Category: Existential-Humanistic

The Challenge of Retirement: Finding Meaning and Self-Esteem in New Ways

Posted on by Psychotherapy.net Team

The Ground Shifts

I retired twice, almost 20 years apart. The first time was the hardest. For almost a year, I missed everything and everybody who was part of my professional world, including the cleaning lady and the postman with whom I had daily chats. Because so much of my identity was tied up with my professional role as a psychologist, I felt totally lost when I left my university position as director of the counseling center. The phone seldom rang, no one seemed to need me, and I was left with a huge hole in my self-esteem. Traveling, while fascinating and worthwhile, couldn’t supply what was missing.

Fortunately, after nearly a year of feeling like I was wandering alone in a desert, I got a phone call from the university asking me to serve as acting dean of students for a year while they conducted a national search for a permanent dean. I accepted gladly and without hesitation. And the following year went by quickly with many challenges and accomplishments. I loved the job! It represented a perfect blend of clinical skill in dealing with students, professors, and college deans, and academic know-how, that is, how to navigate the academic environment.

But the year ended, and I was plunged into retirement once again. This time, however, I was much better prepared. I decided to expand my very small private practice, seeing individuals and couples, and began a twenty-year career working solo in a downtown office in Chicago. Once again, life was fulfilling, but as I began the decade of my 80s, some minor physical difficulties made a second retirement seem wise.

After this second retirement, I began asking myself what I had learned after more than 50 years of clinical practice. I had worked with different ages, races, cultures, sexual orientations, socioeconomic levels, and professions. In the mix of clients over the years were a 9-year-old pickpocket with a wide, girlish grin that lit up her face; a slew of lawyers, a number of whom were suicidal; a circuit court judge with family problems; a few physicians trying to resolve their romantic lives; a beautiful, light-skinned, African-American model who was rejected by her family for not having dark enough skin; a 15-year-old boy who accidentally shot and killed his brother; alcoholics of all kinds, and a politician running for statewide office whose wife accused him of domestic abuse. While such differences in descriptive trappings may seem profound, what stood out for me were their common ingredients.

Among the settings I worked in were mental health clinics, psychiatric hospitals, a home for delinquent girls, medical schools, private practice, and universities. In these diverse places, I performed many different functions, such as teaching, administering tests, directing programs, supervising students, and counseling individuals as well as couples. I worked on the East Coast and the Midwest; in small towns, medium-sized ones, and big cities; in small clinics as well as giant hospitals that stretched over many miles. In all these varied worlds, no matter the differences in local culture, skin color, tattoos, and garments, I found that people are more alike than different.

Besides the obvious physical similarities, I, along with many others, have realized that basically all of us have the same kind of needs, fears, defensive strategies, hopes, and dreams. Over the years, this became clear across all the varied roles I played, whether with administrators, students, colleagues, students, or clients. While everyone has a different viewing lens for perceiving the world that is shaped by unique biological, familial and cultural factors, we are fundamentally the same. We all want to be loved, appreciated, and understood. We want to matter to our friends and family and be special in some way to all those with whom we come in contact. We want to be self-sufficient and competent. We want space and time to be autonomous in pursuit of our own dreams. We want to belong to a group, neighborhood, church/synagogue/mosque, or community—a place of welcome and acknowledgment. All of us want to feel safe in the neighborhoods in which we live and to be reasonably stress-free. We also want some challenge in our lives, that is, some novelty to reduce the boredom of ordinary days. And we want to feel good about ourselves; we want to walk around with our heads held high and a liveliness in our steps.

People everywhere are afraid of the same kinds of things. We are afraid of being assaulted, either physically or verbally. Because both physical and psychological dangers are threatening (one to our lives and the other to our identity), both kinds of peril create fear, tension, and anxiety. Contrary to the old childhood rhyme we used to chant, “Sticks and stones may break my bones, but names will never hurt me,” names, especially the insulting ones, do hurt a lot. So do betrayal, bullying, humiliation, manipulation, and rejection, all of which bruise our fragile sense of self.

We are also afraid of having our inadequacies and our failings brought to light. When we are teased, taunted, or made fun of, our imperfections are made visible for all the world to see. We feel exposed as inadequate in some way and feel vulnerable; we are not as strong, smart or “in control” as we would like. Because vulnerability is scary and psychological assaults hurt, people develop fears about these threats and build self-protective mechanisms to feel safe.

Trying to be safe, we may hide in our rooms or in our heads, lie to ourselves or others, counterattack in person the assaulters or assail their carbon copies, keep others at a distance by obnoxious behavior, or pretend we are very talented, wise, good-looking, or famous. The hiding can be literal, as when a teenager spends all her free time in her room, or symbolic, as when a doctor, lawyer, or engineer keeps his personal self out of sight and remains ensconced in his professional role. Rather than acknowledge hopes, dreams, failings, and inadequacies to close friends and family, the professional recluse relies primarily on his work-related skills to navigate erratically the world of intimacy and relationships. In this manner, he hides from his vulnerability and winds up feeling safe and in control.

Hiding in our heads is a way of viewing the world from a vantage point above the fray. We can think all kinds of negative thoughts there, and nobody is the wiser. In this space in our heads, we are safe from counterattacks and free to be ourselves. Intellectuals, writers, academicians, and other creative souls are often in this group because thinking feels a lot safer to them than feeling. Emotions are often intense, chaotic, and unpredictable, whereas thoughts tend to be logical and manageable.

Other ways of hiding include addiction to computer games. There, ensconced in technology, we avoid the unpredictable world of people by focusing on dragon-slaying and war games. In that way, we maintain a pseudo-connection to others through computer identities that do not risk much vulnerability and yet satisfy our desires to be winning and in control. Addictions of all kinds are reliable hiding places, which often last until physical dysfunction appears on the scene.

Other protective strategies include power-hungry maneuvers such as boasting, bellicose rants, and dictatorial strategies. Braggarts fill the conversational air with their accomplishments in hope that no one will notice how empty they feel. Similarly, the bully and the dictator try to convince their worlds that they are powerful when, underneath it all, they feel helpless and insignificant. Angry, belligerent people who are adept at keeping people away are more comfortable with solitude because closeness to others is fraught with emotional danger. Being betrayed, criticized, disappointed, insulted, and/or rejected are just a few of the perils they try to avoid.

While all the preceding observations have been underscored many times in my clinical and personal worlds and written about elsewhere, several new insights have emerged from my experience, some of which are counter-intuitive. Some are different from those in the psychological literature, and others run counter to the prevailing culture in the US. Since I love to write, I decided to write a book of essays that focused on my clinical experiences and the new understandings gleaned thereof.

Positive Thinking

One of these new insights contradicts the American culture’s focus on the power of positive thinking. In contrast to this popular notion, I think it is safe to say that positive thinking is not always helpful. Platitudes (trite remarks used too often to be interesting or thoughtful) and happy talk do not prepare us for disasters lying just ahead. Every cloud does not have a silver lining, nor is there a pot of gold at the end of every rainbow!

Because the world is filled with all sorts of unhappy events, from disappointments and failures to losses, thinking only positive thoughts is delusional. Trying to maintain a happy face while tragedy engulfs us is unnatural, akin to trying to laugh when our hearts are breaking. Like Pagliacci, the clown who was intent on making others laugh while tears streamed down his cheeks, we shortchange ourselves when we fail to deal with negative events and emotions. For many patients who do not process their negative feelings at the time of a disturbing event, the failure to deal with these emotions may, and often does, lead to symptoms such as anxiety and/or depression. In addition, when positive thinking bypasses the processing of negative events, it can limit problem solving and result in impaired judgment about courses of action.

I have found that whenever there is heartbreak, no matter where it is coming from, the best way of getting through it for most of us is by acknowledging the sadness, disappointment, humiliation, or anger, and then working through it. In a healthy person, the processing of negative feelings goes through phases, much like the waves of emotion that accompany grief, until there is a personal resolution that uniquely fits the person. The problem arises when people get stuck in negativity and can’t move beyond it, which is where positive thinking and therapeutic strategies may prove useful.

Direct Expression of Anger

Another psychological reality that is infrequently articulated in the psychological and popular literature was dramatically conveyed in a few words by a patient. It jarred me when I first heard it. After weeks of catatonic behavior followed by a psychiatric hospitalization, a 40-year-old man intoned, “Madness is better than sadness” as his first words upon recovering. When he was asked what he meant, he responded, “When you’re mad, you can do something, but when you’re sad you can’t do anything at all.”

At this time in our culture when violence permeates the American scene in so many ways—there is video violence, domestic violence, street violence, school violence, and workplace violence—it is difficult to see how madness can be better than sadness. However, what the patient was communicating clearly was that anger is energizing and leads to action, while sadness is immobilizing and induces helplessness. Most of us would prefer to feel alive, in charge of our lives, and full of options, rather than depleted, stuck, and without possibilities. Discerning when and where the direct expression of anger is adaptive and when it is destructive would be beneficial to all of us.

Romantic Love

Another cultural misdirection is our obsession with romantic love. Via scores of dating sites flourishing on the Internet, we run blindly toward the Promised Land of Eternal Love. We buy romantic novels, read manuals devoted to orgasmic ecstasy, and watch sophomoric movies filled with hormone-saturated teenagers groping their way to fulfillment. And yet, all this cultural energy devoted to its arousal and maintenance does not alter the reality that romantic love (sexual feelings and emotional closeness) is ephemeral. Because it is fueled primarily by fantasy, novelty, and emotional arousal at the time it develops, romantic love is almost impossible to sustain. Unless it is replaced by a quieter respect, admiration, affection, or commitment (or has some of those ingredients to start with), romantic love quickly dies, fading away in the light of reality.

Vulnerability

Another idea that has emerged for me over the years is that vulnerable people are easier to relate to than assertive, self-confident ones. Vulnerability is an openness about feelings, successes, failures, strengths, inadequacies as well as hopes and dreams. While our society imbues self-confidence with high status and desirability, and the trait is clearly invaluable, vulnerability is more appealing and more likely to foster intimacy. Vulnerable people are more readily trusted (we know where they’re coming from), nonthreatening, and likable, whereas super-confident individuals earn our respect and admiration. We look up to confident people (they are our role models), but we are less likely to regard them as good friends.

Control

Other new counter-cultural understandings gained over the years include the following: One can’t control reasonably healthy people against their will without their feeling resentful. While punishment and torture work to some degree, they tend to create long-term resentment that manifests itself in sabotage and/or other passive-aggressive tactics. In addition, all of us possess a degree of autonomy that can’t be manipulated under any circumstance.

This powerful realization came from a testing case where I was to administer a battery of tests to a 15-year-old who had accidentally shot and killed his brother. As soon as the young man walked into the testing room, it was obvious that he was in no mood to be evaluated. He sat on the floor with his arms folded across his chest and refused to answer any of my questions. I tried everything I knew to reduce his defensiveness, but nothing worked. So after about 45 minutes, I gave up and started to pack up my testing paraphernalia, saying, “It is clear that I can’t make you talk to me,” as I stood up to leave. At this point, he asked, “What do you want to know?” and became fully cooperative with the evaluation. What changed his mind? Apparently it was his realization that he was in control of cooperating and that I couldn’t make him do anything.

Luck or Chance

Luck or chance have been badly underrated. And yet much of life (genes, parents, family, schoolmates, friends, teachers, roommates, romantic partners, jobs) is a function of timing and chance. Hard work and talent play significant roles in our achievements, but luck or chance is at least as important, if not more so at times. Whether or not we get accepted into our preferred college, get the dream job we always wanted, or win a particular sports event is dramatically affected by the other competitors and the biases of the decision-makers in that situation. Unless we accept that reality, we are likely to take too much credit for our accomplishments and too much blame for our failures, leading either to false pride or undeserved self-depreciation.

Other Insights

Other insights I have had over the years include the idea that healthy narcissism is quite different from the pathological variety. Healthy narcissism embellishes personal achievements with delight and enhances lovability with charm. It provides the joie de vivre—the joy of living—that adds just the right amount of zest to ordinary life. And finally, empathy, the most important of the relationship skills, enables us to relate to others with care and compassion, providing self-esteem enhancement that is deep and durable. It helps us develop friendships and maintain romantic relationships over the long haul.

In all, I am far wiser than I was when I began this journey of enlightenment, although it didn’t begin as such.

An Existential-Spiritual Journey During COVID-19

Posted on by Psychotherapy.net Team

A Place of Uncertainty

As we approach the second anniversary of the first detection of COVID-19, we are no longer in the acute stages of the pandemic. However, neither do we find ourselves squarely in a post-pandemic world, as new variants continue to evolve and spread rapidly, sparking fear and halting daily life. A heightened sense of self-doubt, vulnerability, and anxiety can occur in this “limbo-like” state, particularly for clients experiencing life-threatening medical conditions. Feeling threatened for prolonged periods may increase both the client’s and therapist’s need for certainty and diminish our ability to tolerate ambiguity. In the case of COVID-19, when safety and normalcy are in question, life’s uncertainties may be harder to endure.

Existential approaches are particularly well-suited for addressing concerns provoked by the COVID-19 pandemic such as encountering the fragility of life and the unpredictable nature of events, as well as uncertainty about when (or if) the pandemic will end. For Yalom, the aim of psychotherapy is to help clients fully experience and accept the existential anxieties associated with the “givens of existence,” including death, isolation, freedom, and meaninglessness. As a result of facing death, individuals may experience a sense of urgency to revise life priorities that can lead to improved meaning.

Existential therapists generally suggest that anxiety and existential guilt need to be experienced in an open and honest manner and, when directly encountered, can become a source of vitality, creativity, and purpose. Rollo May and Paul Tillich believed that courage and determination are fostered when anxiety, adversity, and life’s dilemmas are faced. In other words, when we accept our limitations, we also commit ourselves to living fully.

Victor Frankl’s recent series of posthumously published papers does this by shifting emphasis away from the question of “What can one expect from life?” to “What does life expect from us?” Thus, he suggests that it is life itself that asks questions about meaning. While we may feel challenged and forced to face discomfort when we ask ourselves what life expects from us, French philosopher Gabriel Marcel posited that such pain and suffering offer the only pathway to real insight and spiritual growth. Perhaps through these challenging questions that place uncertainty, obstacles, and suffering before us, we discover our meaning and purpose.

Clinical Vignette

The clinical vignette presented below highlights the challenges of how a therapist-client dyad worked through their mutual feelings of “not knowing” and uncertainty by processing their own existential anxieties and fears. A series of dreams of the client and therapist, as well as the use of creativity as a spiritual intervention, are described to demonstrate the complexity, practicality, and depth of the existential approach. In particular, the vignette highlights how dream interpretation can be used in enhancing problem-solving and conflict resolution, mastering trauma, exploring unknown possibilities and paths not chosen in life, wish fulfillment, compensation, communication with the therapist, and integration of self.

Initial Phase: An Exploration of Death and Social Anxiety in the Context of COVID-19

Steven is a 63-year-old man who presented for individual psychotherapy approximately six months after the resection of a non-malignant brain tumor. He experienced one generalized tonic-clonic seizure immediately after his tumor resection, which had a significant impact on his social and emotional functioning.

In terms of constitution, Steven had always been shy and sensitive. He had maintained a group of close friends since high school. Although he never married, he had had two long-term relationships since graduating from college. At the time of his surgery, he had been retired for two years from his career as a special education teacher and had reportedly been adjusting well to his life transition. Steven valued his level of independence, intellectual curiosity, and work ethic. His numerous interests included photography, hiking, reading history, and political activism. After the onset of his neurological condition, however, he became quite withdrawn and fearful about leaving his apartment. Although his seizures were well controlled with medication, the onset of his condition and the implied risks amplified his social anxieties and fear of death. Whenever he did leave his apartment, he felt self-conscious about his word-finding difficulty and occasional stutter, which exacerbated his fear of being ridiculed and shamed. After experiencing months of social isolation and increasing depression, he reached out for therapy at the encouragement of his physician and close friends. He hoped to regain self-confidence, be able to connect with old friends, and resume his recreational interests.

Steven’s comments about his own mortality were interspersed throughout the early sessions and were delivered in an intellectualized and affectively neutral manner. He recalled his experience of waking up from surgery and having a seizure in a vivid but emotionally detached manner, leaving me feeling highly anxious. I felt that he would have been frightened and overwhelmed if this had happened to him. These sessions felt more as if Steven was reporting about his life, rather than experiencing his life.

Given the news of the spread of COVID-19 in New York City during his third month of therapy, Steven agreed to continue sessions via telehealth. On top of the feelings of death and social anxiety and uncertainty secondary to his brain tumor and seizures, he felt the virus was exacerbating his lack of control over his life. Steven had a mindset that his medical condition and COVID were unsolvable problems leaving him trapped in his apartment with no escape.

In the first few telehealth sessions, there was a noticeable shift in Steven’s mood, focus, and communication style. Where previously he would speak at length about his negative interactions with the public in the local supermarket or in the elevator of his building in a detached fashion, his conversation in the context of the pandemic became more emotionally laden, his mood palpably more depressed, and his focus turned inward. While he had already worked through diminished control over his health and restrictions imposed by his physician and medications, COVID-19 surfaced additional fears of brain cancer and not being able to get help if he were to have another seizure.

The threat of COVID-19 increased the reality of his mortality due to his medical condition, and he could no longer speak about it indifferently. Instead, this emotional intensity filled the content of his thoughts and treatment sessions such that he grew more removed from the people and activities that had filled his time with meaning, purpose, and pleasure before his brain tumor. His increased level of avoidance, which had started after his surgery and was exacerbated by COVID-19, further impacted his sense of identity and agency in the world. For instance, Steven expressed that he was afraid of dying alone and nobody finding him. He did not have any religious affiliation but felt that he was a spiritual person when walking in nature or helping others who were vulnerable.

In the second month of treatment, Steven had reported a dream where he “was traversing over a deep canyon. As [he] cautiously walked across a wide rope with railings, it swayed back and forth. [He] saw a dark, shiny mountain across the cavern, but the rope was not attached to the mountain. [He] was unable to look down and felt paralyzed to take an additional step forward. [He] tried to scream out for help, but no words came out.” He woke up sweating and frightened. In session, Steven was asked to tell the dream in the present tense to promote a sense of presence and agency. When asked about the predominant feelings he had in the dream, Steven responded that he was overwhelmed with the anxiety of and fear of falling into the cavern that had no bottom. When asked how he would want the dream to end, he responded by wanting the rope to continue to the mountain so that he could feel safe with his feet firmly on the ground.

During the next few months of therapy, questions that had been previously effective with helping other clients with medical conditions and high levels of anxiety to gain a sense of meaning or agency (e.g., “What are some things that you can control now?” “What are your feelings of fear and anxiety trying to teach you?” and “What do you feel most passionate about in your life?”) were dismissed as unhelpful. Steven emphatically stated that he needed definitive answers to the questions that preoccupied his entire day, such as “Will my tumor grow back and become cancerous?” “If I exert myself through exercise or go to social events with my friends, will I get COVID or a seizure and die?” and “Is the government deliberately giving us misinformation regarding COVID-19?” I felt increasingly anxious and was unable to give a clear answer to any of these questions. As Steven’s therapist, my own experience of “not knowing” was overwhelming, since we were both experiencing our own feelings of anxiety, fear, and uncertainty about getting or spreading the virus. Steven tended to repetitively ask questions with no clear answers and would spend hours searching through social media sites for elucidation. Over time, he noted that the therapy was not helpful, even indicating that he felt more frustrated and withdrawn in both his sessions and his personal life.

Middle Phase: A Shift in the Therapist’s Approach

After consulting with several colleagues, I decided to focus on active listening, patience, tolerating silence, and providing space for Steven to find the words for his feelings. The decision to shift my therapeutic style with Steven was motivated in part by my experience of feeling alone in the room and that my words were not being heard; any interpretations or interventions offered were readily dismissed, as though batted away with a tennis racket. My reactions were further complicated by the difficulty of picking up nonverbal cues on the Zoom telecommunication platform. Ultimately, my countertransference reactions yielded a deeper appreciation for Steven’s emotional life, including his profound sense of isolation, powerlessness, and feeling invisible in the world. I was then able to provide Steven with titrated reflections of this loneliness and helplessness, contextualized within the uncertainty of the pandemic and his medical condition.

Shortly after I shared this particular self-disclosure and processed his reactions, I experienced a dream where “I was dragging a dead body of a man in a trash bag down a busy avenue in Manhattan. The bag was heavy, and it took a great effort to pull the bag toward Macy’s on 34th Street. I struggled to pull the bag toward the holiday window at Macy’s when the dream ended.” I understood the dream to be an indication that I was trying too hard and doing too much of the therapeutic work, and that Steven needed to take more responsibility and ownership of the course of the treatment. I also wondered about the meaning of the Macy’s holiday window scenes of families celebrating together, children playing, and religious scenes, and whether some creativity or spirituality needed to be part of the therapy in order to bring Steven to live more fully again.

This internal shift in my perspective led to a new phase in treatment where Steven was able to gradually mourn his loss of identity, direction, and purpose in life related to his medical condition and COVID-19. We began to explore his regrets in life. Steven was able to recall that he had always wanted to be a professional photographer but had not had the confidence to pursue this wish. He had always wanted to have children but felt that his career in special education partially fulfilled this desire. Shortly after, Steven recalled a dream where “[he] was in his parent’s country house in [his] room looking at a wall of his photographs from one of [his] high school classes. [He] noticed the subtleties of lightness and darkness in the scenes of Manhattan and started to experience a sense of pride and accomplishment. At that moment, [he] overheard [his] parents and other relatives laughing in another room, and [he] felt a sense of humiliation and shame that they were making fun of [his] photographs.” He awoke feeling a sense of hope about his creative abilities and a sense that he now had the time to act on it. He also felt that he did not trust his desires when he was younger and was more concerned about what others would say about his artistic ability. When asked of his associations to the dream, Steven mentioned that the night before he had watched a film of someone who spent years walking every street in the five boroughs of New York. Steven regretfully said that he wished he had the courage and confidence to pursue his deeply-buried artistic dreams.

Working Though Phase: The Use of Creativity as a Spiritual Intervention

After a period of medical improvement, including being seizure-free, Steven started going out of his apartment a few days a week to take black and white photographs in Central Park. During the early morning hours, he experienced a sense of awe, wonder, and adventure in not knowing where his walks would lead in the park. He took black and white pictures of statues, lights filtering through leaves on the trees, animals resting in the zoo, and a formation of geese flying over a pond. Steven experienced a greater sense of freedom, calm, and centeredness during these occasions. His rediscovered artistic passions, which resulted in increased flexibility and confidence in taking risks in other aspects of his life, including contacting friends and colleagues with whom he had lost contact. These photographs activated something on a deeper level in Steven and enabled sharing these photographs with his older friends. He initiated contact with his former school and volunteered to teach photography in a small group setting, which provided a sense of purpose and direction in life.

As Steven’s level of anxiety and medical symptoms improved, he was able to shift his focus from internal preoccupations with not knowing what his future would be like to existential concepts of meaning, values, and priorities. He thought more about his future, making peace with external things that he did not have control over. Steven shifted his position from the passenger seat to taking a more active approach in life. He became curious about how he wanted to lead his life and pursue his social and recreational interests. I facilitated this process by open-ended questions, such as “What has sustained you in dealing with your medical issues?” “Where do you think you found your strength?” and “If you were to imagine your life one year from now, looking back on how you dealt with your medical recovery, what would you think about how you handled things?” In addition, I asked, “If you had not had your neurological condition, would you be dealing with the pandemic any differently (and vice versa)?”

Steven realized that when he began treatment he had been feeling sorry for himself and angry at the unfairness and injustice of having a medical condition after being a good person who devoted his life to helping others. He realized that he was fearful of taking risks and failing, and that he had more to give to others despite his limitations. Steven acknowledged the importance of his friendships and of continuing to develop his personal values and traits. He gradually came to realize his own power to choose how he wanted to view and respond to life’s major challenges. Furthermore, he started to become aware of ways in which his medical condition had made him stronger, including being able to face his mortality and tolerating not knowing and uncertainty. He was eventually able to acknowledge that his courage, determination, and creativity enabled him to cope with his multiple challenges and that he had more to live for.

