Category: Approach

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

Posted on by rezendevknowfully.com

The Blind Spot

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

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


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

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

We Are the 90 Percent

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


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

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

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



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

The Moneyball Approach to Therapy

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

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

But Therapy is So Complicated and Nuanced…

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

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



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

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

My Therapist Was Glad to See Me

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

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

Suicide and Substance Abuse

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

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

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

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

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

When Confidence Hinders Us

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

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

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

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


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

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

The Fact is, We're All About Average

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

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

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

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

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

The God of Psychoanalysis

Posted on by Psychotherapy.net Team

In The Beginning…

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

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

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

The Forbidden Apple

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

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

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

There was a small hubbub. 

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

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

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

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

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

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

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

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

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

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

“But I don’t want to,” she protested.

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

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

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

“Okay,” she said, now intrigued.

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

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

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

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

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

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

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

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

Nothing Human is Alien

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

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

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

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

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

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

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

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

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

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

"Have You Tried Being a Shoeshine Boy?"

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

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

“You’re making fun of me…”

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

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

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

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

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

“Who you are you angry at?”

“All of you…”

“Who most of all?”

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

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

“What is better?”

“You know!”

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

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

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

“Because I love him…?”

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

“He’s the misery I know.”

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

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

“Why can’t you tell us?”

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

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

And so it went.

The Fall

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

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

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

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

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

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

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

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

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

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

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

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

Epilogue: My Return

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

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

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

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

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

“Too long…”

I sat down.

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

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

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

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

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

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

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

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

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

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

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

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

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

“No charge,” he said.

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

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

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

He held his own letter with evident satisfaction.

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

He smiled with even greater satisfaction.

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

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

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

“19 years of treatment and I was him?

“I am afraid so.”

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

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

“I accept,” I told him.

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

“That would be welcome,” he said.

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

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

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

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

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

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

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

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

The Tao of Anger Management: A Yield Theory Approach

Posted on by rezendevknowfully.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Behind the Mask

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


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

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

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

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

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

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

Yield Theory

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


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

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

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

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

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

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

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

Components of Yield Theory

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

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

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

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

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

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

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

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

Conscious Education

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

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

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



 

Treating a Couple After an Affair

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

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

Why Its Time to Take Mobile Seriously

Posted on by Psychotherapy.net Team

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted on by rezendevknowfully.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bringing RAIN to Obsessive Thinking

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Meeting Our Edge and Softening

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

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

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

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

Then a verse from Rumi came to mind:

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

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

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

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

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

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

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

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

Tara Brach on Mindfulness, Psychotherapy and Awakening

Posted on by rezendevknowfully.com

What is Mindfulness

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

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

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

Meditation and Psychotherapy

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

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

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

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

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

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

The Alive Zone

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

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

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

The Trance of Bad Personhood

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

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

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

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

Will This Serve?

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

What We Talk About When We Talk About Love

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

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

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

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

The Squeeze

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

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

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

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

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

No Mud, No Lotus

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

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

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

Awakening to the World’s Suffering

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

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

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

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

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

RAIN

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

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

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

The Healing Power of Writing

Posted on by Psychotherapy.net Team

I’ve been a writer longer then I’ve been a therapist, and so it comes to me as no surprise that writing, and narrative, have seeped into my work. What I want to share with you are some thoughts on how you can encourage clients to tap into the healing power of writing and narrative, and some good reasons (in my humble opinion) for doing so. Many clients may already be keeping a journal even before they come into therapy, but I find that people often limit themselves in journal writing to either venting their emotions, or simply recording the day’s events.

There is nothing wrong with venting feelings or recording events, and either of these uses of writing can be therapeutic. What I’m interested in, though, is helping clients to “shift their story” through writing. What do I mean by this? Many people, by the time they finally decide to seek therapy, are often in crisis and “stuck in their stories.” In the tradition of narrative therapy, I like to pay attention to what people tell me when I meet with them for the first time, and I’m very interested in how they “story” their lives. Usually it goes something like this: “I’m a horrible loser, and I keep doing the same thing over and over and I don’t want to but I can’t stop.” They usually tell the worst version of their life story.

