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You Gotta Have Heart

by Christopher Germer

Mindfulness has become one of the hottest growth areas in the field of psychotherapy in the past few years. It's a surprising hit even among cognitive-behavior therapists, whom nobody would ever accuse of being frothy-brained New Agers. Our scientific colleagues, such as Steven Hayes, regard "mindfulness and acceptance-based therapies" as the "third wave" of empirically based treatments, after behavior therapy and cognitive therapy.

The distinctive focus of the mindfulness-based approach is the intractability of emotions, and the recognition that pushing around difficult feelings often only makes them worse. In contrast, in the spirit of the mantra of the mindfulness approaches—"Change follows acceptance"—they prescribe a combination of awareness and acceptance as the primary intervention.

Several therapy approaches incorporating acceptance have proven to be effective with such difficult-to-treat conditions as the suicidality connected with borderline personality disorder (Dialectical-Behavior Therapy), recurrent depression (Mindfulness-Based Cognitive Therapy), psychotic delusions and hallucinations (Acceptance and Commitment Therapy), and a host of chronic, mind-body disorders, such fibromyalgia, psoriasis, and chronic pain (Mindfulness-Based Stress Reduction). Although the techniques used may differ, these programs share common psychological processes, such as disentangling from thinking ("thoughts are just thoughts") and learning to stay with unpleasant experience.

Nevertheless, in their enthusiasm for these new approaches, therapists run the risk of ignoring another psychological process essential to mindfulness practice—lovingkindness. Throughout the 2,500 years that mindfulness has been a part of the Buddhist contemplative tradition, it never was intended to be strictly an awareness or attention-regulation exercise. Take away lovingkindness and mindfulness is like being forced to watch a frightening scene, close up, under a bright light. That isn't an experience that most of the emotionally distressed patients we see need to have.

What we're trying to do with mindfulness is evoke a complete state of mind, much as a hologram can project an image into the center of a room, or a poem can illuminate a perception in the heart of the listener. Within the cognitive-behavioral tradition, the word acceptance, or radical acceptance (to use Marsha Linehan's expression), is used typically to convey the nature of mindfulness. I've found, however, from personal and clinical experience, that other words are necessary to evoke the heart quality of mindfulness. They include tenderness, care, self-compassion, lovingkindness, and simply love.

Thinking with the Heart

My path to understanding the importance of lovingkindness in mindfulness-based psychotherapy wasn't always smooth. Madeline was one of my first client-teachers.

She was an 82-year-old woman who, even though in good health and of sound mind, despaired that she'd have to leave her beloved home of 45 years, because she lived on a portion of a suburban street where neighborhood children congregated to play . . . and scream. The noise kept her from sleeping, and she was experiencing chronic stomach and neck tension. She'd tried what she could to reduce the noise level—talking to the children's parents, playing soothing music to shut out the sounds. In spite of such steps, however, she lived in fearful anticipation of the next child's shriek. Madeline felt sad about her noise sensitivity because she wanted to enjoy the ebullience of her neighborhood kids, just as she'd enjoyed her own children's energy earlier in her life.

Initially I thought Madeline might benefit from listening in a more spacious way to the sounds around her—not focusing all the time on the children's screaming. I made Madeline an audiotape, "Mindfulness of Sound," that taught her to passively notice all the sounds in her environment. It didn't work. She said she just found the noise of the children too disturbing.

Next I thought she might benefit from internal exposure. If she could mindfully explore her physical and emotional reactions to the noise, perhaps she'd be able to relax. And if her body felt better, I hoped, maybe she'd obsess less about the noise. Ever cooperative, Madeline explored her sensations, thoughts, and emotions whenever she noticed she was anxious: "Where does it hurt?" "What does it feel like?" "Does the pain come and go?" "What thoughts and feelings come along with the stress of those noisy kids?" I instructed her to simply notice what she was feeling in her body and how her body reacted to the external sounds. This exercise didn't help either, not the least little bit. All it did was focus Madeline on just how bad she felt, and made her even more upset with herself and her situation.

The closer Madeline got to her distress, the more overwhelmed she became. We might call this exposure without desensitization, or mindless exposure. The trick with mindfulness techniques is to maintain attentional stability and a certain nonattachment as uncomfortable experience is allowed into awareness, but not become emotionally overwhelmed. In some cases, medication may be required as an adjunct to mindfulness-based treatment. I suggested to Madeline that she discuss taking Klonopin or Paxil with her physician. But she demurred—she rarely took medicine, on principle, and wanted to continue exploring behavioral techniques.

By now, I seriously doubted that I could help Madeline. Then I recollected that she'd volunteered for many years at a nursing home, brought Vietnamese children to the United States after the war, and was active in her church. I started to wonder whether she could bring the same quality of compassion that she had for others to herself. Would lovingkindness help her better tolerate her distress?

Together, we came up with a new meditation: "Soften, allow, and love." Madeline was enthusiastic about this one from the start, so I made another 20-minute audiotape for her to practice with.

The meditation begins with simple awareness of whatever sensations may be occurring in the body. Can you feel the pressure of your body on the couch? Can you notice the movement of your breath? After a minute, attention is shifted to an unpleasant physical sensation. For Madeline, this was either her tense stomach or her neck. The first component of the meditation, "softening," refers to relaxing that uncomfortable part of the body. However, to avoid frustration if relaxation doesn't occur, softening is an invitation to relax.

When you feel discomfort, can you soften that part of your body? You don't have to relax; just allow that spot on your body to soften—if it's ready to.

The next component is "allowing." This refers to allowing the physical sensations of the body to be just what they are—unpleasant, neutral, or pleasant. It's an ancient Buddhist meditation technique.

Can you allow yourself to feel the discomfort as long as it lingers? Can you just let it be, as long as it's there, even if it hurts? You don't have to change it—it'll pass at its own time. Can you let it come and go as it wants to?

Finally, in the "love" component, you try to recollect a feeling of love that can be redirected at your own body. This is a variation on the lovingkindness practice. Instead of reciting phrases, we capture a feeling—a brain state, if you will—and associate it with a new object of awareness. In this case, the new object is a difficult body sensation.

Now, imagine what it was like when one of your children had a tummyache, just like you. Can you sense in your heart what you might have felt, or feel, as you sympathize with his or her struggle? Can you hold that feeling in your heart?

Now, can you give your own stomach the same love that you'd feel for your child if he or she were suffering in the same way? Can you bring some love to the very place where it hurts?

This meditation then led Madeline to fill her whole body with the same love she'd identified, and let that feeling of love gradually radiate out into the room and into her community.

After Madeline learned this meditation, she innocently inquired, "Where does the love come from?" "Where can I draw it from, if it doesn't come up on its own?" We decided that love just seems to be a quality that comes naturally to everyone. Sometimes we feel it most for a child or a pet. It seems to be inherent in all of us, just like awareness. The skill is to recollect what love feels like and to direct it where it's needed most.

Eventually we expanded Madeline's loving awareness beyond her physical pain to encompass the emotional discomfort she felt when her home became too noisy.

Two weeks after learning this exercise, Madeline reflected aloud, "I think I have to learn to love myself more!" Four weeks later, she was feeling some enthusiasm for "working" with her noise sensitivity, and she said she felt 50 percent better. She surprised herself that she was actually beginning to feel affection for the noisy kids. She bought a lovely hat for one neighbor girl—one just like hers—when the child admired it.

Six months after Madeline learned this practice, I called her to inquire how she was feeling. She was still practicing self-compassion on a daily basis. She said, "When I hear a scream and I'm up and about, I kind of welcome it, because it's a part of my world. It gives me a chance to practice, too. I'm not saying I'm 100 percent cured, because there are times when I get annoyed, like when I'm reading the Bible and am with God. Then the noise is intrusive. But I'm generally much happier. I didn't know I could give love to myself!

I asked her if the practice changed anything else in her life. She replied, "I have a sense of my own worth. I don't have to please people. More on top of things, you know? I don't feel victimized. I'm more accepting. If people say something wrong, I let it go. I don't have to be right. I can let it go."

I still wanted to know specifically how she was practicing lovingkindness. She said she intentionally recalled the great compassion she'd felt for her youngest son, about 44 years ago, when he'd awoken with his eyes sealed shut from discharge. Her little boy was terrified, and she was filled with love for him at that moment. "Now I direct that love at myself," she said. "Where exactly do you direct it?" I asked. "I direct it at my upper body. I don't quite know how to describe it; my heart, yeah, it's a heart thing," Madeline replied.

Mindfulness Plus

Lovingkindness and compassion are heart qualities. They bring heartfulness to mindfulness. It's curious to me that heart qualities are marginalized in our profession. Perhaps they're not masculine or scientific enough. Lovingkindness isn't a secondary component of mindfulness; when we have to deal with difficult emotions, lovingkindness is primary and indispensable.

The "Soften, allow, and love" exercise was subjectively different from Madeline's (and my) earlier attempts at mindfulness, because it allowed her to expend less effort to change her experience. The loving attitude allowed her to "let go" and abide in the midst of her suffering with greater equanimity.

Our patients come to therapy to get better—to be cured. They want to become something other than they are, in an effort to avoid pain and maximize pleasure. Therapists shouldn't buy into this agenda though. Even Sigmund Freud noted, "A man should not strive to eliminate his complexes, but should get into accord with them." Lovingkindness allows our patients to just "be." No wasted effort.

Sharon Salzburg, a meditation teacher at the Insight Meditation Society in Barre, Massachusetts, and
the author of Lovingkindness: The Revolutionary Art of Happiness, may be credited with bringing lovingkindness practice to the West. The four phrases Sharon suggests as a starting point for this practice are:

May I be free from danger.

May I have mental happiness.

May I have physical happiness.

May I have ease of well-being.

Repeating these phrases inclines the heart toward our suffering, rather than falling prey to the instinctive tendency to run away. We are not trying to eliminate what's happening at the moment. We're simply practicing love while in pain. It's the practice of care, not cure. But, paradoxically, with emotional suffering, cure often follows care.

For most people, self-compassion in the moment of suffering is a radical act. We're quite good at loving others, but rarely think of directing love toward ourselves in our moments of suffering. Perhaps we don't know how. Maybe we think we don't deserve it. Often we just can't find ourselves in the crowd—we're too busy toughing it out even to know when we're suffering. Practicing mindfulness with self-compassion allows us to know when we're in pain, and it calls forth a new response.

Simply reading about lovingkindness practice is no substitute for the therapist's own personal experience. The reader is invited to write down the four lovingkindness phrases and simply to recite them over and over for a few minutes the next time you feel upset. The more distressed you feel, the more likely you are to experience the deep, internal softening that accompanies the practice. When the mind throws up arguments against the practice, simply take notice and return to repeating the phrases. If the mind didn't protest, there'd be little need to practice.

My client Rachel panicked whenever she blushed, fearing it would signify that she wasn't a competent, intelligent colleague. Anticipatory anxiety led her to avoid social settings. She avoided the coffee room for fear of personal conversations; she was afraid to use a public restroom when others were around; and she avoided public speaking, at considerable cost to her career. She took antianxiety and antidepressant medications for her condition.

Poetically inclined, Rachel rewrote the lovingkindness phrases as follows to help her accept her anxious temperament and blushing, to anchor her awareness in the present moment, and to encourage her to continue to participate in life, even though she usually felt quite vulnerable.

May I have a peaceful spirit-mind and be free from sickness and harm.

May I paddle my currents and laugh with my quirks.

May I see the pulse of waves, feel the gusts of falling snow, hear the cry of the loon, sense the awe of the wilderness.

