Christian Conte on Anger Management

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

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

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

So I thought, “Okay. I can see that.”

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


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

"Oh Yeah? I’m Dr. Conte Too"

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

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

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

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

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

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

Yield Theory

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

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

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

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

And she said, “She’s so stupid.”

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

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

"I Picture These Giant Guys Sitting There with Knives"

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

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

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

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

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

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

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

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

Avert Your Eyes

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


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

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

The Phony Phase

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

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

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

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

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

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

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

Motivating Mandated Clients

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

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

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

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

No More Letters of Apology

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

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

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

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

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

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

You Can Definitely Kill This Person, but…

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

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

Yield Theory for All

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

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

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


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

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

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

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

The Tao of Anger Management: A Yield Theory Approach

“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

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

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.

Tara Brach on Mindfulness, Psychotherapy and Awakening

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.

Continuous outcome assessment

One of the enjoyable side-benefits of attending international psychotherapy trainings is the opportunity to meet bright clinicians and discover exciting new projects. At a recent training on ISTDP by Allan Abbass in Halifax, I met two British psychotherapists and researchers, Stephen Buller and Susan Hajkowski, who are starting an innovative project in the United Kingdom: the Psychotherapy
Foundation
. The overall goal of the Foundation is to promote procedures that improve the quality of psychotherapy. One aspect of their project I find particularly interesting is the focus on the  importance of continuous self-supervision and peer-supervision by therapists, via videotapes of therapy sessions and continuous outcome assessment. In my opinion, it is vital for therapists to get continuous critical feedback on their work from peers or mentors after formal training has ended: your last day in school should be your first day in consultation. Work in any field that does not include  frequent objective (and ideally data-based) assessment is inherently prone to quality deterioration, and psychotherapy is no exception. Our field in particular has a propensity for isolation, with so many therapists working alone in solo practice. For example, it has always seemed strange to me that therapists are required to get Continuing Education training but not required to get feedback on their actual work. Additionally, as has been discussed previously on this blog, a side-benefit of practice-based outcome assessment is that it provides a data set that can be used to inform the public about the benefits of psychotherapy, and help potential clients make informed decisions about which therapist they want to work with.

Encounters with Suicide: A Psychotherapist Remembers Not to Forget

Forgetting Begins

Back when phones had cords and I was sixteen, my mother’s friend called our house one afternoon and told me that she had a shotgun across her lap and asked me if I could give her one good reason why she shouldn’t blow her head off with it. I was alone in the house because I had not joined my family that year on our annual summer vacation in Maine. Instead, I was flirting with an eating disorder by trying to live on iceberg lettuce with low-fat blue cheese dressing and getting up each morning at 4:30 to ride my bike two miles to the Holiday Inn just outside town where I was working as a waitress on the breakfast shift. So there I was, all by myself, trying really hard to think of the right good reason. Already I was imagining the explosion roaring through the headset, the result of my inadequate and faulty answer.

I am quite certain that I did not give her one good reason, but I must have said something that furthered the conversation, because I remember her saying, “Do you know what it is like to live with a man who hasn’t touched you in years?”

Well, no.

I think we talked for a while. I tried to imagine what a compassionate adult would say to her, and tried saying it. I offered her my mother’s phone number in Maine. There was not a telephone in the cabin, but the owners could deliver a message. My mother’s friend refused. “Oh no, I couldn’t bother her on vacation.” I was thinking that bothering my mother on vacation was the best possible idea under the circumstances, but clearly it was not going to happen. My mother’s friend told me that she was feeling desperately lonely now that her youngest child had gone to college. She told me her husband of thirty years was having an affair with a woman in her twenties. I did not want to know any of this, at least not first hand.

Gradually she came out of herself and seemed to remember that I was the kid her daughter used to babysit for. “I shouldn’t be saying all this to you,” she said. I couldn’t disagree. I made her promise that she would not shoot herself.

“You don’t need to worry,” she reassured me. “I’ll be fine. It has been a really bad couple of weeks, but I’ll be fine. My neighbor will be home from work soon. I’ll go see her.” I felt a lack of sincerity in this. “It is quite a distance from blowing your head off to visiting a neighbor, and I was quite sure our conversation had not traversed it.” But there was nothing I could do, so I said, “I’ll tell my mother to call you when she gets home.”

“Don’t call her,” she said. “Don’t bother your mother. I’ll be fine.”

I hung up the phone and put this conversation so thoroughly out of my mind that I nearly forgot to mention it to my mother when she returned from vacation, and when I did tell her I found myself experiencing a sort of delicacy and shame that precluded any mention of the shotgun. I suspect I did not even mention the threat of suicide. I can’t quite remember, but I imagine myself saying that her friend seemed unhappy.

