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A Matter of Life and Death

When the Therapist Becomes the Survivor

by Frank Pittman

I've been in full-time private practice for almost 30 years. I've seen maybe 10,000 families (it certainly feels that way.) In that time, three patients in my practice killed themselves. Strangely enough, the three suicides were eerily similar. Each suicide has left me shell-shocked and questioning my therapeutic attitudes and methods.

I did not expect Adam to be one of my casualties. He reminded me of the guys I grew up with in rural Alabama. He was large, loud and rough, masking his intelligence behind a display of anti-intellectualism and cultural ignorance. I know these guys and I've had success at retraining them, since I'm not afraid of them or contemptuous of their fragile, hypermasculine pride and their awkwardness with emotion. Like so many of the scared, bullying men I see, Adam had been trained to fail at relationships.

Adam had grown up poor and fatherless. His mother divorced his violent father when he was 12. Adam never saw him again. He didn't drink, he went to church a lot and he was an active, hands-on father to his own children. He hovered protectively, though controllingly, over Angela, his quiet, compliant wife of almost 20 years, who was a nurse. He had made a great deal of money building houses, and was now building a gigantic dream house for their large family.

Six months before I saw them, Adam had slugged his hulking oldest son for quitting his high school football team. After being advised by a counselor at work, Angela threatened divorce. Adam, baffled that she would consider leaving him after such a (to him) minor incident, suspected her of having an affair and got first paranoid and then violent, breaking furniture and punching holes in the wall with his fist. Angela went for help to a therapist, who advised separate therapy for her and Adam, as the conventional wisdom in those years was to see violent couples separately and try to get them to divorce. Angela's therapist (who never met Adam) communicated both neutrality and pessimism about the marriage, and pushed for divorce.

Adam saw a psychiatrist, who put him on Prozac, which mixed badly with his two-pot-a-day coffee habit. He became toxically irritable and, as Angela pulled further and further away, increasingly violent. For the first time in all their years together, he actually hit her. Angela's therapist advised her to call the police (I would have given the same advice). They had Adam hospitalized for a few weeks in a special program for batterers. He went willingly and was a model patient. On discharge, he went home and found Angela and his kids had moved out. He stalked her, begged her to come back and, when she resisted, beat her up. At that point, Angela called me in. She had heard I was an expert with over-the-top men.


I saw Adam, Angela, the couple and the whole family in alternating combinations. She had a court order, which, while a good idea, offered no protection. I got Adam to promise us all there would be no more violence. And there wasn't, for the remaining few months of his life. Off caffeine and Prozac, he went into a clinging, dependent depression, but was stabilized on Stelazine for paranoia, Tegretol for explosiveness and Zoloft for depression.

Angela set up a separate home for herself and the children, and put Adam on notice that she was serious about getting a divorce. I did not question her intention or try to slow her down (a failure that continues to haunt me). Instead, I used the pressure of impending divorce to spur Adam on, as I tried to teach him some manners, some sensitivity to someone else's feelings besides his own. I hoped the changes in him would bring about a reversal of Angela's resolve to get away from him permanently. I saw him often by himself, developing what I thought was a great level of intimacy, full of personal revelations, shared experiences of the rural South and humor about the changing world around us. We talked about fishing and revivals. We talked about rattlesnakes, baseball, Hank Williams and the search for an exit from the swamps we grew up in. We talked most about the loss of his grandfather to bad homemade whiskey and his father to divorce. Then we talked about the difference between the father figures he had, the ones he imagined and the one he wanted to be. Once he was calmed and connected, I also put him in a group of non-batterers. I tried to be the gentle daddy he never had.

Adam felt in better control of himself, and redoubled his efforts to get his family back. He completed the dream house, begged Angela to move into it with him, was rebuffed and moved in alone. They had talked a lot, in my office and outside, about the terms of the separation. He was generous, sweet and apologetic with her, without control or bombast. Angela, aware of the drastic change in him, feared her longstanding tendency to pity and protect him. She held firm about divorce, but he (and I) saw her softening. I couldn't imagine him doing better than he was doing; I couldn't imagine that she would want anything better than the reprogrammed Adam. I thought I was doing a great job with Adam and that it was just a matter of time before Angela gave him another chance.