Concluding Thoughts

Existential approaches are uniquely suited to address prominent themes in the COVID-19 pandemic, including anxiety surrounding death, uncertainty, isolation, and vulnerability. Existential therapy provides an important opportunity for clients and their therapists together to face these challenges and discover meaning throughout. Through the process, they are able to live life with greater intention, purpose, self-reflection, and presence, to accept and learn from feelings of not knowing, uncertainty, and anxiety, and to value the benefits of choosing one’s attitude toward adversity.

This case vignette highlights the benefits for both the client and therapist in experiencing, accepting, and learning from feelings of uncertainty. Asking open-ended questions about Steven’s dreams, values, attitudes, and meaning in life enabled him to be more curious and flexible. Incorporating creativity as a spiritual intervention provided an opportunity for a heightened degree of engagement, self-reflection, intensity, hope, and passion. In a parallel manner, my therapeutic shift to slowing down the pace and focusing on the process, tolerating moments of silence, utilizing countertransference reactions, and reflecting on his and my own dreams enabled me to let go of the need to appear as an expert with all of the answers and be more of a “fellow traveler.”

There are moments when clients need their therapists to feel the depths of their powerlessness, loss, vulnerability, and despair in order to find and describe their feelings and to feel understood and emotionally held. There are healing moments when the most important gift that we bring to another person is the silence within us, the kind that is a source of peace, acceptance, and allows the transitional space to be.

Russell Siler Jones on Spiritually Integrated Psychotherapy

Posted on by rezendevknowfully.com

The Inevitability of Spirituality

Lawrence Rubin: Thanks for chatting with me today, Russell. I was initially going to begin by asking you to define spiritually integrated psychotherapy, but perhaps we can work towards that. Instead, I am curious as to why you think there’s been such resistance to integrating spirituality and religion into psychotherapy?
Russell Siler Jones: Thank you for having me, Lawrence, and we could think and talk all day just on that first question. But here’s a first thought, anyway, from a historical and developmental perspective. Psychotherapy is as old as humankind. Conversations to help people feel better have been happening for as long as we’ve been on the planet. And for centuries, many of these conversations happened in religious and spiritual contexts. The field of psychotherapy as we know it, as a professional discipline, is, what, 130 years old? That’s old for people, but against the backdrop of centuries, we’re still pretty young. But when psychotherapy came out of the gates in the late 19th and early 20th century, it had to differentiate itself from the healing conversations that had come before, to legitimate itself.
LR: To scientize itself.
RJ:  Yes, to scientize itself. And so, psychotherapy claimed a position for itself inside a scientific frame—although that has always been a debatable point, to what extent psychiatry and psychotherapy really know what it is they’re doing—and the psychotherapy movement positioned religion and spirituality on the outside of this “scientific” frame.

Then, in the last 30 years or so,
since mindfulness has entered the heart of most therapy practices, we see the field of psychotherapy reaching for help from the spiritual tradition
since mindfulness has entered the heart of most therapy practices, we see the field of psychotherapy reaching for help from the spiritual tradition. Not reaching for all the explicit trappings of the spiritual traditions but reaching for this core element of the spiritual tradition, which is the practice of consciousness and the understanding that to live well, you’ve got to wake up. You can’t sleepwalk your way through this life and do it well. There’s a gravitational pull to being asleep, but living well means that we’ve got to wake up. So, I think the field of psychotherapy reached out and grabbed that “wake-up” practice, which is part of almost every spiritual tradition I know of, and under the banner of mindfulness, has now made it a centerpiece.

There’s way more we could say about psychotherapy’s historical relationship to spirituality and religion. But I also think it’s important to add that it’s not just the field of psychotherapy that’s been resistant to spirituality. It’s people in general that are resistant to it. I know spirituality is appealing, and has all these benefits, and a majority of people say they value it. But many of the things spirituality asks us to do are actually quite challenging. Look inside yourself. Elevate yourself. What is it that you deeply know? What is wisdom calling you to do in this moment that might be difficult to do? Can you pick your head up out of your own self-absorption and let something larger than you be factored in? I think this is hard to do in psychotherapy or in any other context. And even though surveys say that clients want spirituality included in therapy, there is something in us that resists the kind of turnings that are part of spirituality. So we’re drawn to spirituality, yes, but we’re also drawn in lots of other directions, by the various lures of culture and of ego.
LR: It makes sense that if there has been a historical and institutional resistance to incorporating spirituality into so-called scientific practice, then that resistance will filter down to the individual. Interestingly, you spoke earlier about the nascency of psychotherapy and I immediately thought of Maslow’s hierarchy, and that as a field of practice, we’re not evolved enough to actualize and embrace the spiritual.
RJ:
and it strikes me that we are already swimming deep in an understanding of spirituality in this conversation
Yes! And it strikes me that we are already swimming deep in an understanding of spirituality in this conversation. Just your statement right there, about actualization being a spiritual process. And let’s add, since we were just talking about scientism, the need to legitimate our practices with proof, that when we say, “actualization is a spiritual process,” that’s neither a provable nor disprovable statement.
LR: So, are you suggesting that without intending to, our conversation has already broached the spiritual?
RJ: Yes. Absolutely. And wonderfully.

Explicit and Implicit Spirituality

LR: So the differentiation you make in your writings between explicit and implicit spirituality is not only part of our (non-therapeutic) conversation, but also finds its way into psychotherapy. What do you mean by explicit and implicit spiritual conversations in psychotherapy?
RJ: An explicit spiritual conversation is one that, if the average person on the street were to overhear it, they would say, “Oh, they’re talking about something spiritual. Somebody just said the word God, or meditation, or faith. They’re talking about something spiritual there.”

But implicit spiritual conversation, that’s when we aren’t using explicitly spiritual words, but spirituality is at the heart of what we’re thinking or feeling or saying. It’s a conversation about “What are you doing when you really come alive?,” or “What does all this mean?,” or “What’s my reason for being on this planet?” Or a conversation about guilt and forgiveness, or suffering, or joy. People don’t have to be using explicitly spiritual words or even thinking that what they’re saying is spiritual, for them to be tapping into the spiritual dimension.

I think most of the spiritual conversation that happens in therapy happens at the implicit level more than at the explicit level
I think most of the spiritual conversation that happens in therapy happens at the implicit level more than at the explicit level. It is explicit some of the time, but in my understanding of who human beings are, it’s implicit all the time. Every conversation is a spiritual conversation.
LR: Last night in my ethics class, one of my students asked, “What’s the difference between Christian counseling and spiritually integrated psychotherapy?” And in thinking about that question in the context of what you just said, I wonder if a therapist who is not explicitly religious or even spiritual, or is not actively “practicing” their faith, is precluded from being spiritual in therapy.
RJ: Therapists who don’t consider themselves particularly religious can definitely practice spiritually integrated psychotherapy. I know several who are really good at it. And with regard to your student’s question about Christian counseling, I’ll bet it means 50 different things to 50 different Christian counselors. But maybe at the heart of it, for all 50, is that both the therapist and the client have agreed that they are going to explicitly factor Christian beliefs, values, and practices into the conversation. That that’s going to be a part of what they do together.
LR:
Spirituality is a way of seeing. It’s a way of listening. It’s a way of being.
Along with biblical teachings and writings?
RJ: Yes. And I would say there’s overlap between Christian counseling and spiritually integrated counseling. But you could also be doing spiritually integrated psychotherapy without declaring a particular religious or spiritual orientation. And this could occur without your and your client’s ever saying explicitly, “We want spirituality to be somehow part of the way we’re coming at this.” Spirituality is a way of seeing. It’s a way of listening. It’s a way of being. Our spiritual orientation is a way of seeing, listening, and being in the same way that being male is, being white is, being educated at a certain level is. You just can’t wash it out of yourself. It’s going to affect the way you sit in the room and interact with people.

Being a Spiritually Informed Therapist

LR: What are some of the core attributes of a clinician who wants to open their therapy space to the spiritual, but not necessarily the Biblical or the religious?
RJ: A therapist who wants to honor that part of their client’s life and try to leverage it for some therapeutic gain—not one who wants to represent a particular spiritual tradition or try to advance a particular spiritual understanding, but one who wants to work with the spiritual understanding of their client—I would say they’ve got to be spiritually curious. They’ve got to have an interest in tracking it, noticing it, engaging with it. I think another key quality is humility. Humility in the sense of not assuming that the way you see things spiritually is the way the whole world sees it.
LR: Decentering.
RJ: Yeah. Yeah, yeah. You and I, if people could see us in this interview, we both have two eyes and two ears and a nose and a mouth. If people saw us, they would say, “Those are two human beings.” But they’d also recognize that we’re physically distinct. People can tell that that’s Lawrence and this is Russell. And if that’s true physically, why would it be any less true spiritually? So
a therapist who’s going to do spiritually integrated work well needs to really believe that everyone has a unique spiritual fingerprint
a therapist who’s going to do spiritually integrated work well needs to really believe that everyone has a unique spiritual fingerprint. That the way this person in their office relates with the spiritual dimension of their life and connects and comes alive is different from the way any other person who sits in their office does it. Even if the other person and you share a similar spiritual background, you must assume that everyone who sits in your office came from a different spiritual planet, and your work is to get to know who that person from that different planet is.
LR: That process of acknowledging the uniqueness of the other is itself a spiritual engagement.
RJ: I think that’s true. That is a spiritually informed value and practice for the therapist. Although, I do want to be clear. There are many wonderful therapists, many of whom are my friends, who have that same value and who say, “But I’m not spiritual at all. There’s not a spiritual bone in my body.” All this I’m saying to you, it’s just how I see it, and I know that’s not the case for everyone.
LR: Aren’t humility, curiosity, awe, and respect also the core qualities of spirituality? So even though someone may believe that they’re not inviting spiritual conversations into therapy, they are engaging in spiritual practice by virtue of trying to connect with another person.
RJ: I agree with that, and I’m just wanting to protect the space.
LR: The sanctity of the therapy space?
RJ: Yes, to protect every therapist’s right to understand themselves the way they understand themselves. So the therapist who says, “Curiosity and humility, I’m all in. I come from that place, as well. But don’t colonize that and tell me it’s spiritual.” You know, “Don’t plant your flag on my island and tell me that I’m spiritual even though I don’t think I am.” If you don’t want to claim it, I don’t want you to claim it.
LR: That might be a potential error a therapist could make: in planting their spiritual flag in someone else’s domain.
RJ: That’s exactly right.

Engaging Versus Imposing Spirituality

LR: That brings me to the distinction you make in your book between imposing your spirituality on the client and engaging the client around spirituality. Can you say more about that distinction?
RJ: Let me start with the engagement side. Engagement means listening for it and responding to it. If a client says something explicitly religious, you know, “I’ve been talking with my rabbi about this,” we show some curiosity about what that relationship with the rabbi is like and what the role of that is in their life. We don’t ignore it. Some therapists were trained to slide on past the spiritual comments their clients make, because if they talk about it at all, maybe they’re going to cross a boundary. You’re going to end up imposing, so stay away from it.

I think staying away from this client’s conversation with the rabbi or not showing curiosity about it conveys to them that maybe it’s not all that important. So
engaging around spirituality means that there’s a spirit of welcoming and hospitality if they say something explicitly spiritual
engaging around spirituality means that there’s a spirit of welcoming and hospitality if they say something explicitly spiritual. But even if they say something implicitly spiritual, like “That song came on the radio and something happened in me. And I can’t even tell you what it was,” and we pass over it or don’t engage with it, we have lost an opportunity. That moment deserves a “Can you tell me anything more about that? Can we talk about that experience a little more?” So that’s engaging around spirituality, explicitly or implicitly.

Imposition has more the feel of, “Let me tell you how I make sense of what you just said.” Or “Let me tell you a very helpful way to make sense of what’s going on in your life.” I think the gross examples of imposition would be a therapist who says, “You should become a Christian or a Buddhist. Or a cat lover.” I think imposition at a subtler level is when our client says something that in some way is spiritually bothersome to us. And maybe we don’t even know we’re doing it. It could happen even at the level of an unconscious countertransference reaction. But we pull away, we ignore, we cast some sort of shade on what they just said. I think that’s also a way of imposing our own spiritual perspective on a client and their life.
LR: And that’s what you referred to in your book as spiritual countertransference, which in this case would be an imposition or an ignoring or a pulling back from a client when they enter their spiritual realm and you’re not comfortable being there with them. Or you try to pull them out of their spiritual realm because you’re not comfortable or you don’t agree, or it goes against your own teachings.
RJ: Yes, exactly.
LR: Can you give an example of a time when you were impacted by your own spiritual countertransference with a client?
RJ:
feeling judgmental toward a client is an example of spiritual countertransference
Feeling judgmental toward a client is an example of spiritual countertransference, and that’s one I’m just a wee bit acquainted with. Say I’m talking with someone who is giving voice to a racist or sexist or heterosexist point of view, I might start feeling bothered or judgmental or annoyed or hostile. I know myself as a therapist, and I know I’m probably not going to reach across the room and try to shake those attitudes out of them. But I still have to deal with some degree of judgment in myself that becomes a barrier to really being present in a helpful, caring, loving way with that client.
LR: That sounds like “plain old” countertransference. Why does it necessarily cross over into spiritual countertransference when you express or feel negative or judgmental towards that same person?
RJ: I think what you’re smoking out here is that for me, plain old countertransference is also spiritual countertransference. Every experience I have, I feel it in a spiritual way. So judgment—we don’t have to think of that spiritually. But in the spiritual traditions, the deadliest thing going is self-righteousness.
LR: So judging someone negates the other person’s humanity.
RJ: Right. And when I negate theirs, I negate my own. When I’m in judgment of you, even if it never leaves my mouth and is just in my own head, I’m also harming myself.
LR: You’re actually minimizing and dehumanizing yourself by elevating yourself over someone else.
RJ: Yes.

Therapy as a Spiritual Journey

LR: From your description, it seems that spiritually integrated psychotherapy leans towards the existential, humanistic camp of therapy more than any of the more mechanistic, reductionist ones like CBT.
RJ: In the way I come at it and practice it, yes. But I think there are spiritually integrated therapies that tie themselves to the more structured, protocol-based therapy models. There are spiritually integrated CBT protocols.
LR: This may be sort of counterintuitive, but based on what we’ve been discussing, CBT doesn’t seem to have a spiritual flavor to me.
RJ:
ah, but everything has a spiritual flavor
Ah, but everything has a spiritual flavor. I haven’t done a whole lot of thinking about the spiritual flavor of the CBT model, but I think it does possess an implicit spirituality and that spiritually can be integrated into it. For instance, a CBT therapist helps a client identify a core belief such as, “I’m stupid. I never get it right.” And the spiritually integrated CBT therapist might say, “Is there anything in your spiritual tradition or any part of your faith that speaks to that?” And then, perhaps the client pulls on a sacred text or some sacred affirmation that really emphasizes the value of this person, like maybe the client’s value in God’s eyes. The therapist then helps the client to integrate that belief or to try to switch beliefs.

But to your point, in the way I see the world and practice therapy, spirituality is implicit in everything. And it’s not just a way of conceptualizing, it’s not just technique. It’s a way of being in the therapeutic space. I think in that sense, it’s very much in the same family as the existential and humanistic therapies.

What is Spirituality, Anyway?

LR: So are you suggesting that all therapeutic encounters, regardless of theory or technique, are spiritual undertakings shared by two people, even though it may not be explicitly stated as such?
RJ: Yes, I do think that is true. And so, maybe now is the place to talk about what is spirituality, anyway?

First of all, I’ve never read a definition that I find completely satisfying. And the reason is: when we discuss or try to define spirituality, we’re talking about something whose very nature is mysterious and beyond words. So every definition of spirituality in the spiritually integrated psychotherapy literature includes a word that also requires some additional definition. Maybe the best-known definition of spirituality in the literature is Ken Pargament’s notion that spirituality is a search for the sacred. And that’s a great definition, but here we go: what does sacred mean?

In my book, I say spirituality is all the ways you and God relate with each other. But I spend a whole chapter talking about what I mean by God and how I’m using the word God in a poetic, imagistic way. It’s hard to define spirituality. We know it when we feel it. We know it in a way that’s other than linear and rational and definable. But what I mean by spirituality is: it’s the way we orient ourselves to the mysteries of life.
LR:
maybe the best-known definition of spirituality in the literature is Ken Pargament’s notion that spirituality is a search for the sacred…but what I mean by spirituality is: it’s the way we orient ourselves to the mysteries of life
The undefinable!
RJ: Right! And the mysteries of life are these things we’re bumping into all the time. Where did I come from? How did all this get here? What happens after I’m gone? Does anything survive? What really, really matters? What’s worth spending this life on? Do you remember the “Once in a Lifetime” song from The Talking Heads? The line that goes: “How did I get here?” Or Mary Oliver’s poem, “The Summer Day,” where she asks, “Tell me, what is it you plan to do with your one wild and precious life?”

Spirituality is the way we live out answers to those questions, and so we’re doing it all the time. You and I are doing something spiritual right now. We decided that sitting together and having this conversation matters, and it feels to me like we’re bringing ourselves to it with a fair bit of passion.
LR: I guess it’s the passion rising, and I’m sorry to cut you off, but I’m flashing back to the interviews that Bill Moyer did with Joseph Campbell around mythology. Bill Moyer said, “So people struggle to find meaning in life.” And Campbell said something like, “No, people struggle to find a reason for living. Not a meaning in life.”
RJ: And what’s the difference, for you?
LR: The former sounds more like an intellectual exercise, and the latter like a “where people actually live” thing.
RJ: That’s the way I heard it, too. Not many people are sitting around thinking, “What is the meaning of life?” Most people are thinking, “What am I going to have for dinner?” And, “How am I going to get ahead?” “How am I going to get that person over there to pay attention to me over here?” But everyone is asking, “How do I get through this day? And what do I need to do to be happy? And am I OK?” And the way they live out their answers to those questions is connected to whatever they feel in their bones is the reason for living.

Spiritually Integrated Psychotherapy

LR: I had initially wanted to begin the interview by asking “What is spiritually integrated psychotherapy?,” which almost seems to be moot at this point. I think we’ve answered it by saying that all therapy that honors the transcendent, the mystical, the unknowable, the important core values in life as a spiritual process.
RJ: Yes. And let me add on to that wonderful summary you just offered. I would say that the most important question in psychotherapy is this: “What do you want?” We ask it the very first time we sit with a client, and we ask it again and again over the course of therapy, “What do you want?” What do you want to be different?” “What are you hoping for?” Whatever their answers are, embedded in them are some underlying assumptions about what it is that’s worth wanting. What matters enough to want? And a lot of the complexity of our lives is due to wanting things that are at odds with each other. “I want to get ahead at work, and I want a close relationship with my friends and family.” So what do you want more? What do you want most? What do you really, really, really want? These are spiritual questions.
LR: Wanting to succeed at work and to be in a relationship seem to be undergirded by, “I want to feel important.” “I want to be doing something valuable, I want to be loved.” So even those goals, which seem sort of transient and superficial, are, at a deeper level, spiritual goals.
RJ: Yes, if you succeed at work, what will that get you? If you have a good relationship with your spouse, what will that get you? What comes of that? What’s beneath all that? And I think the deeper you drop into that question, the more you land in some set of spiritual assumptions. Unprovable spiritual assumptions, but we organize our lives around them all the same.
LR: It’s not what is spiritually integrated psychotherapy, it’s how deeply will you journey with your client in therapy toward core spiritual issues?
RJ: Yes. Spiritually integrated psychotherapy is about following your client as deeply as they want to go.
LR: Even if you don’t want to go there.
RJ: Yes, following them, inviting them into as deep a space as they want to go to. But no deeper than they want to go right now. I think another way of imposing a spiritual perspective is trying to drag your client into a deeper part of the swimming pool than they want to be in, or deeper than they know, in their bones, they need to go right now.
LR: So when my daughter’s therapist recommends that she’s experiencing death anxiety and suggests she read Irvin Yalom’s “Staring at the Sun,” she might be pushing her a little bit.
RJ: Maybe so. You know, everything we do in therapy is an experiment, and hopefully, we’re paying attention enough to our client to see what happens in this experiment and to adjust. I think people come to therapy because they basically want someone to ask them, “What do you want?,” but also the related question, “What needs to happen?”

So, if your daughter is experiencing death anxiety, a spiritually integrated and implicitly worded spiritually integrated question might be, “What needs to happen?” And that question invites some inwardness and invites your daughter to seek a wisdom from a source that is not maybe part of her everyday, ordinary, or habituated way of handling her death anxiety, and invites a shift in perspective. But anyway, I guess I'm just suggesting that instead of saying, “Go stare at the sun,” the first question could be “What do you think needs to happen?”
LR: Could a related question be, “What does death mean to you?”
RJ: Yeah, absolutely.

Spirituality and Mental Health

LR: I’m curious about the distinction between spiritual health and illness and how a therapist recognizes and works with them.
RJ: Let me say something that I hope is unnecessary, but I’ll say it anyway. We don’t parse between spiritual health and spiritual illness based on the content of our client’s beliefs. We don’t say someone is spiritually ill because they believe something that we think is wacko or is different from the things that we treasure in our spiritual belief system. You know, in religion, there is such a thing as heresy, but in the world of psychotherapy, we’re not interested in heresy. We’re interested in, how well does this person function in their life? To what extent do they experience psychic suffering and to what degree are they impaired? And I think some of the spiritual measures of psychic suffering or impairment would be things like how much are hatred and resentment a part of this person’s experience? How infected or affected by hatred are they? How much is greed infecting and affecting this person? How much—
LR: —about their lives is meaningless?
RJ: Exactly! How connected or disconnected is this person to feeling that “My life matters for something important?”
LR: Worthlessness and meaninglessness infect and affect someone as toxically as hatred and bigotry and greed. Seven deadly sins, right?
RJ:
ome of the spiritual measures of psychic suffering or impairment would be things like how much are hatred and resentment a part of this person’s experience? How infected or affected by hatred are they? How much is greed infecting and affecting this person?
Right. And I think connected to the sense of meaning is a sense of awareness and consciousness. You know, how awake or asleep is this person? And on this point, what we mean by spiritual wellness and psychological wellness are really close to each other: to what extent is this person living their life on automatic pilot, in some habituated, unconsciously driven, stimulus-response sort of way? And to what extent are living with awareness?
LR: It makes me think about addiction.
RJ: Addiction, yeah.

And the opposite of addiction, maybe, is freedom. To what extent am I free in a given moment? And then, another thing I would put in there would be a sense of agency or power. How paralyzed or futile do I feel in my life? And to what extent do I think the choices I make matter? And can I gather my energy behind a choice and a decision that matters?

Another thing to remember is that all these healthy spiritual capacities are usually inseparable from our attachment experiences. They’re inseparable from experiences we may have had with trauma. They’re inseparable from the historical forces that have shaped the world in which I’m coming to be a person. The spiritual dimension is inseparable from all that.
LR: That’s an elegant answer, Russell.
RJ: Thank you.
LR:
when you read the DSM with a spiritual eye, you start seeing spirituality everywhere. Think about the criteria for depression in the DSM. There’s mention of hope, loss of hope, which is a spiritual word
I know you labor intensely to put these complex thoughts into just the right words, but to me, it brings together the field of mental health and spiritual health. Perhaps at the surface are the behavioral, emotional, and cognitive symptoms that people bring to us that they want alleviation from. The person who has, for example, been sexually assaulted has also been spiritually violated. The person who is depressed has, perhaps, lost access to spiritual connection, while the person with an anxiety disorder is struggling with meaning and a sense of powerlessness, perhaps. I wonder if you can rewrite the whole DSM from a spiritual perspective.
RJ: Well, it’s funny, you know. When you read the DSM with a spiritual eye, you start seeing spirituality everywhere. Think about the criteria for depression in the DSM. There’s mention of hope, loss of hope, which is a spiritual word.
LR: Worthlessness.
RJ: Worthlessness.
LR: Lack of will.
RJ: Feelings of guilt. And no longer taking pleasure in things that one used to take pleasure in. The spiritual word for what they’re talking about there is joy.
LR: Andrew Solomon, who is well known for the work he’s done on depression, says, “The opposite of depression is not happiness. The opposite of depression is vitality.” And vitality, it seems based on our conversation, is spiritually elemental.
RJ: That’s right. Another way of talking about that is the phrase “the life force.” That’s how I talk about spirit sometimes with clients who are not explicitly religious. How connected or disconnected are they feeling to the life force?