And may I hold my exposed heart in the embrace of my soul.

A mere three weeks after beginning to practice, she reported that she was taking less Prozac, had stopped Klonopin altogether, and was more energetic in meetings with colleagues. She related another effect of lovingkindness practice that I've often heard from patients: she'd begun talking more encouragingly to herself. Her inner dialogue included supportive comments like: "You'd like yourself if you met you!" "You're who you are, so say what you want to say!" and "Go ahead, quirk out!"

Rachel's increased capacity for self-compassion had another surprising effect. She found she no longer had to turn off the TV when tragic stories, like starvation and disease in Sierra Leone, came on the screen. She had the emotional capacity to handle them. She said, "I'm less afraid of what might come in—yes, the world has terrible beauty."

Bringing Love to Therapy

At the present time, there's only one clinical study I'm aware of that examines the use of lovingkindness exclusively to treat a clinical condition—in that case, back pain. However, a warm attitude can be discovered implicitly in all the empirically validated protocols mentioned earlier. Zindel Segal's Mindfulness-Based Cognitive Therapy (MBCT) and Jon Kabat-Zinn's Mindfulness-Based Stress Reduction program use poetry to help inculcate the gentle quality of mindful awareness. One such poem is "Wild Geese," by Mary Oliver. It begins:

You do not have to be good.

You do not have to walk on your knees

for a hundred miles through the desert, repenting.

You only have to let the soft animal of your body

love what it loves.

The healing qualities of allowing, acceptance, and letting go permeate Oliver's lines. Through this poem, the word love has even found its way into the MBCT treatment protocol. That's a milestone for empirically-based treatment.

Often therapists find themselves working for years on end with the same patients, giving love and compassion, and hoping that it'll rub off in some way. We hope that the kindness we extend to our patients will eventually be brought by the patient to his or her own suffering. Often that doesn't happen. It's as if there's a hole in the bottom of the pot. Sometimes, within minutes of leaving our office, a patient may be hit by despair, just like smacking into a stone wall. These patients are usually the ones with few friends or family to support them. How can we help such vulnerable people nourish themselves?

I'd been treating a 35-year-old man, George, for approximately four years before I taught him lovingkindess practice. He'd been so severely neglected as a child that he could barely walk when he went to kindergarten—he just flopped around. No one cared. He'd also been physically abused on a daily basis by his single, alcoholic mother. He ran away at age 15, and never returned home.

When I asked him how he'd managed to stay alive, and even finish high school, he said he remembered some kind moments with his grandfather. His mantras for overcoming adversity came from muscular role models in World Wrestling Entertainment, such as Ric Flair: "Win if you can. Lose if you must. And you can always cheat!"

He's one of those patients that make you wonder if people can ever recover from a horrible childhood. He was underemployed, but employed. He didn't have any friends, because he didn't think he was worth their time. He was quite overweight, suffered from depression and insomnia, and had been taking antidepressants for years.

Therapy with George was always a delicate dance. I didn't want him to open up his wounds too much, lest he become overwhelmed and unprotected outside the session. This is often a dilemma with trauma victims—they don't have the self-compassion skills to manage reawakened memories, so they may decompensate and regress in therapy. Loving attention by the therapist, which opens up the heart like a flower and exposes old wounds, may cause difficulties outside the session, when clients remain open and vulnerable, but defenseless. Hence, I had to go slowly with George. Fortunately, he'd managed to marry a nice woman, who came to sessions occasionally when he resorted to such primitive self-regulation strategies as cutting himself and punching walls.

I taught George lovingkindness a few months ago, and the impact was almost immediate. As I repeated the phrases to him, his eyes became red and moist. He slowly lowered his head and said softly, "I can do this."

George announced the following week, right off, "I'm coming into my own!" He'd applied for a better job, even though it meant risking rejection. He said he was tired of being ashamed of his childhood, which meant not trying to get ahead. When I inquired what led to this change of mind, he said he was doing lovingkindness in bed, morning and night. He'd taped the phrases to his office computer, and he repeated them to himself whenever he felt "overwhelmed with self-doubt."

It was as though he'd woken up overnight and could see life from a broader perspective. He said he realized his elderly father-in-law said cruel things to him, not because George was actually "stupid" or "useless," but because the feeble, old man was demented. He added, "I'm not personalizing bad news so much."

Over the following weeks, this remarkable trend continued. George said he was volunteering for projects at work, he'd signed up for an art class, and had taken his wife on a "road trip." Where? They visited his old housing project for the first time since he'd left 20 years earlier. He said he was flooded with traumatic memories, but then started enjoying pointing out the sights, like the corner where he often found the dead bodies of junkies on his way to school in the morning. "Now I'm not ashamed. I have a lot of people who love me. Like the Tin Man in the Wizard of Oz. I think, 'I can do this,' 'I deserve this.'" Tears filled his eyes as he told me that he deserves friendship and love.

"I've spent a lot of time motivating others," he added, "at work and at home. Now I am motivating myself!" Months later, his general level of happiness and sense of humor continue to improve.

In George's case, self-compassion practice led to a radically different sense of himself in the world. He developed the nonattachment and happiness of someone who feels truly loved. As Tara Brach wrote in her beautiful book, Radical Acceptance, many people suffer from a "trance of unworthiness." When people feel bad about themselves—self-loathing, shame, self-doubt—they need an antidote at the same gut level of feeling. They need love.

Most of our clients come to therapy already exhausted by heroic but futile efforts to change themselves. We shouldn't further disappoint them by buying into the change agenda. It's ironic that clinicians themselves, when looking for their own therapists, don't usually choose experts in behavioral change. They seek therapists who are known to be warm and kind. Why would we want to offer anything less to our clients? The compassionate attitude has to come first. Kindness is the change agent.

As mindfulness is codified and manualized within our profession, we need to be especially careful not to overlook the primary healing process of lovingkindness. With self-compassion, our patients can bear seemingly unendurable emotional pain. Without it, awareness is barren and lifeless, and can even be harmful.

Christopher Germer, Ph.D., has been integrating meditation into psychotherapy since 1978. He specializes in mindfulness-oriented treatment of anxiety and in couples therapy. He's a clinical instructor in psychology at Harvard Medical School, and is on the teaching faculty of the Institute for Meditation and Psychotherapy. He's also a coeditor of Mindfulness and Psychotherapy. Contact: campsych@earth link.net; website: www.meditationandpsy chotherapy.org. Letters to the Editor about this article may be e-mailed to letters@
psychnetworker.org.

FAMILY MATTERS
By Dennis Butler

Chew Pow
There are many ways to say "I don't know"

She was a diminutive woman, perhaps five feet tall. When she took the seat across from me in the consultation room, her feet dangled above the floor. Her gray hair was tied back in a bun. Her worried face told a thousand stories.

The call from the Refugee Mental Health Program I'd received about her a few days earlier was similar to many others I've gotten through the years: "We're referring Mrs T., a 47-year-old Hmong refugee woman who's experiencing low energy, fatigue, and frightening dreams," the voice on the phone had said. "Two sessions for evaluation, eight sessions for treatment. Submit a treatment plan if you need more."

Because neither of us had any facility with the other's language, a translator was always present. Some were young, and like her, Hmong—indigenous people originally from the highlands of Southeast Asia. They were the ones moved to tears by her stories of death and atrocities in Viet Nam and Laos. When she left the room after one session, a young translator in her twenties told me that these were the stories her own parents wouldn't disclose. Other translators were older, multilingual, from other Southeast Asian ethnic and cultural groups that, I later learned, looked down on the Hmong. They weren't moved in the same way, sometimes even tending to take control of the session and give advice.

Despite my unfamiliarity with her language, I came to recognize by the second session one recurrent phrase, Kuu tsi paub, which sounded like "Chew Pow" to me. It was always translated, "She doesn't know." The phrase was frequently repeated at each session, especially after I asked her a question that started about how long, how many, or how often.

As the Chew Pows multiplied, I considered the possibilities. Was she resistant? Dissociating? Even malingering? I tried to conceal my frustration. A Hmong colleague said that her people were poor historians, that they look at the world in a different way, and that they didn't think in quantifiable terms.

So we moved on session by session, with the Chew Pows ever present. Bit by bit, her history became clearer to me, and her symptoms of a prolonged post-traumatic stress disorder more apparent—fatigue, nightmares, worrying, avoiding contact with other Hmong families, not cooking for her family. Sometimes, she told me, she felt a "bad wind" around her. Especially telling were her stories: images, repeated in her dreams, of villagers killed and mutilated along the trail of escape; the sound of gunfire and screams in the night; one of her children dying of starvation in the jungle.

Now we were getting somewhere, I thought. I was ready to try some techniques. I suggested that when the dreams awakened her, she should say to herself, "I'm in the United States; the enemy isn't here and can't harm me now." At the next visit, she reported, "Yes, I tried that. I hear your voice when I awake and I'm not so scared. But I still have the dreams." "How often?" I asked? "Chew Pow." "Have the dreams changed?" "Chew Pow."

I asked if she'd leave her dreams with me on an audiotape—give me some of her fears to lock up in the drawer of my desk. She agreed. And so, in the sixth session, she related the content of her dreams, in Hmong, of course. For 30 minutes, she spoke softly, pausing only occasionally. The translator, an older Hmong man, sat transfixed. When the session was over, he was quiet and somewhat pale as he left the room.

At the next visit, I suggested that we listen to the tape and have the translator tell me what she'd said. "No, no need," she told the translator. "Now you have the dreams and can lock them up." "Was it helpful to record your dreams?" "Chew Pow."

After that session, her appearance changed. She came in wearing more colorful, but oddly matched, clothing. Sometimes I saw a slight smile on her face. Her legs would swing gently under the chair as she talked about her children. I asked her if she thought these were good signs. "Chew Pow, but if you think this is important, then I accept it as a good sign."

I often explain to the family-practice residents I teach that they acquire much knowledge, but some day they'll achieve understanding—a different way of knowing. Now I began to wonder if there were different levels of not knowing, too? I paid closer attention to each Chew Pow. There were variations. Some were stuttered, some had a flip inflection, others were abrupt. Some seemed angry; others ended in a whine. Clearly she could say "I don't know" in many different ways, reflecting, I suspect, that she'd come to accept that she really didn't know or understand many things in many different ways.

Meanwhile, she was sleeping better. "How Long?" "Chew Pow." The dreams didn't awaken her as often. "How often?" "Chew Pow." "What was different?" "Chew Pow."

She had more energy. She told me she missed the freedom she'd had in her village and the highlands. She told me she didn't know how to help her children with their homework and feared the influence of the gangs in her neighborhood.

Around the eighth session, knowing that the managed care company would require documentation to authorize further treatment. I asked her if her symptoms had changed. "Chew Pow; but I do know that you're a good person, and I'll remember you and will be thankful to you until the day of my death."

In the ninth session, again seeking to put things in quantifiable terms, I asked about her symptoms again. "Chew Pow. I'm grateful for all you have done, and I'll remember you in the final hours of my life on the day I die," she replied. Feeling pressured to satisfy managed care, I tried one last time. "Chew Pow, but I'll remember all you've done, even in the last breath I take in the last minute of my last day." I chose not to ask again, saving me, and perhaps her, some serious embarrassment. We agreed that she'd return to see me when and if she needed.

It took a while for her words to sink in. This woman had witnessed terror beyond my comprehension, experienced a total disruption of her family and culture, and had been resettled into an incomprehensible new world. Yet she'd determined that I was a good person, was grateful for my help, and would remember me until the day she died—something I'd never expected to hear any patient say. She accepted how much she didn't know (in many different ways), but she knew I'd helped her, and she was grateful.