Throughout his adult life, Adam hadn't been connected to anyone else except Angela and the kids. So I thought it was imperative that he heal the longstanding rift between him and his mother. I sent him over to South Carolina for a weekend with her. While there, he also dropped by to apologize and make peace with Angela's family. On his return, I called him to postpone our next appointment for a day, as I had to go the funeral of an old childhood buddy. Adam and I talked for a long time on the phone. He told me how good he felt on his visit with his mother, especially learning the story behind the breakup of his family. He was proud of his new skill of apologizing. He had called Angela and was optimistic he could get her back. He sounded eager to see me a couple of days later.

Adam didn't show up for his next appointment and didn't answer his telephone. I called his secretary and he had not made it in to work, either. She and I both somehow knew what had happened, though suicide had never been mentioned before. She went out to the new house, where she found Adam in a chair with a shotgun in his mouth and his brains all over the living room wall. The divorce papers, which Angela unexpectedly had served on him, were on his lap.

I was stunned. It was not just a personal loss (I wanted to save this guy); it was not just a blow to my grandiosity (I kept telling myself in my newfound humility, this sort of thing doesn't happen to therapists who work as hard and care as much as I). I was sad over the loss of what Adam could, with time and effort, have become. His suicide was a dumb and preventable waste. His children were devastated. Angela felt many things, among them relief: when the abuse started the year before, a well-intentioned counselor had warned her that violent men never change. She had been fearful that she could not get herself and the kids out of the marriage alive.

I had been trying so hard to respect Angela's need to empower herself and feel in control of her life and the marriage, I had been non-directive and neutral with her, so much so that she didn't fathom that I had hopes not only for Adam, but for the marriage. I certainly foresaw a different outcome than this.


I met often with Angela and the kids during the next year or so, and occasionally still do, as they and I try to recover and understand. Adam didn't leave a note. We know he spent the day before his death shopping with a friend for kitchen appliances--not the actions of a man planning suicide. No matter how much he and I had talked about the possibility of divorce, Angela and I think the divorce papers came as a bewildering shock, snapping him out of his, and my, optimistic fantasy that a change in his behavior would get him his life back. To him, the divorce papers meant that there was no hope, no future. He wasn't ready yet for divorce; he didn't yet have a life apart and he was not a patient man.

As I played the case over and over in my mind, I saw clearly that I could have asked Angela to slow it down. And she would have. She was in no hurry and would have proceeded at whatever pace seemed safest for herself, her children and for Adam, whom she still loved. She had no way of knowing what I knew: that, in time, as long as his behavior was different, she would very likely feel safe with Adam. Those who have been abused cannot trust the ups and downs of their own feelings. Even as they track the abuser's behavior and react to the changes they see in the way they are being treated, they can't trust their sense of their own power in the relationship. And even though I had experience, expertise and wisdom about such matters, I didn't use it.

I don't know why I didn't know that those papers would be served that day. Clearly, I knew they were coming soon, but I was actively trying not to direct Angela's divorce process, or anything else she found empowering. I was optimistic in my ability to turn Adam around and, more important, in his ability to turn himself around if he had a different model of manhood. Beyond that, I was optimistic, after so many hundreds of cases in which it has happened, that Angela would take him back and the violence would not recur. So I acted neutral. I realize from this tragedy that it is as idiotic for me to be neutral about matters of marriage and divorce as about matters of life and death.

At the time I saw Adam, I had been so influenced by the feminist critique of family therapy that I'd gotten into the pattern of treating men as amateur human beings and coaching them on just what to do--of supervising them in relationships. It worked great. But at the same time, I'd become increasingly careful to validate women's feelings and avoid telling them what to do. The result, of course, was that many men changed their behavior quickly and many women were left nursing their hurts, feeling like victims and not noticing or responding to the changes in the men or the increases in their own levels of empowerment.