Seeing Beneath the Despair

LR: I’m hesitant to bring this into the conversation because it touches so many nerves. But as I watch and re-watch the assault on the Capitol on January 6th of this year, I wonder what those people shared and if there were issues of spirituality at play that might find their way into psychotherapy?
RJ: I understand why you may edit this out. But I’ll speak into that space, too. And my hesitancy to speak into it may be similar to yours. Or not. But mine is I want to be really careful that I’m not imposing my own worldview onto people who aren’t here to speak for themselves.

But
as I try to make sense of that scene at the Capitol, a good bit of what I saw really was spiritual
as I try to make sense of that scene at the Capitol, a good bit of what I saw really was spiritual. And at the heart of it was despair. The anger was obvious, the rage. But beneath the rage, I think, there is despair. And there are probably many causes of despair, many of them intensely personal. But there are also social forces, collective forces, that are part of it. One of them, in my mind anyway, is economic, the way wealth is so unequally shared.
LR: Yes. Along with racism. The rage around racism is, I think, intimately tied to the violence around the Capitol and assault in other situations, in which there’s this collective sense, perhaps, of anomie, of despair, of worthlessness. But then, I guess we’d have to get into a bigger conversation around spiritual illness in our country.
RJ: Yes, what are our shared spiritual illnesses? Groups and cultures can be healthy or unhealthy, although that’s too either-or a way of saying. Groups and cultures are a blend of healthy and unhealthy, just like individuals, healthy and unhealthy at the same time. You know, I guarantee you, most anybody in that crowd that day, if you could pick them out and have a conversation with them, you would find multiple spiritual virtues in those people. And, I’ll add, multiple spiritual vices. Violence is an expression of a spiritual vice.
LR: Which is?
RJ: Anger is one of the seven deadly sins in Christianity. In Buddhism, the three poisons are hatred, greed, and delusion. Violence has roots in all that. But my main point is, I think we’re all a blend. I have spiritual virtues and vices, and in different moments, in different circumstances, and under the influence of a crowd, my virtues and vices get amplified.

You know, another thing that was spiritual about that day, and about politics in general, is the projection of hope onto a savior.
LR: No Biblical references there, right?
RJ: Right. Yeah, “This is our guy.” “This is the one to deliver us from evil and evildoers.”
LR: One of my mental health counseling interns, an Orthodox Jew, was initially placed in a facility where she was working with young Black men. There, she heard stories of horror and tragedy-filled lives that she’d never heard before. And she was very reactive, very non-self-reflective, very defensive, and at the core, scared. She undertook her own therapy and had some solid supervision and then moved into a different facility with substance abusers where one young man picked up his shirt to reveal a swastika on his stomach. In that moment, she was able magnificently to be aware of the pull toward reactivity…toward instant hatred. But she was able to step back and wonder instead who he was beneath the swastika.
RJ: Wow, what a powerful example of drawing upon a spiritual virtue in a very intense moment. Something in her helped her see that man as a story, to see a past in him, to see deeper than the skin, deeper than the shield.
LR: Deeper than the shield?
RJ: Deeper than the swastika shield. To see the human being behind that shield. Good on her for being able to do that in the moment. That’s not easy. And you know, she earned it. Because it sounded like she had willingly put herself in an uncomfortable situation that stretched her—the previous internship—and it helped her get to that place, where she could remain in the center of her own being. “No matter who this person is around me, here’s the way I’m going to treat him.” That is a very spiritually grounded response that she was able to make.
LR: I’m going to tell her. At Psychotherapy.net, we’re working on a series of videos around counseling African American men, and one of the tragedies that these particular clients experience, and not unlike other people of color, is this sense of invisibility. That they are seen only for their skin color. And it makes me wonder, Russell, if one of the keys to working effectively with clients of other races, other belief systems, other cultures, is a spiritual venture in seeing them. Really seeing them and inviting them into this therapeutic space.
RJ: Yes. “Who are you? Tell me who you are. I see the color of your skin, and I have these implicit biases about you. I can’t help it. I grew up in this culture that tells me repeatedly who you are. And I have these implicit associations and prejudices. But within myself, spiritually, can I recognize my tendency to distortion and to prejudice, and somehow look at you and see you for who you really are? And ask you to tell me that—who are you?—ask you to show me that.”
LR: So if I were to sum up good therapy, we would talk about a powerful connection between two people—one who identifies as a client and one who identifies as a therapist? A shared spiritual journey.
RJ: Yes, I agree.
LR: And I come back once again to that original question I was going to ask, which was, “What is spiritually-integrated psychotherapy?”
RJ:
spiritually integrated psychotherapy is psychotherapy that makes use of the spiritual dimension of our client’s lives and of our own spiritual capacities and wisdom
It’s a hard thing to sum up in a sentence. But if people read this far into the interview, let’s thank them for that with a single sentence. Spiritually integrated psychotherapy is psychotherapy that makes use of the spiritual dimension of our client’s lives and of our own spiritual capacities and wisdom.
LR: With spirituality not necessarily being anchored to God or a particular religious practice, but more a set of core underlying values that we all share as humans.
RJ: Yes. There are theistic and nontheistic spiritualities. But all humans try to live—to find some reason for living and to actually do their living—in ways that are informed by assumptions about what’s real, what’s true, and what matters.
LR: As we come to a close, I want to reiterate that I thoroughly enjoyed your book, Spirit in Session, and hope people will buy it as a result of reading the interview. It is a must-read for those interested in spiritually integrated psychotherapy.
RJ: Oh, thank you for saying that, Lawrence. I believe in the book and want people to read it. One of my missions in this life is to help therapists feel more confident that they can do this kind of work, and the book is part of that. It’s a therapist talking to other therapists, in everyday language, and there are lots of transcripts from actual therapy conversations. Plus, it’s low-cost, so I don’t have a problem pushing it.

And if I could, I’d like to plug two other resources for therapists who want to grow their competence in working with spirituality. One is relatively small scale. It’s the CareNet Residency in Psychotherapy and Spirituality. CareNet is a state-wide outpatient counseling network in North Carolina. It’s part of the Wake Forest Baptist Health System. Our Residency is a two-year training program for therapists licensed at the associate level. They come to work at CareNet, and they join these learning cohorts. We have 10-12 residents at a time, five or six in their first year, five or six in their second year. I’ve been directing this program for 13 years now, we’ve had the most amazing people come through the program, and they’re the ones who taught me how to talk about this and teach it.

The other resource is larger in scale. It’s a national-in-reach training program in spiritually integrated psychotherapy offered through ACPE (Association for Clinical Pastoral Education). Historically, ACPE has offered top-notch training for chaplains and others who provide spiritual care, but they’ve recently developed a psychotherapy wing. I’ve been part of helping ACPE develop a 30-hour continuing education curriculum and a certification program. We now have 38 trainers offering this program across the country. So, if people want to do more than read a book, if they want to connect with other therapists who are trying to work more skillfully with spirituality, I’d encourage them to check out the ACPE website.
LR: I think that’s a good place to stop. I really enjoyed this conversation Russell. This is what I aspire to in these interviews, not just throwing questions at people, but engaging deeply in meaningful conversation.
RJ: Thank you, Larry. This was delightful. Thank you for sharing this platform with me. I hope people will read it and find it useful. And if they do, for me, that’ll be gravy. That’ll be a bonus. This real and rich conversation is already gift aplenty.

Existential-Humanistic Therapy in the Age of COVID-19 in Vulnerable Populations

Posted on by Psychotherapy.net Team

Challenges

COVID-19 has been a sudden, unexpected, and existentially shattering experience for many individuals, resulting in their questioning their sense of safety and security in the world. Whether facing actual illness or loss, fear of getting sick or infecting others, forced isolation, lack of personal space, or economic hardship, people have now been facing unprecedented stressors for close to a year. With a second wave upon us and new variants emerging, there may be a sense that anyone is vulnerable. While vaccine distribution offers promise for individual immunity, there is protracted uncertainty about the duration of the crisis and its psychological, economic, political, and societal consequences.

These COVID-19 phenomena may exacerbate challenges for individuals with a history of chronic medical conditions and trauma, including feelings of vulnerability, stigma, and lack of control. Having previously confronted and accepted existential truths such as life’s uncertainty, the random nature of events, and the inevitability of death, these individuals may, at the same time, be better equipped to cope with aspects of the pandemic (Gordon, 2020). Existential-Humanistic (E-H) therapy can provide effective therapeutic interventions to aid vulnerable populations in optimizing adjustment, coping, and quality of life during the COVID-19 pandemic.

Existential-Humanistic Therapy

Developed in the 1960s, E-H therapy consolidates central ideas from European existential philosophy—the power of self-reflection, taking responsibility for decisions, and confronting freedom and death—with the American tradition of spontaneity, pragmatism, and optimism (Schneider & Krug, 2017). E-H therapists emphasize several core aims that enable patients and therapists to become more present in the moment: increasing awareness of self-protective patterns that block and restrict presence and personal agency; taking personal responsibility for the construction of one’s life and self-narratives; and choosing or actualizing ways of being in the world that are consistent with values. E-H therapy strives to be a catalyst for individuals to develop their level of curiosity, generate experience that is felt to be enriching, and expand their capacity for personal agency, commitment, and action.

The model emphasizes the “whole-bodied” (e.g., cognitive-affective-kinesthetic) ability to choose, within limits, who one will become, and that fundamental change takes place through experiential learning. Bugental (1987) depicted resistance as analogous to wearing a spacesuit which helps sustain life but also narrows one’s experience of the world. E-H therapists believe that when life-constricting protections are reduced, more meaning, purpose, and joy can emerge. E-H therapists focus on the here-and-now experience of the past as manifested in the present moment, including the patient’s body posture, level and quality of presence, tone or voice, and self-protective patterns.

Viktor Frankl (1992), an Austrian psychiatrist and Holocaust survivor, observed that we do not get to choose our difficulties and challenges, but do have the ability to select our attitudes and responses, decide what we make of them, and maintain a sense of dignity. Rollo May (1985) believed that it takes courage to move forward in life despite adversity.

An E-H theme developed by Irvin Yalom (1980) is the idea that individuals have a basic need to construct meaning through tolerating uncertainty, a passionate engagement in life, and living in the moment. He describes existential anxiety as the result of the confrontation with the givens of existence, including death, freedom, isolation, and meaninglessness. Existential anxiety occurs because of the conflict between these challenges and a desire for its opposite. These universal conflicts include the awareness of death and the desire for immortality, a sense of groundlessness and the wish for structure to provide safety and security, feeling of isolation and the need for connection, and the awareness of meaninglessness of life and the need to construct meaning. As a result of facing death, individuals experience the urgency of time and setting priorities. For Yalom, psychotherapy during times of crisis can heighten existential awareness and help clients put current and ongoing life crises into perspective.

Yalom incorporates the concept of “rippling” into his many writings on existential therapy. This is the notion that we pass parts of our self onto others, even to others we never met, much like the ripples caused by a pebble in a pond—whether a personality trait, an act of kindness, a quote or saying, the impact of our work—which tempers the pain of transiency. Along related lines, Hoffman (2021), guided by the work of Rollo May, discussed the existential guilt that accompanies failure to live up to one’s potential or taking responsibility, while in contrast finding that meaning can transform pain. And finding this meaning, according to Remen (2000), does not require us to live differently, but instead to see our lives differently.

It is in this context of seeing life differently that I ask you, as we might ask our clients, to imagine the consequences of living in a house with only one window. For all intents and purposes, the view from that window will define your reality. Only by experiencing the view from a new window, built perhaps on the other side of the house, will you gradually internalize a degree of perspective and relativity, a sense that vision and meaning involve choice and agency. And with that, I now offer the case of Michael.

The Case of Michael

Michael is a 35-year-old aspiring artist who was referred to me for psychotherapy to develop effective coping skills in his adjustment to his recent diagnosis of Multiple Sclerosis (MS). MS is an autoimmune disease that attacks the central nervous system, which can cause a variety of symptoms, including numbness, fatigue, vision loss, and walking difficulty. He was living with his grandmother and mother and had a strained relationship with his father, whom he had never lived with. He entered therapy three months before COVID-19 rattled the city and shut down services.

At the beginning of treatment, “Michael reported multiple symptoms, frequent incidents of falling and losing his balance, a long-standing history of anxiety and panic attacks, and inhibitions in his ability to commit himself to intimate relationships and professional goals”. Since his adolescence, his anxiety had often resulted in shortness of breath that triggered fears of a heart attack and impending death. He was particularly worried that his physical symptoms would continue to get worse and that he would be totally dependent on others for his physical care.

During his initial sessions, he expressed a great deal of frustration that it took a number of years to get a definitive diagnosis of MS. He felt his family and friends thought he was exaggerating his symptoms to avoid pursuing his educational and vocational goals, which resulted in lack of confidence and trust in expressing his own feelings, needs, and opinions. Even when he was given a definitive diagnosis six months before entering treatment, he experienced others as not fully understanding the impact of his “hidden disability.” He was angry that he developed his medical condition at such an early age, started to doubt his belief that “bad things do not happen to good people,” and felt that he was being punished for his lack of motivation and accomplishments.

Capitalizing on meaning-centered and post-traumatic growth perspectives, therapy began by exploring his strengths—deep-seated values and qualities that did not change due to his medical condition—in order to help him feel more empowered. He identified his compassion for others, creativity, and a sense of humor that could help him cope with his multiple challenges. The only moments when he felt passion in life were when painting or taking pictures of landscapes and city architecture.

In these initial sessions, “Michael was able to express a deep sense of loss and sadness over his physical functioning, as he felt his athleticism had formed a core component of his identity during his adolescence and young adulthood”. He grieved the loss of not being able to play sports with his children, if he became a father in the future. These feelings of sadness triggered memories of his paternal grandfather, who had died of cancer during his adolescence. He was one of the few figures in his life who had confidence in Michael’s talent as an athlete and that he would succeed in the future. Michael identified his grandfather’s resiliency and perseverance in the face of his terminal illness as two of his special qualities. The sessions involved asking Michael open-ended questions, including “What advice would your grandfather give you right now in how to handle your MS?” and “How are you similar to your grandfather?” Michael became more aware of feelings of gratitude toward his grandfather and that he too was a survivor and a determined individual.

When the news of the spread of COVID-19 in March 2020 caused a city-wide lock down, Michael agreed to continue sessions via telehealth. At that time, now on top of his anxiety, panic, and fears of dependency resulting from his medical condition, “he identified the virus as compounding his fears of dying or becoming totally dependent on others”. Shortly after, Michael recalled a series of unsettling dreams. He reported that since his diagnosis of MS approximately nine months before, he had a recurring dream where “Martians shot people and then placed them in upright coffins. They had blank faces and appeared as if in an altered state and could only move their hands in front of them.” Michael’s associations to the dreams were fears of not being able to move, ending up in a wheelchair, and being totally dependent on others. He was asked to retell the dream in the present tense and how he would want the dream to end in order to develop a sense of agency. He said he wanted to be able to fight the Martians like his grandfather had fought his cancer and scare them away.

Two weeks later, Michael reported another frightening dream where he was “trapped in a glass cube in [his] home that was invaded by bad guys who were pumping gas into the cube, and [he] had no way out.” He said he felt terrified of dying and feeling helpless. He was asked to visualize and re-experience how he felt in the dream. He recalled that he felt trapped, his lungs were burning, and he was going to suffocate to death. Michael then spontaneously recalled a memory of escaping from the scene of the World Trade Center Attack. He was at breakfast in a diner across the street and saw the plane hit the building. Michael was numb and could not process what had happened. He was paralyzed by fear, but eventually ran down the street when told to leave by a security guard. He did not remember what happened next, but eventually arrived home covered in ashes and debris, and had difficulty breathing and sleeping for several days. He had not thought about this traumatic event in years.

During this phase of treatment, Michael became more aware of how this traumatic confrontation with the possibility of dying, which occurred shortly after his grandfather’s death, contributed to his panic attacks and fears of dying during his adolescence, which in turn impacted his ability to pursue his educational, vocational, and interpersonal goals. Michael became more aware that his strong needs for safety, security, and protection inhibited his pursuit of taking risks in many aspects of his life. Michael further realized that his avoidance of taking chances and exposing himself to failure and rejection was, as Bugental reminded us, analogous to wearing a spacesuit which is life-affirming but also narrows and inhibits one’s experience of the world.

A major focus of the middle phase of therapy involved his fears of dying and what was meaningful in his life. “Michael acknowledged that part of his death anxiety was that he had wasted many years avoiding pursuing his goals of being an artist and having close relationships”. When asked to project himself a year from now and what new regrets he might accumulate, Michael tearfully stated, “Not completing my college degree and becoming an art teacher, and not living up to Grandfather’s belief in my potential.”

This was a pivotal point in Michael’s treatment, which brought him to enroll in a local college, where he took and succeeded in a number of online courses. He continued to realize on a more experiential level that he had been fearful of taking risks and failing since his adolescence, but that he was paying a significant price for pursuing his strong need for security. When asked “What have you discovered about yourself through the challenge of the pandemic?” Michael reflected that, while the pandemic had added new layers of anxiety, it also had provided him with the space to step back and evaluate what really mattered to him. Rather than continuing his past patterns of avoidance, self-doubt, and comparing himself unfavorably to others, he was determined to focus on his creativity and having an impact on others through teaching. He also realized that his previous contemplation of death anxiety and perseverance in coping with his MS served as protective factors in dealing with COVID-19.

Within a few months, Michael transitioned from feeling overwhelmed and vulnerable in the storm of his MS symptoms and COVID-19 threat to feeling more focused, determined, and resilient. Although he had to maintain cautiousness due to his medical condition and COVID-19, he was able to take the initial steps in pursuing a meaningful career that was consistent with his values and identification with his grandfather. Through the therapeutic process, he came to recognize his own power to choose how he wanted to view and respond to life’s major challenges, including his MS.

Concluding Thoughts

This essay describes my flexible application of E-H approach to psychotherapy when working with a patient with a chronic medical condition and a history of trauma during COVID-19. The case vignette highlights different aspects of the E-H approaches, including cultivating presence in the moment, choosing one’s attitude toward challenge and adversity, increasing awareness of what is most meaningful in life, living in manner consistent with one’s values, and expressing gratitude toward others.

For patients who have chronic and life-threatening medical conditions and a history of trauma, COVID-19 may increase their level of anxiety, fear, vulnerability, and social isolation. On the other hand, “these individuals may have developed a degree of psychological protection and resiliency in having already experienced a prolonged sense of insecurity and uncertainty” involving fears of body integrity and mortality.

In my therapeutic work, E-H therapy provides a safe place for patients to reflect on how COVID-19, while frightening and potentially traumatic, is changing them in unanticipated positive ways, including living life with greater meaning, purpose, and sense of urgency. It is my hope that in reading this, that you may experience this new context as an opportunity to explore existential issues such as uncertainty, vulnerability, meaning in life, and death anxiety with patients in deeper ways than before.

References

Bugental, J. F. T. (1987). The art of the psychotherapist. Norton. https://doi.org/10.1037/h0085349

Frankl, V. (1992). Man’s search for meaning (4th Ed.). Beacon Press.

Gordon, R. M., Dahan, J. F., Wolfson, J. B., Fults, E., Lee, Y. S. C., Smith-Wexler, L., Liberta, T. A., & McGiffin, J. N. (2020). Existential-humanistic and relational psychotherapy during COVID-19 with patients with preexisting conditions. Journal of Humanistic Psychology. Published online: November 2020, https://doi.org/10.1177/0022167820973890

Hoffman. L. (2021). Existential-Humanistic therapy and disaster response: Lessons from the COVID-19 pandemic. Journal of Humanistic Psychology, 61, 33-54. http://doi.org/10.1177/0022167820931987

May, R. (1985). The courage to create. Bantam Books.

Remen, R. N. (2000). My grandfather’s blessings: Stories of strength, refuge, and belonging. Riverhead Books.

Schneider, K. J. & Krug, O. T. (2017). Existential-humanistic therapy (2nd Edition). American Psychological Association. http://dx.doi.org/10.1037/0000042-000

Yalom, I. D. (1980). Existential psychotherapy. Basic Books. 

If You Kill Yourself, Don’t Make a Mess: Paradoxical Intention with a Suicidal Client

Posted on by rezendevknowfully.com

"Maybe I was happy for like a day or two”

Marcus once told me he has no memory of what it feels like to not suffer. You’re exaggerating, I told him. He insisted he wasn’t. You are, I fought back. Everyone has such a memory, at least one. Marcus concedes little.

“Well, maybe I was happy for like a day or two.”

“That’s it?”

I’m visiting Marcus in a psychiatric stabilization unit. My task this morning is straightforward but not easy: confirm that he won’t harm himself when he leaves this place, and that he’ll take his medication. “You mean, not think about it?” he blubbers, in response to my direct question whether he’ll kill himself once he’s released. “I think about it all the time.” Coughs. “It don’t mean I will. And it don’t mean I won’t. So that’s that.”

Marcus is rotund and bald, with a noticeable stoop when he stands and a limp when he walks, as if he were an octogenarian trudging through the day under the invincible weight of his age. But he’s not yet even forty.

I walk over to the large window and open the blinds. “Is this okay?” I ask.

So thorough is Marcus’s lethargy that it would take supreme effort to imagine him at any point in his life gamboling joyously while soaking in the sunshine. The way he slouches, the way he mumbles and mutters, the way the sagging flesh on his face seems to collect around his neck, the way his drooping eyes make him look like a human bloodhound, the way he wears his bedraggled clothing, draped tent-like over his fatness—all of it, from his unlaced Converse sneakers to the labor of his breathing, speaks to the torments inflicted upon him as a child and the torments he inflicts upon himself ever since because that past is no mere residue of memory but instead exists within the corpuscles playing bumper cars in his veins. Marcus’s past is vastly alive inside him.

“Knock yourself out,” Marcus says. “I like it dark but it’s fine.”

I can see it more clearly now, with the sunlight drenching the room. The discolored bandage on his neck, the one that covers the stitched-up gash. It is puffy and loose. Like a cloud stained by urine. I ask if I can see the wound.

“For what?”

“For fun,” I say, winking.

Marcus tugs gently on the urine-cloud bandage. All the while he is mute, tongue sliding through soft lips, not unlike a narcotized snake. His tai-chi pull reveals the inch-long railroad track a little off-center on his pink, fleshy neck, the entire slow-motion divulgence giving the unveiling the feel that something ceremonial—no, something intimate—is happening.

The Real Nature of Suffering

Intimacy is what good talk therapists hope to achieve through this special encounter—which is why I strongly hold the view that talk therapy is a kind of artistry, for all art stems from an encounter between the artist and the subject, wherein the two become entwined in an intimate collaboration. What I mean by intimacy in this context is that a special kind of healing can occur when facades fade away, when neither person sees the other as potentially useful, which is to say the other is not a means to an end, the other is not expected to perform a function in one’s own advantage-seeking scheme, where the other is not to be used in some way (subtle or otherwise) to get some wanted outcome.

So talk therapy is something entirely different from having a rap session. An hour of heartfelt exchange without a handheld computer vitiating the experience—that right there makes it sadly unique. We might think of lovers sharing an intimate moment, but when there is the subtle (or not-so-subtle) underlying quest to keep the other close because the other serves the useful function of bringing about an inner experience that we have become attached to (meaning, we love the other’s presence because of the ability that the other has in bringing about a certain feeling within us), the intimacy is tainted thereby. Healing intimacy, I mean to suggest, and the face-to-face encounter that gives rise to it, is untainted. And it is this sort of intimacy that creates opportunities for the therapist to connect with the real nature of suffering.

