physically, but there were times when I couldn’t leave my house. I couldn’t do much of anything, and there was a growing capacity to come into a beingness and an openheartedness that allowed me to feel just as alive and present and happy as if I could have been romping around outside and running through the hills.I think of that as freedom. I think of freedom as our capacity to be openhearted and awake and have some spaciousness in the midst of whatever is unfolding. The gift of it is that we start to trust who we really are. There’s a sense of trust in the awareness that is here, the tenderness of our heart, the wakeful openness of our being. This becomes increasingly familiar, rather than the identify of a self-character that is able to do this and doesn’t do that and is great or terrible at such and such. We are living from a sense of what we are that can’t be grasped by words or concepts, but can be realized and wholeheartedly lived.

So, that is the fruit of True Refuge—that our true refuge is our true nature. Our true refuge is our true nature. It’s none other. The three gateways are just different energetic expressions of true nature.

DK: How did getting a degenerative chronic pain disease change your work with people?
TB: Before this happened, I was pretty much an athletic jock type that had some vanity around my fitness. And I’ve emerged much more humble, and also much more compassionate towards others. I know what loss is. There’s something I sometimes call the “community of loss,” where each of us has lost something deeply important—whether we’ve lost a partner, or lost a job, or lost our health, our home. I just got back from teaching a weekend at Kripalu Retreat Center in Western Massachusetts, and a number of people there had been hit by hurricane Sandy. One woman was telling me what it was like to have her home totally demolished. The community of loss. The more awake we are to realizing we’re part of it, the more we’re holding hands with others, really the more compassionate a world we have.

Awakening to the World’s Suffering

DK: Speaking of which, I know that political activism has been a big part of your work. You bring issues of social justice into your teachings. One of the things that comes to mind is a talk that you gave about racism within your spiritual community—not overt racism, but a more subtle but nonetheless insidious kind of racism that we find just about everywhere in our culture. It was painful for you to be made aware of it and you shared it as a way to bring awareness into your community. I have also appreciated the way that you struggle with modern politics in your work—trying to remain open-hearted but still having a coherent political voice. How important is it in the work that you’re doing? How has that changed over time?
TB: Well, it only becomes increasingly clear to me that the awakening of our heart and mind means awakening to our belonging to the world and that there’s not a spiritual path that can be extricated or isolated from that belonging. This means that not speaking is in fact making a statement. Our thoughts, our speech, and our actions in terms of the broader community completely matter. They matter. They express our awakeness and then they affect what happens in the world.It feels essential that those who value being spiritually awake recognize that that includes being engaged consciously in our larger world, wherever it is that we feel particularly drawn.

We have to recognize that our earth is dying, that denial is the biggest danger in the world for our planet. We have to be willing to be touched by the suffering of the earth, the air, the creatures that are going extinct, to be touched by the pain that people experience when they’ve been discriminated against and shamed and isolated in different ways, marginalized in our culture—that’s part of being awake and open in the world.

DK: What kind of social or political activism are you currently involved in?
TB: I try to respond to what goes on in our own community, and our community is involved with a number of domains. There are some green activities that are, I think, pretty cool. We’re fumbling around on the diversity front, sometimes in a painful way. Like most communities that have a majority of white people, the big question is how to wake up and be more responsive to the racism that is just naturally there. It’s just part of the culture. I’m also very much supporting getting the mindfulness curriculum and mindfulness in schools around here. And we have a lot of activity around teaching in prisons. So the best I can do as a leader in the Washington area is to support those kinds of activities. As you can tell, I do feel passionately that it’s not meant to be just on the cushion.
DK: So it’s not separate at all—any of it.
TB: Nothing is separate. We belong to this world, and it’s part of the way we’re trying to bring compassion to these bodies and hearts and minds. We need to bring compassion to those that are suffering from an unjust society, and we need to bring compassion to the earth.
DK: Is there a place for anger in this struggle?
TB: Absolutely. We all are wired to have a range of emotions that are just life energies, and to not regard them as wrong or unspiritual is really important, to respect them. They all have an intelligent message, we wouldn’t have been rigged with them if they didn’t. Our work is to learn how to be in relationship with them in a way where we can listen, where we can embrace the life energy and not get identified with the storyline they may elicit.What happens with anger is we can get fixated on, “You did something wrong to me.” When this happens, the practice is, instead of believing the story, to instead see if we can honor the energy and feel what’s going on inside us.

This usually involves bringing real kindness and mindfulness to the feeling of being hurt, the feeling of vulnerability, the feeling of fear, but not buy into the storyline of, “you’re bad and I need to get you back.” Because if we can pay attention to the message of anger—“there’s some threat, I need to take care of it”—and feel where we feel threatened inside, we’ll reconnect with the natural intelligence and compassion of our own heart-minds, and then respond with more wisdom. So go ahead and create boundaries, go ahead and speak your truth, but from a place of presence and intelligence and kindness, not from a burst of reactivity.

DK: Which takes a lot of practice over a lot of time.
TB: Huge practice, because we’re basically moving against our more primal reflexive reactivity, and learning to cultivate a response from the more recently evolved part of our brain. Our conditioning is to have an impulse arise and act out of it, so as to release the tension and feel soothed. It’s coming back to that quote from Victor Frankl. This is saying, “Pause….First come home to the experience that is here and pay attention.” That is the heart of the training, and it takes practice. In True Refuge, I use the acronym RAIN, and I’ve added some different dimensions than are usually emphasized in much of the Buddhist teachings. It’s a really simple and powerful handle to, instead of react, come into a relationship with what’s going on in a much more wise and balanced way.

RAIN

DK: Can you briefly go through what you mean by RAIN?
TB: Sure. RAIN is an acronym to support us in cultivating mindful awareness, and the basic elements of mindfulness are to recognize what’s going on in the moment and to allow it. That’s the core of RAIN: to Recognize and Allow. What happens often is we’ve got a tangle going on—let’s say it’s anger. We’ve got a storyline of the anger, and we’ve got the feelings, and we’re wanting to do something, and it’s all jumbled up. What we’re doing with RAIN is saying, “Okay, I Recognize anger is here and I Allow it.”But it’s still feeling very sticky and very demanding of attention. So we deepen attention with the “I”—Investigate. But it has to be a compassionate investigation because if we investigate as a detached observer, or we investigate and there is some judgment and aversion, then the more vulnerable places within us will not reveal themselves to the investigation. For investigation to unfold to truth, we need to bring real compassion. I sometimes think of it as the rain of compassion or self-compassion, because we really need that quality.