The interesting thing is that these “stuck” stories that clients express are usually true! They simply aren’t the whole story. I often think that I wouldn’t want someone to write a story about my life with only the negative parts, and leave out any of my strengths. This is precisely what someone stuck in depression or addiction usually does—express a somewhat factual but only partial account of their lives. What I find is that when someone who is stuck like this keeps a journal, it usually only serves to reinforce their “stuckness” and goes something like this: “Well, I messed up again today. That’s no surprise, given that a loser I am.” (This would NOT be a therapeutic use of writing!)

If a client expresses that they have an interest or willingness to try writing in a journal, I will ask them to imagine the blank page as a safe space where they can try out new ideas and new stories about themselves without being judged. And this is where I feel that writing can be most therapeutic. I will ask clients to write about a success that they had during the week, no matter how small that success is, and write about it in great detail. Additionally, it can be useful to ask a client to explore who they would be if they didn’t feel so stuck in their problem. Most important, I ask the client to imagine themselves as being on a journey, where they can travel away from their current story about themselves and end up somewhere else. And through writing, they can explore that “somewhere else” in a safe manner. No one else ever has to see what they write.

More important than any particular writing technique or style is the power of allowing a blank page to become much more than a blank page. When a person truly allows a piece of paper (or blank screen) to become a safe space for exploring dreams, wishes, hidden strengths and values, an amazing transformation occurs. Suddenly the horrible story of being stuck is revealed to be just that, a story. And since stories are written, they can be revised, especially if we are the ones who wrote the story in the first place. Writing then becomes an empowering act that sparks the client’s creativity and imagination.
 

Philip Guerin on Bowenian Family Therapy

Posted on by rezendevknowfully.com

The Family of Origin

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

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

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

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

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

Triangles

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

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

Differentiation of Self

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

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

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

Techniques

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

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

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

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

The Invention of Genograms

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

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

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

Functional and Dysfunctional Attachment

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

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

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

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

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

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

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

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

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

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

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

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

Who Cares About Creativity?

Posted on by Psychotherapy.net Team

“Who cares about creativity? I have real problems to deal with!” This is a common reply that I get from clients (and sometimes from colleagues!) when I bring up the topic of creativity. However, the more I have a chance to write and reflect on the subject of creativity, the more convinced I become that creativity is an essential part of the healing process.

I recently had an opportunity to interview Dennis Palumbo, a therapist and writer in private practice in Los Angeles, CA. Dennis brings a unique perspective to therapy, as a former Hollywood screenwriter (he was a staff writer for “Welcome Back Kotter” and wrote the film “My Favorite Year”) and now therapist to up-and-coming and established writers, artists and Hollywood executives. The topic that came up was the connection between creativity and anxiety. Dennis mentioned that his clients will often say the following: “If only I could get rid of my anxiety and self-doubt and depression, then I could finally write!” To which Dennis invariably replies:” Write about what?”

The clients I work with often don’t see themselves as creative, but they certainly also express the wish to get rid of all the things that they see as “bad”—their anxieties, sadness and losses—and sometimes express the hope that I can “fix” them. And certainly, an important part of the work that we do is helping clients achieve symptom reduction. However, there are some things in life that can’t be “fixed” or “reduced,” such as the loss of a loved one, or a chronic illness, or the anxiety that we all face knowing that we are finite beings. And sometimes, the only thing there is left to do, beyond accepting the situation, is to “use it.”

“Using it” is a term I’ve heard many times in theatre, as a direction to actors who are facing various feelings that may be coming up in their lives. So, if an actor has an angry breakup with his girlfriend prior to getting onstage to play Hamlet, he can use his anger or sadness and allow it to inform his performance. However, in my experience, clients don’t need to be actors or writers to creatively transform their painful emotions. For example, a client who loses a child to a drunk driver, and then reaches out to other parents to form a support group is using the power of creativity to transform their feelings of grief into empathy and social action. It is my experience that people aren’t satisfied with symptom reduction. Their depression or anxiety may get them into the room but the question remains: What am I going to do with myself, with this person that I am, with all of my strengths and weaknesses?

In this way, anxiety and depression become more than symptoms to be reduced. Instead, they become an invitation into the creative process, an opportunity for a client to create a new and more satisfying life. I am always interested in questions that stimulate the client’s imagination, asking them to imagine who they would be without their problem, or what message they think their problem might be sending them. And I firmly believe that if we, as therapists, care about creativity, our clients will come to value it as well.