The real nature of suffering—what is that? Well, I’m looking at it as I look at Marcus’s sagging face, with his eyes barely visible and his lips now sucked into his mouth. I hear it in his mumbling, the gravel, scratchy vocalizations that evoke a sense of futility about life. “No matter what Marcus says, the way he says it conveys his attitude that the whole enterprise of living is fruitless and cruel.” To Marcus’s way of thinking, life consists of events that happen to you; events are rarely neutral and they surely are not participatory; events by and large inflict suffering and there isn’t much to be done to exert control over them. All that is to be done is to take cover.

The existentialist philosopher Martin Heidegger and Doors singer Jim Morrison speak of our being “thrown into” the world, which is to say we have had no say (unless you believe in karmic reincarnation) in what our fundamental life circumstances will be. Will we be born in an affluent country or a war-ravaged one? Will our parents be wealthy or will they be drug addicts? Will they be skilled in the art of parenting or will they mutilate the child’s soul through mental torments or physical deprivations? A pile of shit or a basket of rose petals, or something in between—you don’t get to choose which you get thrown into. I’m sure Marcus has never read a word of Heidegger and I doubt he has ever grasped Morrison’s reference to “thrown-ness” when he sings, “into this world we’re thrown.” But Marcus understands thrown-ness in a way that few do. His understanding is purely experiential, and thus utterly non-conceptual. And that is why it is pointless to talk with him right now about choice and responsibility and meaning—all core concepts in my therapeutic repertoire, but useless at this moment.

His is an attitude of hopelessness, a recalcitrant, immutable belief that his emotional pain is permanent. But there is much more to it, as I see it through my own existentialist lens. Depression might be a clinical description of how Marcus experiences his life, but to restrict ourselves to that misses the deeper truth. Being depressed is, for him, a strategy, in the same way that the fox’s “sour grapes” in Aesop’s fable is a strategy, an emotion experienced to deflect something more painful. Depression is his cover. He has learned to use it—learned helplessness, one might say—to announce to the world that he is not responsible for his choices, that he cannot be blamed or held to account for his many self-sabotaging acts. In effect, helplessness and dysphoria serve as protection against the rigors of transcending his life circumstances. Depression protects him from any demands that he relate to his own life as a process of creation and the living of it as a kind of artistic endeavor.

"I'm Surprised You Used a Knife"

“Does it still hurt?” I ask.

Marcus taps on the wound with two fingers, as if to test it. “Nah,” he says. “Not if I don’t turn my head.”

“I’m surprised you used a knife,” I say.

Marcus had told me early on, repeating it often, that he envisioned himself going into the woods and shooting himself in the head. A fantasy perhaps, some aesthetic end to his particular decrepit story, as if a gun-blast obliterating the cranium in a quiet forest is the quintessential response to an ugly and alienated existence. A worthy denouement to a life of unmentionable sorrow that, though silent to the rest of us, now screams inside his head. A knife? No, I’m sure of it—he’s never mentioned that that would be a suitable instrument to effectuate his escape from the tribulations of his life. And bleed himself out on his mother’s kitchen floor like a slaughtered pig? Not the Marcus I had come to know. He had told me a gun-blast to the head in a secluded area of the woods, a spot he had already designated in his death-welcoming mind, would not leave a mess for others, as if his remains would be shoveled and disposed of with no more ceremonial fuss than the discarding of road kill.

He’s a complete mess inside and yet he has this concern for the mess he might leave when his inner mess becomes too intolerable.

Marcus and I have talked of suicide and death from day one. “Day one,” and many days thereafter, was in his a squalid single-room occupancy hotel. Existential therapy in a paint-peeling, cigarette-smelling room with a mattress on the floor, a small knee-high table abutting it—so much easier to roll cigarettes that way—and an always-on large flat-screen television five feet away. “I think about it all the time, every day, it’s how my life is.” Usually in the morning: such thoughts to be considered before he heaves himself off of the mattress to endure more inconsequential suffering. Not one session ends without him mentioning suicide.

I always make it a point to demonstrate that I’m unafraid of the subject. We’ve even laughed together over how naïve so many are to think that our so-called “survival instinct,” our presumed “will to live,” ineluctably trumps our desire for self-destruction. Self-destruction, alongside myriad habits of self-numbing, is so omnipresent in our world that it seems absurd to think that we humans actually do treasure the gift of living.

If we treasure life, really treasure it rather than just give lip-service to it, then why so much squandering of it?

“What does anyone know about living?” Marcus had said to me once. He wasn’t really asking me a question. He was declaring his own wisdom, his own hard-earned wisdom, the only kind of wisdom that’s worth a damn.

His remark reminded me of the scene in the Vietnam movie Platoon where Sgt. Barnes, the dark character competing for the soul of the Charlie Sheen character says to a group of young soldiers who are smoking pot: “Death? What y’all know about death?” Sgt. Barnes, with his scar-chiseled face and pain-knowing eyes, has undoubtedly peered into some abyss and thus has little patience for the young soldiers who seek escape and avert their eyes from the abyss through petty distractions. I don’t recall how I answered Marcus. But I do remember being impressed by the fact that he understood so well the interdependence of life and death, that to understand life one has to understand death. Not that Marcus spoke from a place of understanding death—far from it. He never spoke with any particularity about how contemplating death might bear on the artistry of living.

“I became an altar boy when I was 12,” he continued. “Did that for a few years. Father Lewis didn’t know nothin’ about living. I’ve seen psychs, therapists, energy doctors, fuckin’ you name it, and none of’em knows a goddamned thing about living.”

Not much to argue with there. I told Marcus that hardly anyone knows anything meaningful about how to live. How pathetic we are, I told him, the vast majority of us in the land of plenty, in the art of living. How can we know? After all, we lack a vocabulary for it. In this money-making, status-seeking, distraction-obsessed culture, we’ve lost the capacity to talk about it; we’ve lost the tools to even think about it in any serious way. Marcus lit a cigarette, offered me one, and as I waved him off I realized I had lapsed into preacher mode. I’ve been prone to do that.

I always refrain from talking Marcus out of suicide. He has commented on that fact a few times, usually to express gratitude for not doing what other health-care providers do—tell him that it would be best to forge ahead (best for whom?), that things will get better (how the fuck do you know things will get better?), that killing himself would only leave a legacy of pain (oh, I get it, I should suffer through life out of obligation). I never take that approach, for two reasons.

First, I think it is useful to look upon the urge to kill yourself as arising from a “self” that wants to manage the pain (which includes vanquishing it entirely). That managerial “self” must exist against another “self” that generates and experiences the pain. There is thus a polarity within the suicidal human organism: the managerial “self” who can’t stand the pain polarized against the pain-experiencing “self” who just won’t stay sequestered in some psychic locker tucked away among all the other toys in the attic. To preach at the managerial “self” about the folly of suicide, to guilt-trip the managerial “self” or appeal to that “self’s” sense of obligation, only leads to an intensified desire to commit suicide because it ignores completely the interplay of the polarities within the human organism. The polarity itself needs to be addressed.

Second, I don’t believe in the notion that living is an obligation and I don’t think it is truly therapeutic to signal such a notion to others, including those in despair. It’s an implicit mental model that generates ripples of more pain and suffering. I’m not one to promote to a desperately suffering person the brightly lit news of how wonderfully magical life can be, if only you just hang on. I do the opposite: I go towards the darkness, the pain, even the madness itself; I climb down into the pit of despair and sit with the person and ask questions like What’s holding you back now? What’s held you back in the past? Why haven’t you’ve given up already? Usually that sort of questioning arouses a spirited discussion, led by the client (a crucial fact), about what makes living worthwhile. It can often take a while to get there, but I have found that it almost always happens.

"If I Had a Gun"

I ask him again to tell me about his choice of killing implement, this time with a forward-leaning posture and a hand-slicing gesture, using my body in the way I used to do in my former life as a courtroom lawyer cross-examining witnesses. “I would have used a gun,” Marcus explains. Silence, for two beats, and then he adds, “If I had a gun.” He taps the wound again. “All I had at the moment was a knife. So I. . . .” He falters in his speech, as he often does.

“So you used it,” I say to complete Marcus’s sentence. He nods. “Small wound,” I add. “Scary, but small.” He shrugs. He tells me he doesn’t want to talk about it anymore and I tell him sure, no problem.

Do It Day

A week passes and I visit Marcus again, this time to prepare him for discharge. But first I have to make a judgment—can Marcus leave this place?

“Look, Marcus, you keep talking about killing yourself and sometimes you do stuff like—hell, you know, you cut your throat, for Christ’s sake.”

Marcus interrupts me. “Yeah, and I wouldn’t be here right now if I had a gun around. I woulda killed myself a long time ago. I woulda killed myself a lot of times.”

“Yeah,” I say, holding back a laugh. I guess I’m not too successful because Marcus asks me, with a stupefied look, what’s so funny? And I tell him nothing and he insists that he wants to know so I tell him it’s just the shit you say, Marcus, and he asks me what shit? and I tell him you just say funny shit sometimes and the fact that you don’t know that it’s funny just makes it funnier. Marcus shrugs and he smiles wanly. That’s my cue to push forward and quit the banter.

“Anyway,” I say in a low register, “I get that you always think about it. But let’s talk about doing this whole thing right.” Marcus perks up. His lips separate and form an oval. “First off, let’s set a date. No messing around. Let’s write it in your calendar.” Marcus has a paper calendar taped on the wall near his bed. We go back and forth about a suitable day to “do it” and Marcus keeps saying this is ridiculous, it’s fucking ridiculous and I keep countering no it isn’t, we need to do this right, and then he says stop messing around, Dan, and I tell him I’m very serious right now. It’s early April and we discuss Memorial Day as “Do It Day.” Marcus keeps repeating this is ridiculous, fucking ridiculous, and then—

Paradoxical Intention

Paradoxical intention is what Victor Frankl called it in his book, Man’s Search for Meaning. The fundamental idea is that of going towards, rather than away from, the peril, the darkness, the pain. Resistance and evasion prolong and intensify suffering; healing is predicated on overcoming. Still, ushering a client towards the distress is frightening, which is probably why Frankl’s paradoxical intention is most often restricted to treating garden-variety phobias. I don’t use Frankl’s technique in any formalistic way. I use it more by happenstance because it accords well with my Zen training, which in turn harmonizes with my therapeutic orientation towards existentialism. That probably explains why I am not frightened to use it with Marcus. My time in a Zen monastery was replete with exercises in paradoxical intentionality, largely invoked to lighten the practitioner’s attachment to “self.”

He relents.

“What difference does it make?” he says, clearly exhausted by the rapid banter. “Let’s make it Memorial Day then.”

I ponder that date, staring at the calendar. It’s a free calendar with a Walgreens logo and a photo of two youthful faces, white male and black female, bearing happy smiles, the cliché image of human joy and social progress. “No, not then,” I say.

“Why not?” Marcus asks.

““You should have one more summer before you call it quits. It’d be stupid to waste a summer, get what I’m saying?””

“No, I don’t.” He starts to rise off the bed. “C’mon, let’s get me signed outta here. That’s that, huh?”

“Summer! Dontcha want one more summer?”

Marcus considers my expression. I feel exuberant, like I’m proposing something wild and fun, maybe even sinister. “Yeah, you’re right,” he says gamely.

“That’s the spirit. Live it up and then do it on Labor Day.” I reach over and pull the calendar off of the wall. I find September and I write “The End” in the little box for Labor Day. Marcus is looking at me with electric eyes. “But here’s the deal, Marcus. I’m serious about this, so listen to me.” I pause, wait for the emotional gravity of the moment to hit. “You can’t back out of this. If you are feeling then what you are feeling now and like you’ve felt in the past, then you have to make Labor Day the last day of your life.”

He nods but I can tell he’s puzzled and yet interested in this therapist-led madness. I tell him we are going to designate a place for The End but that we’re not going to do that now because it’s worth thinking hard about since it’ll be a really important event and we need to treat it as such. I insist that he promise me that he will not harm himself in any way before Labor Day.

“Understand, Marcus? You need to promise me that.” I get him to promise. “But there’s one more thing, Marcus.” I say this solemnly.

“What’s that?”

“This is crucial. This is the key to the whole deal.”

“Fucking what?” Marcus is no longer slouching. He stopped slouching several minutes ago but I’m noticing it now.

“You only get to do it—it’s only The End—if you live it up this summer. You have to go to the beach, like, every day. You have to ask women out and not give a rats-ass if they say no. You have to . . . you know . . .”

“Get laid?”

“If that makes you happy. And I want you to go to the library and go on the Internet and make a reservation for a campsite in August.”
“I love camping,” he says.

“I know, Marcus. You’ve told me that before. That’s why I’m telling you now—I’m telling you, you hear?—to reserve a campsite.”

“Willya come out? To the campsite, I mean.”

“Sure,” I say hastily. I grab his knees, squeeze them together. “Listen to me, man. You have to live it up this summer and then you can do it on Labor Day. You must do it on Labor Day.” I let go of his knees and lean back in my chair. “Unless, of course, you aren’t depressed anymore like you are now.” Marcus picks up the calendar from the floor where I dropped it. He studies it. “Deal?” I say.

“Deal,” he says.

We shake on it. Then I leave the room and return with a legal pad. Marcus asks me what I’m writing and I tell him I’m writing an “Odysseus agreement.”

“What’s that?”

“It’s a thing you sign. It’s your signed promise not to harm yourself, and if you do feel like you’ll harm yourself, you’re promising here that you won’t, that instead you’ll call nine-one-one or somehow, someway, get yourself to the hospital.”
“What’d you call it?” he asks

“An Odysseus agreement is what it’s called.”

“A what?”

“Hey, Marcus, what does it matter? Let me write this and you sign it. Okay?”

“Yeah, okay. So that’s that. But what’s with the name?”

“Marcus, lemme write this,” I protest. “Sooner we do this, sooner we get you signed outta here. That’s what you want, right?”

“Yeah, but what’s this Odys thing? Never heard of that word.”

“O—dyss—e—us,” I say, as I put the pad and pen on the floor. I explain to Marcus, because he really wants to know, a bit about the Homeric poem, The Odyssey—about the gore and blood-thirsty violence, about vengeance and honor, and I tell him that back then, in ancient Greece, they valued things differently than we do nowadays. Heroism, courage, unflinching acceptance of death. “Back then, to be respected and to have self-respect, you had to have conquered your fear of death.”

“Sounds like The Gladiator,” Marcus says, referring to the Russell Crowe movie.

“Yeah,” I say, “the Greeks influenced the Romans.”

“So why is this thing you’re writing called what it’s called?”

Odysseus, the hero in Homer’s classic, requested to be tied down to the ship’s mast because he couldn’t trust his ability to withstand the call of the Sirens. I explain the whole scene to Marcus and he gets it.

“Oh. So, signing this piece of paper, that’s like you tying me down to a pole on the ship.”

“Exactly.”

He laughs. Not a chuckle, but a real laugh. “Go on, then. Write it and I’ll sign it. That’s that.”

Postscript

Marcus is still alive. He discovered that “living it up” isn’t as easy as one might think. Working with Marcus reminds me how difficult being easy-going actually is. Giving oneself permission to live life with ease, free from attachments to our dramas, is something that requires patience and practice. Permission-giving has been the therapeutic project preoccupying me and Marcus, once the Labor Day moment passed, with Marcus telling me, “I’m game to keep going.” Physical challenges continue to get him down—structural damage to one knee, a bad back—but he has become more resilient, largely because he takes fewer things personally. The sessions following those described in the essay—sessions where he was encouraged to “live it up” before following through on his determination to “end it all”—led him to a realization that treating life as an obligation only intensifies suffering. Our slogan these days: Nothing matters, but everything is honored.
 

Creatures of a Day

Posted on by Psychotherapy.net Team

The following is excerpted from Irvin Yalom's new book, Creatures of a Day: And Other Tales of Psychotherapy, with permission from the author. Available from Amazon.

All of us are creatures of a day; the rememberer and the remembered alike. All is ephemeral—both memory and the object of memory. The time is at hand when you will have forgotten everything; and the time is at hand when all will have forgotten you. Always reflect that soon you will be no one, and nowhere.

—Marcus Aurelius, "The Meditations"

The Crooked Cure

Dr. Yalom, I would like a consultation. I’ve read your novel, When Nietzsche Wept, and wonder if you’d be willing to see a fellow writer with a writing block.

—Paul Andrews

No doubt Paul Andrews sought to pique my interest in his email. And he succeeded: I’d never turn away a fellow writer. As for the writing block, I feel blessed by not having been visited by one of those creatures, and I was keen to help him tackle it. Ten days later Paul arrived for his appointment. I was startled by his appearance. Somehow I had expected a frisky, tormented, middle-aged writer, yet entering my office was a wizened old man, so stooped over that he appeared to be scrutinizing the floor. As he inched slowly through my doorway, I wondered how he had possibly made it to my office at the top of Russian Hill. Almost able to hear his joints creaking, I took his heavy battered briefcase, held his arm and guided him to his chair.

“Thankee, thankee, young man. And how old are you?

“Eighty years old,” I answered.

“Ahhh, to be eighty again.”

“And you? How many years do you have?”

“Eighty-four. Yes, that’s right, eighty-four. I know that startles you. Most folks guess I’m in my thirties.”

I took a good look at him and, for a moment, our gazes locked. I felt charmed by his elfish eyes and the wisp of a smile playing on his lips. As we sat in silence for a few moments looking at one another, I imagined we basked in a glow of elder comradeship, as though we were travelers on a ship who, one cold foggy night, fell into conversation on the deck and discovered we had grown up in the same neighborhood. We instantly knew one another: our parents had suffered through the great depression, we had witnessed those legendary duels between DiMaggio and Ted Williams, and remembered rationing cards for butter and gasoline, and VE day, and Steinbeck’s Grapes of Wrath, and Farrell’s Studs Lonigan. No need to speak of any of this: we shared it all and our bond felt secure. Now it was time to get to work.

“So Paul, if we may use first names—”

He nodded, “Of course.”

“All I know about you comes from your short email. You wrote that you were a fellow writer, you’ve read my Nietzsche novel, and you have a writing block.”

“Yes, and I’m requesting a single consultation. That’s all. I’m on a fixed income and can’t afford more.”

“I’ll do what I can. Let’s start immediately and be as efficient as possible. Tell me what I should know about the block.”

“If it’s all right with you, I’ll give you some personal history.”

“That’s fine.”

“I have to go back to my grad school days. I was in philosophy at Princeton writing my doctorate on the incompatibility between Nietzsche’s ideas on determinism and his espousal of self-transformation. But I couldn’t finish. I kept getting distracted by such things as Nietzsche’s extraordinary correspondence, especially by his letters to his friends and fellow writers like Strindberg. Gradually I lost interest altogether in his philosophy and valued him more as an artist. I came to regard Nietzsche as a poet with the most powerful voice in history, a voice so majestic that it eclipsed his ideas and soon there was nothing for me to do but to switch departments and do my doctorate in literature rather than philosophy. The years went by, my research progressed well, but I simply could not write. Finally I arrived at the position that it was only through art that an artist could be illuminated and I abandoned the dissertation project entirely and decided instead to write a novel on Nietzsche. But the writing block was neither fooled nor deterred by my changing projects. It remained as powerful and unmovable as a granite mountain. No progress was possible. And so it has continued until this very day.”

I was stunned. Paul was eighty-four now. He must have begun working on his dissertation in his mid twenties, sixty years ago. I had heard of professional students before, but sixty years? His life on hold for sixty years? No, I hoped not. It couldn’t be.

“Paul, fill me in about your life since those college days.”

“Not much to tell. Of course the university eventually decided I had stayed overtime, rang the bell and terminated my student status. But books were in my blood and I never strayed far from them. I took a job as a librarian at a state university where I stayed put until retirement trying, unsuccessfully, to write all these years. That’s it. That’s my life. Period.”

“Tell me more. Your family? The people in your life?”

Paul seemed impatient and spat his words out quickly, “No siblings. Married twice. Divorced twice. Mercifully short marriages. No children, thank God.”

This is getting very odd, I thought. So affable at first, Paul now seemed intent on giving me as little information as possible. What’s going on?

I persevered. “Your plan was to write a novel about Nietzsche and your email mentioned that you had read my novel, When Nietzsche Wept. Can you say some more about that?”

“I don’t understand your question.”

“What feelings did you have about my novel?”

“A bit slow going at first, but it gathered steam. Despite the stilted language and the stylized, improbable dialogue, it was, overall, not an unengrossing read.”

“No, no, what I meant was your reaction to that novel appearing while you, yourself, were striving to write a novel about Nietzsche. Some feelings about that must have arisen.”

Paul shook his head as though he did not wish to be bothered with that question. Not knowing what else to do, I continued on.

“Tell me, how did you get to me? Was my novel the reason you selected me for a consultation?”

“Well, whatever the reason, we’re here now.”

Things grow stranger by the minute, I thought. But if I were to offer him a useful consultation, I absolutely had to learn more about him. I turned to ‘old reliable,’ a question that never fails to provide heaps of information: “I need to know more about you, Paul. I believe it would help our work today if you’d take me through, in detail, a typical 24-hour day in your life. Pick a day earlier this week and let’s start with your waking in the morning.” I almost always ask this question in a consultation as it provides invaluable information about so many areas of the patient’s life. Sleep, dreams, eating and work patterns, but most of all I learn how the patient’s life is peopled.

Failing to share my investigative enthusiasm, Paul merely shook his head slightly as though to brush my question away. “There’s something more important for us to discuss. For many years I had a long correspondence with my dissertation director, Professor Claude Mueller. You know his work?”

“Well, I’m familiar with his biography of Nietzsche. It’s quite wonderful.”

“Good. Very good, I’m exceptionally glad you think that,” Paul said, as he reached into his briefcase and extracted a ponderous binder. “Well, I’ve brought that correspondence with me and I’d like you to read it.”

“When? You mean now?”

“Yes, there is nothing more important that we could do in this consultation.”

I looked at my watch. “But we have only this one session and reading this would take an hour or two and it is so much more important that we—”

“Dr. Yalom, trust me, I know what I’m asking. Make a start. Please.”

I was flummoxed. What to do? He is absolutely determined. I’ve reminded him of our time constraints and he is fully aware he has only this one meeting. On the other hand, perhaps Paul knows what he is doing. Perhaps he believes that this correspondence would supply all the information about him that I needed. Yes, yes, the more I think about it the more certain I am: this must be it.

“Paul, I gather you’re saying that this correspondence provides the necessary information about you?”

“If that assumption is necessary for you to read it, then the answer is ‘yes.’”

Most unusual. An intimate dialog is my profession, my home territory. It’s where I am always comfortable and yet in this dialog everything feels askew, out of joint. “Maybe I should stop trying so hard and just go with the flow. After all, it’s his hour. He’s paying for my time.” I felt a bit dizzy but acquiesced and held out my hand to accept the manuscript he proffered.

As Paul passed me the massive three-ring binder, he told me the correspondence extended over forty-five years and ended with Professor Mueller’s death in 2002. I began by flipping the pages to familiarize myself with the project. Much care had gone into this binder. It seemed that Paul had saved, indexed, and dated everything that passed between them, both short casual notes and long discursive letters. Professor Mueller’s letters were neatly typed with his small exquisitely fashioned closing signature, while Paul’s letters—both the early carbon copies and the latter photocopies—ended simply with the letter ‘P.'

Paul nodded toward me, “Please start.”

I read the first several letters and saw that this was a most urbane and engaging correspondence. Though Prof Mueller obviously had great respect for Paul, he chided him for his infatuation with wordplay. In the very first letter he said, “I see that you’re in love with words, Mr. Andrews. You enjoy waltzing with them. But words are just the notes. It’s the ideas that form the melody. It’s the ideas that give our life structure.”

“I plead guilty,” retorted Paul in the ensuing letter. “I don’t ingest and metabolize words, I love to dance with them. I greatly hope to be always guilty of this offense.” A few letters later, despite the roles and the half-century dividing them, they had dropped formal titles of Mister and Professor and used their first names, Paul and Claude.

In another letter, my eye fell on an important statement written by Paul: “I never fail to perplex my companions.” So, I had company. Paul continued, “Hence, I shall always embrace solitude. I know I make the error of assuming that others share my passion for great words. I know I inflict my passions onto them. You can only imagine how all creatures flee and scatter when I approach them.” That sounds important, I thought. ‘Embracing solitude’ is a nice cosmetic touch and puts a poetic spin on it, but I imagine he is a very lonely old man.