DK: Yeah, it’s so easy to bring a subtle kind of judgment into that kind of investigation. Like, “why do I always trip out on this?” or “here’s my damn depression again.”
TB: If you think of a child who’s upset and you want to find out what’s going on, if there’s not a sense of caring, if you just ask questions, it’s not going to work. So we begin to investigate within ourselves, ”Okay, anger. What am I believing right now?” If we ask that question, it can easily veer off into concepts. But the more we bring a gentle presence, a caring presence, a clear presence to the actual experience of what’s going on, the more there is a shift in a sense of our identity. If you’re very, very present with the anger, you’re no longer the angry person believing in the story; you’re the presence that’s present. You are the awareness that’s noticing. That shift in identity is the whole key to the transformation that Buddha talked about in awakening to freedom. And the body is the major domain of investigating—the throat, the chest, and the belly. Just really arrive and sense, “how is this experience playing out through this body?”After the “I” of RAIN gives us that presence, the “N” is “Non-identification.” Another way to say it is the “N” is “Natural awareness.” We are re-embodying or reestablished in our natural, vast, compassionate awareness.

DK: So, it’s really the opposite of dissociating?
TB: Exactly right. Neither dissociating nor getting possessed. When we’re identified with an experience, either it grabs us and we become the angry person, or we disassociate and become kind of numb and cerebral. Either one of those is, in a way, moving away from the reality of the present moment. RAIN is the way to come into the present moment. We can bring it into our relationships so that when there is conflict with another person, or with another country, or with some “other” that we consider kind of unreal or bad, if we’re able to first bring RAIN inwardly and just sense what we’re feeling and be with that presence and open up our sense of identity, we can then look at another person with the possibility of inquiry. What is really going on here? What is the unmet need? What is your vulnerability? What are the fears or hurts that might have led you to that behavior? We get to see through the eyes of wisdom. RAIN, or more broadly speaking this capacity for mindful awareness, is actually the grounds of compassion for ourselves and each other. It gives us a chance to really sense who we are beyond the mask.
DK: Thanks so much. It has been a joy to talk with you.
TB: Thank you.

Philip Guerin on Bowenian Family Therapy

Posted on by rezendevknowfully.com

The Family of Origin

Ruth Wetherford: So, Dr. Phil Guerin, give us your background. What is your current situation? How have you gotten into family of origin work?
Philip Guerin: Well, my family of origin work goes way back. I’ve been in practice now about 45 years. I was a medical student at Georgetown, and the program was primarily a psychoanalytic program, so I spent my medical school time using psychoanalytic-psychodynamic models, transference models. I didn’t meet Murray Bowen until I was a resident, and he was my introduction to family of origin work. His whole model is mostly family of origin work, so that was a good introduction.By the time I met him I was already somewhat impatient with what in those days was called “the working through process” in the transferential model. I myself had been in therapy as part of the training and was somewhat dubious about how much the working through process really took place. In my own analytic therapy, I didn’t see much attention being given to it. And in working with patients, I found that things tended to drop off and never quite got through the working through process. And as a result, people often had dredged up a lot of negative affect and feelings about their important objects during their individual therapy and were then left with no place to work that through, other than to hold on to negative precepts about those people which resulted in exaggerated distance and a lot of blaming of those people for their own neurotic hang ups.

RW: That is a common complaint of people in therapy as well as of therapists. We do all this digging, we excavate the woolly mammoth—now what do we do?
PG: Exactly. So I found that trying to find a way that one could put some structure on the family of origin, and then define the field that those people occupied, look at the key conflicted processes, the important triangles, the cutoffs—all those things that we know about from our family system training—and really actually work through some of that process with somebody who knew the terrain. I was fortunate enough to have a guy through my terrain in the person of Bowen. And I did some significant relatively long-term work with him on my own family of origin. So that’s how I got into it. And I have found that it has been a real help in my own personal life. And, on the other hand, difficult to sell to people in terms of being relevant to their everyday lives.So I had to learn to not sell it, but to integrate it somehow around the symptoms of the relationship conflicts that came up so that people could see and learn its relevance. I don’t know what you think, Ruth, but I think in our current culture there’s even less investment in family of origin as an important and valuable asset in people’s lives.

There’s so much fragmentation of families, in particular the multi-generational families, that I think people, now that I’ve been in the business long enough, they kind of self-select in terms of coming to see me. So I either end up with somebody that’s coming in with the family of origin problem or somebody that isn’t awfully interested in it and we end up focusing on their symptoms and maybe working the family of origin in as part of that process.

RW: What are some of the basic concepts that you really like about this approach that help you organize your observations and your moves as a therapist?
PG: I think that the two things that are key, in terms of helping people with this clinically, is that much of the developmental and/or situational stress in our lives emanates from family of origin stuff. You know, you haven’t seen your mother in 15 years and she suddenly has a terminal illness. Something happens to your brother and he loses his job—there’s any number of those kinds of situational things. And the developmental things are obvious—when somebody gets married they are supposed to shift their loyalty from their parents to their loved one as their primary object of choice, but that’s actually very difficult to do.And what that brings up is a triangle right out of nowhere, which you also had when you were a little kid—just born into a family and you started out somewhere caught up between your mother and father. So those kinds of things and contextualizing them into the larger family I find really helpful as a road map to develop people’s treatment plans.

RW: So there’s the concept of the triangle and the other concept is…?
PG: Well, I think the triangle is obviously very central. But when I see a clinical situation that comes to me I make an assumption that it’s based on an increase in stress in the people’s lives.
RW: Stress is a key concept.
PG: That manifests itself in an exacerbation of relationship conflict or some physical symptoms that’s returned or depression or anxiety. And those things are best understood if you can put them into context of a family—the family of their spouse and kids or the family they came from.

Triangles

RW: In your book, Working with Relationship Triangles, which you wrote with Fogarty, Fay and Kautto, you go into great detail about the nature, structure, and process of triangles. It’s a working manual about how to apply your theories and ideas into action. One of the things that you say in the book is that a triangle is not a threesome. A threesome is not a triangle. What is the distinction you’re making here?
PG: I think that’s a distinction that Fogarty makes and it’s something he puts very high on the list of things that people have to be able to do. What it means is that a threesome is three individual relationships in which there isn’t a lot of reactivity among the folks. There’s nobody on the outside looking in. There isn’t an intense conflict in a dyad that the third person is getting distance from. He used to talk about it as an equilateral triangle in which there was calm in each of the three relationships. And if there’s calm, then all kinds of good things can happen.But triangles are very pervasive. You don’t have to put three people together very long before they fall into triangles.

RW: So you’re saying that the term “triangle” itself implies not just that each of the dyads that you’re in with two other people is affected by their relationship with each other, but that it has become dysfunctional in some way.
PG: Yeah, and that can be by excluding one person. The concept of triangle has built into it that it’s dysfunctional and inhibits people in the system from finding ways to uncover and deal with their difficulties.