My pragmatically mechanistic approach toward relationships (i.e., ignore your feelings, do what will get the desired response from your partner and let the new interaction change the emotions) has a certain limitation. There are some offenses against marriage that feel unforgivable--at the moment and for a little while after. And no change in behavior can provide the necessary reassurance--at the moment and for a little while after. We all have grounds for divorce (or suicide), but we know that tomorrow is another day. I get so carried away with my belief that any change can be made and any offense can be overcome that I may leave behind some traumatized casualties of life's cruelties. Adam and I got ahead of Angela. After the offenses stopped, we needed to slow down long enough for the healing to take place.

I often think about my three suicides. All three of them were men who had done the unforgivable and couldn't get their families back quickly enough. I beat myself up about them and sift through them to find what I can do to keep it from happening again. People can make such a mess of their lives that they see no hope, but suicide is too hard on the survivors--including me. It threatens to make me cautious, pessimistic and risk-averse. To be truly helpful, I need my jaunty optimism about what can be survived in life and in marriage. Without it, I can't keep people afloat long enough for them to get their lives back. Did I give Adam too much hope? Did I give Angela too little? Did I fail to coordinate the trajectories of the changes the therapy was bringing about by being two different kinds of therapists--feminist for her, behaviorist for him? Did I go to the wrong funeral on that last day? If I'd known the papers were being served that day, I would have been with him, even if only by telephone. If he had just called me when the papers came--

Clearly, it will never be over for any of us.


Frank Pittman, M.D., is a contributing editor to The Family Therapy Networker and is in private practice. Address: 960 Johnson Ferry Road, N.E., Suite 543, Atlanta, GA 30342.

 

My Most Spectacular Failure

Voluntary Simplicity Meets Shop Til You Drop

by Mary Pipher

I will never forget the Correys, who were referred to me by their family doctor in western Nebraska. As is not unusual in our vast, rural state, they flew to our sessions by private plane. Frank was a wealthy businessman and realtor. Donna was a housewife. They had a 16-year-old daughter. Every other week for a year, I saw them, during which time I tried pretty much every trick in my therapeutic arsenal. I spent hours discussing their case with trusted colleagues and read up on their particular problems. I don't know how many nights' sleep I lost worrying about how to get these folks on the right track. And in spite of all my efforts, the Correys were one of my most spectacular failures.

From the moment I met the Correys in my waiting room, I was baffled about why they were together. Frank was tall, good looking and suave; Donna dowdy and sullen. They were both in their mid-forties, although Frank looked younger than that and Donna older. She barely bothered to greet me, and stared resentfully at Frank. As soon as we were seated, Frank jumped in to complain about Donna's spending. He was clearly used to being in charge, confident and eager to explain their situation. And Donna was used to being passive and angry.

Frank explained that even though they lived in a town with only a grocery store and gas station, a town one hundred miles from the nearest mall, Donna used catalogs and the shopping channel to spend nearly $8,000 a month. I couldn't believe I heard him right, and actually asked him to repeat the figure. I tried to keep my expression mild and non-judgmental, but inside I was appalled. I can go months without buying anything but groceries, and have not spent $8,000 on consumer goods for myself in my entire life.

According to Frank, Donna tried to keep her spending secret. He only discovered the extent of her extravagance when he found credit card bills or his secretary noticed that his business accounts had been cleaned out. Ironically, even though Donna "owed" Frank more than $50,000 for unauthorized spending, she had little to show for it--no boats, fur coats or new cars, just boxes of shoes, clothes and household gadgets. Of all the questions and reactions I had to this case, my big question was--how could anyone stay married to such a loser wife?

I generally divide an intake into thirds: one-third for the presenting problem, one-third for some contextual information and one-third for a discussion of therapy. And I give each person a chance to explain the situation. Frank blamed Donna's spending on her depression and low self-esteem. He said he would be happy if only Donna would cook, clean and limit her spending to $1,000 a month. I thought to myself, "Climb a low mountain, Frank."