And then, a couple of letters later, I had an ‘aha’ moment when I came upon a passage that possibly offered the key to understanding this entire surreal consultation. Paul wrote, “So you see, Claude, what is there left for me but to look for the nimblest and noblest mind I can find. I need a mind likely to appreciate my sensibilities, my love of poetry, a mind incisive and bold enough to join me in dialog? Do any of my words quicken your pulse, Claude? I need a light-footed partner for this dance. Would you do me the honor?”

A thunderclap of understanding burst in my mind. Now I knew why Paul insisted I read the correspondence. It’s so obvious. How had I missed it? Professor Mueller died fifteen years ago and Paul is now trolling for another dance partner! That’s where my novel about Nietzsche comes in! No wonder I was so confused. I thought I was interviewing him whereas, in reality, he was interviewing me. That must be what is going on.

I looked at the ceiling for a moment wondering how to express this clarifying insight when Paul interrupted my reverie by pointing to his watch and remarking, “Please Dr. Yalom, our time passes. Please continue reading.” I followed his wishes. The letters were compelling and I gladly dived back into them.

In the first dozen letters there seemed a clear student-teacher relationship. Claude often suggested assignments, for example, “Paul, I’d like you to write a piece on comparing Nietzsche’ misogyny with Strindberg’s misogyny.” I assumed Paul completed such assignments but saw no further mention of them in the correspondence. They must have discussed his assignments face to face. But gradually, halfway through the year, the teacher-student roles began to dissolve. There was little mention of assignments and, at times, it was difficult to discern who was the teacher and who the pupil. Claude submitted several of his own poems seeking Paul’s commentary and Paul’s responses were anything but deferential as he urged Claude to turn off his intellect and pay attention to his inner rush of feelings. Claude, on the other hand critiqued Paul’s poems for having passion but no intelligible content.

Their relationship grew more intimate and more intense with each exchange of letters. I wondered if I held in my hands the ashes of the great love, perhaps the only love, of Paul’s life. Maybe Paul is suffering from chronic unresolved grief. Yes, yes—certainly that’s it. That’s what he’s trying to tell me by asking me to read these letters to the dead.

As time went on I entertained one hypothesis after another but, in the end, none offered the full explanation I sought. The more I read, the more my questions multiplied. Why had Paul come to see me? He labeled a writing block as his major problem, yet why did he show no interest whatsoever in exploring his writing block? Why did he refuse to give me details of his life? And why this singular insistence that I spend all our time together reading these letters of long ago? We needed to make sense of it. I resolved to broach all these issues with Paul before we parted.

Then I saw an exchange of letters that gave me pause. “Paul, your excessive glorification of sheer experience is veering in a dangerous direction. I must remind you, once again, of Socrates’s admonition that the unexamined life is not worth living.”

‘Good going, Claude!’ I silently rooted. ‘My point exactly. I identify entirely with your pressing Paul to examine his life.’

But Paul retorted sharply in his next letter, “Given the choice between living and examining, I’ll choose living any day. I eschew the malady of explanation and urge you to do likewise. The drive to explain is an epidemic in modern thought and its major carriers are contemporary therapists: every shrink I have ever seen suffers from this malady, and it is addictive and contagious. Explanation is an illusion, a mirage, a construct, a soothing lullaby. Explanation has no existence. Let’s call it by its proper name, a coward’s defense against the white-knuckled, knee-knocking terror of the precariousness, indifference and capriciousness of sheer existence.” I read this passage a second and third time and felt destabilized. My resolve to posit any of the ideas fermenting in my mind wavered. I knew that there was zero chance that Paul would accept my invitation to dance.

Every once in a while I looked up and saw Paul’s eves riveted on me, taking in my every reaction, signaling me to go on reading. But, finally, when I saw there were only ten minutes left, I closed the folder and firmly took charge.

“Paul we’ve little time left and I have several things I want to discuss with you. I’m uncomfortable because we’re coming to the end of our session and I’ve not really addressed the very reason you contacted me – your major complaint, your writing block.”

“I never said that.”

“But in your email to me you said … here, I have it printed out…” I opened my folder but, before I could locate it, Paul responded:

“I know my words: I would like a consultation. I’ve read your novel, When Nietzsche Wept, and wonder if you’d be willing to see a fellow writer with a writing block.”

I looked up at him expecting a grin but he was entirely serious. He had said he had a writing block but had not explicitly labeled it as the problem for which he wanted help. It was a word-trap and I fought back irritation at being trifled with. ““I’m accustomed to helping folks with problems. That’s what therapists do. So one can easily see why I made that assumption.””

“I understand entirely.”

“Well then, let’s make a fresh start, ‘tell me, how can I be of help to you?’”

“Your reflections on the correspondence?”

“Can you be more explicit? It would help me frame my comments.”

“Any and every observation would be most helpful to me.”

“All right.” I opened the notebook and flipped through the pages, “As you know, I had time to read only a small portion, but overall I was captivated by it, Paul, and found it brimming with intelligence and erudition at the highest level. I was struck by the shift in roles. At first you were the student and he the teacher. But obviously you were a very special student and within a few months this young student and this renowned professor corresponded as equals. There was no doubt he had the greatest respect for your comments and your judgments. He admired your prose, valued your critique of his work, and I can only imagine that the time and energy he gave to you must have far exceeded what he could possibly have provided the typical student. And, of course, given that the correspondence continued long after your tenure as a student, there is no doubt that you and he were immensely important to one another.”

I looked at Paul. He sat motionless, his eyes filling with tears, eagerly drinking in all that I said, obviously thirsting for yet more. Finally, finally, we had had an encounter. Finally, I had given him something. I could bear witness to an event of extraordinary importance to Paul. I, and I alone, could testify that a great man deemed Paul Andrews to be significant. But the great man had died years ago and Paul had now grown too frail to bear this fact alone. He needed a witness, someone of stature, and I had been selected to fill that role. Yes, I had no doubt of this. This explanation had the aroma of truth.

Now to convey some of these thoughts that would be of value to Paul. As I looked back on all my many insights and at the few minutes remaining to us, I was uncertain where to begin and ultimately decided to start with the most obvious: “Paul, what struck me most strongly about your correspondence was the intensity and the tenderness of the bond between you and Professor Mueller. It struck me as a deep love. His death must have been terrible for you. I wonder if that painful loss still lingers and that is the reason you desired a consultation. What do you think?”

Paul did not answer. Instead he held out his hand for the manuscript and I returned it to him. He opened his briefcase, packed the binder of correspondence away, and zippered it shut.

“Am I right, Paul?”

“I desired a consultation with you because I desired it. And now I’ve had the consultation and I obtained precisely what I wished for. You’ve been helpful, exceedingly helpful. I expected nothing less. Thank you.”

“Before you leave, Paul, one more moment, please. I’ve always found it important to understand what helps. Could you expound for a moment on what you received from me. I believe that some greater clarification of this will serve you well in the future, and might be useful for me and my future clients.”

“Irv, I regret having to leave you with so many riddles but I’m afraid our time is up.” He tottered as he tried to rise. I reached out and grabbed his elbow to steady him. Then he straightened himself, reached to shake my hand and, with an invigorated gait, strode out of my office.


 

Gary Greenberg on the DSM and Its Woes

Posted on by rezendevknowfully.com

The Book of Constructs

Deb Kory: Gary Greenberg, you are a psychotherapist and a writer, author of Manufacturing Depression: The Secret History of a Modern Disease and, most recently, The Book of Woe: The DSM and the Unmaking of Psychiatry, from which we’re featuring an excerpt to go along with this interview. You’ve written for Mother Jones, Harper's, Rolling Stone, The New Yorker, The Nation, and McSweeney's to name a few. In these books you've taken on the mental health industry, psychiatry, pharmaceutical companies, and the culture they have created. Let's start with your most recent book, The Book of Woe. Why did you decide take on the DSM?
Gary Greenberg: Well, I actually didn't decide. I was happily ignoring the whole thing and knew what any person scanning The New York Times would have known until I got a phone call from Wired magazine asking me if there was something about the DSM that might be worth their while. At the time I was sort of aware that there was this rebellion at the top within the American Psychiatric Association—that the guys who had done the DSM-III and the DSM-IV were really unhappy about the DSM 5—and so I started looking into it and realized that their complaints were really about the nature of psychiatric diagnosis. That interested me and I told the magazine I would write the article. I've been thinking and living in this whole set of questions for many years, and it didn't seem all that remarkable to me, but the reaction I got from people who I thought would have also seen it as old hat was pretty strong, so the decision that I made wasn't to go out after the story, but having gone after the story I decided to feed the curiosity of the people who responded to it. In particular because everybody grouches about the DSM.
DK: It’s kind of a monstrosity. Unwieldy on so many levels.
GG: Nobody likes the DSM, including, for the most part, the psychiatrists who author it—but also therapists, clinicians, researchers and academics too.
Nobody likes the DSM, including the psychiatrists who author it.
And when you look into what people object to, a lot of their objections are—I don't want to sound haughty—but they're uninformed. There's an understandable, and for the most part accurate, instinctual objection to the whole idea of it. So I thought it would be interesting to do with the DSM something like what I did with Manufacturing Depression, which was to explore it as an instance of a problematic mental health culture.
DK: It seems like sort of the same book written from a different angle, where you're deconstructing the way that we think about mental health and disease, and taking on two of its principle constructs: depression and diagnosis. One of the things I've heard you say is that the DSM is a book of constructs, not of real entities. Can you explain what you mean by that?
GG: Whether it’s correct or not, in medicine real entities are those that have a biological basis, where you can find the causes and the boundaries of a disease through biochemical means, whether that's by culturing tissue, or looking under a microscope, or doing a blood test, or whatever it is you do. The problem with mental illness, or with psychological suffering in general, is that it's very difficult to come up with those biochemical assays. In fact, I shouldn't say, “very difficult,” but rather, “at this point, impossible.”
DK: Because?
GG: Mostly because the brain is so seemingly infinitely complex and the tools that we have for understanding it are comparatively crude. And if you pay attention to neuroscience, the field changes dramatically all the time. It's a moving target.

So you don't really have the basis for understanding mental illness in terms of real entities in that respect. On the other hand, for many different reasons, there is a strong need to have those entities. From the political and ideological having to do with the authority of medicine, right to the most practical having to do with how society decides to ration its health care resources, and everything in between. The way that psychiatry has bridged that gap is by using the rhetoric of science to create a DSM without ever being able to say that those scientific sounding categories are truly scientific. In other words, you can create the construct and then build all sorts of science around it.
DK: From inside it makes perfect sense.
GG: Right. But so does schizophrenia. And this is a problem with all ideologies. If you accept their basic premise, then everything else makes sense. In scientific methodology this is known as the validity problem. None of the categories in the DSM are valid, and that becomes a problem particularly because once you use that rhetoric it is inevitable, inescapable, that the categories will become reified, meaning that people will take them as real, and they'll use them as real, and they will become the basis for all sorts of political, economic, and individual decisions based on their reality.

One of the things that you find when you talk to the people who make the DSM is they're all really smart—well most of them are really smart people—and they're quite capable of understanding and appreciating the problem that we're talking about. But they have trouble taking account of the fact that the reification is a problem for everyone, not just for the professionals.
DK: Say more about that.
GG: In other words, they're happy to say to you, “Yeah, I understand that. We all know these are just constructs,” as if their knowing it is enough. But what that really means is that they don't want everybody else to know.
DK: Because it confers power on them?
GG: Right. It's the problem of the noble lie. Actually, I think that the best example isn't really the noble lie as Plato saw it, because that's a more complex topic. It’s more like what the Grand Inquisitor presents to Ivan Karamazov [from Dostoevsky's The Brothers Karamozov], which is that, “We in the Grand Inquisitors coterie, we know this stuff and nobody else needs to know, and in fact we're using our knowledge to help people.” That's exactly the pitch that the Grand Inquisitor uses to justify what he's doing to Ivan Karamazov.
DK: That power dynamic does a lot of harm.
GG: Of course. Power unquestioned is always a problem, and the problem is always damaging to the people that don't have it.
DK: If I were to draw your work together thematically, it seems to be challenging power in its various manifestations. You’re also a journalist and have obviously written widely on a variety of topics, but because you're a psychotherapist, you’ve taken on its institutions of power.
GG:
Power unquestioned is always a problem, and the problem is always damaging to the people who don't have it.
I think that's an interesting point. I think that's true. I don't think any of that is particularly conscious. I imagine that’s why I chose these professions—they both try to unearth power relations in one way or another, and claim, anyway, that that's the truth that they're uncovering.
DK: But they reify that power at the same time that they are claiming to unearth it.
GG: In what way?
DK: I'm thinking more of psychologists and psychotherapists than journalists, though the claim could be made for them too. There is a power dynamic in the therapy relationship that I think we are often unwilling to recognize. They come to us, they pay us, they have all kinds of transference reactions to us that we help them “work through” while we choose to reveal those aspects of our internal experience we think might be helpful to them. Having gone through the medical system I think psychiatrists are much more clear about their power in relationship to “patients,” whereas many psychotherapists are not. You take on psychiatry a fair amount but haven’t necessarily gone after psychotherapists.
GG: Well, the only direct approach I make to that question is my critique of cognitive-behavioral therapy.
DK: Talk about that.
GG: Do I have to?

The Problem of Piety

DK: Well, you don’t have to but I think it might be interesting to our audience.
GG: Cognitive-behavioral therapy is an ideology of optimism that is used by therapists to induct people into a more genial understanding of their lives and their circumstances. It's in some ways the diabolical twin brother of Freudian psychoanalysis, in that it trades on optimism rather than pessimism. CBT believes in the perfectibility of the human as opposed to the depravity of the human. It posits, without saying so, a benevolent universe, which is the opposite of what Freud thought.
DK: Is it their certainty that you have a problem with? You seem to wrestle with the notion of certainty a fair amount in your writing.
GG: Well, piety is a problem. Ask the people at Charlie Hebdo. If power is the general preoccupation of my books, piousness is the specific preoccupation. Unquestioned belief. For all of his problems at the granular level, at the macro level Freud was the master of ambivalence and uncertainty, and I think that there is a connection to be drawn between understanding life as infinitely uncertain—at least mental life—and the tragic sensibility.
I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life.
I think that cognitive-behavioral therapy tries to overlook, or ignore, or erase the tragic dimension of human life. So, to get back to your original question, why do I go easy on psychotherapy? Well, this is one way that I don’t go easy on it and, as you and I both know, CBT is the dominant theme of psychotherapy in this country right now.
DK: Along with “evidence-based” therapies.
GG: It links in with the evidence based therapy thing, which bleeds over into my second criticism of psychotherapy, which is that we're way too tied in to medicine. Regardless of what we individually, or even as institutions, believe about psychiatric drugs, that's not the issue. The issue is how do we get paid and how do we get our status and authority in society? When I pick up the phone and I call somebody and then say, “Hey, this is Dr. Greenberg,” I get a different response than I would if I called up and said, “Hey, this is Gary Greenberg.” I'm not averse to using that power, but I'm implicated in a whole web that I shouldn't be. That critique shows up in both of my books, where I repeatedly question the whole business of psychotherapy.
DK: These days almost everyone talks about therapy as a business.
GG: Well, you've got to make a living.
DK: True enough. But it’s disheartening to me, nonetheless.
GG: We're all doing it. You make your accommodation with it however you can. The problem, when it comes to the DSM and to the medical-model aspect of our practice is that it is so at odds with what we purport to do. If you start your therapy by giving a person a diagnosis that you don't believe in, there's no way that you can't see that as a contradiction of the terms of psychotherapy, because it's dishonest.

The Rhetoric of Disease

DK: That’s interesting. I recently had someone come in claiming to be bipolar, and I pulled out my DSM for the first time in quite awhile because, in my mind, bipolar is not something to dawdle around. It has a high suicide rate, and is one of those diagnoses we are taught is genetic and kind of untreatable without medication. How do you deal with something like schizophrenia or bipolar or autism where there's clearly a mental disorder of some sort happening, there’s a pretty compelling case for genetic transmission, etc. Is there some utility in using the DSM for something like bipolar disorder?
GG: Well, I don't know about the DSM, but I do know about the larger rhetoric of mental illness. The DSM is just the most obvious example. I believe that as symptoms get more severe, and as impairments get more severe, the justification for using the rhetoric becomes greater, because it is a rhetoric that is quite effective. For instance, the rhetoric would say, “Schizophrenia is a biological brain-based illness that is just the luck of the draw. Maybe you had some stressors, but you definitely had this serious predisposition and your brain's all fucked up and now you're going to have to manage this all your life. And the best way to manage it is with Geodon.” Or you can go farther with that. You can say to somebody, “You have to take responsibility for you who you are, just like I do. And who you are happens to be somebody with this vulnerability, and that means keeping yourself in situations that aren't likely to kindle your psychosis. It means recognizing the prodromal nature of it. It means taking medications when it seems to be necessary to keep you and the people around you safe.”

That whole rhetoric is very helpful. I believe at some point it makes sense. And I even would go farther and say that there are some psychiatric illnesses, mood disorders, certainly the autism spectrum, that really are the luck of the draw, in the same sense that type 1 juvenile diabetes is. So the best we're going to do is help you cope. And I think that the rhetoric is useful there.

The problem is that that's the model for everybody, and we have no way of determining who it is that we should consider that way and who we shouldn't. It's like not knowing the difference between who's got type 1 diabetes and who should just eat less sugar, and just treating them all the same way. That's a problem. And it's not a problem that's been intentionally created by psychiatrists. I'm not a Scientologist. I don't believe that that's what's happened here. But I do think that because of its blindness to its power—and I do hold psychiatry more responsible than the rest of us because you and I are just living off of their crumbs when it comes to this stuff—psychiatrists have failed to make those distinctions, have failed to start with the assumption that only a small minority of people who are suffering with mental illness, even severe mental illness, have that classic disease structure. Now it’s reasonable to say, “Let’s err on the side of caution.” We’re talking about serious stuff here, and it's a useful model.
DK: So you sometimes use it with your clients?
GG: I just had a patient go into the hospital because she was sure that laser beams were doing something to her bones. She was a howling, psychotic mess. She's in the hospital and I'm really hoping that one of the psychiatric drugs that they throw at her will work, because her brain's on fire. It’s a useful way to look at it in this instance.
DK: So you pull it out of your toolbox when you need it.
GG: Yes, but do we know when we should and when we shouldn't? Absolutely not. But to get back to your patient who came in with the bipolar diagnosis, you took out the DSM and then what? You never finished the story. Did you then get them to tell their history of manic episodes?
DK: I did. We went through all of the assessment and then I said, “Okay, according to this book”—I mean I literally said this—“you qualify, but I need to qualify that this book is also a load of B.S.”
GG: Yes! Now was this bipolar 1 or bipolar 2?
DK: It's still not clear.
GG: So my guess is, if somebody shows up in your office and they're basically okay, and they tell you they just got diagnosed with bipolar and you're thinking, “What?!” chances are that person is going to qualify for the bipolar 2 diagnosis.
DK: Right, with the less intense mania.
GG: It only requires hypo-manic episodes. And so what you have there is the diagnostic creep that I just outlined.
All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?”
That diagnosis just arrived in 1994. I don't know how long you've been in practice, but I've been in practice for a long time and I remember when these people started showing up in my office with their diagnoses and their anti-psychotics and their stabilizing drugs. All of a sudden there's all these people that—sure, they’re not happy, but they are not psychotic—telling me that they're bipolar and they're on Depakote and they're on Abilify. And I'm thinking, “What in the world is going on out there?” I think there's cases where that's a totally useful and justified approach, and I think there's cases where it isn't, and that's where all the trouble lies.

The Serotonin Myth

DK: In your book, Manufacturing Depression, you say that serotonin came along and seemed to make people happier and so the drug companies had to find an illness that would make people need it, right?
GG: It's not quite that conspiratorial. In the case of depression and antidepressants and neurotransmitters, it’s like strands of a braid that came together advantageously for some patients, and many doctors, and most of all for the pharmaceutical industry, which was brilliant, clever, and lucky.

I guess that's a little cynical. I have to be fair, the cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit. They knew that it was wrong, and then they did tone down the rhetoric to some extent in their advertising. The consumer advertising started right around the same time that scientifically the serotonin myth fell apart, the late 90s, but you wouldn't know that to look at the ads. That, to me, was their most egregious move.
DK: They didn't correct for it, they just took advantage of it.
GG: Exactly. They knew that if you could sell it as that kind of disease, it was so overdetermined that it would succeed and they could not resist it. You would have to be some kind of Boddhisattva of advertising to resist that temptation.
DK: A lot of people, myself included, only recently came across this information that it's really not about serotonin deficiency. We literally have no idea why they work, and for whom they work.
GG: Right. Now you say you just came across that. You're an intelligent, well-educated person with a PhD, right?
DK: Yes, but I’ve also benefited from antidepressants, so I had a little bit of denial in the game around it. I’m one of those people with a seeming genetic predisposition for depression for whom SSRI’s just helped, with no bad side effects. I thought I understood why they were helping, but it turns out no one knows yet what they do.
GG: There's two ways to look at that question of why. One of them is, do we know neurochemically what's going on and what, if any, deleterious consequences there are? And the answer to that question is no.
DK: Well, we know a little bit.
GG: We know that you're increasing the activity at certain receptor sites, including some of the serotonin receptor sites, although these drugs aren't as precise as they are sold as. And we know that serotonin appears to be associated with increase in neurogenesis. And we know that at really high doses you can see the axonal growth that appears to be the direct result of increased serotonin activity. So there's all these things that we know, but why that changes a person's mood…
DK: There's no causal correlation.
GG: Right. In order to know that you would have to have an account of how the brain produces consciousness, and good luck with that, because that's just not going to happen. So what you're left with is to say, “Okay, well this drug makes me feel better.”
The cynicism in the pharmaceutical industry didn't really start until the mid-1990s, by which time scientists knew that this whole serotonin deficiency theory of depression was bullshit.
And I don't mean that necessarily in the same way that smoking a joint or whatever makes you feel better. It just makes you feel better, and it works, and it doesn't hurt my life in any other way, and I'm going to take it. To me, anyway, the only problem I have with that approach is the same as with any drug. It's like, “Okay, well, am I hurting myself in any way?” It's the same question I have about vaporizing nicotine. Obviously, the reason that that's become controversial isn't because we know that it's bad for you.
DK: It's because we don't know that it isn't bad.
GG: No, I think it's because we are an anti-drug society, and it just makes it really clear what's going on in smoking cigarettes. People don't smoke cigarettes to get cancer. They smoke cigarettes to get high, and the vaporizer just eliminates the middleman and delivers to people the drug that they want. And in our society, unless you're on antidepressants, or happen to be addicted to caffeine or alcohol, you can't just openly say, “I'm going to do this in order to change my consciousness.”

So I think that the controversy arises because of that, and then it is also true that we don't really know the long-term effects of using nicotine—although we know enough to know that it is not carcinogenic.
DK: And we don't know the long-term effects of taking an antidepressant.
GG: Right.
DK: So how do you deal with people who come in and seem to suffer from depression—have a family history of it and display severe depressive symptoms—who then respond really well to antidepressants?
GG: The way you do with anything that you're wondering about. You just take it as it is. You support it. “Okay. So, tell me about it.” Of course, people aren't stupid, and they tend to expect, particularly from me because of my relatively high profile, that I will disapprove. So I have to spend a little time reminding them that I really don't disapprove. If they actually read what I wrote, as opposed to listening to what people say about it, they would know that. You have to start by letting them know that, for the most part anyway, it's cool with me if this is what you decide to do. But one of the hallmarks of being mature and self-possessed is recognizing that you can't have it both ways. If you want to be on drugs, you've got be on drugs, and live with whatever that means to you and with whatever the implications are. And among the things that it means to be on antidepressants, particularly long-term, is struggling with the question of what's you and what's the drug. People have these severe doubts about their functioning and about their success. There's a whole version of the imposter syndrome that goes along with being on long term antidepressants.