Trauma forces us to recognize that there are things in the world that we don't know and don't understand. Whom can we trust? What's really important in life? For what are we truly grateful? After what Mrs. T. had experienced, seemingly nothing could ever be certain again. But recovery isn't based on knowing how many. It's based on reconnecting with that which is basic and essential in oneself, in relationships, and in life.

Mrs. T said she'd remember me until the day she dies. I, too, won't forget Chew Pow and the lessons she taught me. I occasionally pull out her tape and listen. What did she record? Chew Pow—I don't know. But it really doesn't matter. It isn't about the words, it's about what happened when we were together. She taught me to become more comfortable with not knowing many things, yet staying connected to who my patients are and what's important to them. Is she adjusting? Yes. How do I know? I can't tell you how, but I know it's true. And I'm deeply grateful to her for helping me reconnect with why I do what I do.

Dennis Butler, Ph.D., is a psychologist and professor of family medicine at the Medical College of Wisconsin in Milwaukee, Wisconsin. Contact: dbutler@mcw.edu. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

From the Editor
Jan/Feb 06

As an undergraduate English major, I was unimpressed with my required foray into Psych 101. The leaden jargon of operant conditioning and psychoanalysis seemed more like assaults on the English language than methods for understanding the mind or healing the wounded psyche. It was the great authors I read in my literature classes—Shakespeare, Blake, Yeats, Austen, Hawthorne, Dickinson, Melville—who seemed a far superior source of wisdom about human nature, and who certainly had more to say about truth, virtue, and happiness.

But when it came to making a career choice and perhaps following in the footsteps of my impressive-sounding Lit professors, there was a problem. The more I learned about the politics of the English Department, the more it seemed to be a rank stew of envy, backstabbing, and professional claustrophobia. And my professors themselves, I eventually discovered, were, for the most part, frustrated, bored, and often alcoholic. The study of literature in itself apparently wasn't a failsafe ticket to moral elevation and personal enlightenment.

With so many of my role models seemingly in need of psychotherapy, I decided to give that profession another look. Now, after 30 years in the field, I suddenly find much to remind me of my graduate years, when I was uplifted by great literature. After decades of being preoccupied with emotional pathology in all its DSM-documented permutations, psychology seems to have shifted its attention to the study of what's best in us, where it comes from, and how it emerges to enrich our lives. From a growing body of research into what's called Positive Psychology has come the news that mental and emotional health may have a lot to do with being good, rather than merely being happy. Social psychologist Jonathan Haidt reminds us in his article, "Higher Ground," of how important for emotional well-being are the "moral" emotions—gratitude, compassion, altruism, forgiveness, and, particularly, awe, the feeling of emotional elevation we get when we engage in religious worship, contemplate a magnificent landscape, or witness acts of charity, selflessness, and courage.

Much of the credit for this interest in self-transcendence goes to psychologist Martin Seligman, the de facto CEO of a Positive Psychology movement that's yielded a large and growing body of solid research into what gives people "authentic happiness" (the title of Seligman's bestselling book). According to Seligman and his cohorts, the keys to a satisfying and meaningful life sound a lot like what your grandmother might have advised: hard work, self-sacrifice, purpose, duty, a positive outlook—in short, moral character. What's more, Seligman has even worked out a tough-minded course for helping people actually achieve happier lives. It's a kind of happiness boot camp, replete with morally prescriptive exercises encouraging gratitude, appreciation, optimism, and similar virtues.

Networker Book Review Editor Richard Handler, who isn't himself personally inclined to Pollyanna-ish excess, took Seligman's 20-week Telecourse (with almost 200 other happiness seekers) and found it deeply instructive, if not always in ways that the Positive Psychology people might have expected. While recognizing the contribution Seligman and his band of merry men (and women) have made to therapy, Handler was left wondering whether science can really understand happiness. More to the point, he wonders if it's really possible to devise "a practical system, a curriculum, a didactic course of happiness and wisdom" whose tenets can be absorbed like those of any other skill or habit.

Perhaps, he suggests, elixirs as fundamentally mysterious, elusive, and undefinable as happiness, awe, wonder, gratitude, and appreciation aren't quite ready for mass-market bottling just yet. Nonetheless, as a corrective to the standard, largely amoral, psychopathology-based and self-absorbed psychological culture—in which the words virtue and self-sacrifice are almost taboo—Positive Psychology and the contemplation of what Haidt calls the "vertical dimension" of human experience are long overdue. Positive Psychology isn't therapy, nor is it intended to be; but in its various manifestations, it certainly might enrich even the most traditional therapist's understanding of what makes human beings tick.

IN CONSULTATION
By Frank Dattilio

Throwing Away the Script
Helping trainees trust their gut

Q: As a supervisor, I often find that trainees are overly rule-bound and rigid in the way they approach clients. How can I get them to loosen up and learn to trust their own gut instincts more?

A:It's true that students often feel more secure approaching every clinical encounter strictly "by the book," and are frequently so afraid of making mistakes that they stifle their own capacity for therapeutic intuition and emotional connection with their clients. Sometimes freeing their therapeutic imagination requires bold steps.

I remember one time, years ago, while teaching a graduate course in abnormal psychology, assigning an exercise to several class members in an attempt to help them understand what it feels like to be considered abnormal. I had them board a city bus during the morning rush hour and sit in the back. Then they were to yell out the name of each stop as the bus came to it. Half the students couldn't muster the nerve to complete the assignment, which drove home the point. Those who did follow through quickly found themselves sitting alone on the bus and feeling quite "odd."

Getting students to loosen up and rely on their own instincts—use their own radar systems in therapy—is one of the greatest challenges for any teacher, and requires a willingness to be unorthodox. You must be able to let instinct be your guide, maybe to the point of mild wackiness.

Gail was at a crossroads in her training. A highly intelligent and technically adept third-year psychiatry resident, she was wondering whether she'd chosen the wrong field. "I don't know what's wrong," she said to me one day during supervision. "I just can't get a handle on being a therapist." A newly married woman of 28, she wanted so much to do the right thing as a budding psychiatrist, but was somewhat rigid and a bit concrete in her thinking. For example, she'd told a patient who was struggling with a life decision for more than a year to "just decide and be done with it!"—failing to recognize that the "struggle" was the actual problem, not the inability to decide.

She attributed her narrow focus to the pressure that science instilled in her to always be analytical and sharp. Whatever the reason, it wasn't the first time she'd complained in these terms, and in exactly this same, tired, discouraged tone of voice, and I was beginning to wonder whether she was in the right profession.

"What do you mean you can't get a handle on being a therapist?" I asked, suppressing my own impatience.

"I just don't think that I'm in touch with my patients," she said. "I'm going through the motions, asking all the right questions, using the proper techniques that I was taught, but something just doesn't feel right to me. It's just not clicking—I can tell by the look on my patients' faces."

When I asked Gail what she thought she was doing wrong, she sighed and said she just didn't know.

"Well, you say things just don't 'feel' right," I probed. "What would 'right' feel like to you?" She didn't know the answer to that, either.

"I just know that it feels as if I'm doing therapy with blinders on—I just can't get a grip on what's happening," she noted.

"And what's so bad about that?" I offered. "That describes what most of us encounter initially in the therapy process. Sometimes not really knowing what's happening is the best route to feeling your way into a real sense of your client's struggle. Sometimes you just have to let go of what you know and let the therapy flow along its own course."

Gail looked at me as if I'd suddenly started speaking Farsi. "I just don't get it," she said flatly.

I was close to telling her to just forget it, that I couldn't help her, when an idea popped into my head and I decided to try something just a bit weird. I had nothing to lose and, even if it didn't help her, the thought of trying it out made me feel better right away. I told Gail that I had an idea for her next supervision session. Instead of watching her with a client, I'd meet her at the nearby Starbucks, and then we'd go to an unnamed destination. All she should do to prepare for this outing was to think about a shape. "It can be any type of shape someone might hold in his or her hand. I just want you to think about that shape and what it would look like, and keep the image fixed in your head." Gail all but rolled her eyes at this apparent tomfoolery, but nodded her head. "Fine," she replied sardonically.

A week later, Gail and I trekked across the snow-covered medical-school campus toward a Gothic-style structure known as the College of Arts. When she'd said she couldn't get a handle on being a therapist, the word, hands popped into my mind. So I'd arranged for a colleague in the art department to allow us to use one of the pottery wheels.

I sat Gail down in front of the foot-driven wheel, plopped a lump of wet clay in front of her, and told her to try to form the shape that she'd been thinking about all week on the pottery wheel. With a bucket of water to her right and a towel on her knee, Gail began to pedal the wheel and dove into shaping the amorphous lump into the image that had been percolating in her mind.

"You're so weird," she said, laughing nervously.

"I know," I replied, "but just be patient with me and think about feeling your way around this undefined shape until you've molded it into the form you want. But first, we need to add one crucial thing." I took out a blindfold and covered her eyes and said, "Now I want you to make that shape you've been carrying around in your head."

"What?" Gail screeched.

"Remember the shape in your mind and then mold this clay into that shape the best way you can," I instructed.

"This is ridiculous," she said. "I don't understand what this is supposed to prove." She was becoming a little agitated, but I persisted.

"Look, just see if you can do it. Keep the shape in your head and form it as you go along. Try to work at translating your thoughts to feelings as you feel out the shape of the item in your mind. Focus on the emotional sense of struggle and try to rechannel it by creating the shape you desire."

As Gail began to form her shape—a cherished vase she'd recently broken by accident—I suggested that by feeling the actual form evolve through her fingertips and molding the moist clay, she might begin to develop a sense of freedom to follow her instincts, to let herself go and wing it—the kind of freedom required when doing therapy. As I talked, it occurred to me that the same thing was happening to me as a teacher. In guiding Gail, I was being guided by my own intuitive sense of how to communicate with her. This experience was as much a revelation for me as I hoped it would be for her.

I remembered that during my own early learning, when I was working with difficult families, I'd felt similarly to Gail. I also recall that I was helped enormously by an unexpected experience—attending a concert. The concert opened with the crashing of kettledrums. It was as though the drums were alerting the audience to the fact that the percussion was to play a very important role in the concert. After a time, the drums fell silent, while the other instruments in the orchestra laid down a solid foundation of sound. Then the drums joined in again and blended with the orchestra. What struck me that evening was the concept of keeping some themes silent for a while, which is sometimes the way families cope with certain dynamics or stressors. Initially inspired by that concert, this insight regarding the ebb and flow of communication has remained with me during the course of my work as a psychotherapist.

About a half-hour later, with much laughter and a little bit of cursing, Gail had created her vase out of a shapeless mass. I took off the blindfold and said, "Okay, take a look."

Gail made a show of being unimpressed. "Ooh, did I make that?" she jeered sarcastically. "So, what's your point?" But she was smiling and her eyes were bright—at least she showed more energy and spirit than she had for some time.

"You need to do something like that with your clients," I said. "Don't always be so driven by the rules. You can't be afraid to try something outside your usual frame of reference. You might want to try not to be so calculating and take a risk—just like I did with you. Risk letting yourself not know how things are going to turn out all the time with your clients."

Hearing this, Gail sat up straight in her seat as if she were intent on taking a new posture.

As we talked further, we agreed that you need a good therapeutic plan—a directional map—once therapy is well underway, but that, sometimes, you must first feel your way blindly along in the dark to determine which direction you want to go, what strategy you want to use. Whatever techniques and interventions you use, you can't neglect your basic instincts about people—the gut-level intuition, that helps shape the course of therapy. Letting go and being patient are integral to finding your way.