Forgetting Returns

I remembered this incident only recently when I was sitting in session with a client who was telling me about how she was going to buy a gun in order to shoot herself. This client, now in midlife, has been suicidal to varying degrees since she was sixteen, so her thoughts were not new, but the method she was proposing was far more likely to be lethal than anything she had considered before. At one level, I was working hard to assess her immediate safety and devise a plan. At another I was aware that I was feeling oddly wooden, disconnected, and ashamed. I knew I was irritated with her, as well as anxious. She is coy, deceitful, challenging—there is a way in which she teases me with the drama of her death, a drama she has been crafting with loving care for decades, a narrative in which her final explosive act of rage sears all of us who know her. It is a story she caresses like a beloved, spoiled pet, but also one that frightens her, and I have found over the years that she is readily diverted by small gestures of empathy on my part, or that she inserts her own delaying tactics, such as the need for a pretty death dress, or her plan to be honest on the permit application for the gun regarding the purpose of her purchase.

What she will not do is explore how this story serves her, what its purposes are in her life, what it helps her to avoid. I struggle to find some way toward this conversation, but as often happens, my own thinking is muddled by anger, anxiety, and that odd sense of shame. The only question I seem to be able to articulate clearly to myself is, “Will she kill herself now?” I believe she would not, and extract a promise to that effect. The promise comes easily, almost too easily, and prompts a new discomfort: I worry she is lying because, after many years of experience, she knows what would happen if she acknowledges an active plan. In the end, we contact her husband together, and afterward I let her leave.

And when she leaves, I forget completely—not about her, but about her thoughts of suicide. At our next session, fortunately before I have a chance to reveal my forgetfulness, she reminds me, but I forget again anyway. Or maybe forgetting is not quite the right word. It just seems to fall out of my mind. I start having defensive little conversations with myself about this forgetfulness. Maybe, I tell myself, it is because I am not really worried. After all, I am as confident as I can be when she leaves that she will not kill herself. She has been doing this for over 30 years. She can’t live in a hospital. But then I worry that I should be more worried. And then it falls out of my mind again, until our next session.

Of course it is hard for all of us who are clinicians to think about suicidal clients. It is frightening. It is a sad, hostile, violent act, in which we stand to lose a great deal at many levels: most importantly our client, but also self-esteem, self-trust, and professional reputation. We fear losing our livelihood if we fail these clients. We fear blame from ourselves and others. We choose not to think about it in many ways, including by resorting immediately to hospitalization as a way of ensuring not only our client’s physical safety but our own emotional safety. We insist on safety contracts before exploring deeply with the client. We find excuses and the means to get rid of them. “We rush to make repairs before we have the courage to examine the injury, slapping bandages on wounds so deep we are afraid to see them.” We increase medications, we loosen boundaries, we are afraid to ask questions, we demand answers we want to hear. With those who make chronic threats, we can become impatient and irritated. Some of these actions are of course sometimes necessary and desirable. But often what we are feeling first and foremost is a need to put a lot of distance between ourselves and the thought of a client’s suicide. These intense feelings and avoidances are common in one way or another at one time or another to all of us as clinicians, and certainly in this case they were part of mine, but I was beginning to suspect that for me, there might be something else coming up as well.

The Roots of Forgetting

On the surface, it seemed obvious. My father’s family worked very hard to forget my grandfather’s suicide. This dramatic issue, however, seemed so far from my direct experience I wasn’t sure if I could legitimately connect it in any way to what I was noticing about my feelings and behavior with my client. On the other hand, it seemed risky to assume my own even indirect personal experience with suicide was irrelevant, so I gave it some thought.

“My grandfather hanged himself when my father was four, and my grandmother did all she could to erase every memory of him.” I know a couple of things about my grandfather that I am pretty sure are true. He was a rumrunner in Pennsylvania during Prohibition, and he brought big bands like the Dorsey brothers to local hotels and night clubs. I have seen only one photograph. He is a broad-shouldered, dark-haired man standing next to a three-year-old version of my father on a merry-go-round horse. Once after my grandmother died I went on a search of her house for evidence of his life. I thought I had hit the jackpot with a pile of photo albums in the closet of an extra bedroom. It turned out that in each of the scalloped-edged photos from the 1930s, every one held carefully in place with little black corner pockets glued to the page, she had ripped out the images of my grandfather, leaving the others standing and laughing and smiling in front of buildings and cars, unaware of the torn edges framing the emptiness where he had been.