Differentiation of Self

RW: How much do you use and think about the concept of “differentiation of self”?
PG: Differentiation of self is one of those things that obviously was one of Bowen’s original concepts. And he stuck with that through his whole career and believed it to be of primary importance because he believed that if individuals could increase their level of differentiation—which in concrete clinical terms means that they are less emotionally reactive and can think their way through their problematic relationship road blocks—then everything would fall into place. Symptoms would go away. Functionality in relationships would improve. I find that it’s abstract enough that it’s difficult to stay focused on that.And so one of the things that I developed was the whole idea that we are mostly left with the level of differentiation that we’re born with. We can make some progress on it over time, but mostly by finding ways of working within that to improve our ongoing level of functioning. It’s kind of like functioning in spite of your level of differentiation.
RW: When we add to that definition the internal ability to feel and think what is true for oneself’ separate from the pressures of your closest social environment and separate from coercion, that eliminates many people who are dependent for their survival, their food, etc. on the dominating power of others.But for that subset who can have the freedom to think and feel what might be true for them, and in so doing reduce the emotionality that you were just talking about, that strikes me as something that one can do, slowly and incrementally throughout one’s life if one knows how liberating and freeing it can be. In fact, the first time I was reading about differentiation of self with Bowen, I thought, “What a light bulb for humanity because it rescues us from the prevailing power dynamics in most families—that the rights and needs of the many are meant to be sacrificed for the good of the few.” And this concept that we’re equally entitled to our own subjective experiences, that seemed so new.

PG: I think you put it very succinctly and I think you put it in a way that is very useful for folks. I have been struck over the years by the power of emotional forces and how easily they can overwhelm even the best of strugglers who are trying to get to a differentiated perspective.
RW: Yes, that’s so true.
PG: It’s out of respect for the power of emotionality that I put some qualifiers on differentiation as the central process of family of origin work. I think it’s also one of those things that people hide behind a lot; they talk about how much they’re differentiating themselves but, frankly, I don’t see it, right?From the work I’ve done in my own family, I’ve found how easy it is to kid yourself for five years that you are rolling along increasing your differentiation when it finally hits you over the head that you haven’t been. You’ve been playing the side game, but it doesn’t have much to do with differentiation.

RW: Right. Just following up on what you said about how easy it is to think we’re differentiating, to me the cue of the power of that emotional force is anxiety. I’m getting ready to go visit my family—why am I so anxious? And it’s so helpful to think about who are the two people with whom I feel most anxious and why, and then go into those thoughts. I think you’d call it an application or a “thought experiment.” What kinds of applications have you used that that might help people understand how to go about thinking about this more deeply?
PG: Well, I like to use the concrete behaviors in people’s relationships and develop them into experiments with some kind of modification of a behavioral pattern. And while you’re doing that, pay attention to what’s going on internally. And if you start to get anxious, that’s important information. And pay attention to the reactive behaviors and the important other people in your family. And sometimes you’ll find that the reactivity that they have shuts down your ability to even think.
RW: So you ask for observations.
PG: I do.
RW: And you help people identify what in particular they’re going to be looking for to observe?
PG: You mean like if they’re making a trip home?
RW: Yeah, or a phone call, email, text or any contact with the person who is the trigger for anxiety.
PG: Yeah, or outside of the therapy session as well. Because you often end up working with one family member in a lot of this.
RW: Yes. And you do make a point that the work is best with those people who are open to the approach of taking control of their own calming and who understand that they can try to change their participation and the repeating sequences of interaction. Have you asked people to identify the repeating difficult sequence of interaction that makes their anxiety shoot up?
PG: Well, if they’re going to be going to a family of origin visit, I would be probably more generic than that and just have them go and really try to keep their own anxiety in check and observe what they see around them. And then bring what they observe back and we’ll put it together and talk about it and maybe design something that goes on over time—combination letters, telephone, other visits, etc.And I think that that does help people get a sense of mastery and a sense that they don’t have to be so anxious and frightened about moving into the relationship and changing their responses to difficult interactions.

Techniques

RW: You said in your Bowenian family therapy video that Bowen sneered at the word “technique.” I wonder do you have techniques?
PG: I think that in Working with Triangles and in some of the stuff that I’ve done in the form of chapters in other people’s books, I spell out a number of techniques that I think are important to the method. And I think there’re seven of them. I probably couldn’t even come up with more than three of them now. But I certainly have techniques that I think are just applications of observations and theories about the way relationships work.
RW: Donald S. Williamson, who wrote The Intimacy Paradox, and Betty Carter and others do have explicit sequences of moves to help people identify the toxic triangle and calm themselves, notice the repeating patterns, identify their own reactions to things that are said, and then develop a self-stated goal for their own change in behavior. Then they take a step, however small and metaphoric, toward that goal and report back on how it went. In this way they differentiate themselves gradually and hopefully humorously.When people do this there’s an enormous amount of emotion that’s released which, according to those family therapists, needs to be expressed outside the family—the hurt, the anger, the intensity—so that through the release of pent-up emotion there’s less pressure to have it come out in interactions. How much of that emotional release have you experienced using such a cognitively based therapy?
PG: Well, I think that in all those paradoxical ways if you ask people to put their cognitive apparatus to work and observe and experiment with the relationship process they’re a part of, the emotion surfaces in very dramatic ways. And if it’s going to be external, I hope it’s in a context with somebody who is a coach or a therapist because otherwise, you know—I was just watching a movie over the weekend which was a remake of a 1939 movie called Women, in which part of what was going on was the group of women that surrounded Meg Ryan when she found out her husband had an affair. And they had more opinions about what she should do and ways to deal with her upset. And so that can be somewhat questionable in terms of its helpfulness, but I think if it gets spilled to your coach or your therapist, it can be very beneficial. You somehow neutralize the negative power and then go back into the relationship that is the source of it and get it talked out.
RW: Yes.
PG: That would be the best outcome. But I still think that the emotional vulnerability in each of us that triggers us to respond in an emotional way is very profound. And all the designs that Betty or Donald and myself come up with are ways of helping with this, helping the moment, helping the month—but over a long-term process of life it’s very easy to get pulled back in on an emotional basis and to be unaware of it.And so it becomes kind of a lifetime work. It’s very different than being in therapy for life, you know. I think that the difference is that therapy ties you to the individual, who is the therapist, and that the process of working it through is in that relationship. There’s nothing wrong with that. It works. But if it doesn’t get back into the natural relationships of your system, it’s going to be limited in the impact of that.

RW: Yes. You make the point in the book that when the therapy progress seems to be bogged down it’s useful to look for invisible triangles that may be holding the person’s behavior in a stuck place. And you mention that sometimes it can be the individual therapist or the couple therapist. So you’re alluding to the fact that we therapists ourselves have our own levels of differentiation and sometimes we tend to side with the client or patient against the people they’re complaining about. And what a mistake that is in that the therapist needs to work toward his or her own differentiation. Say more about that.
PG: Well, I think if you don’t develop an ability to empathize with your individual patient about what they’re struggling with and to hear them out and to validate them that the struggle is real and there’s justification for their feelings, then you’re not going to have too many patients for very long.That’s the first phase. And the second phase is, well, now that you know those feelings are natural and that maybe 90% of the folks on the planet would have them, well, how are you going to put them into a context that helps you develop a way to go work them through with that person? We therapists have to watch for that very fine line between being supportive and validating and just providing no real motivation to go do something about it.