When her turn finally came, Donna pointed out that Frank was a millionaire and the sums she spent were insignificant. She complained that Frank was almost never home, and when he was home, he stayed in the basement managing his stock portfolio on his computer. She said, "Frank's moody and he takes no interest in us unless there is a crisis." She agreed she was depressed. She had once been active in her community, but in the last few years she had withdrawn from everyone but her daughter.

Ah-ha, I thought, now I get it. Her spending was functional. It kept Frank's attention. Frank worked all the time to keep Donna in dough, which she then spent rapidly to punish him for working. He worked to avoid a dull, depressed wife, while she spent to deal with her loneliness and sense of inadequacy, brought on partially by Frank's neglect. Still, even though I had a crisp intellectual formulation of the case, I suspected from the first that I wasn't quite on target. I couldn't get over Donna's spending and I was impatient with her stolid, stubborn demeanor. I felt sorry for Frank that he was stuck with such a lump.

At the end of that first session, I made a few recommendations to the Correys --that they tear up their credit cards, that Frank come home for dinner a couple nights a week and that they have a date as a couple. I suspected Donna was clinically depressed, so I encouraged her to exercise and to buy a copy of David Burns's Feeling Good. Neither one of them was happy with my suggestions. Frank insisted time demands made it impossible to spend more time with Donna. Meanwhile, Donna refused to cut up her credit cards. But they let me bully them into agreeing to try these assignments and we rescheduled for two weeks later. I sighed as they left.

Right after our first session, the cast of characters expanded. Donna scheduled an appointment with a psychiatrist, who prescribed antidepressants and wrote me a letter saying that she thought the real problem was Frank, who was invested in his wife's being labeled sick and was a mean son of a bitch, although she said this in medical jargon. The psychiatrist didn't see Donna's spending as any big deal, and what's more, she actually liked Donna, whom she described as having a keen sense of humor and good insight.

I was baffled by the psychiatrist's take on this case. I didn't see any meanness in Frank. How could the psychiatrist have missed his charm? And where was Donna's sense of humor when she was with me and Frank? I explained the discrepancies in views by recalling that the psychiatrist was recently divorced and perhaps angry at men. I knew she was a major consumer herself.


The Correys did have a few dates, mostly dinner at the nearest restaurant, a Pizza Hut 30 miles from their home. But the dates didn't generate any romance. Donna didn't exercise and hated Feeling Good . I found myself resenting the failure of bibliotherapy. After all, books always helped me. Donna eventually agreed to cut up her credit cards and to attend Debtor's Anonymous, which meant Frank flew her in for a group meeting once a week. They actually liked these meetings, although Donna didn't really reduce her spending. Somehow, no matter how carefully Frank and I tried to control her, Donna found ways to charge stuff or order junk over the Internet, Although she said the medication helped, Donna was still mildly depressed and still not cooking or going out in her community. Frank stayed mad about Donna's spending, although not that mad. Meanwhile, no matter how therapeutically neutral I tried to be, I remained appalled by her extravagance.

By now our sessions had lost any therapeutic momentum. Increasingly, I felt as if I were dragging a barge across the desert. The couple would fly in, report little change in Donna's symptoms, Frank's work habits or their relationship, and fly out. Both said they were dissatisfied with the relationship, but after 22 years of marriage, neither was considering divorce.

The less progress I saw in our sessions, the harder I tried. I utilized every technique I could think of. I tried paradoxical techniques and prescribing the symptom. Thud. I saw them alone and encouraged Frank to draw a line in the sand. Thud. I saw Donna alone and encouraged her to find women friends, go back to school, get a job, take walks or find a volunteer commitment she could enjoy. Thud. I recommended a vacation, which they half-heartedly tried and both hated. Thud. I encouraged them to  communicate their needs, set up a budget and work on their emotional relationship. Thud. Thud. Thud.