My grandmother lied about her husband’s death for more than 30 years, claiming he had died of a variety of unlikely ailments, including back problems. Nonetheless, her feelings of abandonment, rage, and shame were palpable to everyone who knew her. Even once she had admitted the real cause of his death, her explanations were dislocated and strange, and for me, always at least secondhand. In one version my grandfather was in a mental hospital and had what we now call bipolar disorder. In another, less likely but still my preferred version, he was also in a hospital, but possibly hiding from mob associates who murdered him.

There is no one left now who knows what really happened to my grandfather, or who can really even guess why. Like in the children’s game of telephone, the stories I have heard are probably distorted beyond recognition from their original source as they have been whispered down an almost century’s long lane. Even my own memory is confused by odd and inexplicable distortions and images. I remember with crystal clarity, for example, driving with my father and hearing him tell me that my grandfather probably had an affair with one of my grandmother’s many older sisters. I remember seeing the colors out the passenger side window, rural New York in the fall: the fields yellowing, bark darkened with rain, leaves brown and drifting, hints of lavender and red, the steady green of conifers. There was only a little gray in my father’s beard. I remember not just envisioning but knowing, remembering, the dark-haired older sister I never met, more settled than the younger, more beautiful red-haired one my grandfather married. I imagined her specifically. I could see her hanging laundry on a warm day in her flower-patterned dress. I could see the intense sexiness of the seam of her stockings drawn along her slim calves from the fall of her skirt to her square-heeled shoes.

But my father is bewildered by my memory of this conversation and has no recollection of any such affair. Why have I imagined it? Why has he forgotten? I am reminded of another children’s game, where one child draws a head and folds the paper over so the drawing can’t be seen, another draws the arms and folds her part in turn, another the legs, another the feet. Once unfolded, a figure is revealed, a crazy patchwork of imaginings. This is my portrait of my grandfather.

He is for me essentially fictional, his only reality in my life the shadow he cast on those he chose to leave behind. There is no pain in his release of any claim on me, although the long, slow-burning coals of the suppressed rage that were his legacy have in their way come down to me. Yet I think that in these odd moments—with my mother’s friend, with my client—I become aware of something else my grandfather has left with me. He lives with me in my unreasonable, inherited loyalty to my cranky little gnome of a grandmother, who demanded that my father never remember, never even try to remember, his father. He lives with me when my client’s words obediently fall out of my mind. In my father’s family, it is an act of loyalty to erase my memory and bury my anger and fear. Even though he died 20 years before I was born, my own memory of my grandfather is in its way constant and precise: “I remember him by forgetting.”

Awareness and Remembering

As so often happens in therapy, it is hard to be certain that this subtle, internal shift in awareness that I experienced thinking about my inability to hold my client’s suicidality in mind produced a change in my client. The role of therapist self-knowledge and self-awareness in the course of therapy is really immeasurable, in both senses of the word—certainly not readily quantified, but equally certainly a source of lasting, profound growth for ourselves and for our clients. I know it has become easier to get past my anger, fear, and denial when my client is suicidal, and this has created a change in the quality of our conversations about it. We are less focused on management and more focused on meaning. Usually by the time we wrap up with a safety plan it has become unnecessary, more of an addendum than a centerpiece of our conversation. Between sessions, I do not forget how she has been feeling. I know I will feel deeply angry, sad, betrayed and, yes, guilty, if she kills herself one day, but whatever happens, it will not be because I have allowed that possibility to fall out of my mind. She still holds on to her fantasy of killing herself, but for some time now speaks of it not as a plan, but as a feeling. “I am feeling suicidal” for her is no longer a threat of immediate action, but a description of despair. Like partners in a dance, we have both taken steps away from the concrete and into the symbolic, for I have replaced the concrete act of forgetting with engagement and curiosity.
 

The Truth About Facebook and Your Practice

Many marketing professionals point to the 900 million worldwide users on Facebook and say you must have a strong presence there to have a successful practice. They discuss the myriad ways you can use Facebook: your profile; a business page; advertising and frequent posts. They tell you how to get more “Likes” and “Fans” and the referrals will come. As a psychologist who has experimented with everything Facebook has to offer a private practitioner, I totally disagree with this common advice. You can waste a great deal of time and money on Facebook and have very little to show for it if you go into it naively. In this post I’ll discuss why this is so, and review one area I have found that does work well to generate referrals from Facebook.