Gail was definitely intrigued, yet still puzzled. "But I don't feel I have a real sense of collaboration with clients during treatment—that feeling of working together with someone."

I told her to think about the clay; once she allowed it to happen, wasn't the clay really guiding her fingers? "Sometimes you simply have to let go in therapy and trust that you'll discover the way by allowing it to emerge, particularly in the beginning, when clients are very guarded. Use your delicate fingertips," I urged.

"With the clay, you combined your sense of feel and touch with your knowledge of what you were trying to shape. It was instinct as much as intellect that allowed you to make your vase."

The same thing held true for therapy, I told her. "You have to trust your 'fingertips'—your own feelings—as much as your brain. If you can let yourself take a risk and not feel you have to calculate every move, a real felt understanding of the situation and the people involved will emerge. And out of that, your sense of collaboration during the course of treatment will begin to take shape, as well as your sense of mastery."

In my subsequent supervisory meetings with Gail, she appeared a lot less anxious and discouraged. "It's still a struggle for me, but I'm learning to let go. I think about that pottery wheel a lot, and I've put that crummy vase I made on my desk at the office to remind me to 'let go.'" In later sessions, Gail reported that she was making headway with her patients and had actually begun to look forward to seeing them.

Gail's memory of this important lesson will consist in part of that sloppy mess of clay that she was able to turn into something resembling a vase while blindfolded. And when she gets stuck in her head, unable to "think" her way through a tough case, perhaps she'll remember her eccentric supervisor. Perhaps she'll not only recall his advice, but also how she "got it"—just as I, to this day, recall those kettledrums.

Frank Dattilio, Ph.D., A.B.P.P., is a clinical psychologist in private practice in Allentown, Pennsylvania. He's on the faculty of psychiatry at Harvard Medical School and the University of Pennsylvania School of Medicine. Contact: datt02cip@cs.com. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

Clinician's digest

By Garry Cooper

Exercising for Mental Health

Therapist Jane Cibel really makes her clients sweat. After a brief check-in, during which they report how their lives and therapy homework have gone in the past week, they get on her treadmill for five to eight minutes, and then hit the weight machines in her office for a full workout. Throughout their workout, she'll ask them the kinds of questions about their thoughts, feelings, and memories that other therapists ask clients.

For years, Cibel, who's certified as both a social worker and personal trainer, had been thinking about integrating exercise and therapy. Then four years ago, as the research continued to accumulate showing that exercise is as effective as therapy or meds for certain conditions, Cibel finally made the break with tradition. She set up her Washington, D.C., office with exercise equipment and told her clients to wear workout clothes to sessions. As word of her unique practice spread, her caseload shifted toward clients who are unhappy with their bodies, although she doesn't specifically treat body-dysmorphic or eating disorders. Underlying her clients' dissatisfaction with their bodies, she says, is usually depression, anxiety, or other mood disorders, and those are the issues her distinctive approach primarily addresses.

Cibel believes that much of the benefit of exercise comes both from making an initial commitment to taking action and from an increasing sense of accomplishment. While her clients work on their bodies, she reinforces their courage to change, their strength, their endurance, and their balance. "I'm not just commenting on their physical effort but using metaphors for how resilient they are," she says.

Cibel also uses homework exercises to build psychological strength. She'll tell depressed or isolated clients to call a friend or check the newspaper for community activities. She'll instruct clients trembling at the brink of career transitions to bring in a draft of their re'sume' or schedule a few job interviews. She also advises them to do at least two workouts between weekly sessions. The sense of mastery they gain from their workouts and from her positive feedback, she says, stays with them during the week and encourages completion of the homework assignments.

Cibel carefully monitors her clients to make sure the exercise doesn't harm them. She warns that therapists who start their clients on exercise regimens without appropriate training might be exposing themselves to liability. But, she says, therapists who want to use exercise to bulk up clients' emotional confidence and strength can always suggest that they head for the nearest gym and sign on with a personal trainer.

Autism Epidemic?

It's been widely reported in the media that autistic disorders, once considered rare, are approaching epidemic proportions. As many as 1 in 150 children are now thought to have autistic, Asperger's, Rett's, childhood disintegrative, or pervasive developmental disorders. The Autism Society of America estimates that more than a million people, both children and adults, in the United States have an autistic disorder. In California, the number of individuals seeking services for autistic disorders jumped 273 percent between 1987 and 1998, and then doubled in the next three years; all told, that's a 634-percent increase from 1988 to 2002.

Many claim the epidemic is caused primarily by childhood vaccinations, with the major suspect a mercury-derived preservative called thimerosal. Animal studies clearly demonstrate its toxic neurological effects, and since 1991, when the Food and Drug Administration mandated three additional childhood vaccinations that were heavily laced with thimerosal, the incidence of childhood autism has increased fifteenfold. A few years ago, the FDA and other federal health agencies, responding to public concerns, called for eliminating and/or significantly reducing levels of thimerosal in childhood vaccines, while still maintaining that today's vaccines are safe.

This spring, an article in the April Current Directions in Psychological Science claimed that there never was an "epidemic," and that the increases in autism are actually caused by an expansion of diagnostic criteria. Morton Ann Gernsbacher from the University of Wisconsin, the article's lead author, points out that between 1980 and 1994, the DSM significantly broadened its diagnostic criteria for autistic disorders. The 1980 diagnostic markers of "pervasive lack of responsiveness" to others, "gross deficits in language development," and "peculiar speech patterns" evolved in 1994 into "impairments" in social interaction and communication and "restricted, repetitive and stereotyped patterns of behavior, interests and activities." While the 1980 DSM had only two autistic categories—Infantile Autism and Child Onset Pervasive—the 1994 edition has five.

While those convinced there's an autism epidemic point to the alarming increases in cases reported by school districts around the country, Gernsbacher says that the increase is due to new reporting requirements. In the years since the reporting requirement changed, she argues, larger and larger numbers of previously undiagnosed or misdiagnosed children have begun to show up. Such an increase isn't new. Gernsbacher points out that after "traumatic brain injury" became a mandated reporting category, its incidence increased 5,059 percent in a 10-year period, and no one would suggest a sudden epidemic of traumatic brain injuries.

The stakes are high in determining whether an autism epidemic exists. If increasing levels of mercury in the environment are causing more cases (in addition to thimerosal, mercury is present elsewhere in the environment), everyone needs to know. For legal and psychological reasons, parents need to know whether their child's autism has come from genetics, vaccines, the environment, or broader and more accurate diagnoses. Gernsbacher, whose 9-year-old son Drew is autistic, has her own personal stake. She believes that if people accept that autistic disorders are distributed randomly and in large numbers across the population, most of the stigma associated with autism will disappear.

Are Gay Parents Good for Children?

Last January, President Bush announced at a press conference, "Studies have shown that the ideal is where a child is raised in a married family with a man and a woman." But when you look more closely at the research, you begin to wonder about the validity of the studies the President had in mind.

The American Academy of Pediatrics (AAP), the established organization of pediatricians, has no doubts about the issue. Its guidelines, arising from a 2002 review of research by Tufts University Professor of Pediatrics Ellen Perrin, say there should be no barriers to gay-parent adoption and custody. "There's no good evidence that same-sex parents are any less fit than heterosexual parents, and some of them may provide subtle advantages," Perrin says. She admits, however, that there have been no definitive studies of the psychological effects of growing up in a gay household, primarily because of sample problems. Until recently, there just weren't that many openly gay parents. But that's been changing, she says.

The AAP stance is in marked contrast to that of the American College of Pediatricians (ACP), which says that children of gay parents are definitely at risk for emotional problems. But the ACP, a small organization that broke away from the AAP over its position paper, seems as concerned with promoting certain values as with promoting children's emotional and physical health. The college says its mission is "to develop sound policy based upon quality research," and that it "recognizes the inherent value of both a father and a mother, united in marriage." The ACP position paper opposing gay parenting cites no peer-reviewed studies that directly find a negative effect of gay parents on children. Instead, it draws its conclusion primarily from studies finding that gay adults have higher incidences of psychological and health problems.

In fact, the idea that children do worse when raised by gay parents appears to be based on the assumption that there's something inherently wrong with homosexuality. "Homosexual parents don't do well because they have more partner changes, more drug abuse, more history of missing work, and all these things conspire to make a homosexual parent less suitable," says psychologist Paul Cameron, perhaps the most prominent researcher who opposes gay parents. Cameron is Chairman of the Family Research Institute, an organization that believes "in preserving America's historic moral framework and the traditional family." Perrin, he says, used "biased studies from homosexual journals." (About 7 of her 23 journal citations come from peer-reviewed journals such as the Journal of Homosexuality). By contrast, 10 of Cameron's studies about homosexuals have been published in one journal, Psychological Reports, which, says Perrin, authors have to pay to be published in.

Responding to positions of researchers like Cameron, Perrin insists that it "isn't the sexual identity of the parents that matters: it's things like how well the parents get along, how integrated the kids are in school—the same social factors that matter to all kids."

On-line Case Consultation and Confidentiality

On a therapists' listserv, a therapist recently asked for advice about a client who'd been thinking about breaking up with his girlfriend, who's eight months pregnant and obsessed with a rock star. In using an online listserv to seek help, is this therapist leaving herself open for professional sanctions and lawsuits? Yes, says John Riolo, a social worker and consumer advocate for therapy clients.

Therapists don't realize, Riolo contends, that even their posts to invitation-only listservs are widely accessible—often for years—to a much wider audience. In actuality, the screening process for ensuring that only mental health professionals join a listserv is far from effective. It's easy for anyone, including clients, to join listservs under assumed identities. Meanwhile therapists, often lulled by the supposed anonymity of listservs, may think that by not naming their agency or the state in which they work, they're protecting their clients' confidentiality. But anyone can easily track down a therapist's location and affiliation from their name or e-mail address. From there, a husband can discover, for example, that his wife is having affairs, even from a seemingly innocuous statement like, "At our agency, a 30-year-old borderline married client confided to me that she's picking up men in a bar."

Not all professionals agree with Riolo. Social worker Joel Kanter, who moderates a listserv of clinical social workers, thinks that Riolo is being too alarmist. Therapists often share case material, prudently disguised, at conferences and in articles, he says, and if they take the same camouflaging precautions on listservs, they can adequately protect confidentiality. The advantages of online consults—getting quick feedback from a large community of professionals—far outweigh the small confidentiality risk, he says, pointing out that he's never heard of any complaints or sanctions arising from on-line consultations.

But Frederic Reamer, chair of the National Association of Social Workers (NASW) task force that wrote the association's code of ethics, points out that discussing a client on the Internet can run afoul of several of NASW's confidentiality provisions, including the proscription to "avoid discussing confidential information in any setting unless privacy can be ensured." The American Psychological Association's ethics code has similar provisions.

Some listserv moderators have modified their policies in response to Riolo's articles. One listserv asks members to send case consults directly to the moderators instead of to the entire list, so that the moderator can disguise identifying information about the clients and the therapist. That, Riolo contends, is insufficient, pointing out that several members of that listserv, forgetting the provision, have posted to the entire list, leaving themselves and their clients wide open to trouble.

Riolo's series of articles on confidentiality can be found at www.psychjourney .com/cseries.htm.

Examining Controlled Separations

Ever since the Wall Street Journal published an article last summer about therapists who use controlled separations with couples, Meg Haycraft, a therapist from Skokie, Illinois, who was mentioned in the piece, has been getting calls from couples who want to try it. The idea of a controlled separation, which its adherents paradoxically insist is a powerful tool for encouraging couples to stay together, is catching on, even, surprisingly, among the staunchest marriage proponents.