Does Depression Exist?

DK: Do you think depression exists? Is it real?
GG: What does that mean?
DK: Is it an actual illness? You say that it is manufactured.
GG: No, I’m saying that I’m sure there are situations, brains, people who certainly qualify. Let's say that the ability to feel depression as it's described in the DSM is heterogeneous—in other words, there are many ways to get there, both existentially and biochemically. I'm sure that's true. And let's say that some subgroup of people who qualify for the diagnosis—which is insanely broad—
DK: It covers a large swath of American culture.
GG: —nine symptoms, five of which qualify you; there's 125 different combinations to be depressed, just for starters. But let’s say some subgroup of the people that qualify are suffering from some identifiable biological fuck up, some hiccup somewhere. Or maybe more than one. And it wouldn't matter what their circumstances were, once the depression was kindled, they're screwed. Again, I don't know who they are. Nobody knows who those people are. In the meantime, the presumption is that everybody is. And that's the problem.
DK: There's not a model for the remaining majority.
GG: Yes. And I also think that the question of, “Is it an illness? Is it real?” is, in some respects, a red herring. Because why are you asking the question? What is the importance of that question?
DK: Hmmm. That’s a good question.
GG: Why does it matter to know that it is or it isn't?
DK: I guess I’m interested in how much of our internal lives are constructed by social structures and beliefs. I listened to an amazing podcast called "Invisibilia" recently, an episode entitled “How to Become Batman” where a blind guy, blind since birth, learned to “see” by using echolocation, a clicking sound with his mouth, and because his mom let him run wild and didn’t treat him like he was blind. Let him ride bikes, climb trees, fall and get hurt, all of that. Apparently his visual cortex has actually created something like sight for him. It made me think about how we are both blinded and liberated by our beliefs. So if we had an entirely different model and way of seeing depression, it could transform the world.
GG: So the reason that you're asking the question is because you see certain shortcomings, at least potential shortcomings, to understanding it as an illness.
DK: Oh, for sure, at the very least.
GG: The advantage of seeing it as an illness is that certain social resources become available to you if you see it that way. Drugs, medical care, sympathy, understanding, none of which is to be sneezed at.
It's notable that one of the major ways of getting social resources in our society is to be sick.
It's notable that one of the major ways of getting social resources in our society is to be sick.

But there are also disadvantages, as you just pointed out. If you see yourself as sick then you act sick, and if you're sick you're less empowered, maybe you're less active, maybe you take less responsibility for yourself. You cited an extraordinary example, but you're certainly not going to do that if what you decided to do is to live the life of a blind person. So, yes, there's something liberatory about it which is much more likely to be achieved if we understand illness as a contingence category as opposed to an absolute category. As something human-made as opposed to something scientific and medical.
DK: I’ve written extensively about psychologists’ complicity in torture at Guantanamo and other CIA black sites, and in researching what led to it, I found that the profession of psychology emerged out of war, has been funded in large part by the military in terms of training programs and research grants, and is thus inexorably linked to the American war machine. I haven’t had a chance to delve into the role that scientism plays in all of this—and I understand scientism to be viewing science as a religion, basically—but one of my speculations was that this desire for the profession to be perceived as a hard science, to be seen essentially as a “man among men,” was a big part of the problem. You wrote some about this in your article in Harper's, where you take on positive psychology guru Martin Seligman, whose own research is deeply embedded with the military and who coached the very psychologists who created the program at Guantanamo in his theory of learned helplessness. I'm wondering if you have any thoughts about the role of scientism in the militarization of psychology or if you see any connections between what you're critiquing in your work and what's happened with the psychology profession becoming kind of an arm of the military.
GG: Well, I think to start with, there's lots of psychologists like yourself who are appalled at that outcome, so it's pretty clear that it's not a necessary outcome. There are even psychologists who don't buy Marty Seligman's self-serving excuses for his own implication in these things. That conference that I wrote about in Harper’s took place in 2009 and the issue was still alive at the time, and Seligman had some very greasy responses to those questions.
DK: Yes, he claimed to have had no clue what they were intending, which wasn't very credible given where and when he delivered his lectures and the meetings he was involved with.
GG: But there are people who don't buy it and who are critical when these discoveries are made. But, having said that, I think your point is well taken. There is a kind of wish among all the medical health disciplines to be on the inside rather than on the outside. And whether you're on the inside by virtue of having a professional license or by virtue of having the authority to declare people mentally ill, or to get services for kids through special education, or to help the military figure out how to make soldiers resilient, I think this desire to be considered an insider can be problematic. And that in itself is complicated because sometimes it's simply wanting to make a living, or to make a decent living. Obviously, if we didn't have our professional licenses then we probably wouldn't make as much money as we do. If we didn't have our ability to bill insurance companies or, in my case, help people get reimbursed, then we would make less money. So some of it is just about that, but a lot of it is about wanting to be in the mainstream, because, like I said earlier, you can't have it both ways. If you're not in the mainstream, there are some severe prices to be paid.

A Foot in Each World

DK: Do you feel like an outsider in this profession?
GG: I have one foot in each world. Yes, I feel like an outsider in the sense that there's lots of things that I don't do that I would do if I wanted to be on the inside, like joining insurance panels and stuff like that. I probably feel better about that than I ought to though because it's not that important. It does restrict my access in some ways, but mostly what it does is restrict my income.
DK: Right, it can be a tough choice to side-step the whole insurance industry.
GG: Yes. But I'm clearly an insider in the sense that I described before. I pick up the phone and say, “This is Dr. Greenberg,” then I get somewhere on the phone tree.
DK: Do you do that with a smirk?
GG: No. I do it totally straightforwardly, because I'm just trying to be effective and that is the way you're effective. These questions can come down to a kind of moral anorexia—a sort of refusal to take in the goodies that are out there because we all know they're tainted. I think that in some ways you've got to be fair to yourself and to others and say that the life lived entirely outside is very, very difficult and in some ways less effective. There are people who I have helped not by virtue of my education, or my training, or my insider-ness, or my license. It is something inherent to those that have allowed me to help them, but my availability to them, even if it's not about money, just the fact that I'm out there and legally practice my trade, just the fact that I'm available to them is what made it possible for me to help them.

The Writer as Therapist or the Therapist as Writer?

DK: I also was a journalist before becoming a psychotherapist, and I tend to come at things with a critical point of view, and I often have the experience of being critical of the “profession,” of training programs, of the way that we organize—and don’t organize—around issues of justice, etc. But at the same time, I simply love the work, itself, with clients and some of my very best friends are therapists. I feel like I’ve got a real love-hate relationship with the profession that I haven’t fully worked out yet.

One of the reasons I’m so interested in your work is that you seem to be able to traverse both worlds—to be a writer, and to write honestly and critically and self-revealingly about the profession while still very much being in it. Do you see the writer in you and the psychotherapist in you as fundamentally complementary? Do they ever come at odds? Do you ever not write about things because you're worried about your clients?
GG: In both of the books that we've been talking about, I write a little bit about my actual practice, but I hate doing it. I would not be disappointed if I never did it again. I don't know if that's a principled stand—I just don't like doing it. I think it's really hard. I don't know if you ever saw the TV series “In Treatment.”
DK: Yes, I loved it. It rankled me, but I loved it.
GG: That was the most realistic handling of psychotherapy ever, that I've seen, in the mass media—and it was boring. Nothing happens.
The person that I am as a therapist is not someone that I want to write about.
I mean, it's okay with me, I was interested in it, but I don't think it did well because it's just day-to-day what goes on in therapy. It's really hard to write about. There are some people who can pull it off nicely, like Irvin Yalom, but for me anyway, the person that I am as a therapist is not someone that I want to write about.
DK: What do you mean?
GG: If someone comes into my office for therapy, I feel like it's a total breach to write about them, even if I ask for permission. Even if I disguise them. That's how I feel about it, having done it now a few times. The Book of Woe went through a very, very extensive legal review and the case material was altered to the point that it was no longer factual. It was really fiction, and if I'm going to write fiction I should write fiction. I really believe that. I don't know that a reporter has any obligation, or even ability, to be objective, but to intentionally make shit up? If you’re going to make it up, make it up. If you're not going to make it up, don't. And if you can't write about it without making it up, don't write about it.
DK: Do you feel like you have to sort of forget about your therapist self when you're writing? Are you split off in some way?
GG: I guess so. I never really thought about that. No, I would say it’s the other way around. I have to forget about my writer self when I'm doing therapy. I can't really think about myself as a writer when I'm working with people. Once in a while something so fascinating occurs, so remarkable that you picture yourself writing about it, but in general therapy is something that I go and I do, and it's a performance—and I don't mean that in a cynical way—it's a thing that I do. But the writing draws on all of me in a way that the therapy doesn't.
DK: So do you feel you are more of a writer than a therapist?
GG: I guess so. I never really thought about it before. There's something that I do as a therapist—there's a way that you use yourself, and all of you has to be available to yourself. But you also as a therapist have to bracket certain things.
You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient.
You have to look at the fact that you want to write about somebody, and that has to be just as subject to scrutiny as your desire to have sex with your patient. It's like, “Okay, yeah, that's something that I feel, and I've got to figure it out, and I've got to deal with it here.” But I can't take it for granted any more than I can take it for granted if I had a sexual impulse, or some strong negative reaction to somebody. Whereas with writing, that's a whole different kind of discipline, where you have to take whatever it is and transform it into words.
DK: You aren't thinking, “What if Sheila reads this?” when you write?
GG: No. I probably should, but I think if I did I wouldn't be able to maintain both disciplines, because people actually do read my writing.
DK: And they come in to talk about it sometimes?
GG: Oh yeah. Sometimes they do. I've got a relatively wide readership, but I'm certainly not a famous writer, and therefore most of the people that I work with may not even know that I have a writing career.
DK: So you don't bring it in.
GG: No. I don't bring it in at all. My books aren't in my office. I don't mention it.
DK: Do you feel like it would be an intrusion?
GG: Yeah, of course. I don't talk about the argument I just had with my son either. Actually, there are situations in which I might talk about writing, but it very much depends. I see people who are artists or writers, and with those people I do sometimes bring it in.
DK: That’s interesting. I'm struggling with my identities in a way that it sounds like you haven't and don’t. You just write, and you're not tormented about it.
GG: Well, I was doing therapy for many years before I got into writing.
DK: Well this has been a fascinating interview. Thank you so much for your time.
GG: Thank you.

Psychotherapy and the Care of Souls

Posted on by Psychotherapy.net Team

To Serve the Soul

In Greek mythology, the wise healer and teacher Cheiron is part horse and part human, a centaur of sorts, but quite different from his wild and hardly civilized half-horse/half-human brothers. He did his work of healing and teaching in a cave. As a therapist, I sometimes think of myself as part animal, sitting in my cave, dealing with primal aspects of human existence, barely able to distinguish healing from teaching.

The modern therapist seems to think of the problems that come to him or her as deviations from the standard of normalcy and health. The point is to restore a person to a point where the presenting symptoms have been removed, as if by psychological surgery. I don’t see it that way. People come to me because deep down they can’t experience the joy of being who they are. They don’t feel in the positive flow of life. They may feel stuck in some repeating pattern that seems to go back far into their history. They may be focused on, or better, mesmerized by some symptom like an obsession or paranoia or anxiety. Generally, it’s the nature of life to flow, like a river, and not to be stuck or stopped.

Whenever I want to get on track with my work as a psychotherapist, I think back on the word. It is made of up two key Greek terms: psyche (soul) and therapeia (serve). “Psycho-therapy” means “to serve the soul.” Psyche is not mind or behavior, and therapeia does not mean healing or making better. I always keep in mind that my job is to serve the soul, or care for it. When I used an ancient phrase, common in Platonic literature, as the title of my most popular book, Care of the Soul, I was simply putting the word “psychotherapy” into English.

I think of the soul as the life in us that is immeasurably deep. Sometimes it feels like a spring or font of existence, making us feel alive and giving us something of a direction and identity. To a large extent it is autonomous, having its own purposes, desires and intentions. When you delve deep into it, you encounter basic human themes and patterns, what Plato and Jung and others call “archetypes.” The need for love, the desire to create, the comfort of home, the excitement of travel—these aren’t the characteristics of any particular person. They are, at least potentially, ways in which all people may experience life.

When these archetypal patterns come to life in a person, they usually have a strong force and allure. You are happy to be in love and can think of nothing else. You fear illness and death, and that emotion, with its clinging thoughts, gets hold of you. You glimpse a certain career, and you go after it with a passion.

Soul is intimate, embedded in life, vital and energetic. It seems to constantly want more life and vitality and therefore can be a threat to the status quo. “As you tend your soul, you may try to sense what it needs and wants, and you may discover that its needs may not dovetail with your own wishes.” In that spirit, the Irish poet W. B. Yeats said that his poetry came out of a tension between his own ideas and those of an antithetical self he felt inside him.

As I see it, this other being in us, the soul, is vaster than our small minds can contain. It’s strong and mysterious, and at times a true adversary. Our job is to get to know the soul and cooperate with it, understanding that our happiness and peace on earth depends on a positive and creative response to it. Psychotherapy may entail simply living in a way cognizant of the soul and its purposes.

Soul offers a deep and powerful sense of identity that counters any tendency to be caught in the limited understandings and values of the family or the culture. It asks that we each become individuals, not so identified with the structures around us. This need is so strong that I imagine it in the familiar imagery of rebirth: we are born into biological life and culture, and then we have to be born again into our own individuality and uniqueness. Along with Socrates, I would describe psychotherapy as a kind of maieutics, or midwifery. We have to assist at the birth of the soul into life, which implies the arrival of a unique person. Socrates said: “My concern is not with the body but with the soul that is in the travail of birth” (Theatetus, 150 b).

The Travail of Birth

The travail of birth is exactly what happens in therapy, to one degree or another. Travail means labor, but I see it more as a process. In formal therapy you reflect openly and seriously on the past, on dreams, on emotional difficulties, on relationships and a number of other issues, the material of a life, and process them. As you look more deeply and imaginatively at them, you see better what wants to be born and what hinders the birth. For many people, early traumas and bad parenting and unfortunate adult influences and threatening injunctions keep their longstanding hold and stand in the way of the soul’s movement into life.

Years ago I read the religion scholar Mircea Eliade’s unsettling description of a primitive rite of passage, and it has stayed with me. Young people would be placed in the earth, naked, perhaps under a pile of leaves, overnight or for several days, within a ritual context of masks, drums, body paint and dance. Then they’d be taken out and washed and clothed, adults now and fully part of the community.

I see therapy along these lines. “To be born into your individuality is no light matter. You need an impressive experience of death and rebirth.” Most of the time a real and transformative round of therapy is a step-by-step process of being reborn. The therapist is the elder in charge of the rite, but he or she is only the guide, not the healer. The point is to arrange an effective rebirth, letting the person then go on to discover his life. The therapist does not decide what life is best for the person, whether to be more dependent or independent, emotionally contained or effusive, whether to be married to a different person or to live somewhere else. The therapist doesn’t know what is best for the person, he or she can only assist at the birth of the soul.

Above all, a therapist needs purity of intention, the capacity to hear stories of suffering without responding unconsciously out of his own prejudices. A therapist has to know himself so well that he will pass on any temptation to engage in his own typical reactions. He will not take credit for any progress, and in fact will not think in terms of progress, but only care. Care is not heroic, it isn’t getting anywhere and it has no need to solve problems. A good therapist doesn’t see life as a problem to solve but as a gift to be observed closely and supported.

A therapist will not be deluded by the delusions of his patient. He will not be taken in by any loose complexes in his patient that try to trip up the therapist. If a patient says, “You haven’t given me your full attention today,” a good therapist won’t defend or explain himself. He might simply say, “You’re right. I’m preoccupied with my own situation today. Let’s start again.” He will not feel the guilt the patient wants him to feel and will not accept any adulation the patient tosses his way. Both are traps. He is neutral, not willing to get pulled away from his center by a patient’s neurotic need. In the face of sober and heavy influence, he may find neutrality in lightness of spirit and good humor. He may laugh easily but never sardonically.

Overcoming Our Complexes

A good therapist has moved past his need to help. While it’s true that doing therapy is being in therapy—the therapist may work through some of his own issues while being with another—the therapist is also neutral about his life work. He is not thrown when a patient doesn’t respond well to the therapist’s ideas and efforts. He doesn’t himself need a patient to get better or to go through the therapeutic process the way the therapist thinks is best. The therapist surrenders any pet enthusiasms, such as hoping that his patient will become more independent, artistic, self-aware, or emotionally expressive.

This neutrality is not indifference but an achievement in the therapist’s own opus, the work of his soul. He is not led on by his complexes in relation to his patients, the deeper meaning of the interesting classical notion of counter-transference. He is not at all perfect, but he is not acting out with his patients. He has an unusual degree of self-possession. He can reflect effectively on his own allegiances, philosophies, theories, techniques and ideals. He has developed his own approach and is not completely identified with a given figure in psychology or with a special theory.

A therapist also has to know how to deal with complexes of the people he assists. Jung described a complex as a sub-personality. I would put it differently: a complex has a face. Acting out a complex is like putting on a costume, though you don’t know that you’ve put it on. These figures of the deep psyche that take over a person, like Dr. Jekyll swamping Mr. Hyde, are unusually intelligent, convincing and full of shadow.

A person with a mother complex may strike you at first as being caring, thoughtful and capable of deep emotion. Only later do you see that this figure, this daemonic possession, dominates the person and may suffocate and overpower others who come into its domain. A mother who is atrociously critical of her daughter may believe that she is only doing what is best. Others may tell the daughter how lucky she is to have such a wonderful mother, and the daughter is thrown into painful confusion. Should she be grateful, or should she run away?

The therapist has to deal cautiously with the complex that enters his consulting room. He must not get caught, but that kind of neutrality is not easily achieved. He may be especially susceptible to certain complexes and not see them for what they are.

Complex is not the best word, perhaps, but it is traditional and important. A complex is more like a powerful presence that can assume the cohesion of a personality, although sometimes it is only an urge or an impulse. It can completely overwhelm a person or it can be merely an influence. In any case, a therapist needs courage and circumspection to deal with one, whether in his patient or in himself.

Religious traditions teach as much about these presences as psychology does, and it might help a therapist to do some study in religions and even see his role as being both psychological and spiritual. Religion specializes in rituals that help us meet the complexes in highly symbolic ways. In traditional Catholic confession, for example, you acknowledge dark spirits that invade your life, and the confession of these presences goes a long way toward dealing with them.

Personally, I have cultivated powers of intuition, skill at working with images, and knowledge about traditional spiritual rites and images so I can be prepared for images people use in telling their life stories and reporting their night dreams. I have drawn on the model of C. G. Jung, who was concerned both to be an intelligent, rational thinker and researcher and at the same time to go to great effort to employ the non-rational methods of the spiritual traditions. He was a stone-cutter, calligrapher, painter, and architect in his own way, making his personal environment link closely with his inner life.

Guide of Souls, Leader of Rituals

My mentors—Jung, James Hillman, and Rafael Lopez-Pedraza—have emphasized the role of the mythic Hermes in the work of therapy. Jung said that the work or opus begins and ends in Mercury (the Roman name for Hermes). This means that in this work you have to be imaginative, clever, quick-witted and skilled with language. You appreciate paradoxes and apparent opposites. You see past and through any material that is presented, and you go beyond the modern notion of the highly educated, trained expert. You need a deep and probing appreciation for the intricacies of the psyche, and your preparation has to be both scholarly and personal.

I have a deep appreciation for the work of therapists and I honor and support any therapists I meet. They have a key role in modern life as they address matters of the soul and spirit. In some ways they are the modern priest, priestess, guide of souls and leader of ritual. Their work is challenging for all its depth and mysteriousness, but it is equally rewarding precisely because it goes so deep.

But some therapists make a mistake in thinking of their position as one of a trained advice-giver or aid to adjustment and smooth living. Their job, rather, is to be courageous enough to face the demons with their patients and get tangled in the complicated mysteries of a human life. To do their job effectively, they need to know depth psychology, philosophy, solid religious thought and art. They should be at home with dreams and extraordinary fantasies. They should be able to see through aggression and masochism to glimpse the positive mysteries trying to be expressed and lived.

This kind of therapist has thought deeply about the mysteries of human personality and doesn’t reduce them to simple patterns. Throughout his life and career this therapist continues to explore complex matters, prizing any resources that help, and faces his own complexes. He is always on the border, Hermes-like, between the inner and the outer, the personal and the universal, ordinary life and the sacred, and the surfaces and the depths. He is shaman-like, able to traverse levels of reality and experience. He has adapted to the mysterious nature of his work by being himself a mysterious person, not too easy to read and comfortable being neutral in the face of another’s passion.

The Cheiron therapist works in a cave, a place set apart from the normal way of seeing things. He needs a lot of animal in him to sense the many messages from his patient and from within himself. He has to take on the mythic dimensions of a centaur because work with the soul is too much for the human mind. “The therapist is willing to be bigger than life and almost other than human, a person of huge imagination, able to hold almost any manifestation of human struggle.” He has to be naturally religious, in the sense of honoring the natural life flowing through himself and his clients and responding effectively to the great mysteries that only the best art and religious forms have been able to grasp. He is a person able to contain the immense joys and sorrows that visit every human life. And all of this in an ordinary person, humble in the best sense, in love with life and able to love those in distress. It’s a wonderful calling and a grace to those who accept it.

Thomas Moore on the Soul of Psychotherapy

Posted on by rezendevknowfully.com

Therapy Isn't Healing

Deb Kory: Thomas Moore, you are a writer, a theologian, a psychotherapist, a musician, a former monk, and a professor. You lecture widely on incorporating aspects of the soul into daily life, and have written many books on the subject, including the bestseller, Care of the Soul. You've just released a book called A Religion of One’s Own, which seems in part intended to bring meaning back to the word and to argue against the secularization of modern life. Since our audience is primarily psychotherapists, I'd like to first ask you about psychotherapy: How you define it and what role do you see it playing in bringing soul back into the world, and into your clients?
Thomas Moore: I go back, as I always do in my books, to etymologies. I like to think about how people first thought about the use of the word since the very beginning. The word therapy has been around for a couple of thousand years at least, and originally among the Greeks it meant to care for or attend to. I like that meaning of the word. It never meant to heal or to fix or anything like that. In fact, there's a passage in Plato where a student asked Socrates what he means by therapy, and Socrates says, "It's like someone who takes care of horses. They give them water and food and take them for some exercise and clean their stalls. That kind of thing is therapy."

So it's an interesting definition of the word. Then if you put psyche with it—psyche is the word for soul—you get psychotherapy, to care for the soul, to attend to the soul. That's how I see therapy.
I'm not interested in helping a person get along in life, and I'm not interested in helping them improve or get better as a person. That's more of an ego kind of project. I'm interested in the soul, which is deeper.
I'm not interested in helping a person get along in life, and I'm not interested in helping them improve or get better as a person. That's more of an ego kind of project. I'm interested in the soul, which is deeper.