My exasperation and confusion peaked during one session in which, as Frank itemized her wasteful spending, Donna actually fell asleep. After I woke her, I asked Frank how he felt about Donna's sleeping. He insisted that he didn't mind that much. After all, Donna was tired. At that point, I almost jumped out my own office window.

How could I work with someone who was about as different from me as a woman could be? Donna was passive, preoccupied with consumer goods and she actively disliked exercise. She was bored by trees and prairies and had no interest in education. That boggled my mind. How could anyone not be interested in education? I knew I was being judgmental, but I was convinced that I knew how to be happy and she didn't. There was no question in my mind that my way of being in the universe was better than hers.


I felt more sympathy with Frank, who was at least a hard worker. Also he was a high-powered salesman and could sell me on his excuses, his interest in making things better. But I didn't really understand Frank either. He wasn't much more cooperative in therapy than Donna, especially with my insistence that he tell his wife what he would and wouldn't put up with and then hold that line. In fact, as I worked harder and harder to fix this couple, they seemed to become more locked into their original problem behaviors.

Finally, I had it with the Correys. When Frank found that Donna had opened a new line of credit and charged another $10,000 of purchases, I fired them. I can still see the three of us in our last session, me earnest and serious, trying to hide my anger and wishing them well with a different therapist, "who would offer them a fresh approach." There was Frank, not as unhappy at being fired as I would have hoped. In fact, he was a little rude to me, as if I were an employee who no longer mattered. And Donna, smiling for the first time since we had met. As they left my office, she said almost kindly, "Don't be too hard on yourself, we are nutty and we're hard nuts to crack." There, for the first time, was the sense of humor the psychiatrist saw.

I thought a lot about the Correys in the months after our termination. I'd ignored the wisdom that people only change when they feel deeply accepted for who they are. Instead, I'd let my own values about spending prejudice me against Donna. And I had other values conflicts as well--over reading, education, gardening and the importance of taking action.

A wise therapist once told me that our first task in any therapeutic encounter is to find something to respect in our clients. Without respect it's impossible to really help anyone. I realize I flunked Therapy 101. I didn't respect Donna and I let that important fact slide. I suspect Donna sensed my lack of respect and that's why she fell asleep in our sessions. She had no connection to lose with me. The big lesson from the Correys was that I need to find something I can truly and authentically respect or I need to get out. I can't pretend respect. And without it, there is nothing on which to build a therapeutic alliance.

Being a therapist is intellectually taxing, emotionally draining work, and respect is what fuels the process; it's what gives us a reason to care. Without it, the work is mechanical, for us and our clients. With no respect, there can be no connection, and without connection, therapy loses its meaning.

Mary Pipher, Ph.D., is author of the bestselling books Reviving Ophelia and Another Country: Navigating the Emotional Terrain of Our Elders. She is a clinical psychologist in private practice in Lincoln, Nebraska. Address: c/o Family Therapy Networker, 7705 13th Street, N.W., Washington, DC 20012.

 

Altered States

Why Insight by Itself Isn't Enough For Lasting Change

by Brent Atkinson

In the 15 years that I've been following developments in neuroscience, the most compelling clinical lesson I've learned is likely to rub you the wrong way. An overwhelming body of research now suggests that we clinicians rely too much on insight and understanding--and too little on repetitive practice--in promoting lasting change.

This wasn't welcome news to me. I'm a couples therapist, and I got into this business because I loved transformative moments when intimate partners' defenses crumbled and their deep emotions emerged. That was what juiced me--not, getting couples to do the same things over and over again.

Yet, year after year, I watched couples let go of judgment and blame for an instant, only to show up for the next session as miserable, critical, or withdrawn as ever. They didn't even remember the profound insights they'd had that I felt sure were going to rock their worlds.

Then I encountered a series of studies published by neuroscientist Jaak Panksepp, from Bowling Green State University, and came to understand that when they were upset, my clients were in the grip of one of seven major body-brain mood states, which he calls "executive operating systems."