The intervention has been around since 1998, when Lee Raffel, a therapist from Port Washington, Wisconsin, published Should I Stay or Go: How Controlled Separation (CS) Can Save Your Marriage. The book lays out guidelines for helping couples craft a detailed agreement for temporarily living apart. But unlike standard separation agreements, the couple agrees not to file for divorce while they're separated. They also discuss how to continue seeing each other, and agree to work on their relationship through exercises, homework, and occasional conjoint therapy sessions.

It isn't for everyone. Raffel advises against it when there's violence or substance abuse involved, primarily because abusers and violent spouses probably won't honor the separation agreement. She also cautions therapists not to use it solely because they feel unable to manage conflictual sessions. She herself offers couples an eight-session contract in which to address their conflicts, only suggesting a controlled separation when they can't seem to make progress or avoid arguments. Other couples whom she considers candidates for controlled separation are already separated and may need the structure offered by this approach.

Raffel estimates that two-thirds of her controlled-separation couples have saved their marriages. Elsie Radtke, who counsels couples for the Archdiocese of Chicago, estimates that about half of her clients who separate end up divorcing. Whichever figures you use, it's still a lot of divorces avoided. "Controlled separations," says Haycraft, "may be the missing piece in today's culture that sees the only options as toughing it out or divorcing. It's a device to slow things down, to be the springboard of hope again."

When Grief Lasts

In recent years there's been a growing shift within the grief-counseling community: the old idea that grieving people must detach completely from the deceased has given way to a gentler notion that the bereaved should accept the reality of the death while maintaining thoughts of the deceased that are integrated into their ongoing lives. Now a new kind of grief therapy explicitly incorporating this perspective has been shown to work with the most stuck mourners of all, those people suffering from complicated grief.

While the usual acute grieving lasts anywhere from 6 to 18 months (with or without a therapist's help), the symptoms of complicated grief last much longer. Sufferers remain stuck in the initial, most debilitating stage of grief—longing for the deceased, avoiding places and situations that evoke memories of their loved one, experiencing recurrent pangs of grief, and unable to think about the future with any enthusiasm or hope. Now an article in the June Journal of the American Medical Association presents promising results for Complicated Grief Therapy (CGT), a therapy adapted from effective PTSD and depression treatments.

CGT, which takes about 16 sessions, begins with a history of the relationship with the deceased, including the story of the death, and psychoeducation about grief. The exercises and discussion that follow shuttle between helping grieving people engage with the loss and encouraging them to consider the future. This helps clients feel they can move forward at the same time that they cope with the loss of their loved one. Unlike previous models, it doesn't try to get people to achieve "closure" in their grief.

After the psychoeducation phase, "revisiting" begins. This is an exercise in which the bereaved person imagines that he or she is back at the time of the death and retells the story of how the person died, says the study's lead author, psychiatrist Katherine Shear, from Columbia University's School of Social Work. The therapist tape records the story, occasionally asking what the client is feeling. Clients take the tape recording home and listen to it between sessions.

After three to five sessions, the therapist introduces structured-memory exercises, instructing clients to recall favorite or positive memories of the deceased, then not-so-positive and even negative recollections. This helps clients feel that they're free to think about the deceased person in a range of ways. Interspersed with the memory work, therapists encourage clients to revisit situations and activities they've been avoiding. This strategy is similar to in vivo exposure in PTSD treatment. For instance, if the person has been avoiding movies, because going to movies was a favorite activity with the deceased, the therapist may encourage the client to merely look at the movie section of the newspaper and contemplate seeing a movie, with the eventual goal of actually sitting through a show.

A full manual of CGT will be ready in a few months. Shear encourages therapists to adapt the overall orientation and any of the techniques with their clients who are experiencing protracted grief.

Resources

Exercising: Cibel's website is at www.psychfitinc.com. For the latest review of research on exercise and mental health, see Harvard Mental Health Letter (December 2005); Autism: Current Directions in Psychological Science 14, no. 2 (April 2005): 55-58 ; Gay Parents: Perrin's report is at: http://pediatrics.aappublications.org/cgi/content/full/109/2/341 and the ACP's position is at http://www.acpeds .org; Grief Therapy: Journal of the American Medical Association 293, no. 21 (June 1, 2005): 2601-08.

CASE STUDIES
By Dan Short

Erickson's Legacy
Strategic therapy rests on skillful information-gathering

Milton Erickson has become a legendary figure among therapists for his skill in standing the traditional idea of "resistance" on its head. With his keen observational skills and his grasp of the multiple dimensions of people's lives, Erickson demonstrated again and again that getting a clear and detailed idea of his clients' unique needs, beliefs, and behavior patterns was the key to successful therapy, especially in cases that hadn't responded to more traditional approaches. Known most of all for his strategic use of existing personality features, he carefully utilized every bit of information
he gathered from the client. The case that follows, inspired by his approach, shows the unfolding of a strategic approach as more and more relevant clinical information emerges.

Sophie entered the office looking defeated and demoralized. Every movement seemed to require effort. She had dark rings under her eyes, her short hair lay flat on her head, and she was obese. The therapist who'd referred her expressed concern that her depression was worsening, despite a regimen of antidepressants and supportive counseling.

On her small frame, Sophie carried 191 pounds. "My arms are larger than most men's thighs," she said wearily. During the previous 12 months, she'd watched her weight increase as her motivation for self-care decreased. Treatment wasn't working—even the mental health experts didn't seem to be able to help her—which made her situation seem hopeless. She was slowly sinking into a dark place, from which she could see no escape.

So I asked her, "Will you tell me what it is about the problem of weight that causes you the most distress?" As is often the case, Sophie surprised me with her response. Depression, she said, was the most loathsome consequence of her obesity, because the condition forced her to take antidepressant medication and, as she put it, "These drugs make me feel like I'm not living in my own body." Then she added, "But no one will work with me unless I take medication. What's your opinion?"

I suspected that the question of whether to take medication was an issue of power and control, just as her eating disorder was. In both cases, she felt that she had no control over what went into her mouth, and no more ability to say no to a doctor than to stop herself from overeating. I didn't want to be just one more authority figure telling her what to do.

Nevertheless, Sophie wanted an answer, as well as validation. So I chose my words with care, "I'm not licensed to practice medicine. It isn't appropriate for me to tell you to take medication or to stop medication." Then, leaning forward for emphasis, I continued, "I can only give you psychological advice. And my psychological advice is that you do everything you can to take care of your body."

One of my basic strategies in therapy is to tell clients it's okay for them to take care of themselves as best they know how. This blanket permission was intended to avoid a covert power struggle, help Sophie access her own latent resources, and validate her fundamental right to take care of herself.

Hearing this, Sophie seemed more animated. She began telling me how miserable she was on her medication, of which she'd tried a variety. She'd been depressed most of her life, with good reason. Her mother had abused her, as had her husband, a crack cocaine addict, until the day she found him dead, having committed suicide. "After his death, I gained 40 pounds," she said. "At this point, I've experienced a complete loss of motivation. I can't make myself exercise, or even clean my house."

I let her continue telling her story uninterrupted until she seemed content to stop, then told her I was sorry that she'd experienced such terrible events. People like Sophie, who've been abused since childhood, tend to blame themselves for all the bad things done to them, and often have never been told that they don't deserve to suffer. I don't like to focus on the past or on a person's symptoms, but people shouldn't suffer alone, so I listen to these stories with respect and acceptance.

Then, I inquired about her goals. "Now tell me, what do you really want?" Suddenly, a different Sophie appeared. With energy in her voice, she said, "I have eight grandchildren who I absolutely adore. I want to be there for them. I'm also good at my job and like the recognition I get. I don't want to be forced to do things I don't want to do. I don't want to be forced to take medication! I want to get off my blood-pressure medication. I want to be able to eat food and enjoy it. I want to live life." She paused, "I want you to use hypnosis to make me lose weight."

Sophie wanted me to "make" her lose weight. The only way she could see herself succeeding was for someone to take control. This put me in a bind. After a lifetime of resenting always being told what to do, she'd resent me, too, if I did as she asked. At the same time, refusing her request would only add to her sense of powerlessness. So I replied, "I'll agree to use hypnosis with you, as you've requested, but first you must get your weight down to 185 pounds." She stared in confusion: "But how?"

"Use any means that you can believe in." By saying this, I was able to show a willingness to do what Sophie asked of me, as long she demonstrated a willingness to cooperate. I learned from Erickson that, while therapy should help a person learn to believe in his or her capabilities, it's this spirit of cooperation that gets the client's energy activated.

For her second visit, Sophie entered my office making jokes about her progress. She'd lost eight pounds in seven days! She held out her hands and feet to show me that they were no longer swollen. "I think all eight pounds were water." She attributed her rapid success to her own decision to stop taking antidepressant medication. Ironically, by exercising her right to take care of herself, as suggested, she'd helped herself by rebelling against the people seeking to help her.

As the session progressed, Sophie described deep feelings of worthlessness and a chronic need to punish herself. "I know I set myself up to be in an unhealthy relationship and stay in it. I somehow just have to keep hurting myself," she insisted. Because it seemed highly unlikely that I'd be able to convince her otherwise, I decided to use her existing belief as a therapeutic contingency.

After asking her to close her eyes and go into a trance, I stated in a frank tone of voice, "You've made it clear that you're unable to stop punishing yourself, so you might as well face the facts and punish yourself with clear intention. You feel very little self-worth. You'll spend more money than you can afford buying gifts for others, but you won't buy anything nice for yourself. I know that it's almost painful for you to do anything kind toward yourself. Therefore, this upcoming week, you're to punish yourself with acts of self-kindness!"

The strategy here is that, if a negative behavior can't be stopped, it should be made useful by connecting it to something positive. One of many benefits of this approach is that it helps clients feel less helpless and less antagonistic toward their behavior.

Starting the third visit, Sophie was smiling and laughing as she told me about a very positive review she'd just gotten from her supervisor, who'd called her a "model employee." She looked healthier. She told me proudly that she'd been feeling less of a need to punish herself, and that her internal voice was less condemning. She'd also bought herself a new bedroom suite.

Then, without my asking, Sophie shared some very painful information about her mother. Eyes cast downward, she said, "She was physically abusive." I could tell from her eyes and posture that she didn't want to say any more. She'd been thoroughly conditioned as a child to respond to authority with slavish obedience, but making her talk about painful memories wouldn't be different from forcing her to take a pill she didn't want. Neither of these are intrinsically problematic, but when this type of client feels forced by the therapist to suffer through a healing ritual, then there's risk of creating greater amounts of depression. Following a lifetime of education in learned helplessness, Sophie needed to see that she has choices. So, after a brief pause, I asked her what she'd like to use the rest of our time talking about.

She raised her head and a smile shot across her face. "I made my phone call to get signed up at a gym!" she replied. We spent some time marveling over this wonderful accomplishment and her stunning progress in therapy, and then talked about possible solutions for her problems with one of her daughters and a grandchild for the rest of the session.

The Central Problem

Sophie's fourth and fifth visits with me didn't go as well. She came into the fourth session criticizing herself harshly and left doing the same. "It's my complete lack of self-discipline that keeps me fat," she doggedly insisted. At the start of the fifth visit, she was still clearly in an unhappy state, insisting that she hated everything about her physical being. There seemed to be nothing I could do to help her think well of herself. All the joy from her initial breakthrough had faded. It seemed as if Sophie was sliding back into the darkness that had dominated most of her life. I was reaching out with a helping hand, but didn't know where to grasp.