When someone comes to me for therapy, I'm always listening at a very deep level, because I want to know what their soul is hungry for. I listen to their stories and look for where they are getting in the way of their soul’s unfolding. What is trying to emerge? Where are they headed in spite of themselves?
DK: So you are against the whole idea of therapists being healers?
TM: Yes, pretty much.
DK: Can you say more about that? Is it because it’s too omnipotent a role?
TM: Yes. I think the idea of care is different from helping or healing. Healing sounds like you're really going to once and for all fix this person and resolve their problems or get rid of their pain. Sometimes, in fact most of the time, what I feel I have to do is be with the person in their suffering or their pain, and in the moment I may hope that we get to the point where they don't suffer anymore, but I don't think I can get there by being the hero and thinking that I can get rid of their pain. I can't. But together what we can do is see what's going on and, as they get to be closer to their deeper life, their attitude in life shifts and they usually make different life decisions. Those things tend to resolve the pain and the suffering.
DK: So you don’t necessarily feel responsible for what happens in therapy?
TM: I don't feel responsible, no.
I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I?
It’s tempting at times to tell people what I think they should do, but I don't think that's my place. I'm rather shocked when I hear from some of my clients that they've been in therapy with people who tell them what they should be doing. I can't imagine it because I don't know—who am I? I don't have any special insight or any kind of revelation about people's lives. So what I do is I go with them and I try to get a glimpse of who they are and what's wanting to emerge.
DK: That’s in striking opposition to all of the manualized and “evidence-based” psychotherapy that’s currently in vogue.
TM: I'm not interested in any of that.
DK: You're kind of outside of that system altogether.
TM: Totally on the outside of that system.
DK: It sounds like part of what you've been trying to do throughout the course of your career is to critique that system, because it's in every profession in one way or another. Perhaps that’s what you mean by secularization?
TM: Yes, it is.
DK: It’s almost as if science, itself, has become a religion.
TM: I think when you secularize, the ego comes to the foreground, in the sense of, “I know what's going on. I need to be in control.” My approach has been more what I would consider a religious approach, in the deepest sense—not as part of any particular religion, but rather appreciating and acknowledging that there are things going on that I don't understand and can't control, but I can help with by being an attentive listener. I respect what's happening in a person, and I try not to listen to it with the thought that I know what's best or I know what's healthy. I never use words like that—“healthy” or “correct” or “right.” I watch my language carefully and try to let the soul of a person be revealed. When they see who they are at that soul level, they can make better decisions for themselves.

A lot of people have not had much education in psychology, and they don't really understand too much what's going on with their emotional life or their relationships. So we have to go deep into it where they can see what's happening, and then make their own decisions.

“Who Wants to Adapt to a World That is Crazy?”

DK: You also said that you're not interested in helping people get by in the world. Is part of that because the world is kind of nuts?
TM: That's certainly a part of it. Who wants to adapt to a world that is crazy? I've been saying ever since I first wrote Care of the Soul that if you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.
If you do care for your soul you're going to be quite eccentric because, for one thing, that's where your individuality is.
The more you get in touch with your own soul, the more individual you become. Jung called this work individuation, and I think that makes sense because you become more of an individual from being in tune with who you are.

Another piece of this modern approach that I don't agree with is this idea of having some kind of standard for normalcy. We have these standards that are expressed in these lists of disorders, the DSM-5, but behind all of that is the assumption that there is such a thing as being normal and well-adjusted. I would probably have a very different type of DSM myself because I'm not interested in adjustment and being normal so much as really being in touch with that deep place. People may not fit in very well when they do that. They may be odd, and their friends may wonder what's going on with them.
DK: Do you see yourself as radical?
TM: No, not at all. But I was in Berkeley a couple of months ago, and I was at what was considered, I guess, a radical radio station, and I was just talking about things that, to me, seem quite ordinary. Afterwards the two people interviewing me said that I fit into their program quite well because it was also radical. But I don’t see myself as radical; I’m quite traditional.
DK: Am I right that you didn't get any kind of traditional psychological training? You didn't go through a psychotherapy school, right?
TM: Well, my training was actually in Rogerian therapy. I did a lot of counseling work when I was doing my PhD in religion. I did my religious studies work at Syracuse University, which is a very broad program. I studied world religions in one phase of it and depth psychology in another phase and the arts, especially literature, in the third part. These three parts came together to be the focus of my study of religion. When I was doing that, it occurred to me—I don't know why—that the only way I could really learn psychology would be to also train as a therapist. So I did.

A lot of my work was in counseling psychology, which was mainly based on Carl Rogers' approach. I did a lot of coursework and supervised practice, practicums, and led groups. Usually you can get a license if you have a PhD in religion or if you have some background in religion plus some psychological training, and I had both, so I put those together and got my counselor’s license.
DK: Did you decide at a certain point to leave the constraints of being licensed or are you still licensed?
TM: No, I just moved to another state, and the state I moved to requires the kind of therapy that I just don't understand or really want to do. So I no longer do therapy as such as a licensed therapist. I counsel people on this work of the soul based on my books, and I tell people that I'm not a therapist in the sense that people do it today and that I can't do that kind of therapy anymore. I mean, I probably would do it if the system were set up in a way that I could fit in, but I can't, so I don't. In fact, it’s just not what I do at all.
DK: What is it about the system that you can't abide?
TM: Well, a number of things. I'm not interested in quantified studies at all. That's never been a part of my life. I'm trained in the classics. I know Greek mythology very well. I know history and the history of philosophy and theology and medicine.
I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.
That gives you a great deal to work with. Anyone who knows Jungian psychology would know that my background in religion and mythology are perfect for a Jungian analyst. I've studied Jung for years. In fact, a week ago I was in Canada speaking to a Jung society, and I'm going in a couple of days to a Jung society in the Southern United States. I speak to Jung groups frequently because I do know Jung well. They're interested in my background in religious studies and the arts and also my work over all these years, all these books about the soul. So that’s an area where I could fit in more easily, but I’ve never become a Jungian analyst because I feel it’s too narrow for me. I don't want to have to fit in with the language and ideas of Jungianism.

A Religion of One's Own

DK: Your most recent book, A Religion of One's Own, is that a play on Virginia Woolf?
TM: Yes, it is.
DK: My sense from reading it and from reading many of your works is that every system of belief or philosophy is too narrow, that you're fundamentally ecumenical. You love to dive deeply into various traditions, but you’re not interested in being a certified member of anything.
TM: I don't think anyone should be confined to one particular system of belief.
If you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way.
I wrote A Religion of One's Own to make that clear. It could also be “a psychology of one’s own.” It’s important to honor the traditions and you can study any branch of psychology you want, but I think if you really want to be someone who is alive in what you're doing and not just following a system, then you want to make it your own in some way. I happened to take it pretty far in making it my own.
DK: You're a little eccentric.
TM: Yes. That's exactly it, and that's just the way it is. I'm surprised because I'm not a radical type. I'm kind of an easygoing person. I don't challenge the world too much except in my writing. In my style, I write a lot of things that go against the themes of the times and the spirit of the times, but I don't do it in a style or a manner that is confrontational. I simply present and say, "Well, if you want this, great. If you don't, forget it."
DK: So your style isn't confrontational, but your ideas are or could be perceived as such.
TM: Yes.
DK: I’m imagining with this recent book you’re being critiqued both from the Left and the Right.
TM: Yes.
DK: There’s a fair amount of religiophobia on the Left and there are a lot of therapists, in my experience, who harbor a not-so-subtle contempt for religious people. Or rather, some religions are considered okay: Buddhists are fine, Mormons are not. This really goes unchallenged in therapy culture.
TM: Yes, I agree.
DK: And then on the Right you’re probably just seen as an apostate. Are you getting challenged on that at all on this book tour?
TM: A little bit, but very little actually. People get the idea right away, and they're interested in it. The majority of people who hear this idea say to me, "Well, this is what I've been doing and thinking all along, and it's really helpful for me to have it articulated."
I’ve had feedback from people saying that they don't need religion. The secular world is all they need.
That's the response I get most of the time. Now, maybe there are people out there who are more traditional in their religious practice who just aren't interested and so aren't talking to me. On the other hand, I’ve certainly had feedback from people saying that they don't need religion. The secular world is all they need.
DK: I'm thinking of people like Bill Maher, and a lot of these so-called “new atheists” who think that religion is the root of all evil.
TM: The problem I have with them is that they usually pick a very childlike or fundamentalist type of religion and critique it as if it stands for all religions. Take me on, you know? Years ago, actually, I tried to have a debate with Carl Sagan because he was saying that a lot that goes by the name of religion is superstition. We had set up a debate, but then just at the point when we were making the arrangements he developed cancer, so it never happened.

Critiquing the most simple-minded and fundamentalist forms of religion is easy. I critique them, too, and have a lot of that kind of atheism in me as well. I have no problem with that; but when you look more deeply at the richness and depth of so many traditions, when you get right down to the subtleties, I'd hate to see us turn into a totally secular world.

DK: How do you deal with the reflexive antagonism that people have toward religion? If you were speaking to a group of therapists who were more of the secular type, how would you argue for integrating more of this soul work into therapy?
TM: I have worked with psychiatrists and other kinds of therapists, and a lot of them come to me and they want to open up. They want something more in their practice, but they don't know what that would be. I try to give them background, history, a lot of examples, a lot of material—to let them see the intelligence of the spiritual traditions. I present it to them as someone who really loves these traditions, but I'm not a member. I'm not defending them. I'm not that kind of person.
DK: You're not an “ist” or into “isms.”
TM:
I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.
No. I'm not. I'm not in one of these traditions either. Though I sometimes call myself a Zen Catholic, because in my own life, I was born into Catholicism. It's not something you just set aside intentionally; it's something that's just part of you. I don’t actually participate in the Catholic Church, but that’s because I think they don't want me. I'm not sure it's because I don't want them.
DK: Do you think you'd be excommunicated?
TM: Oh, yeah. There is plenty of grounds for that.

With therapists, though, I try to give them an intelligent approach to how to include spiritual matters in psychotherapy. I try to show them that you can't really separate spirit from soul. I talk about the difference between those things and how you can't separate them.

The Planet Has a Soul

DK: Can you talk about the difference between spirit and soul?
TM: Well, it's dicey in a way. In the traditions that I follow, the spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray. These are all things that take us up and away.
DK: Those are spiritual.
TM: Yes, and these things are good, very valuable and important.
The spirit takes us away from our bodies and our appetites and our relationships and our everyday lives in order to have a big vision, a cosmology, a cosmic vision to ask questions about how the world came to be or how to live and to meditate and pray.
But the soul at its depth has not been developed very much. There are many traditions that deal more with the depth of our everyday life, like the importance of home and the deep fantasies and emotions connected with home. Memories of home and the need to be at home and to feel at home with what we're doing, the importance of family and feeling family even if it's not literal. It might be the family spirit at work or in your town, to be living a sensual life or a sexual life. A lot of spiritual people have trouble with sexuality because it's in another direction. It seems to be a problem. So what I try to do is speak for those things, for the soul. I'm also someone who loves the spiritual as well. I value both of those directions.
DK: So the soul is more grounded. It's more earthbound.
TM: Yeah, definitely grounded.
DK: Is there more of an ethical dimension to it?
TM: Yes, there are ethics, but it's a different kind of ethics because soul ethics are rooted in, let's say, your love of the planet or your love of your place, your home, or your appreciation for the individuality of people because you know people directly. That's a more heart-centered ethics. But there is another important kind of ethics, which is spiritual, which would mean you have a vision about the planet and about history and people and how we need to behave. All of that kind of thing could be very spiritual. So I like to have those two together. You need both motivations for an ethical life.
DK: Given you're deeply rooted in your own ecumenism and ethics, what do you think our role is in trying to make the world a better place? You say we aren’t healers, that we help people only in the sense of getting people connected to their soul’s hunger. What about the world beyond the therapy room? Are we bound by ethics to try to, for example, fight against climate change and all the ways humans are destroying the planet and each other? Or is that separate from our work as therapists?
TM: Let's go back to the definition of therapy: care of the soul. One interesting aspect of soul is that in the traditions about the soul, it's not just humans. The planet itself has a soul. I’ve got some documents here in my study from five or six hundred years ago that say that the planet has a soul and that the things on the planet have a soul. So if psychotherapy is care of the soul, the care of the planet is a kind of psychotherapy. Do you know what I mean? You don't just care for people or individuals.

I do a lot of work with hospitals and have been for a long time. I go into a hospital and I try to talk to the doctors and nurses especially about the importance of family because the illness a person has is a soul illness as well as a body illness, and the family plays a role because that's part of a person's deep life. It's a very important part. So we try to talk to hospitals about the importance of including the family. Not just tolerating them, but really seeing them at the very center of illness, both to heal and even being partly responsible in some ways.

A Psychotherapy of One's Own

DK: I have been licensed for about a year after a very long process, many thousands of hours of unpaid labor and studying and writing a dissertation and post-doc hours and licensing exams, and I feel a little bit like after all that time I'm starting from scratch in a way. There was a lot along the journey that simply wasn't useful and I almost had to fight to keep my soul. There were things that I brought to my clients from the very first day that I value—just a certain way of loving and being with people that I feel is the most fundamental part of the work I do—more than any theories or techniques. Yet hardly anyone ever mentioned the word “love” in all my years of training. I felt like I had to fight to retain the soul of my own work and to not get all weird and rigid and overwhelmed with the whole professional side of being a therapist.

There are people I know who are seeing 10-12 clients a day, trying to pay off school loans, pay the mortgage—it can become a real grind. In private practice therapists often don’t see other therapists at all except in passing on the way to the bathroom between clients. It can be a very lonely business and it’s easy to feel isolated from the more systemic problems of the world. I do see myself as a bit of a radical and an activist, and it doesn't align very well with this ten-clients-a-day paradigm that keeps us from connecting with each other and leaves us too exhausted to think about larger world issues.
TM: Well, you might have to define psychotherapy as your own. For example, after doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way. Some people don't like that, but that's just the way it is.
DK: What don't they like?
TM: People think it's not substantive enough because I don't write academically or reference research studies. I'm writing therapeutically, so it doesn't look so substantive, but the average reader knows. I get feedback all the time from people saying, "This book came to me when I really needed it." I must have heard that a hundred times in the past week.
DK: That's all the evidence you need, right?
TM: It’s a different way of being a therapist. I also learned when my books began being read around the world—today it's a small globe so the books get out there—that therapy is not a narrow thing. When I work with an individual then, I really like it because it's a piece of a much bigger work that I'm doing.

After publishing Care of the Soul twenty years ago, immediately I began getting invitations to speak at medical conferences and hospitals and medical centers. I never intended to do that.
DK: That must have been surprising.
TM: It was very surprising, but you see, that's another example of what I do.
After doing therapy for a number of years I discovered I could be a writer and live that way. But I've seen myself as a therapist-writer, in the writing itself, which I try to do in a therapeutic way.
I go into a hospital or go to a medical conference. I'm the therapist really, and I'm representing the soul of the situation. So I try to work with doctors and nurses, and I listen to them and see what's going on there and I talk to them the way I would as a therapist. I talk to them about the soul of their building, "It's not doing well right now. What can we do to make it fit into this whole process more?" So all of that, to me, is therapy. Just as Socrates says that taking care of your horses and feeding them, that's what he means by therapeia or therapy, I'd say going into a hospital or going into your own home and looking it over and seeing how it is and what it needs also is therapy.

Looking at the planet and saying the planet needs us too, and we're not going to solve the problem of global warming just by convincing people that it's a moral need or your life is at stake. We need a therapy of the world. We need to be able to say, "There is reason for this. This is your home. Get motivated. Take care of it."
DK: That's not confrontational, right? Because that's not your approach.
TM: No, I don't agree with that approach.
DK: Can you say more?
TM: When we take the confrontational approach, we polarize right away. We tend then to see ourselves as right and the other person as wrong. And then we get into some type of moralistic debate that goes nowhere.

The Passion of James Hillman

DK: I think it would be interesting for our readers to know a little bit your relationship with James Hillman. It sounds like you two were very close. He was one of your teachers?
TM: He wasn't a teacher exactly, but he was a mentor. He was a friend more than anything. I met him in 1970 and I started corresponding with him in about 1973. He was living in Zurich at the time, and was sending me articles he was writing. I had been studying Jung very intensely, but I really liked Hillman's revision of Jung, the fresh direction that he took Jung's work. Then, just by accident, he and I ended up in Dallas, Texas. I was teaching at Southern Methodist University, and he got a job at the University of Dallas. So we both ended up in the same city by a fluke and that’s when we became very good friends. We did a lot of things together socially, spent a lot of time together the two of us, and we have a very similar type of temperament. Well, not temperament, but background and interests. He was very confrontational, and so when working together it was interesting because we had two very different styles. But we were passionate about the same things.
DK: What were those passions?
TM: We were passionate about psychology moving into the culture rather than just being individual. In fact he gave up doing individual therapy after a while.
DK: I didn’t realize that.
TM: He didn't agree with it.
DK: Then what did he do?
TM: “Therapy of the world,” he would call it. There's a tradition in the old writing, it's called anima mundi, the soul of the world. He picked up that theme, and he would give lectures and work with city governments, and give talks at political meetings and he would say he was bringing a “soul orientation” toward those kinds of subjects and those concerns. When we weren't in the same place, we exchanged a lot of letters and postcards because we didn't have email in those days. We were friends for over thirty-five years.
DK: You presided over his funeral, right?
TM: I did, yes. He was Jewish and he always had interesting things to say about my Catholic background, so it was kind of surprising that he would ask me to officiate at his funeral, but I think it was based on our friendship and his knowledge that we shared so many ideas about religion and psychology.
DK: My sense is that you can feel like you have much more in common with people from other religions than your own when you come from this more ecumenical place.
TM: That could be what it was, yeah. In our conversations he was always being the depth psychologist and trying to see in a deeper way what was happening in the world around him, so I learned a lot from him just being with him and used his work pretty directly at first. One big difference between us in our work was that he didn't have a very positive opinion of the spiritual dimension. He was good at criticizing it, but didn't have a real appreciation for the spiritual—and I do. So in that way we were very different.
DK: But he was into the concept of soul, right?
TM: Yes, but not in a spiritual or religious context.

“To really love a soul, even if it's weird and strange”

DK: Can you give us a sense of how you work with clients?
TM: Well, I started off by saying before that I'm not so interested in managing a person's life. That's not what I want to do. That's not how I see psychotherapy. That's something else. Psychotherapy is care of the soul. It's therapeia, serving the soul. So when someone comes to me, from the very beginning I'm interested in their soul. What are they coming in with? What's not visible? Not even what they tell me because they don't often know that deep level of themselves. So I don't just take everything at face value, but I do look for signs and try to join them. I agree with you that it’s based on love—love of the person and love of the material and what they're going through. There's a love. I learned that from Hillman—to really love a soul, whatever's going on, even if it's weird and strange.
DK: And dark.
TM: Yeah, dark. Whatever it is, you appreciate it. So I do that, and then I would say most of the time I spend working with dreams. My work is almost all dreams. It's not interpreting dreams. I don't say, "Give me your dream, and I'll tell you what it means, and we'll apply it." But I do ask people to bring their dreams because what I hear from their dream is this deeper level. That soul level comes through in their dreams. At first it takes a while to get it because the dream images are confusing initially. After a while you get to know the individual person's set of images in their dreams. I absolutely need them. I couldn't do the work without them. The dreams give us the direction to go in and what to talk about and how to understand what's happening.
DK: Does your interest in dreams stem from your study of Jung?
TM:
I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream.
I think it came from Jung, yes. When I first started reading Jung, I was really taken by his own dreams, especially what he talks about in his memoir, Memories, Dreams, Reflections. He talks there about his own dream work being central to his life. Instead of talking about what's going on in the external world, most of what he writes about is this dreamland, this deep fantasyland. It was very substantial and really made an impression on me. There was so much more there than if you just talk about what's happening on the surface.

His other work, especially his alchemical work, also draws on dreams and shows the connection between alchemy, mythology, and the dream. I've studied the imagery in religions, their stories and narratives and rituals, so when I hear a dream, I see a lot of those rituals and stories in the dream. This was Jung's method too, to compare an individual's dream to what you know about religion and mythology and even art.
DK: Do you bring those associations into the therapy and give them some context?
TM: Yes. You compare them or just see them interact with each other, and that helps you see much more of what's going on in a dream, which otherwise could be quite confusing. Jung felt that if you know myth and religion and the arts well, then you'll have a much better chance of working with dreams, and that’s just what I did. The first thing I did in my studies of religion was to read Jung’s collected works. After that I was able to study all of these religions and their traditions with Jung in mind. I was always thinking, "How do they speak about what's going on in the psyche and the soul?" I bring that background in religion to the dream work. Then I see what's going on in a person's life, and I can see the roots of it more.

Airplanes and Rivers

DK: Can you give an example?
TM: Sure. I write about this one in my book, and I got permission from the dreamer to make it public. This was a young man who came to me with some OCD, some obsessive compulsive practices, little rituals that he did.

The first dream he told me was that he saw these sharks in a river, and he originally wanted to go down to the river. It looked like a nice thing to do. But then when he saw the sharks, he backed away and went away from it. That was the first dream. Well, that tells us quite a bit really. Right away you've got a river, and a river itself is a tremendous image in the history of religion. There are so many great rivers. I'm not saying that his river was one of those, but knowing about those rivers you have a deeper sense of what it means in a dream to have to approach a river.

Very often it might be something like this river is the stream of your life or the stream of your time going on as you experience it. If there are sharks in it, you may not want to go into it. Obsessional practices sometimes look like people are afraid to really live. They have these practices that keep them at a distance, that keep them protected. So that gave us a lot of help right away in the very first ten minutes of working with him. Then we just keep going, more dreams, more stories, and we get deeper and deeper. Not just the surface behavior, but what's going on deep. We discuss the person's family life, childhood, and you see the themes there. A person only has so many themes in life, and they remain, they don’t change radically over the course of one’s life.
DK: And they remain in the dreams?
TM: They come and go. Dreams tend to be cyclical. You may have a series of dreams that have a certain type of imagery in them for maybe six months or up to four or five years, but then they may shift. Or they may come back again later in life. For example, I could talk about my own. I had a series of airplane dreams that lasted maybe eight years, and then they just stopped coming. So the dreams may not last forever, but it’s interesting when they stop. You can ask yourself, "Why did they stop right now?"
DK: Were yours plane crash dreams?
TM: No. My dreams were about trying to take off in a city. The planes would try to get into the air, but they weren't on an open runway. They were in a city trying to take off.
DK: And what did you come to understand about that?
TM: Well, I felt all along that I needed to adjust to the world more. I had to grow up, essentially. I had to live in the culture more. In fact, my books got me more and more into society, into people's lives. As I got more grounded in the world and in society, that dream no longer appeared.
DK: I also have recurring airplane dreams. I was just going to ask you about them.
TM: Yes, go for it.
DK: Mine are also usually in a city, and I witness a terrible plane crash. The context is always different but basically I witness these horrifying plane crashes over and over again, and I can't do anything about it, and I'm completely freaking out. It's devastating every time.
TM: See this is interesting. Can we talk about that for a minute?
DK: I would love that.
TM: So my first reaction to it is that the interesting thing about it is that you freak out. It's not that the plane crashes. I think it's okay that planes crash in the dream because sometimes that high-flying, that airy kind of existence has to come down and you crash. I would connect that with the Icarus myth, the story of Icarus who flew too high to the sun and his wings melted, and he crashed down to the earth. So there's a kind of crashing that takes place when you fly too high or when you're flying too long, that kind of thing. I wouldn't explain this dream that way, but these thoughts would be in my mind as I thought of our continuing conversations. So I would think, "Well, this is an issue where it may be necessary for planes to crash, but that really bothered you. You really have a hard time with that.”
DK: With the fall?
TM: Yeah, with the fall.
DK: That resonates with me.
TM: You used the word fall. That would take us into all that mythology of the fall that's in the book of Genesis, you know the fall of Adam and Eve. There's a lot written about the fall, a fall from innocence, or a fall from whatever. So there's so much there already just without even knowing anything personally about it. There's a lot there to think about before we go too far.

DK: It's so different from the experience of having someone go, "Well, that sounds like depression." So often we therapists get habituated to using language that really lacks imagination. Even in this one minute improvisational therapy that we just did, the myth and the story and the way that you responded just now was almost with a kind of excitement. As opposed to, "Tell me about your sleep hygiene” or “what are your automatic thoughts?" That kind of rote diagnostic way of relating to clients.
TM: Yes, exactly.

There's No Done

DK: Do you tend to see people for a long time? How does therapy end? You don't want to make them better, so how do you know that they're done?
TM: There's no done.
DK: There's no done?
TM: No. There's no done. There can't be.
DK: I like that.
TM:
Therapy is care for the soul, so it's not about seeing a particular person or using a particular method. A person may decide, "I'm not going to do this anymore," but one hopes they'll continue to care for their soul in some way.
Therapy is care for the soul, so it's not about seeing a particular person or using a particular method. A person may decide, "I'm not going to do this anymore," but one hopes they'll continue to care for their soul in some way. They may find another therapeutic thing to do. They may take up gardening or make movies or something that will really be good for their soul. In going through that process, they're going through a process very similar to what therapy is.