Yes, Facebook has millions of users, and it also has the longest time per visit of any website (about 20 minutes). But monetizing those eyeballs is not easy, since few people go on Facebook with a primary purpose of seeking information. People go to search engines to find information, and go to Facebook to socialize, play games, look at pictures and videos their friends have posted, and comment on those posts. This means the only way you can successfully promote your practice on Facebook is to return to the 20th century model of “interruption Marketing,” where you do what the major TV networks, newspapers and magazines of that era did: you interrupt people's attention from what they are focusing on to check out your product or service. But we're in the 21st century, where the prevailing advertising model is “permission marketing” (see Seth Godin's brilliant 1999 book by the same name). As consumers we now get to choose what we want to see and hear. We give people, businesses and networks permission to tell us about their wares—and get annoyed or angry when this permission is violated. And on a rapidly-updating newsfeed such as Facebook, a post about your practice will usually elicit far less interest and attention than the photos from a friend’s vacation or the video of a sibling’s new puppy.

While every practitioner should have a free business page on Facebook (see https://www.facebook.com/pages/create.php), gathering “fans” for your page or getting people to “like” your posts is almost always a complete waste of time. Becoming a “fan” of a psychotherapist page or liking one of their posts is a quick, superficial action that implies a very low level of engagement with your work (aside: what does imply more engagement is when someone gives you their email address; building an email list is a very wise practice-building activity).

The one unique advantage that Facebook has over the search engines involves pay-per-click advertising. Unlike Google, who is forced by their business model to let everyone play the search game, Facebook has an exact way to segment who sees your ads. Thanks to the remarkable amount of personal data Facebook users put on their profiles, Facebook can offer the most highly targeted advertising in the history of business. Pick your target market very precisely—by age, gender, education level, city of residence, marital status, age of children or personal interests—and Facebook has a way for you to get your message out only to that specific niche of people. Specialize in working with children between the ages of 12-15? Want more referrals from women between the ages of 35-55 with a college degree who live only in two very affluent zip codes? Have a new workshop for Baby Boomer retirees? No problem; no one else but those people will ever see your ad. Combine that with an emotionally engaging photo and a problem-oriented headline (i.e. "Panic Attacks?" or "Still Arguing?" or "Defiant Teenager?") and you have a great chance of interrupting focus from the social activities to your service.

One important note: when people click on your ad, Facebook gives you the option of having the person visit your Facebook business page or leave Facebook and go to a specific page on your website. Get them off of Facebook to your website! There are far too many distractions on Facebook that greatly reduce the chances of someone focusing on your services for more than a few moments.

In summary, approach Facebook with caution and experiment with pay-per-click ads—but only if you have a very specific, targeted niche. For all others, create a business page, update it when necessary, and enjoy the social aspects of Facebook. Just don’t expect it to fill up your practice.
 

Mental Illness in Politics

In a recent debate about mental health services in Britain’s House of Commons, a Member of Parliament paused and laid aside his prepared notes, departing from the abstractions of rhetoric, the lingua franca of all legislative bodies since antiquity, and spoke at length in concrete terms of his own past experience with debilitating depression. The very next speaker, possibly prompted by his colleague’s candor, decided to see and raise the ante on a past history of mental health challenges, revealing that he presently deals daily with the symptoms of obsessive-compulsive disorder and has done so, sometimes more successfully than others, since childhood. In the course of this rather remarkable Thursday afternoon an additional two members chipped in, relating personal stories of dealing with mood disorders.

The use of gambling terms to portray the day’s events may strike the reader as being somewhat flippant, but considering the stakes, also apropos. These four individuals each took a sizable risk in revealing information that could quite possibly effect their future electability in a negative way. Those in the political class rarely reveal weaknesses to the electorate if it can at all be avoided; and, of course, the stigma endemic in a mental health diagnosis, past or present, need not be elaborated upon. Yet, at least initially, the wager has paid off for those involved, as press accounts speak of their courage and statesmanship in dealing with such an issue so honestly. Reportedly, comments emanating from their various constituencies have been overwhelmingly favorable as well. At least one mental health advocacy group has praised the day’s events as a shining moment for the parliamentary government system.

Just now in the United States, public discourse is much noisier but less substantive. We are, of course, in the final months of one of our multi-years long Presidential campaigns and have just completed the nominating convention phase. Party conventions have largely outlived their usefulness in an age when the nominee of each party is almost always known months before they convene. Today they serve primarily as a sort of infomercial designed to sell or re-sell a particular candidate to the populace. Due to the lack of any real suspense and a general disillusionment with government at present, the vast majority of Americans may simply be glad there are so many more viewing options than there used to be when the conventions first began to be televised in 1948. Still, despite the largely ceremonial and theatrical nature of the political conventions, at the end of the process one of the two men celebrated will be the next President of the United States.