RW: That’s right. If I see your point of view and validate your feelings, that does not mean I agree the others also have a point of view and that to do nothing about it. It doesn’t mean you can’t change your own reaction to it.
PG: It also doesn’t mean that part of your response doesn’t have its own negative set in it, you know? That’s a big part of the problem actually.
RW: Yes. You mentioned that this thinking leads you to ask questions that help the person see how their own interaction is negatively influencing the others and that we think of ourselves as innocently going along reacting to others, but we forget that they’re reacting to us. Say more about that.
PG: Well, it’s like the whole concept of constructive criticism. How many people do you know who are good at accepting constructive criticism?So I think an awareness of yourself and the toxic parts of you and how you trigger people into their own stuff is essential as a therapist,

An awareness of yourself and the toxic parts of you and how you trigger people into their own stuff is essential as a therapist.

The Invention of Genograms

RW: You coined the term genogram, is that right?
PG: Well, there’s a rumor to that effect, yes.
RW: Well, talk about the genogram and how useful that’s been to you.
PG: Bowen started using what he called “the family diagram.” And if you look at his writings and you watch his speeches, he never converted that over to genogram. Until the day he died, he talked about the family diagram. When I had left Georgetown and was at Einstein teaching the residents and fellows and medical students and the like, I did a lot of what you were talking about Don Williamson doing. I had what we called “TOF groups”—therapists’ own family groups—which was a practical way of trying to get people to learn the theory and the idea of the impact of the people in your family on your emotional functioning. And part of it was for people to, in seminar style, put their genogram up on a board, either a blackboard or an easel pad. And it just seemed to me that we were also teaching about generational repeats all the time.We were talking about intergenerational triangles and it was impressive how much the issues and the relationship patterns repeated themselves generation to generation. So I just thought people might relate to this and the notion of a genogram might stick in their head. It kind of gives you a structure with the membership of your system and the major issues in your system and the cutoffs and where they are and what drove them.

I think it’s been very helpful to people over the years and it’s probably one of the techniques or structures that people from other therapy approaches use.

RW: So after you create a genogram with people—whether you’re working with one person or a couple or a family—it helps you to understand the different forces that hold the system in place.
PG: Yes.

Functional and Dysfunctional Attachment

RW: In Working with Relationship Triangles, you say, “Quite apart from how people feel about the closeness or distance between themselves and others, we should make another distinction between kinds of closeness and distance. Closeness can be a kind of functional attachment. This allows people in a relationship to preserve their boundaries and their autonomy in thinking, feeling and action while they remain connected in a personal way to each other. Alternatively, closeness can be reactive and driven by anxiety, a kind of dependent clinging or anxious attachment that says implicitly or explicitly, ‘Please don’t leave me. I’ll do anything to keep you. If you leave, something terrible will happen.’ Similarly, distance can be a deliberate and planned exercise to deal appropriately with a developmental or relationship problem” (page 59).I quote this because it jumped out at me as very consistent with what a decade and a half later is the very important focus on attachment and the patterns of attachment—secure versus anxious and avoidant. Because you’re making the point, I think, that once we excavate what the core issue is—and it will often emanate from the marriage that then creates the nuclear family—the dynamic has to do with the tension around closeness and distance, in being able to get access to a feeling of connection or “are you there for me?” Functional attachment, anxious attachment, those are precursors to this new attachment conversation that’s going on. When you work with people, how do you focus on that issue, that struggle in them to find a happy, close enough, but not engulfing, far-enough-away-without-abandoning equilibrium?

PG: That’s a very good question. And I think if you realize that most attachments that people have with one another is of the anxious attachment variety that gets called love—as opposed to the kind of functional attachment where you add to that an ability to be open about your feelings for the other person. That’s different. And that is the root towards the kind of intimacy that all of us are looking for. I was thinking while I was listening to you read that section, “Yeah, that’s pretty good. I agree with that.”You were talking about techniques before—one of the techniques becomes the use of the process question: “Do you think that the importance of being connected to your husband comes from a need for a kind of closeness that will benefit you both in your ability to be intimate with one another and to function as individuals and as a dyad? Or do you think it’s kind of a clingy attempt to hide out behind him or in the relationship itself?” They’ll say, “Will you repeat that?”

I think that you take that notion and you try to get people to think about it. And you try to get people to think about it by asking some fairly brief—a lot briefer than that last question came out—questions to focus them on how much of their attachment is being driven by their anxiety, being driven by a fear of a loss of the other, being driven by a way of toning down what they’re experiencing as criticism. I think that can be very helpful to people.

Each of us has a different allergy in this regard. I mean, some people just have an emotional allergy to somebody who is clingy and wants to have their arm around them all the time and wants to exchange intimacies. Other people have an allergy to too much distance and too much avoidance and an inability to talk about the personal in the relationship itself. And how much of that is testosterone versus estrogen driven or whatever? I don’t think we know.

RW: No.
PG: But it remains something that’s consistent over the decades that that is a part of the problem and also can be a part of what feels good in a relationship. We used to have arguments at Einstein family study section where we’d talk about, “I don’t care if it is emotional fusion; it feels too good to let go of it!”RW: How have you been evolving professionally and philosophically since the publication of your last book?

PG: Well, I’ve gotten involved in a whole bunch of stuff that mainly has to do with being the grandfather of 11 grandchildren.And that has taken away the drive and the energy to write another book. But it’s been worth it. I mean, the kids are terrific and watching them—my oldest grandchild is 19 now and my youngest is 15 months—watching them continues to teach me about myself in ways that are very important. But I’ve been thinking, you know, not a bad idea to start getting back to some of that.

RW: Do you have another book in you? And if so, what would be the message of that book?
PG: I think the ideas that are in The Evaluation and Treatment of Marital Conflict, book that we put out in the middle ‘80’s, and even some of the stuff that was in the original textbook you were talking about before, are only partially developed. I think that the concepts develop most clearly when you’re putting them to the test with your students. And we still do that, but not with the kind of intensity and frequency that we used to. In recent years as managed care has come in, training programs are kind of atrophying. There used to be a battle between five or six models of doing things, and the debate and the discussion and the application to clinical situations of the models were very enriching, very enlightening, very energizing.If I was going to put another portion of my energy into my work as opposed to my grandchildren—they’re going to probably tell me to do that pretty soon—I would try to work towards applying the models that were developed in the late ‘80’s and early ‘90’s and see if they can hold up, you know? Try to make distinctions between ‘70’s and ‘80’s versions of intimacy and attachment and present day. Are they different? What are the differences? Can there be an evolution that provides more refined and sharper models that improve clinical outcomes?

Flying-By-the-Seat-of-Your-Pants Therapy

RW: And would you include integrating the various models?
PG: I think as much as they can be integrated, yeah, absolutely. I think that there’s a need for that. And the question is how do you do the integration without getting the lowest common denominator? And I think that some concepts go together and others don’t. But it’s rare that there’s been one way of thinking about these things. Ego psychologists had a structural way of approaching things just like Minuchin and others have had a structural way of approaching things, you know? And I think that the analytic psychodynamic models really evolved into the multi-generational systems whether it’s Bowen and Fogarty and myself and Carter and Monica and all those folks or if it’s a more strictly psychodynamic approach to things, or Haley and some of those people who really came out with a totally different perspective.So all that stuff that was done kind of side-by-side in the ‘70’s and the ‘80’s. I think if people had time and the interest in the information, more developing could take place. And hopefully that development would provide a refinement that could be taught to people that are doing therapy because it seems like folks are flying by the seat of their pants a lot in doing therapy these days.