That's the beauty of Jung's idea of alchemy. He thought that alchemy was the model for the therapeutic process. We can go through any kind of alchemy any place in life. Getting a new job, that's an alchemical process to some extent. You have to process it, go through various stages, and so the therapy never has an end. That doesn't make any sense.
DK: Do you ever fire people?
TM: That's a good question. I don't recall that happening. No, I never did that. Most of the time when people want something, there are a couple of reasons why they would stop. One is that they want something they think I'm not giving them. They want something more specific. They wanted just the practical stuff. I tell them I can't do that. That's not what I do. I don't just say that. I try my best to go deeper into whatever it is they bring up.

On the other hand, some people just don't want to face it. If we had an hour talking about your dream, you'd have to face some things that are not so easy to do. When people hear about dream work, they think “oh, that sounds fun!” But it turns out to be very challenging and some people find it to be too much and so they just leave. I usually think that it's too bad because the process seemed to be getting somewhere.
DK: So you've been fired, but you've never fired anyone.
TM: No, I don't think so.
DK: Well, thank you so much for taking the time to share a bit yourself with our readers. It’s been fascinating.
TM: Thank you, it’s been a pleasure.

After the Diagnosis: Helping Patients Cope With their Emotions

Posted on by rezendevknowfully.com

The New Normal

“I just got diagnosed. Now what do I do?”

The focus of my professional work is on helping patients to cope with medical diagnosis, so I hear this question a lot. But many psychotherapists tell me that their patients also talk to them about their health issues, including sudden, serious medical diagnoses.

As mental health professionals, we may provide the only opportunity that newly-diagnosed patients have to talk to someone in this situation. The traditional medical establishment is equipped to help patients from a medical, but not an emotional, perspective. Family members and friends are also suddenly thrust into the emotional chaos surrounding the diagnosis, and often need help with their own emotions and helplessness.

Our patients facing a medical diagnosis look to us for help in sorting out complicated and scary feelings during a highly stressful time so that that they can move forward in their lives. In this regard, our job is to help patients define and embrace a “new normal” —with a positive self-image, retention of as many cherished routines and rituals as possible and supportive relationships—but also help them to integrate the effects of treatment and make ongoing lifestyle adjustments. Patients facing a diagnosis want nothing more than to be as normal as possible.

If newly-diagnosed patients are able to get needed emotional support early on in their diagnosis, they will be that much better prepared to cope as they move forward with their treatment. As therapists, we help them to prepare for the road ahead.

Medical Diagnosis=Stress

Receiving a catastrophic medical diagnosis is a stressful and sometimes traumatic event. Newly-diagnosed patients feel an immediate sense of uncertainty—life will never be quite the same. And life may end. And like other stressful events, our minds and bodies are hardwired by nature to react. The initial reaction is shock, as our conscious minds essentially shut down while, subconsciously, this information is processed.

As the shock fades, it gives way to one of three reactions that occur in response to stress: flight, freeze, and fight. The flight response is primarily an emotional reaction, and patients may be so caught up in their emotions that they may not be able to make objective decisions regarding their condition and its treatment. On the other hand, those having a freeze response may be unable to acknowledge their feelings at all or may have a fatalistic view, either of which may result in inaction. Those in fight response are best equipped to deal with a new diagnosis. They have access to their emotions as well as their logical resources, and are able to harness both as they face their illness. Most important, patients can be taught how to be Fighters.

These basic reactions impact the kinds of emotions that newly-diagnosed patients experience, and how they cope with these emotions, as well as how they deal with their diagnosis from a rational standpoint (e.g. information-gathering). For better or worse, how patients cope during those first few days and weeks after receiving the diagnosis will have implications throughout their treatment process—from decision-making to coping with the treatment to ongoing recovery and life management. And if those patients find their way to the office of a mental health professional, we can play a formative role in their journey.

The First Reaction

Whether catastrophic or chronic, almost invariably patients describe their reaction with one word: shock. People often experience numbness, as if they are in a trance, or simply have “no feeling at all.” The experience of shock is often associated with disbelief or a sense that their emotions might be so strong that they should be held at bay for fear that they might be overwhelming. There are of course exceptions. For example, when a condition from the past is recurring, or when symptoms over time have rendered the diagnosis inevitable, patients may report an initial feeling that “the other shoe has finally dropped” or that they are about to go down a road that that they have previously been on. Still, it is only human nature to cling to that possibility that “it won’t happen to me.” This belief is mainly unconscious; after all, most of us don’t spend our time assessing our chances of getting hit by a medical diagnosis.

Carole described her reaction when she was first diagnosed with cancer.

"It was like the world suddenly stood still. I mean, all I could hear was my own breathing, and the thumping of my heartbeat. At first, I was completely numb, and I wasn’t thinking anything. And then I started saying the word “cancer” over and over. Still, no feelings. But deep inside, I realized that, no matter what, my life was never going to be the same."

The initial shock may last a moment, hours, days, or may continue on, as the patient’s emotional and rational sides are both struggling with the news. If you have been through the experience of a diagnosis, you might remember how you first reacted, or didn’t react, to the news; or maybe you have seen someone else go through it and felt your own helplessness as you watched them struggle.

In a way, being faced with a diagnosis, while not usually a death sentence, is similar to hearing about a death. As Carole, in the example above, described her diagnosis—nothing will ever be quite the same. Newly-diagnosed patients are left with the knowledge that, yes, bad things can happen, that they really aren’t invincible after all. And the diagnosis —whether it requires extensive treatment that interrupts normal life for months or longer, or whether it requires medication and alterations in diet and lifestyle—will at some point require the patient’s acknowledgement and full attention. Knowing that this looms ahead can also be initially overwhelming for the patient, and the healthcare professionals they are working with may or may not be able to provide emotional support for their patients.

During this time of initial shock, patients are often not open to more information, nor willing to discuss their diagnosis and what it means. It is difficult to communicate with patients who may be unable to hear or comprehend what they are being told, which presents a particular challenge to their healthcare providers who may need to begin a medication regimen and/or make a decision about the path of treatment. The newly-diagnosed patient may need some time and space to sit with the news, and if the healthcare professional pushes them too hard to discuss the treatment plan or to make a treatment decision during this time, the patient may become defensive and refuse to talk further, potentially becoming even more resistant.

Patience is required. Human beings can’t be forced to take in more information than they can process at any given moment moment, and often the best way to help patience move through this early stage is to be willing to sit with them, offering support while being sensitive to the readiness of the patient to process this news. Psychotherapy can provide vital support during this time, a chance to vent about the frustrations and the fears.

Clearly, sensitivity to how a patient is responding must be balanced with the level of urgency in taking any necessary action. For example, it may be appropriate for the therapist to act as a patient advocate by encouraging the patient to schedule a follow-up appointment with their healthcare provider to further discuss the diagnosis and formulate his/her questions. And even to help the patient formulate a list of questions to ask their healthcare provider. Scheduling a follow-up session with the patient to discuss and process what they learned in this second appointment can also be invaluable.

The Three Fs

Accepting that life is going to change is the first step toward coping with the emotional impact of the diagnosis and making decisions. Though newly diagnosed patients come to this realization differently and at different times, most patients fall within one of the fight/flight/freeze responses.
 

Fight Freeze Flight
Positive Thinking Isolation Empowerment
Rigidity Helplessness Emotional Coping Skills
    Rational Thinking

Flight: The Case of Dave

The best way to introduce the Flight response is through a case example of a newly-diagnosed patient I’ll call Dave. An active man without a history of health problems, his diagnosis of a heart condition took him totally by surprise. His physician presented him with what she thought was the best recommendation, which was a triple bypass, and then suggested that Dave go home and do some thinking before making a decision.

Dave later reported that the sense of shock continued not only that evening, but for a couple of days afterward. He couldn’t believe that he, of all people, was being told that he was in anything but top condition. And his heart? Not a chance. He told his wife only that his doctor was watching his heart, but that he was absolutely fine, which of course she was skeptical of but knew better than to push if Dave wasn’t ready to talk. Dave describes the next few days like this:

"”Once the numbness started to wear off, I kind of went into a panic mode. It was like I had this thing around my heart and I wanted it cut out as soon as possible.” I was afraid to think because I was afraid I might talk myself into doing nothing, or that I might put too much strain on my heart. I imagined my doctor as my savior. I wanted to put all of my faith and trust in her and have her direct my path. I was in such a rush, I asked her to call the cardiologist she had recommended to try and influence him to schedule me for surgery as soon as possible"

While Dave is placing all of his trust in the first physician he encounters, he is also running toward the treatment that feels most expedient. He is not considering the implications of the treatment, in terms of side effects, recovery, and ongoing lifestyle management. As a result, he may later discover that this is not a treatment that he was prepared to deal with, which has implications for ongoing compliance as well as dissatisfaction with his healthcare provider.

The flight reaction has other implications as well. Individuals in this state may—out of a sense of panic—run toward unproven alternative treatments with potentially alarming results. They may also be susceptible to the recommendations of healthcare providers with whom they feel comfortable with emotionally but who may not offer the best treatment option. For example, they may profess to “love” their practitioners, which can preclude them from obtaining a second opinion on the diagnosis, investigating treatment options, and at least checking into the credentials and track record of their physician. Patients in Flight reaction may also attach themselves to an unproven, non-medical treatment with potentially alarming consequences.

The flight reaction can also result in such strong emotions that patients are unable to access their logical mind. Excessive crying, expressions of anger, giving in to fearfulness—these responses signify that a patient is also in flight of a different sort—not toward the first available treatment or the most loved practitioner, but instead running away from their diagnosis.

Freeze: The Case of John

Not all patients “take flight” toward the first available treatment. Some don’t take flight at all. Instead, the initial shock gives way to sitting and staring into space, waiting for the nightmare to pass, or for someone, often a family member, to step in and take charge. This is understandable. After all, between the shock of the diagnosis, and their perception that they are unprepared to make the decisions that are suddenly thrust upon them, or that they have no hope, they are essentially immobilized.

When in freeze reaction, emotions appear to stop working, not because they are broken but because they are being tightly held in place. And while this might be an opportunity for the rational side to kick in and take charge of the situation, logic without emotion is not necessarily going to result in rational thinking, as evidenced by John.

"I just sat there when the doctor told me, and I guess I’m still just sitting still. I can hardly get out of the chair, to tell you the truth. I kind of decided to be philosophical about it. I don’t know much about this but I do know that statistically, the numbers are against me. I mean, what can I do when fate isn’t on my side"

John is using the defense that individuals in freeze reaction often adopt: refusing to react emotionally. Not getting actively involved in learning about the condition and its treatment. Unfortunately, this also means giving up.

Essentially, the freeze reaction is an extension of the original feeling of shock, but with some key differences. Shock is the mind’s way of shutting down the emotions, and allowing the brain to process the information, before reaction. Patients in freeze reaction aren’t consciously suppressing their emotions, but their emotions are nonetheless inaccessible to them. They may think they are being “rational” based on their view of the facts, but there are risks involved when the logical mind is operating without the emotions.

Patients in freeze reaction, because they are operating without their emotional side, may adopt an attitude of hopelessness and helplessness. By not allowing themselves to work through the initial emotions, like anger and fear, they essentially remain stuck. Often they refuse to discuss their condition any more than absolutely necessary with their healthcare professionals, and may avoid telling family members as long as possible. Whereas patients in flight reaction may completely give themselves over to their emotions at the expense of rational thinking, patients in freeze don’t acknowledge their emotions, which leads inevitably to avoidance isolation.

One characteristic common among patients in freeze reaction is an unwillingness to make decisions about their treatment. They rely on their physicians, possibly working with family members, to make these decisions for them. In essence, they decide not to decide.

Fight: The Case of Marie

Being open to emotions can result in an inner sense of optimism and hope. If this optimism is balanced with rational thinking, patients are in the best position to make treatment decisions, deal effectively with treatment and lifestyle changes, and otherwise cope with the changes and challenges that may arise as they face the future. These are the fighters.

Fight doesn’t necessarily imply aggression and, in fact, sometimes patients resist this word because of that association. “Being a fighter means being empowered in terms of understanding the diagnosis, the options for treatment, and what lifestyle adjustments need to be made in the near future and beyond.” Being empowered is about arming oneself with emotional coping skills as well as rational thinking.

Fighters acknowledge the feelings that arise as a result of hearing the diagnosis and continue to honor their own emotions. It would even be reasonable to say that dealing with the emotional aspects of a diagnosis opens the door to rational decision making. Fear may, realistically, never fade away. The anger and disappointment may flare up at times. But emotions like fear and anger, when they are acknowledged and experienced, may also give way to hope, optimism, and a renewed passion for life.

Marie said it this way:

"I sat and cried and asked 'why me?' for quite awhile, maybe a few days. And then I stood up and said, 'I am going to fight this beast. I’m not going to let it beat me down.' The next day I made a list of who I needed to talk to, where I needed to go for information, and what I needed to start planning for. That doesn’t mean I don’t feel overwhelmed sometimes, because I still do. But I’m also in active mode."

Marie didn’t hold back on her emotions but, instead, faced her disappointment and fear. She sat alone with her emotions and, in her case, had a good cry. She also discussed her emotional reactions with a member of the healthcare team, who was comfortable being a “listening ear.” Had she not taken the time to experience how she was feeling, she would have been forced to sit with a large block of emotion, and it would have essentially taken all of her mental energy to hold it down. By doing so, she was able to start asking questions and making decisions.

Patients in fight reaction are more prepared to take action with their condition. By working through their emotional reactions—feeling their feelings and expressing them to supportive listeners—they are not running from their feelings, nor are they so overwhelmed by them that they can’t think. The result is a sense of self-confidence that comes from being aware of, and open to, emotions. Fighters also have access to their rational minds. This doesn’t mean that they are in perfect balance every day, or that they don’t have bad days when nothing seems to go right, but they are on the whole able to search for, and process, information. They are more likely to ask questions and to evaluate alternatives. They take more control over their treatment decisions and the ongoing lifestyle adjustments that they need to make.

Their balance of emotions and logic results in an attitude of empowerment toward their healthcare and the individuals who deliver it. For some patients, the fight attitude comes naturally; they may be more temperamentally inclined towards this kind of response to adversity once they move beyond the initial shock. These individuals will sometimes present challenges to their healthcare team, because they tend to be much more active in their own treatment, and believe that the ultimate decisions regarding sources of information, treatment alternatives, and lifestyle adjustments, lies in their own hands. However, the healthcare team can work with patients experiencing freeze and flight reactions to create and enhance fighter skills.

Psychotherapy: Bridging the Gap That Healthcare Professionals Can’t Fill

Healthcare professionals are not expected to be psychotherapists or counselors, nor to deliver direct mental health services to their patients. On the contrary, attempting to counsel patients without the benefit of being a trained mental health professional can be harmful to the patient and risky for the untrained professional. But newly diagnosed patients often have a hard time processing the overwhelming information they are bombarded with by their healthcare providers, and this is where psychotherapy can play a vital role.

Often patients are so flooded with emotion when they first receive their diagnosis that they aren’t really listening to what they are being told; they might “hear” it, but not be able to make sense of it and, as a result, they may miss key pieces of information or misinterpret what they’ve heard. This can be frustrating and alarming for the healthcare professional, who may or may not have the patience or skill to help their patients through this initial phase. Psychotherapy can help the patient to cope with the fear and anxiety that may be preventing them from processing information about their diagnosis and their treatment options, and to evaluate the options from both rational and emotional perspectives.

This can also be a good time to involve family members in the therapy. They often need support as well in processing and understanding the diagnosis, figuring out how best to support the patient, and deciphering what their role will be throughout the treatment process. Both patients and their families and close friends may not yet have the words they need to discuss their feelings and reactions with each other, and therapists can play an important role in helping to facilitate communication between patients and their loved ones.

Newly-Diagnosed Patients in Psychotherapy

A new medical diagnosis brings with it the probability of change—in routine, in relationships, in self-image—and human beings are creatures of habit, not wired to embrace change. Uncertainty about the future and what challenges might soon be presented, fears about loss, including finances, relationships, favorite activities and one’s future dreams are all a part of what the newly diagnosed patient brings to therapy.

Some of the factors that influence the way an individual reacts to a medical diagnosis include:

  • Perceptions of the severity of the diagnosis—Patients often have minimal information about their condition when they first receive their diagnosis, or erroneous information, or a vague awareness of the condition but not enough of the facts to evaluate it in terms of the implications for their own lives. These perceptions —and misperceptions —may lead to an emotional reaction that is not consistent with reality. Alternatively, patients may be well versed in their condition and experience emotions that are realistic and consistent with its severity. Either way, perceptions have a direct influence on emotions.
  • Personal coping style—Some people grow up in families in which emotions are always on the surface, and family members are encouraged to express how they are feeling. In other families, emotions are not so acceptable, and are suppressed. Newly-diagnosed patients who don’t have a history of being comfortable with their own feelings will most likely have difficulty talking about, or expressing, how they feel.
  • Prior experience of illness—Newly-diagnosed patients who have had a past illness may experience some of the same feelings that they experienced in the past. Having already dealt with a medical diagnosis may have provided them with coping skills to deal with a new diagnosis; alternatively, the diagnosis can reignite fears and other feelings that they had hoped not to re-experience. Patients who have helped a friend or family member cope with a medical condition may react similarly.

The Unanswerable Question

Newly-diagnosed patients inevitably ask one question: “Why me?” This may be a medical question, as the patient tries to understand the medical reasons behind the diagnosis, though there is usually an undercurrent of self-punishment—“If only I’d eaten better” or “if only I didn’t smoke” this would never have happened. People may also feel guilty about asking this question, as it can seem to suggest that it would be more fair and right if it happened to someone else. And patients may also express acceptance, but nevertheless ponder the randomness of life.

The point for therapists is not to answer this question. For many patients, “Why me?” opens the floodgate to releasing their own emotions, because it is a way of articulating that basic question of fairness and the role of fate, core issues that patients grapple with as they begin to process their diagnosis and move toward acceptance and empowerment. Ultimately, “Why me? is an existential question, and as therapists, we can use it to delve more deeply into the meaning of life for our clients and, if appropriate, work with them to cultivate a deeper connection to their religious or spiritual communities and practices.

Facing Difficult Emotions

When I first met with a patient I’ll call Yolanda, who had been diagnosed with cancer, she said:

“All I could think about was how concerned my doctor was when she told me I had cancer. I had never seen this look on her face before, and I just kept thinking that if she was this concerned, I must be in big trouble. I felt like I was on the edge of a cliff and I needed to hang on to something but there was nothing to hang on to. And at any second I might go falling into the darkness.”

During the course of our counseling sessions together, I was able to help Yolanda identify the emotions that she was experiencing, especially those that she thought she “shouldn’t” be feeling (I always begin by kicking the positive-thinking police out of the room). I also supported her as she began to deal with her diagnosis on a day-to-day basis, including giving the news to her family, making the treatment decision, undergoing surgery and chemotherapy, and making lifestyle changes. Helping Yolanda recognize, accept, and cope with the emotions around her illness allowed her to move into an empowered fighter position.

Yolanda gave voice to her greatest fears about cancer. As we worked through the “why me?” question, I told her about similar experiences by other patients facing cancer to help normalize her reaction. It’s important for people to remember that they are not alone and that many have walked the path before them. I also encouraged her to arm herself with real facts by asking questions of her treatment team and information-gathering on her own, and at her own pace. Information is an antidote to fear.

As Yolanda faced her fears about her cancer diagnosis, I encouraged her to express other emotions as they arose. Allowing herself to be angry was an important step for her, as she was able to express her frustration at having to take a break from her active life to go through treatment. As she stated, “I want to scream at life and how unfair everything is!” During a later session, as she was beginning cancer treatment, she talked about attending a wellness lecture and leaving feeling ashamed that she “might have avoided this if I had taken better care of myself.” And during chemotherapy, she expressed sadness that she wasn’t able to “be the mother that my kids need me to be.” Yolanda needed the opportunity to express these emotions in a safe, non-judgmental environment so that she could continue to cope with her day-to-day life and responsibilities.

Challenging Harmful Beliefs

As patients react to the stress of their diagnosis, their fundamental beliefs about life are put to the test, many of which, from a Rational Emotive Behavior (REBT) perspective, may be irrational and therefore lead to reactions and emotions that are unproductive and self-destructive. I was able to gently help Yolanda to identify beliefs that resulted in, as she said, “beating up on myself” and “telling myself that I shouldn’t feel the way that I do.” Irrational beliefs common to newly-diagnosed patients include:

  • My life will not change unless I want it to.
  • I must be available to the people who need me at all times.
  • If I live a good life, bad things won’t happen to me.
  • If I don’t keep a positive attitude, other people will think I am a failure.
  • If I don’t maintain control of my emotions I will collapse.

“I can’t emphasize enough the importance of first and foremost being a supportive, listening ear in the true sense of Carl Rogers—non-judgmental, unconditional positive regard.” This is what patients need most when they first get diagnosed. Motivational interviewing techniques can also be helpful in assessing readiness and introducing alternative ways of coping.

As Yolanda was ready for me to move from the role of supporting and normalizing her emotional reactions to examining her beliefs and understanding the connection with her emotions, I used a more active approach to help her identify her triggers, reframe her irrational beliefs, challenge either/or thinking, recognize and replace negative self-talk with health-enhancing affirmations and use progressive relaxation techniques.

A Note About Grief

Newly-diagnosed patients often go through a grieving process, and this can be an essential step in coming to terms with their condition and moving forward with treatment and lifestyle adjustments. When they grieve, they are beginning the process of accepting that a change is occurring in their life. Regardless of the diagnosis, accepting that life is going to be different in some way, and that these changes are out of their hands, is an important step forward. For many newly-diagnosed patients, their diagnosis causes them to take a look at one or more of their basic beliefs about life and to reevaluate them. This may be the first time that they have looked at these beliefs and how they affect their actions and emotional reactions. During this process, assessing a patient’s spiritually, and encouraging them to seek spiritual guidance in whatever way is meaningful to them can be helpful in getting through the grieving process.

Sensitivity to the Influence of Culture and Gender

It is also important for healthcare professionals to be aware of the influence of culture and gender. Cultural background can influence how patients interact with the medical establishment, how they experience and express emotions, and their willingness to accept mental health intervention. Gender can present further complications in expressing emotions around illness as well as in getting informed. In Western culture, women tend traditionally to be more active medical consumers than are men.

Working with the Healthcare Team

The healthcare professionals that are working with newly-diagnosed patients can greatly benefit from the ability to understand and recognize how patients are reacting to their diagnosis, and psychotherapists can play an important role in consulting with them. Understanding whether a patient is having a flight, freeze, or fight response, for example, will guide healthcare professionals in gauging their readiness to receive information, so that it is presented in a manner in which patients will most likely be receptive. Those in flight reaction may need some additional emotional support while those in freeze reaction may need some coaching in interpreting what they read and hear with a sense of optimism. Fighters may ask a lot of questions for which the team needs to be prepared. And going forward with treatment and recovery, patients who don’t become fighters may continuously erect barriers to compliance and life management.

I often work directly with physicians and, depending on the wishes and permission of the patient, will contact the healthcare team to share information and, as needed, to advocate for my patient. Where possible, maintaining open communications with healthcare providers, and offering to support them during especially difficult times during and after treatment, can be invaluable to the patient. Many healthcare providers also recognize the emotional component as key to enhancing recovery and ongoing compliance and are happy for the support.

Offering the healthcare team an understanding the patient’s particular reaction style can help them tailor their approach in ways that leverage the patient’s strengths. We can specifically give the team advice about how best to:

  • Present information on the condition and its treatment
  • Coach patients through the treatment process
  • Make recommendations on lifestyle management
  • Encourage patients to seek support with activities of daily living
  • Monitor ongoing compliance

Preparing for the Road Ahead

Finally, I always tell my clients: You are not a diagnosis. Your diagnosis is only part of who you are. Remind yourself every day that you are a fascinating, multi-dimensional creature with a past, a present, and a future that belongs to you and to you alone. Embrace life and your potential to live your life, with all of its triumphs, set-backs, surprises, and detours. Now, let’s get prepared for the road ahead!