It used to be a common practice to accord the nominee’s home state delegation the honor of putting the candidate over the top in the delegate count. Typically, the state in question would abstain from awarding its delegates until the appropriate moment, passing in the roll call so that they can be returned to at the appropriate juncture. This tradition was set aside at both conventions this year. Had it not been, President Obama’s home state of Illinois would have had the honors at the Democratic Convention. Absent from that state’s delegation was a man much in the news of late, Representative Jesse Jackson, Jr. Mr. Jackson is now reportedly back at home with family but had been in treatment in a number of facilities, most recently, the Mayo Clinic since June of this year for physical and emotional issues the latter eventually identified by medical personnel as being Bipolar II.

During the time of Rep. Jackson’s inpatient hospitalization, his opponents in the fall election have somewhat predictably attempted to call into question his ability to adequately represent his district due to his supposed mental status. (Jackson’s emotional collapse reportedly occurred following his primary victory and he has remained on the ballot as the Democratic Party’s nominee.) The usefulness of this tactic seems limited, as Jackson is widely expected by observers of the local political scene to retain his seat in Congress in November. The opinions from more relevant quarters—state and local Democratic Party VIPs and prominent elected officials have generally been guardedly supportive of Mr. Jackson during his hospitalization. Similar courtesy was extended to one of Mr. Jackson’s high-profile visitors to the hospital, former Rhode Island Congressman Patrick Kennedy, when he also acknowledged and sought treatment for mental health issues several years ago. Kennedy continued to serve in Congress following his diagnose until choosing to retire in 2010 to devote his time to a brain health research initiative.

Knowing what we know as trained professionals about the efficacy of modern treatment for Bipolar illness, this optimism and slowness to judgment seems perfectly sensible. It is quite reasonable, after all, to assume that Mr. Jackson, his physicians and family have all collaborated in the best manner possible to ensure his recovery and, considering his continued status as a candidate, his ability to successfully withstand the continued rigors of public service at minimal or no detriment to his wellbeing.

The importance of this relatively new attitude of acceptance in regard to political clay feet cannot be overstated, I believe. A single generation ago the current Republican Presidential nominee Mitt Romney’s father, George, a candidate for the same office in the 1968 election effectively crippled his campaign when an offhand remark he had made to a reporter the previous year came to light in which he had explained that his prior but since renounced support for the Vietnam War had come about as a result of a “brainwashing” by Pentagon officials. In the 1972 Presidential campaign, the Democratic Vice Presidential nominee, Senator Thomas Eagleton of Missouri, was summarily dropped from the ticket after damaging press scrutiny of his history of hospitalization for depression and treatment with electro-convulsive therapy.

The turning point, when a mental health diagnosis ceased to be politically fatal, may perhaps be traced to Lawton Chiles’ 1990 campaign for governor in Florida. Rather than attempting to conceal his treatment for depression (as Eagleton allegedly had after being invited on to the ticket by nominee George McGovern), Chiles spoke openly about it and extolled the virtues of the then-revolutionary Prozac, which he felt benefitted him greatly. He went on to win his party’s nomination and won the governorship with nearly 57% of the vote in the fall election, going on to serve two terms.
Odds are that there are more than 4 members of 650-member British House of Commons and more than 1 member of the 435-member United States House of Representatives dealing with mental health issues.

Perhaps others in these august legislative bodies will now be comfortable in sharing their trials and success stories, further normalizing the experience of living with a mental illness. Those of us concerned with advocacy can possibly take heart that as the elected class comes to understand that mental illness is not an automatic disqualification for service and that it can strike anyone, and that those able to successfully avail themselves of treatment dealing with it are quite capable of carrying out tasks as important as governing large Western democracies, policy makers may begin to be more receptive to arguments on the importance of adequate funding for mental health and expansion of preventive services. Time and helpful affirmation from the ballot box will tell.

Reid Wilson on Strategic Treatment of Anxiety Disorders

What is Anxiety?

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

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

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

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

From Resistance to Detachment

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

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

Exposure Plus

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

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

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

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

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

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

The Art of Persuasion

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

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

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

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

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

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

Chasing the Anxiety Boogeyman

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

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

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

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

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

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

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

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

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

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

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

The Anxiety Game

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

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

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

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

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

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

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

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

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

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

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

The Meaning of Anxiety

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

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

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

Getting to “Aha”

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

If that’s true, then

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

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

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

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

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