Some of therapy has kind of dwindled down to giving advice, you know, from your own particular perspective, which isn’t bad unless it’s the only thing you know. I would love for a day to return where people were working together to define models and refine them and make them reproducible.

Maybe that’s not possible in this time-crunched era that we’re in now, but I would like it.

RW: Many people are calling for a broader dissemination to people. The APA, for instance, is looking for ways to teach psychology outside of clinics, hospitals, private practice and academic settings, using the internet, for example. What are your thoughts about that?
PG: I am intrigued by it. I think folks my age are a little intimidated by the technology, but I think it’s crucially important. What my kids can do with a computer in terms of scope and rhythm and efficiency is so far ahead of what I can do. The grandchildren are even better at it.
RW: I agree and I’m glad to hear it. Are there any final thoughts you would like to share before we close?
PG: Well, I think that making the family of origin work relevant is important, without trying to shove it down people’s throats. A long time ago in our work we saw it as essential to not try to sell a particular approach, but to start with where clients are feeling the pinch, where they’re feeling the pain, and to proceed in a way that first and foremost helps them with their symptoms—whether that’s prescribing medication or using cognitive techniques or incorporating family system theory into the work.And then continuing to check back in with them about what makes sense for them because they’re putting in time and putting in money, so they ought to have some say about where our focus is and where we’re trying to take them.
RW: That makes good sense. Thank you so much. I have greatly enjoyed our discussion and appreciate your body of work and your willingness to share this with us now.
PG: Well, thank you for asking me.

Reid Wilson on Strategic Treatment of Anxiety Disorders

Posted on by rezendevknowfully.com

What is Anxiety?

Victor Yalom: So, Reid—good to be here with you. I guess a good place to start would be to define what anxiety is and how you distinguish between normal, healthy anxiety and irrational or counterproductive anxiety?
Reid Wilson: Well, that’s a broad question. We’re programmed to be anxious when we feel threatened—whether it’s an immediate threat or a distal threat—so anxiety disorders break down, in some ways, like that. Someone with panic disorder is threatened by an immediate danger; someone with generalized anxiety disorder tends to worry about things coming far in the future. We define people who have anxiety disorders, loosely, as those who have irrational fears of those kinds of threats.But the body responds impeccably to false messages. That’s part of the trouble of trying to help people get better—so much of the anxiety disorder symptoms have to do with naturally occurring responses to a perceived threat. So in many ways, as we do the treatment, we work against nature for a while until we can bring someone into balance.

VY: Before we get into treatment, let me try and understand that a little better. Anxiety is a natural mechanism to protect us against threats, but when it becomes counterproductive, or when our sensation of anxiety doesn’t match what’s going on in our environment, it becomes a disorder.
RW: Right.
VY: And the range of anxiety disorders is quite diverse, right? You have general anxiety disorder, panic attacks, specific phobias, OCD, PTSD. Is there a commonality among those? Is it useful to think of those together, or are there things that are quite discrete?
RW: I think that the most difficult one to sort out is post-traumatic stress disorder and there’s a tremendous number of researchers who are trying to figure out what the common denominators are within post-traumatic stress disorder. With the other disorders, there is a great deal of commonality. People with anxiety disorders have an intolerance of uncertainty and distress, and much of what we need to address in treatment is about resistance—about all the fighting and pushing away of symptoms that people with anxiety disorders use to stay out of discomfort. It’s not so much that someone’s having uncomfortable symptoms, it’s their response to their symptoms. Their tendency is to go, “This is terrible. I can’t handle this. I need to escape,” and we need to change that response.What varies is the contribution of genetics. Obsessive-compulsive disorder is almost completely genetic, whereas someone with a specific phobia of animals can have little or no genetic influences and be much more influenced by traumatic experiences or environmental factors.

In terms of how people respond, there’s a lot of commonality as well. That’s why part of what I’ve been trying to work on over the years is how to peel away all these innovations and exercises and structures that we use for people with anxiety disorders down to the lowest common denominator.

VY: I’ve seen you work with clients, and this idea about changing their response to their symptoms seems to be a core of your approach, but it’s kind of counterintuitive to clients as well the therapist. Can you say a little bit more about that?
RW: Sure, but it’s not like I have invented a system that hasn’t been around for a while. If we look at what’s been going on with mindfulness approaches to treatment, some of the work that’s been done in Buddhism for a couple of thousand years has to do with stepping back and observing the present moment, not reacting to it personally, and not taking the events to heart, as most people do. Part of what I have been trying explore is how you get people from point A to point B as efficiently as possible.

From Resistance to Detachment

VY: And what’s point A? What’s point B?
RW: Point A is what we’ve been speaking of, which is the resistance, the fighting, the trying to get away—“It’s bad or wrong that I’m experiencing this.” Point B is detachment. When people resist their experience of anxiety or panic, there is a significant amount of psychic energy invested in that resisting. When working with people, I try to respect the degree of energy that’s going into the fight.To expect our clients to move from the intense energy of resistance all the way to detachment is too grand an expectation. That’s why we have a lot of trouble keeping people in treatment, or even having people begin the treatment to start with. When you’re shopping around for help with your anxiety, what you hear is, “You’re going to have to do exposure over a number of weeks or maybe months. You’re going to have to go toward these terribly uncomfortable feelings and sit with them for a length of time, and then you will begin to notice a change.” But people who suffer from anxiety disorders are concerned with the immediate moment. Everything gets very tight for them. Their concern is, “but what do I do right now?” That’s what I want to present to people.

VY: Just so I understand, when you talk about resistance and all the energy that goes into resisting, how would this work with panic disorders? Is it that lot of time and discomfort is about anticipating and fearing the panic attack rather than the panic attack itself?
RW: Certainly. A panic attack, which lasts for 30 seconds—actually that is a relatively long panic attack—is less than .1 percent of the day, but people will focus the entire day on trying to prevent themselves from experiencing another panic attack. Somebody with obsessive-compulsive disorder may only wash their hands for 25 minutes a day, or check the doors and locks and windows for a half hour a day, but when you ask them how long they spend obsessing, they might say, “eight hours.” It’s very consuming psychically. All that bracing is the energy that needs to be redirected toward getting better.
VY: So how do you get from A to B?
RW: I attempt to honor and respect the energy of the resistance and help clients use that energy in a different way. The opposite of being frightened and bracing against a sensation or a pending dangerous experience is to let go. But letting go doesn’t represent a change in the emotional state. I believe we need to maintain the degree of emotion—so the opposite of terror is, to some degree, excitement or desire.In other words, we’re going to move toward that which we fear with a sense of zeal. It really gets crazy. It’s already paradoxical to move toward it and here we’re doubling down. It’s not, “Oh what I need to do is face my fear, therefore I’m going to step into that crowded elevator”; it’s, “I’m seeking out that state that I’ve been afraid of.”