Then I remembered one of my basic therapeutic guidelines: whenever you're uncertain of what to do, collect more information. Like riding a teeter-totter, highly complex therapy requires a back-and-forth process of assessment and experimental intervention. So after pausing a while to silently study Sophie's demeanor, I decided to risk a question designed to stir up emotions and, hopefully, help me better understand her needs: "Sophie, what secret are you still keeping from me?"

Hearing my question, Sophie regressed. It was as if the reply were coming from the lips of a 6- year-old child. "I dirty my panties," she whispered. In short, fragmented sentences, she alluded to problems with involuntary discharge of urine and feces, which she'd suffered with intense shame for decades.

After sharing such a carefully guarded secret, the most urgent question in Sophie's mind must have been, "Will he now reject me?" I wanted to communicate complete and total acceptance. However, it would have been impossible to show I accepted her fully, even with her problem, if I immediately tried to fix or eliminate it. So, I looked directly into her eyes and told her warmly that I was very pleased she'd found the courage to share her secret with me.

She visibly relaxed. My response seemed to communicate that, whatever her circumstances, she was fundamentally alright as she was.

Content with my response, Sophie shifted her attention back to the problem of overeating. This was much less distressing for her to talk about. I asked if there was a food that she felt was irresistible. Sophie responded without delay, "Krispy Kreme donuts!" Merely talking about the donuts seemed to create excitement in her. I asked if it seemed logical that once cured of her addiction to this most irresistible food, she'd be able to gain self-control in relation to all other foods. Sophie agreed that this made sense, but as she put it, "There's no way you can get me to stop eating Krispy Kreme donuts."

I agreed with her, but qualified her statement. "There's no way I can get you to stop eating Krispy Kreme donuts unless you give me permission to. If you give me permission, then I can help you end the addiction this week, and it won't even require the use of hypnosis."

Sophie shook her head. "This is my week to go on vacation to Puerto Penasco. My favorite thing to do there is to treat myself to all the wonderful greasy food you can buy from street vendors."

I responded enthusiastically. "This is perfect! All you have to do is give me permission to intervene, and then follow my instructions as fully as possible."

Sophie cautiously agreed, so I explained the intervention. "After you leave my office, buy yourself half a dozen Krispy Kreme donuts. Take them home and put each donut in a baggie. You leave for your vacation tomorrow, so you can pack the donuts in your suitcase tonight. While on vacation, eat all the food you want during the day. Don't deny yourself anything. Then each night, just before you brush your teeth, pull out one of the baggies and eat a Krispy Kreme donut. Do this every night. It'll be difficult, but do your best to eat all six donuts."

To understand the logic behind this intervention, it's important to recognize the large number of failure experiences Sophie had accumulated while trying not to eat this type of food. She was waiting for me to ask her to do something that she knew she couldn't do, and if I had, the exercise would have doomed her to more failure. However, asking her to do something which she believed she couldn't stop herself from doing was a safe way of laying a foundation for hope.

Sophie looked at me with an incredulous stare and said, "You just don't understand how much I love these donuts." Then she agreed to give the exercise a try.

Sophie came in for her sixth session wearing a mischievous smile. After exchanging a few pleasantries, she caught my eyes in a sideways glance. "You already know that I'll never again eat Krispy Kreme donuts, don't you?"

With a chuckle, I confessed, "I've had the unhappy experience of eating old, stale, soggy donuts out of plastic baggies. It really ruins your taste for donuts!"

Then she confessed. "I stopped eating them after the third one. I thought to myself, 'There's no way I'm going to eat these things, no matter what Dr. Short says!'" The situation was comical and Sophie was enjoying herself. Even more important, she'd learned she could look in the face of an authority figure and joyfully confess that she'd followed her own will, not his.

The Power of Hope

Having shifted toward an internal locus of control, Sophie confidently declared, "Once I get disgusted with something, I'll make whatever changes I need to make." She was now ready to take on the central problem, so I asked one last set of questions before discussing an intervention. I wanted to make absolutely certain I had an accurate understanding of the situation.

"I'm sorry to have to bring up this unpleasant topic, but I feel that I need to know a little more about the problem of your dirtying your panties," I said gently. I didn't want to be in a position of trying to help her change something I didn't fully understand and, at the same time, I didn't want to shame her in any way.

As she talked more about this, it turned out that the behavior dated back to early childhood, when Sophie was severely beaten by her mother after accidentally staining her panties. From that point on, this part of her biological functioning became the focus of obsessive, negative attention. The mother even got the family doctor to examine her daughter for defects, which Sophie experienced as painfully intrusive and mortifying. The doctor told her that she should do Kegel exercises to strengthen the muscles used to hold back urine, which only increased her anxious preoccupation with this part of her body.

Sophie began checking her panties several times a day and hiding them in the trash whenever she thought they were dirty. This habit carried over into adulthood. With a look of shame, she confided, "The problem happens while I'm at work. I hide my panties in the trash, feeling that everybody in the building knows that it's me doing this. It's so humiliating." Because of the problem, she felt horribly inferior to others, and lived in constant fear that somebody might discover her "dirty" secret.

After she finished this sad story, I said, "Would you like me to help you cure yourself of this?"

Sophie's face turned pale. "But it's impossible," she said. But the idea had so riveted her attention that she didn't seem to be breathing.

I responded with great confidence, "Sure it's possible! I can help you initiate the cure in a single session."

Sophie was highly skeptical. "But the doctors have already tried everything. I did the Kegel exercises; they didn't work. When I had my hysterectomy, the surgeon went in and surgically altered my bladder, but it didn't help, either. They told me nothing else can be done."

"The doctors that worked with you can believe whatever they'd like. But I happen to believe that you have perfectly good muscles in your body, and I can prove it to you by asking a single question."

Still fresh from the Krispy Kreme donut cure, Sophie was ready to place tremendous confidence in our alliance. More important, she was ready to be released from the bondage of her neurotic behavior. So I asked a question to which I already knew the answer, "Do you ever dirty or wet your panties during the night?" Sophie shook her head no. I gleefully responded, "There you have it! If your muscles are good enough to hold your urine during eight hours of sleep, then they're certainly good enough and strong enough to hold your urine during the four to five hours between your daytime bathroom breaks."

Sophie began to get enthusiastic, "You mean if I can keep clean at night, then I can keep clean during the day!?"

"Yes," I said. "You just have to give your unconscious mind permission to start using the ability you already have."

With eager anticipation Sophie asked, "But how do I do that?"

I felt there could be added value in helping Sophie say "no" to me. So I indulged my creative side and gave her a plan I thought she'd reject. My plan involved a paradoxical ritual that was likely to work, but wasn't right for her. She quickly exercised her option to reject it.

"Well," I responded, "if you don't want to do it my way, then you can come up with your own plan. We'll have you implement that one first, and if it doesn't work, then you always have my plan as a fallback."

Sophie thought for a moment, asked some questions about self-hypnosis, and decided she'd go to bed each night repeating to herself, "Unconscious mind, make my bowels and bladder work as well during the day as they do at night." She'd repeat this until she fell asleep. The plan was clearly identified as hers, and I conceded that perhaps it was better for her than my plan, which, of course, was true, because it gave her greater agency.

The seventh visit would be my last opportunity to meet with Sophie. She came in smiling and let me know early in the session that she was ready to continue her progress on her own. Raising both arms in the air like an exotic belly dancer, she happily announced, "I feel so good about myself, I hardly care if I lose any more weight . . . but I have a strong feeling that I will." It was clear that things were going well. Interestingly, she didn't bring up the topic we'd discussed in the previous session.

Eventually, my curiosity got the best of me. Apologetically, I asked, "Sophie, it's really not any of my business, so you do not need to answer this question, but I'm wondering how the self-hypnosis worked?" With a coy smile, Sophie cautiously stated, "It came so close to being a perfect week." Then a tear ran down her cheek, "I'm almost too scared to think that it's true."

At first, I misinterpreted her statements. I insisted, "Even just one day of clean panties is a wonderful accomplishment you can continue to build on!"

She interrupted, "No. I made it to the bathroom each time! It's just that I was so scared I'd dirty my panties that I kept running to the bathroom to check. I must have gone to the bathroom 300 times this week, but each time there was nothing there."

My jaw dropped, "Amazing!" I said, "You managed to pull off a complete cure on your first attempt. Congratulations!"

Sophie left the office full of pride and enthusiasm for the future. A year has now passed without her requesting any further assistance.

When a clinician uses a strategic approach to therapy, it means that each interaction is guided by an understanding of what variable experiences the client needs to glean from therapy. To work strategically, you have to get to know the person in front of you. It isn't enough to read textbooks or study group statistics. Most important, it's necessary to recognize that healing emerges from within the client and, therefore, that's where a foundation of hope is constructed.

As this case illustrates, life transformations occur by simply shifting clients' attention away from that which they've failed to do, onto those things that they can, without question, accomplish.

Case Commentary

By Carol Kershaw

"We tell ourselves stories in order to live," a haunting line from Joan Didion's The White Album, came to mind as I read this case by Dan Short. While the hypnotic story his client tells herself is one of obesity and imprisonment by a shameful secret, Short succeeds in focusing her on possibility rather than deficit. As her depression begins to lift, she becomes more interested in losing weight her way. Rather than siding with her victimhood, he sides with her strength and self-empowerment.

As with many overweight patients who begin to have success losing weight, Sophie stumbles and stops her self-improvement program. Short senses there's something unspoken and asks her to reveal the secret. Sophie is relieved to tell the truth to someone who's fully accepting of her problem. Convinced that Sophie has the internal resources to keep from having accidents while asleep, Short helps her develop her own plan for successfully controlling her soiling.

Theory often follows the successes of an astute clinician, and in Erickson's case, there are many interpretations about what he did. While Short emphasizes Erickson's devotion to doing strategic therapy, some people believe he did neurolinguistic programming, and others insist he did paradoxical therapy. Still others focus on the symbolic-communication aspect of his work. In fact, he did all of this and more. He was a master at assessing what clients needed to learn and how to help them do so, no matter how unorthodox the methods required.

Throughout this case, Short mentions some of the general therapeutic strategies that guide his work. But such general strategies must always stand the test of their relevance to an individual case and I had some questions about the overall relevance of some of the strategies he mentions. For example, he says, "One of my basic strategies is to tell clients it's okay for them to take care of themselves as best they know how." Of course, this isn't something we'd say to a child abuser. Sometimes the best way clients know how to take care of themselves is through harmful measures. A better guideline might be to emphasize the part of the client that wants to make "better choices."

Elsewhere Short says that if a negative behavior can't be stopped, try to make it useful by connecting it to something positive. But the opposite can also work. It can be helpful to suggest the negative behavior is an attempt to learn something and query what that might be.

Short also states that whenever you're uncertain of what to do, start collecting more information. While this may work sometimes, it's frequently more helpful to be quiet and allow your own unconscious mind the opportunity for creative thought, which will also make the client carry more responsibility for change as well.

Author's Response

The reviewer makes an important point that I'd like to further emphasize: skillful therapy requires discernment. It isn't enough to memorize a set of rules and then rigidly apply them to every person who enters the office. Paradoxically speaking, one should never sacrifice learning for the sake of preserving absolute generalizations.

Dan Short, Ph.D., is a clinical psychologist and trainer in Ericksonian hypnosis, living in Phoenix, Arizona, who specializes inbrief treatment of recalcitrant problems. He's the lead author of Hope & Resiliency: Understanding the Therapeutic Strategies of Milton Erickson. Contact: hope@IamDrShort.com; website: www.Hope AndResiliency.org.