Exposure Plus

VY: So that’s what you mean by “strategic therapy” or “paradoxical therapy”—encouraging people to go towards their fears with a kind of relish?
RW:

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it.

Strategic therapy is messing with patterns. So we’re going to find the pattern, and then mess with it. Telling people to go toward what they fear is exposure, but we’re trying to do exposure plus. Go toward it and change my emotional state to, “I want this feeling. I want this experience.” But we need to be clear about what we are asking people to seek out. People with anxiety disorders have an intolerance of uncertainty and distress, so what they need to seek out is not that crowded elevator, not that battery they perceive is contaminated, but the generic sense of uncertainty and distress.

That’s a really the hard sell for people because it requires them to separate from the content of their worries and invite in more generic uncertainty and distress. And then the frame becomes, “I want to get better. I want to be with my family again. I want to be able to take the job on the 23rd floor. I want to fly to my cousin’s wedding in three months.”

Habituation is a fundamental element of exposure therapy and we know from the research that it takes three variables to get fully habituated and get better: frequency, intensity and duration. So if they want to get better they need to have enough distress, frequently enough and for long enough to make this practice count.

But I want to teach them the most generic way to do this as possible, because what we know is that anxiety disorders run the life cycle. Somebody can finish treatment with us and be doing great and be down to “normal” in terms of anxiety, and then three years later have a whole other brush with either the same disorder or another anxiety disorder. So we want to train people in a protocol that they can brush off again and start using if and when they encounter the disorder again.

The Art of Persuasion

VY: How do you propose this to your clients in the first place, and how do you get them to that state of wanting to go towards their fear?
RW: Persuasively. That’s my job—to find any and every mechanism to help change their mind. So I’m going to work at the level of frame of reference and I’ll use examples of other patients. I’ll use metaphors, I’ll give analogies, I’ll use logic, whatever I can use. I told a woman the other day, “If your son were in fifth grade and had to play the guitar every night, you could imagine him going, ‘Darn, I have to practice now.’ But if he sat down with his high-school cousin who plays in a rock band, and saw how cool it was, this fifth grader would begin to want to practice guitar every night. You can imagine the difference between a fifth grader having to practice for an hour, and a fifth grader wanting to practice for an hour.” That is the kind of shift I’m seeking for my clients and I’ll use these kinds of analogies to help them understand it on a deeper level. Every angle I can find to start loosening up their rigidity and resistance.
VY: We recently filmed you treating two clients for a new video series on Strategic Treatment of Anxiety Disorders that we’re releasing along with this interview, and one thing I noticed about you is you really take charge. You’re very directive. You tell the clients what to do. You tell them what may happen.It’s very different than a lot of therapists are trained. I think whether we’re trained from a more client-centered or psychodynamic point of view, that legacy of therapists being somewhat passive and letting the client lead the way has seeped into so much of our training as therapists. I’m wondering if you’ve observed that therapists have a hard time with taking charge in the way that you do.

RW: I would challenge what you’re saying because, yes, I’m dogmatic and I boss people around and I can be very dominant. On the other hand, I also try to come across one-down in certain situations.

Yes, I’m dogmatic and I boss people around, but I also try to come across one-down in certain situations.

“I’m not sure about what I’m saying right now, but what do you think?” I turn back to them to find out whether they’re starting to understand what I’m saying. I give them a protocol but say, “It’s an experiment. Let’s gather information about it.” There is a balance between coming on very strongly to somebody and, at the same time, accessing a sense of curiosity.

When I train therapists to do this, it’s somewhat intimidating to them and counter to how they have learned to do treatment. But we’re also talking about therapists who come in to get trained because the patients or clients that they see are pretty tough nuts to crack and they need some therapeutic leverage to help people move along. So I think they are also receptive to the ideas.

VY: One client that we see you working with in Exposure Therapy for Phobias, presents with a fear of flying, which, upon exploration with her, you narrow down to claustrophobia—a fear of enclosed spaces and suffocation, not being able to breathe. You do classic exposure therapy with her—which I had heard and read about but never seen in action—where you actually put a nose clip on her, put a pillowcase on her head and wrap that pillowcase with tape. Later you get her to go inside an enclosed box. That requires, first of all, that therapists get out of their cozy chairs and stand up and move around. That’s something that many therapists have no experience doing.
RW: Sure, it’s a big step but people are relatively motivated because we have a certain percentage of people with anxiety disorders that have very rigid belief systems. If you don’t find a way to start cracking that belief system open, it’s very frustrating for you as a therapist.

Chasing the Anxiety Boogeyman

VY: So give us a sense of how this works over time. I get the general principals, but how does it actually play out over sessions?
RW: Well, I work at the level of principles so I am not technique-focused, and that already makes me a little different than other CBT therapists. I don’t start with, “Here’s how you get better.” I start at the level of, “Here’s how I perceive what’s going on now for you. Help me understand. You know yourself—let’s see if we’ve got a match here.”

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves.

Psychoeducation is a big part what I do, particularly around the physiological and neurological aspects of these disorders. I talk about the neurology of fear and what happens with the amygdala when we are scaring ourselves. It’s important for everyone to understand this aspect, which has to do with bringing the amygdala into the threatening situation and letting it just sit there and experience the situation and discover that it’s secreting too much epinephrine. We do that by quieting the prefrontal cortex. We need to stop scaring our amygdalas so that we can be present in the elevator, in the grocery store, with our heart rate accelerated, and discover that it doesn’t need to make me us excited.

A lot of the crazy kind of talking we engage in has to do with refocusing the attention of the prefrontal cortex so that it doesn’t keep continually saying, “Uh oh.” We’re trying to override that message with an executive voice that says, “I can handle this. Let’s go toward this.” So we need that in place.

And then we’re sending people out with experiments to do in which they notice those thoughts popping up or have that sensation in their body that’s been scaring them and then step back enough to go, “It’s happening—it’s okay this is happening,” and then transform it to, “I want this. Give me more.”

My orientation is a set of principles founded on the notion that content is irrelevant. That’s the first step that I need to get across to everyone. Then I personify the anxiety disorder to help them detach from the content of their worries. I’ll say something like, “The anxiety disorder hooks you by picking a topic that is personal to you. That’s how it creates doubt and resistance in you.”

So, for example, if you’re a single mother with three kids and have just lost your job and are not sure how you’re going to pay the rent in two months, that’s very stressful for you and it certainly is going to cause you to worry. But if you develop a sub-routine of worrying throughout the day about it, there’s no redeeming value in that process. So in your case I’ll say, “the anxiety disorder picks the fact that you’re going to have a hard time paying your rent and taking care of your kids. That’s a topic that’s threatening to you as a parent with young children.”

VY: But why do you personify? Why do you say, “it picks?” Do you actually believe that, or is that a tool that’s helpful?
RW: Do I actually believe that? What we’re trying to do is put into language something that’s unconscious, so I believe not so much that as—
VY: There’s no an anxiety boogeyman out there trying to get us, right?
RW: Well, maybe. What I believe is that to perceive it in that manner is therapeutic. It is a way to begin to get a sense of what’s going on. That’s what I want to do—help clients get ownership in comprehending the disorder. What is the nature of the disorder? Why is it running me? In many ways, I’m unconscious of the game that’s being played on me, so I want to bring that up to consciousness.
VY: Alright. So going back to the example of the single mother and her worrying throughout the day, what do you do with that?
RW: First off is to distinguish the content. If I don’t distinguish the content from the process, she’s going to think I’m crazy, because she should be worried. So first we isolate out worries that are signals: “I need to go find another job and I need to go to the government to see if they can help me for this period of time”—these are worries that she actually has a responsibility for and can take some action on, and now is the right time to take action. That would be the definition of a worry that is a signal, and we’re not working on those so much, though we certainly have to problem-solve.
VY: That’s what you would call normal or adaptive anxiety.
RW: Right, exactly. We’re separating that out. We do need to do problem-solving. If I can help you with that, then I’m going to work with you on that too. But on the other side is the worry that is just noise—repetitious, unproductive thinking that causes distress. That’s the content that is irrelevant and that’s what we want to isolate. So we’ve got the circumstances of your life, and then we’ve got how the anxiety disorder has come in and taken hold of that.Another example: If you’re afraid to fly, I’m going to try to teach you interventions to relax on the plane; but if you think the bolts are going to fall off the wings, there’s nothing I’m going to do to help you be comfortable. That would be inappropriate.

If instead we can change the story and get somebody who has a fear of flying to understand that the discomfort they’re feeling is inside them, is their responsibility—it’s not about the pilot or bad mechanics—then perfect. That’s what I want. People come in with a list of 15 things they don’t like about flying, but if they can say, “basically it comes down to feeling out of control,” we’re in business. That’s a theme of all anxiety disorders that we want them to understand.

The second piece is coming to accept their obsessive thoughts. Whether it’s, “when can I pay my bills?” or “was that battery contaminated?” their job is to accept them, to be fine with them. That can seem like a crazy intervention for people because we don’t go the route of reassurance around content. Instead we’re asking them to say: “It’s fine. That thought popped up because I have an anxiety disorder. That’s what we do. We generate thoughts that freak us out. And so instead of freaking out about it, when it shows up, I’m going to accept it.”

In order to get to the place of acceptance, we’re going to play some kooky games, like, “Give me your best shot” and “I’m not worried enough—make me more worried.”

The Anxiety Game

VY: You use the term “games” a lot. What do you mean by games?
RW: Perceiving the disorder as a mental game. Personifying the disorder. When I have an obsessive thought or an anticipatory worry or dread that I know is noise, I want to step back and notice it. That, in itself, is an intervention: “Oh, I’m worrying again. Oh, there’s that thought.” Now the next thing I am asking people to do, if they’re going to play the game vigorously, is to ask the disorder to increase those reactions that they’re having.So, for example, if I’m having a worry about not being able to pay the rent at the end of the month and that’s scaring the bejeezus out of me, I’m going to step back and notice it, acknowledge I’m feeling afraid about it, and request that the anxiety disorder increase my worry: “Please give me another fearful thought. That really scares me, but not quite enough.” So I’m always turning to the disorder and requesting it increase what it just gave me.

Viktor Frankl was the first person to write about paradoxical intention, and how he framed it was: Look for your predominant uncomfortable sensation and ask that sensation to increase.

VY: This is what was referred to as “paradoxical therapy.”
RW: “Paradoxical intention” was what Frankl wrote about in Logotherapy. And I did that for 20 years or so, but about 10 years ago I made a little switch—from asking my heart to beat faster to asking panic disorder to make my heart beat faster.That does an interesting thing which is, “I’m no longer responsible for increasing my heart rate. The panic disorder is responsible for it. I can now turn my attention back to my task of the moment.” Now, when you’re really anxious, you’re not going to get very far away from your fear; your obsession may show up again in eight seconds. But my position is to return to that request—”Please make my heart beat faster.”

VY: It sounds kind of ludicrous.
RW: It’s absurd.
VY: Right.
RW: And that’s what we’re looking for.
VY: And how do clients respond to that, typically?
RW: Well, as long as I have them long enough. If they heard me in a lecture hall, they might walk away shaking their head, but if I have enough time with them, they can see what it’s like. We go through it for a while and, if I can convey it to them well enough and convince them to try it out, in low-grade experiences where they’re not highly threatened, they can experience themselves getting better. Experience is the greatest teacher. That’s why I want to convince them to experiment with it to one degree or another.You really have three choices: Resist, permit or provoke. And I think much of the treatment of anxiety disorders over the last years has been to “permit” symptoms, to “allow” myself to be anxious. Allow things to sit there inside me. Allow the worries to show up. But that’s where people are going to finish the work; it’s not where I think people should begin the work—which is to provoke that which they’re afraid of.

VY: I had the pleasure of getting to know you a bit making these videos with you and I must say you’re a funny guy. When you do these paradoxical interventions, there’s a humorous side to it that fits with your personality. But does that work for everyone? Can therapists who have more sober personalities find a way to play with this?
RW: I don’t know how much humor is required in these protocols, but it’s a resource that I have and we use what we have. The most important thing, I think, is the resource of making contact and getting rapport with people and you can do that from the very beginning; and then it’s trying to access curiosity. I don’t think you have to have humor in order to authentically invest in being curious about, “What will this do for you if you try this out?” You know, I do talk about principles, but this is psychotherapy and it takes some finesse to help someone. I think people who have a lot of training in psychotherapy know how to do some of that stuff.
VY: I know it’s very hard to make generalities in therapy, but do you have a typical length of treatment for certain types of disorders?
RW: We typically have a 12-session intervention for people with panic disorder but we’ve got new data published that they’ve brought it down to five sessions. If we can unbundle what we’ve been doing and go to that lowest common denominator for intervention, we can shorten things up. It takes longer with Axis II disorders because those are woven into the fabric of the personality, so even though we can create a protocol, and they can use that protocol, it may take months for them to finish off that work for themselves, versus somebody with panic disorder who, in a very brief period of time, can be up like a phoenix.The interesting research that’s being done now is on ultra-brief treatment of panic disorder—even of post traumatic stress disorder—where they have been able to put a protocol in place successfully in five sessions with somebody with PTSD, which seems pretty remarkable to me.