Carol Kershaw, Ed.D, is codirector of the Milton Erickson Institute of Texas and a psychologist in private practice who specializes in hypnotic psychotherapy and neurofeedback. She's the author of The Couple's Hypnotic Dance. Contact: hypnopsych@aol.com;
website www.mhehouston.com.

Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

BOOKMARKS

By Richard Handler

Has Therapy Gone PC?

Some Distinguished Psychologists Critique the Field

Destructive Trends in Mental Health: The Well-Intentioned Path to Harm

Edited by Rogers Wright and Nicholas Cummings.

Routledge. 346 pp. ISBN: 0-415-95086-4

Nobody wants to be called "politically correct." The term has become the universal, all-purpose insult, used by both the Right and the Left as the definitive put-down. And perhaps no field gets such a bashing for its alleged "political correctness" as psychotherapy.

On the Right, therapists are ridiculed as ersatz mommies and daddies with professional degrees, who've turned us into a nation of victims and squirmers, whiners and wimps. Critics like Christina Hoff Sommers, in her book One Nation Under Therapy, bemoans the overpsychologized, pathologized nation that America has become.

On the Left, one hears a variation on the same theme. In Therapy Culture, Frank Furedi, an old-fashioned British lefty, rails against therapists as active agents of psychic dispossession. According to this critique, it's in therapists' interest to keep us passive and blinded to the problems in the wider social context that form the roots of our individual malaise.

So the Right castigates therapists for individuals' loss of autonomy, while the Left lays the blame for our loss of community connection to the same culprits. Both agree that we're being infantilized by a new Nanny State.

Now, in Destructive Trends in Mental Health, two distinguished psychologists long associated with progressive political struggles within the field, Rogers Wright and Nicholas Cummings, have edited a book that echoes many of the charges that up to now have come from outside the therapy profession. This isn't a book that can be dismissed as just another ideologically inspired, partisan attack.

So who are Wright and Cummings and why do they have the right to
lecture us this way? Cummings is past president of the American Psychological Association; Wright is the founding president of the Council for the Advancement of Psychological Professions and Sciences—psychology's first independent organization dedicated to public policy and political advocacy. In the 1950s, both men took on the American Psychiatric Association and helped establish psychology's legitimacy as a profession on a par with psychiatry. Both also helped lobby a reluctant insurance industry to provide third-party payments for psychological, as well as medical, services. For half a century, both men have worked relentlessly, and by and large successfully, to raise the professional and economic standing of psychologists and social workers.

In their book, Wright and Cummings make some of the same overall points as do the PC critics. They, and the other authors in their book, contend that psychology, like the culture it serves, enforces politically correct attitudes that squelch research into verifiably effective treatments and curtail the range of help clients can receive. They, too, excoriate victimology and accuse psychologists of promoting it. In spite of "the impressive record of promoting racial, ethnic and cultural diversity in its membership and organizational structure," Cummings writes, "self-interested destructive trends have permeated the mental health professions, threatening harm to the patients who seek their help and betraying the society they are sworn to serve."

Their charges of runaway political correctness add up to an exhausting critique. Research into intelligence, for example, no matter how valid, is now career suicide—researchers risk snubs and pickets for being undemocratic, elitist, and even racist just by presuming to measure it. Many lesbian and gay activists want to forbid the right to treatment for troubled clients who come into therapy wishing to change their sexual orientation. The seemingly irrepressible urge to invent new psychological pathologies has produced the expanding-syndrome phenomenon: witness the wholesale application of diagnostic labels to kids, with ADD and AD/HD being the worst offenders.

Still, you have to wonder what all these oft-repeated complaints about the culture of therapy have to do with what goes on in the average therapist's office. The therapists I know certainly don't intentionally encourage dependency and victimhood. Managed care even limits the client's reliance on treatment—the one dependency a therapist might be tempted to encourage. Nobody can get third-party treatment anymore for endless psychoanalytic-style visits. So what's at issue? Why are these men so angry? And why, in a heated preface, does Cummings call psychologists politically "clueless" and downright "stupid"?

What seems to bother Wright, Cummings, and the other contributors to this book more than the content of political correctness is its baleful effect on the scientific foundations of psychology. They believe that political correctness is behind the shortsighted view that science is somehow irrelevant to what psychologists do. For instance, Cummings says that he supported the 1974 American Psychological Association resolution stating that homosexuality isn't a psychiatric condition. What's often forgotten, however, is that further resolutions were passed, prescribing the need for more scientific research into the issue. But none has ever been done. In short, writes Cummings, "the two APAs had established forever that medical and psychological diagnoses are subject to political fiat."

This de facto dismissal of science has set the standard—or lack of one—outlined by four authors in the chapter titled "Pseudoscience, Nonscience and Nonsense in Clinical Psychology." Writers Scott Lilienfeld, Fowler, Lohr, and Lynn argue that, in a field that shows insufficient respect for scientific evidence, questionable therapies, like Rebirthing, Critical Incident Stress Debriefing, Thought Field Therapy, and the infamous and destructive Recovered Memory Intervention (now discredited), have been allowed to proliferate. Since the profession has no established code of "best practices," there's no assurance that science will dictate what works and what doesn't. According to the authors, the effectiveness of too many popular approaches still remains unproven.

Similarly, syndromes are named and renamed, apparently on the basis of social trends, rather than any particular scientific merit. Thus, what was once called multiple personality disorder is now given the stiff, scientific-sounding term dissociative identity disorder (DID), though precious little more scientific study of this pathology has been done in the process. According to critics of DID as a diagnostic entity (like its forebear, multiple personality disorder), the growth in the number of people who are said to suffer from this condition has always seemed to depend mainly on fashion and media exposure. According to the authors, these lapses provide a rich breeding ground for public cynicism about the whole profession. However, it should also be noted that many practicing clinicians consider the position taken by Lilienfeld et al. as so extreme that, if their approach became the standard, it would probably do away with much of the range of clinical practice, leaving only the barebones of "empirically validated" cognitive-behavioral specialties. Coincidentally, these are the authors' own specialties.

These four writers, and the editors of the book, also contend that too many psychologists with Ph.D.s are scientifically illiterate and poorly trained in empirical technique. They assert that a student could spend years in graduate school and earn a doctorate in clinical psychology without becoming scientifically competent. As a remedy, they recommend "the APA and other accrediting agencies must insist that clinical psychology training programs require formal training in critical thinking skills," and that doctoral students become "scientifically discriminating consumers of the psychological research literature."

But the real anger of this book's authors isn't only about the squandering of professional reputation: it's about the impact of money and the mental health marketplace on sound therapeutic practice. Cummings and one of his coauthors observes that "Psychology is not only the most politically correct profession in the health care field, but it's lowest paid and most economically depressed . . . managed care has decimated psychology independent solo practice." According to Cummings, psychotherapists have seen their practices "spiral downwards" towards a "fifty percent decline in their incomes beginning in the early and mid-nineties."

Cummings argues that the manufacture of syndromes, the explosion of ADD and AD/HD, DID, and even the proliferation of depression diagnoses, reflect the field's implicit use of pseudoscience to recover its own economic fortunes. Psychologists aren't just PC by inclination and liberal leanings: they need the new therapeutic cover to recoup their wages.

To drive this point home, Cummings has fun with disorder inflation—if you're bored with your job, you might qualify for the diagnosis of "EED" or "employee ennui disorder, " he writes The trouble is—and this is key—the jig is probably up. There's only so much erroneous science and fakery the public (and insurance companies) will stand for.

Yet Cummings offers salvation to the truly repentant. You don't have to make up syndromes to earn a living, nor do you have to cater to the latest "societal trends." And the socially and ethically responsible alternative is as close as the office of your nearest primary health-care provider. "The healthcare system," writes Cummings, "is burdened by the sixty to seventy percent of patients visiting primary care physicians whose symptoms reflect psychological distress rather than disease." The solution to the problems of both the primary care doc and the psychologist is to give the former his or her very own "behavioral primary care provider"—in other words, a psychologist or social worker standing shoulder to shoulder with the beleaguered physician at the family-practice center. After the usual seven minutes with the MD, the doctor accompanies the patient down the hall, to his colleague, the Ph.D. or M.S.W.

Such a revolution is already under way in the United States—at Kaiser Permanente clinics, at 167 installations of the U.S. Air Force, at Veterans Affairs, and at various community health centers around the country. If this keeps up, writes Cummings in an expansive mood, the flow of patients into the mental health field can expand by "an astounding nine hundred percent." You don't need lots of fancy diagnostic labels. People are distressed, suffering psychic pain along with their physical woes. Tend to the hordes of people coming to doctors with psychosomatic symptoms—what in the Freudian days was called "hysteria," and now, conversion disorder—and you're doing something real and necessary; no need to concoct new diagnostic entities.

Such a shift in the health care system isn't yet even in its infancy—it's still a tiny embryo, requiring a long time and lots of labor before it emerges into the full light of day. But, insists Cummings, it can't come too soon for the health of the psychotherapy professions. According to the authors of this book, without this correction, One Nation Under Therapy may decide it's cheaper and more honest to disregard therapy altogether.

Richard Handler is a radio producer with the Canadian Broadcasting Corporation in Toronto, Canada. Contact: rhandler@sym
patico.ca. Letters to the Editor about this department may be e-mailed to letters
@psychnetworker.org.

Being There

The Dalai Lama gets Buddhism and neuroscience to go face to face

by Katy Butler

It was early November in Washington, and the press conference, in Constitution Hall just off The Mall, was crowded with reporters and photographers. His red-robed Holiness the Dalai Lama, flanked by men in classy dark suits, including meditation teacher Jon Kabat-Zinn, University of Wisconsin neuroscientist Richard Davidson, and the president of Georgetown University's Medical School, was pondering my question about science and religion. "Given the American conflict between devotees of evolution and adherents of creationism," I'd asked, "how does Your Holiness reconcile your interest in modern science with the creation myths of Tibetan Buddhism?"

Tenzin Gyatzo—Ocean of Wisdom, embodiment of compassion, the exiled Buddhist monk believed by many Tibetans to be the 14th reincarnation of the first Dalai Lama, born in 1935 in a part of Tibet so medieval that a pocket watch was an advanced machine—gave a rumbling cough and flung a corner of his robe higher over one bare, muscular shoulder. He was vigorous and down-to-earth, and, despite the honorifics, there was nothing self-consciously holy about him. Looking over his glasses at me and 20 or so other reporters from publications ranging from The Washington Post to The Shambhala Sun, he began speaking rapidly in Tibetan.

"The basic understanding of the emergence of cosmos in Buddhism is based on the interactions of the basic elements: water, air . . .," his dark-suited translator, Thupten Jinpa, began in his impeccable Oxbridge accent. "No!" His Holiness interrupted, in English. "First, element of space." He sliced his hand down. "Then, energy." The hand came down again. "Then heat, then water, then . . . solid. So there is no conflict with science there. A natural process."

"But when there is a conflict?" I pressed on.

"In one Abbhidharma text, there are concepts of world systems, universes resting on Mt. Meru, and things like that. It is so evident that we have to reject them," the Dalai Lama went on, lapsing in and out of Tibetan and English as the cameras flashed, occasionally pausing for his translator to catch up. "I am often telling people that if the author of that book—a great Indian master, on other subjects his writing is very authentic—but as far as the cosmos is concerned, if he reappeared out of the 4th century, he'd have to rewrite all these things." He raised his eyebrows and stared at us.

"One of the basic stands in Buddhist epistemology is that if a person upholds any particular viewpoint or tenet that is contrary to reason, then that person cannot be accepted as worthy of engagement," he said. "And even more so in the case of someone who rejects the evidence of empirical facts."