VY: But many therapists, whether they’re in private practice or some kind of agency or other setting, tend to see clients that are a mixed bag. They come in for relationship problems or work issues or some anxiety and depression and, whether they’re Axis II or just have general life problems, their anxiety disorder is only a part of the clinical picture. How do you use these techniques within the context of a longer-term therapy?
RW: When I do presentations for therapists who are treating clients with anxiety disorders—whether they have other comorbid disorders or not—I try to get them to think about how they can structure their sessions in such a way that clients leave each session looking for an opportunity to experience some degree of uncertainty and distress regarding the themes of their anxiety.That’s a pretty simple protocol for the therapist. It doesn’t take a rocket scientist to figure out how to do this work—look at me. It’s a difficult treatment, but it’s not a complex treatment

VY: What makes it difficult for therapists? What’s hard to learn about this?
RW: It’s difficult because you’re looking at somebody who’s been entrenched in their way of solving the problem for a long time. You’ve got a client who does not tolerate not knowing how things are going to turn out. You’ve got a client who, as they try to experiment with something you’re suggesting, must trust you and trust the protocol without knowing how it’s going to turn out.That is the difficulty, because the disorder doesn’t allow them to feel confident. And if you listen to clients when you talk to them as they’re intently trying to learn what you have to give to them, they’re looking for security in what you offer them. “I’ll be glad to do what you tell me to do as long as you’ll give me a 100 percent guarantee I’ll have zero symptoms ever again.” And that’s not going to work. Einstein said: ““You cannot solve a problem from the same consciousness that created it. You must learn to see the world anew.” That’s the thread that runs through all of the treatment.

VY: I would imagine it’s also hard for therapists because they’re natural caretakers, they’re empathic, they want their clients to feel better…
RW: We do have this tendency in our field to keep rapport and be gentle, to not get people too upset. I think a lot of people gravitate to the treatment of anxiety disorders because they have an affinity to that arena. They know what it’s like to be anxious, they may have anxiety problems themselves, they’ve figured out some techniques and want to help others with it. But this is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

This is a contact sport. It’s aggressive. It works better when you’ve got a therapist who is already a risk taker.

It’s like the primary care physician who’s trying to help you decelerate from a benzodiazepine that you’re dependent on. When they’re really kind and gentle with you, it sometimes takes forever to get off of them. When they’re a little tougher with you and push, then sometimes it works out better for you.

VY: So you need to be comfortable pushing a client into discomfort.
RW: That’s right.

The Meaning of Anxiety

VY: Existentialists such as Rollo May, who wrote the classic text, The Meaning of Anxiety, and other existentially-oriented psychotherapists would and have argued that there’s meaning in anxiety and we can learn about ourselves, about life, have insight, by delving into it—that it’s not something that should be brushed aside. Do you think that there’s meaning in anxiety?
RW: Well it’s fine to look at it that way, and on an individual-to-individual basis you may have to delve into that. But it does not mean that someone has to continue to express their anxiety in such a primitive fashion. People with panic disorder are expressing conflict very primitively. I certainly believe with panic disorder—and I’ve written about this—that there are benevolent purposes of the symptoms. And to look at those and understand those are helpful, but once we understand them, let’s negotiate another way to get those needs met.
VY: What are the benevolent purposes of the symptoms of panic disorder?
RW: It’s often to keep from being abandoned. There’s some data that a certain percentage of people with panic disorder suffered early childhood loss. Let’s say my father died when I was four, and my mother got severely depressed and laid on the couch every day. There are a lot of ways that I would have learned to cope as a child with that kind of loss. As I grow up, that stuff, existentially, kind of becomes who I am in the world. If my mother turns away from me because my dad left or my father left and never talked to me about why he left, I begin to think that I am not worthy as a human being. What parent, who loves his child, would abandon his child? There must be something inherently wrong with me. Some people with panic disorder use it unconsciously to maintain relationships so that their partner, their parent, whoever, won’t abandon them. That’s a benevolent purpose.
VY: So there’s secondary gain in that.
RW: That’s kind of a derogatory term, but it’s something like that. If we can step back and look at how the unconscious might have stepped in to take care of me, based on my belief about who I am from long ago, then there is a benevolent purpose behind why it showed up.I had a patient who came to me with OCD. She had two children with a workaholic physician who didn’t help with the kids at all. Her biological clock was ticking. She wanted to have another baby, but was concerned about her ability to take care of three kids instead of two. One day, she saw her son chasing her daughter with a kitchen knife and instantly she developed obsessive-compulsive disorder. She couldn’t stop thinking, “Oh my God. Could I hurt someone with a kitchen knife?” She had to get rid of all the knives in the house, everything sharp, all the scissors; no children could come over and be in her home for fear she would harm them. And of course, she was then too sick to have another baby.

So that’s another example of a benevolent purpose of the disorder. I think we do want to look around for some of those things and begin to take care of those, too. If the unconscious is driving some of this stuff that we aren’t aware of, then we’re going to have trouble helping people get better. The other definition of “strategic treatment” is doing whatever is necessary to help somebody get better. So if we need to do some family therapy or psychodynamic work or couples work or Sullivanian work—whatever it takes to help them turn the corner.

VY: It’s nice that there are cognitive-behaviorists who acknowledge unconscious psychodynamics. You’re very integrated. It seems like you really strive to hone in on what works.
RW: I hope that’s true. We just got some new data that suggest that that can help people more rapidly change their relationship with the disorder. We just did a study of people with obsessive-compulsive disorder going through this protocol, 80 people at a time, for two days. And the changes that took place were pretty remarkable, in terms of the measurements of the reduction of their obsessive-compulsive disorder and in altering their beliefs.If you just think about OCD being one standard deviation beyond the mean, where people get so totally caught up in obsessions and rigid belief systems, it’s quite amazing that we can bring about lasting change after only a few days.

Getting to “Aha”

Some folks have done some interesting research on what we called “applied relaxation,” which is learning relaxation skills and applying them to a variety of situations. In six sessions of an hour and a half each, then another six sessions of 45 minutes each, with practice homework throughout that time period, the major thing that these people changed after all this work was their beliefs.

If that’s true, then

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.”

I think we should be leading with belief change instead of leading with interventions that require a great deal of time to give someone insight and then for them to go, “Aha.” That’s how exposure and response prevention happens. We’re going to run them through this protocol until weeks or months later they go, “Oh, I see now. I don’t have to do my compulsion to get rid of my obsession.” Can we speed that up? I think we can.

VY: Final question. What advice would you give for students or early career therapists treating this population? Any pearls of wisdom?
RW: Look for any way to sit in on someone doing treatment with someone using these kinds of protocols. See how this works. That’s part of our motivation to get these anxiety disorder videos out there, so that people can immerse themselves moment-by-moment in this protocol. Whenever I do a workshop to teach these skills for therapists, it would be totally and completely fine for clients to be sitting in on the workshop as well because they can understand it just as easily.When I was in training and working with couples or borderline personalities for the first time, I’d go into supervision and say, “Okay. She said this. Now what do I say?” And he would help me figure that out. And then I would say, “Yeah but what if she responds like this? Then what do I say?” It can be daunting if you’ve not done this and observed it directly.

VY: Well I have always felt that we are a strange profession. You wouldn’t have dental students read about doing a filling and then send them off to do it without watching someone and then come back a week later to meet with a supervisor in a closed room and try to recall how they did their fillings. In fact, that was one of the reasons I started making training videos in the first place.I’m grateful that you consented to have your sessions recorded and I’m excited to release them and make them available for people who want to learn about the innovative approaches that you developed. So thank you so much for taking the time to go into this level of detail.

RW: Well, thank you as well for giving me the opportunity.