That set the tone for three days of sometimes laborious and occasionally luminous onstage conversations between the Dalai Lama, a sprinkling of Western contemplatives, and a phalanx of heavy-hitting research scientists from institutions like Stanford University, the National Institutes of Health, The Max Planck Institute for Brain Research in Frankfurt, Germany, and the University of California, San Francisco. Interrupted briefly halfway through when the Dalai Lama went to the White House to meet with George W. Bush and Condoleezza Rice, the colloquies, held before an audience of 1,700, were part tutorial on psychoneuroimmunology and neuroscience, part pseudo living-room conversation, and part Readers Digest condensed version of the latest scientific research into meditation.

Although the Dalai Lama has met privately with leading Western scientists in similar gatherings 13 times since 1987, this was only the second such dialogue to be open to the public. Sponsored by the nonprofit Mind and Life Institute, the conference title was "The Science and Clinical Applications of Meditation."

Much of the science, on the health advantages of meditation, turned out to be old hat. It's amazing how thoroughly meditation has moved from the fringes to the scientific mainstream. However, watching monks and scientists grope painfully toward a common language to describe great mysteries wasn't old hat at all.

Each day, two complex, highly sophisticated cultures, long strangers to each other, attempted to find points of overlap and contact. Except in brief flashes, each dumbed itself down in the effort to make contact, and much was lost in translation. At some point, nearly everyone onstage looked confused enough to need an interpreter.

Each morning and afternoon, the Dalai Lama walked onstage, waved, and smiled at the audience. He then joined assorted monks and scientists seated in comfortable chairs around coffee tables banked with pots of red flowers. The idea was to create the impression of a salon in the Dalai Lama's living room in Dharamsala, India, but the set was determinedly secular—heavy on laptops, suits, and bottled water, and lacking a single Buddha image, meditation bell, or brocade throne. The Dalai Lama would pull down an orange golf visor to protect his eyes from the stage lights, fiddle with his robes, and then listen politely as a rotating cast of scientists, some seeming almost awestruck in his presence, opened up their laptops and projected PowerPoint slides onto huge overhead screens like those in sports stadiums.

The aspects of meditation highlighted on those screens—compressed into bar graphs and bulleted lists—bore little resemblance to a silent Zen retreat or the guttural chanting of Tibetan monks in the midst of meditative visualization. The screens displayed only a tiny part of the Buddhist story: meditation as a source of emotional, physical, and mental stability. But in the Buddhist tradition, that stability is just a starting point, a foundational practice that's buttressed by ethical behavior and the cultivation of positive mental states like compassion and equanimity, as well as by a deeper investigation into the nature of mind, self, and reality. The hope is that, over many years, practicing these activities will catalyze the profound shift in perspective that Buddhists call insight, awakening, or enlightenment.

But Western science has no words for "opening the dharma eye," few for the notion of compassion, and even fewer for conveying the possibility that the felt sense of a solid, permanent human identity is an illusion. Except in quantum physics, science's articulated concerns remain overwhelmingly within the discrete, the linear, and the quantifiable. As a result, the scientists at the conference—even those with meditation training—started out at the shallow end of the pool.

Jon Kabat-Zinn, for instance, reprised research showing that his Mindfulness- Based Stress Reduction, a secularized form of Vipassana Meditation, speeds up the healing of psoriasis treated with ultraviolet light, and has improved immune function and mood in novice meditators working at a high-stress biotech company. Zindel Segal of the University of Toronto described how his mindfulness-based cognitive therapy, which builds on Kabat-Zinn's work, had reduced relapse rates in people with chronic depression from 66 percent to 34 percent by teaching them to turn away from rumination and emotional numbing in favor of nonjudgmental awareness of emotional states, whether disappointment or joy.

Then neuroscientist Richard Davidson waded a little deeper into the water, describing how, when one advanced Buddhist monk meditated on compassion, his brain produced some of the fastest waves ever recorded in the left prefrontal cortex. The same monk, a later experiment showed, could consciously shift from one meditative state to another in 90-second increments, and those shifts were reflected in his brain imaging.

This, Davidson suggested, was welcome news for ordinary mortals, because it confirms the brain's neuroplasticity—its ability to reshape itself with mental training—just as Buddhist masters have maintained for centuries. "Compassion and happiness aren't fixed states, but skills," Davidson said, touching on ethical concerns rarely mentioned at science conferences. "They can be trained, and we see significant changes after only several weeks of [meditative] practice. They aren't inaccessible to the ordinary person."

That gave the colloquy's only Christian advocate of meditative prayer, Father Thomas Keating, a chance to try to draw the waders into even deeper water. "This is the beginning of taking contemplative experience seriously," he said, suggesting that there are fruits of meditation that appear on entirely different radar screens than do curing psoriasis, reducing depression relapse, or even developing compassion. "The new physics is saying things more mystical than any Sunday sermon about our extraordinary interconnectedness and interdependence," he continued. "Scientists are finding that we mystics weren't stupid after all."

And so it went, with frequent missteps. On the first afternoon, for instance, Robert Sapolsky of Stanford University spoke of "adventitious suffering"—the human ability, unique among mammals, to layer optional distress atop inevitable pain. Our bodies and brains, explained Sapolsky, were shaped by evolution to mobilize against sudden, acute stresses, such as physical threats. But we produce the same cascades of neurochemicals when we face a glowering boss or quarrel with a neighbor, and, over time, this damages brain cells and almost every other bodily organ.

Not surprisingly, the notion of adventitious, or extra, suffering became a major subtheme at the conference, since Buddhism's basic texts emphasize how life's ordinary pains are amplified by the workings of the human mind: its tendency to regret the past, desperately crave the pleasant, hysterically push away the unpleasant, and worry about the future. But Sapolsky's presentation left the Dalai Lama foundering in the thickets of the Tibetan/English language barrier. "We are trying to find a Tibetan word for stress," his translator explained, bedeviled by the fact that the English word covers a multitude of phenomena, from social challenge to torture.

There was another awkward silence when Sapolsky threw up a PowerPoint list of the effects of stress on male and female reproductive systems, which included the term erectile dysfunction. "I must say," Sapolsky said, as the Dalai Lama and his translator conferred again under their breaths and the crowd burst out in relieved, nervous laughter, "I never in my life thought that I'd be sitting on a stage with the Dalai Lama talking about erections."

And the confusion over a mutual vocabulary continued. "There's social stress, hierarchy stress, physical stress," Esther Greenberg, an NIH researcher in psychoneuroimmunology said later on, a little desperately, realizing that she and the Dalai Lama were not only speaking different languages, but using different conceptual frames. "Is there such a thing as stress in your tradition? And how can we start a dialogue with you if we're using different terms?"

Father Keating chimed in on a more positive note, saying that it was amazing the two cultures were talking at all. "For four hundred years, science and religion have been at each other's throats, when they even got that close," he noted.

Yet the disjunctions between the Western and Eastern viewpoints threaded through each day, sometimes embodied within a single person. "I live two lives," said the pediatrician and Zen teacher Jan Chozen Bays, her bright face shining above her formal, black and white Japanese robes. "The Zen teacher in me sees that when people begin to practice, it's almost like they've been given a vitamin. It could be that meditation practice is supplying them something absolutely essential—as essential as sleep, food, or being loved.

"Yet we've been hearing that Mindfulness-Based Stress Reduction can cure everything from asthma to heart disease to psoriasis," she went on. "And the medical part of me says that's too simplistic, and that as we unfold this more, it won't be so simple. Whenever someone says, 'Oh this medicine can cure everything,' I get very skeptical. It sounds like snake oil."

If anything became clear over the three days, it was that meditation isn't the simple relaxation technique Western scientists once assumed it was, nor is it a single hammer capable of hitting any nail. Like exercise, the term covers panoplies of specific trainings that may produce different patterns in brain imaging, and few have been studied thus far. "There are dozens of mindfulness practices, and hundreds of forms of concentration practice, mantras, visualizations, contemplations," pointed out Jack Kornfield, a California clinical psychologist and Vipassana Meditation teacher. "One of my teachers described 21 levels of silence—the silence of darkness; luminous silence, where the body space becomes filled with light; silence with or without content. There are meditations on compassion, lovingkindness, joy, equanimity. All have many different levels and many different trainings. I'd like to have them differentiated."

To complicate matters further, the Dalai Lama explained, all forms of meditation are only one leg of the three-legged stool of the Buddhist contemplative tradition. The other two are ethical training and insight. "At the initial stage, one needs to find a way of restraining from impulsive, destructive behavior. You adopt a set of precepts or a code of life," explained the Dalai Lama. "Then, since this destructive behavior stems from restless, undisciplined states of mind, you cultivate mental stability. Then you apply your mind with focused attention to deal with negative and destructive tendencies. The actual antidote for those tendencies is the insight—recognition that the various problems of an undisciplined state of mind are rooted in a false grasping at self."

Yes but, what exactly did he mean by this? Ironically, it was left to two German non-Buddhists, one living and one dead, to put what the Dalai Lama had said in terms that a Westerner might understand. The living German was Wolf Singer, director of the Max Planck Institute in Frankfurt, who spoke on the final day of the conference. Referring to his 30 years of research on the neuroimages of cat, rat, and human brains, he called attention to how diffused our brain functions really are. "Intuitively, we've always had the idea that there ought to be a coherence center somewhere in the brain where decisions are reached," he said. "But there is no such center. The brain has no command structure. It's a highly distributed system, with many functions occurring simultaneously—an orchestra without a conductor. An object (of perception) in the brain is reproduced by many thousands of neurons, all working simultaneously, never coming together in one place."

At the same time, Singer added, the human brain has been shaped ad hoc by evolution, so it sees events in simple, hierarchical, linear, cause-and-effect terms, and is basically incapable of understanding its own complexity. "We lack the intelligence," he said, "to understand these things.

The complex, nonlinear systems that we can't understand, he suggested, exist not only inside the human brain, but outside as well. "The system we're in cannot be controlled by us—it's evolutionarily nonlinear. We cannot deliberately steer it. So let's try to become a little more humble, reduce the emphasis on the almighty self, and enjoy openness, the maybe—be comfortable with it, and not try to produce certainties."

To this, the Dalai Lama later responded. "You referred to the notion of a controller self. Three thousand years ago, intelligent people began to investigate where is 'I,' but we cannot find that self." Like the headlights of two great freight trains converging through the darkness from distant points on the map, the two men illuminated territory impossible to put into words fully.

What they were getting at is perhaps best summarized by a slide containing a quote from the dead German scientist, Albert Einstein, displayed earlier on one of overhead screens. It said:

"A human being is a part of the whole, called by us 'Universe,' a part limited in time and space. He experiences himself, his thoughts and feelings, as something separated from the rest, a kind of optical delusion of his consciousness.

"This delusion is a kind of prison for us, restricting us to our personal desires and to affection for a few persons nearest to us. Our task must be to free ourselves from this prison by widening our circle of compassion to embrace all living creatures and the whole of nature in its beauty. Nobody is able to achieve this completely, but the striving for such achievement is, in itself, a part of the liberation, and a foundation for inner security."

Networker Features Editor Katy Butler was a finalist for a National Magazine Award in 2004. She's written for the New Yorker and The New York Times, and teaches at the Esalen Institute. Contact: katybutler9@earthlink.net or www.katybutler.com. Letters to the Editor about this article may be sent to letters@psychnetworker.org.

Treating the Nonhierarchical Family

By Ron Taffel

You Can Go Home Again

By Martha Straus

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