Our Brains' Executive Systems

Panksepp uses the terms rage, fear, seeking, lust, care, panic , and play to describe the signature emotion of each system. But they're more than passing moods. They're complex neurochemical cascades, in which hormones race through the body and brain and electrical impulses fly over familiar neural synapses, shaping what we feel, do, and think. When one of these systems becomes active, emotions, motivation, and thoughts take over in the service of the goals it's programmed to achieve. It's as though we've gotten on a plane to Paris, and no amount of fiddling with the seatbelt is going to change the plane's direction before the wheels touch down at Orly.

Four of the systems are wired for love: they draw us together. One of these is old-fashioned lust. Another promotes spontaneity and play. A third, the instinct to nurture others, which Panksepp calls care , is activated by the release of the hormone oxytocin into the bloodstream and brain. Another mood system Panksepp calls "panic" is experienced as yearning or even abandonment, when an intimate partner leaves on an unexpected business trip or storms out of the house during a fight.


Most of these mood states can help promote emotional bonding during couples therapy. But the states that therapists find the most frustrating in the consulting room--and often the most common--are two other body-brain mood states that used to be called fight or flight. Activated by the amygdala, they produce self-protective thinking and action. Fight, which Panksepp calls rage, quickens the breathing, sends blood to the muscles in preparation for striking out, and releases adrenaline and noradrenaline into the bloodstream and brain. It sharpens some mental functions and leads a person to think in decisive, impulsive, blaming, oversimplified ways. It's accompanied by the attitude "You're wrong, and I'm right."

This hormonal cascade can be lifesaving in the appropriate situation--in the face of a dangerous driver, say, or a possible mugger or rapist. But in intimate relationships, it's often toxic. In its grip, men (and some women) can become physically abusive; others yell, nag, blame, and complain. And as almost everyone knows, it's much easier to get on this particular tiger than to get off.

The second self-protective cascade, which Panksepp calls fear, produces feelings ranging from anxiety to intense fright, along with worried thoughts and the impulse to freeze, flee, withdraw, or hide. It, too, is accompanied by critical thoughts about the intimate partner. A man in the grip of this neurochemical cascade may exhibit sullen, disgusted, or spacey withdrawal in the face of a barrage of angry complaints from his wife.

Hence my frustration. I couldn't understand why couples continued in these patterns when they'd learned--in those magical moments of insight--that blaming or withdrawing didn't help them get what they wanted. It seemed so irrational. But when people are in the grip of these emotional takeovers, certain parts of the prefrontal cortex (the folded outer layer of the brain behind the forehead) are less active than when they're calm. The prefrontal cortex is the seat of free will and self-awareness. It allows us to plan, strategize, imagine the results of our actions, and choose to do one thing rather than another. When portions of it are inactive, as they appear to be when we're in the grip of one of our executive operating systems, our inner switchmaster is asleep: we simply can't shift from one state or course of action to another. So the wife keeps blaming, like a hamster on its treadmill, and the husband, in an equally mechanical state, keeps staring out the window.


Learning to Shift Mood States

When I first encountered this information in the early '90s, I worked at getting clients to shift out of these powerful mood states. When I got frustrated, I reminded myself that they were caught in neurochemical reactions beyond their control. I'd usually have one partner wait in the waiting room for a few minutes while I worked with the other, finding that a few minutes of concentrated empathy, validation, and acceptance would often calm someone down. Under these conditions, they could hear me say--in a soothing tone--that blaming would only stimulate the other's defensiveness and not get them what they wanted. We could then brainstorm more pragmatic, emotionally open, skillful ways of communicating. I was training them to reactivate the neocortex--the inner switchmaster--in the face of strong emotion.

I assumed the lessons would stick, but I was disappointed. I'd underestimated the hardwired nature of my clients' automatically activated, neural- response programs, ingrained through years of relating to each other. They needed far more practice than a weekly therapy session could provide.

It wasn't enough for my clients to rehearse new thoughts in calm moments. They needed to practice new ways of thinking under "game conditions"--when they were actually upset and least able to think clearly. And they'd have to do this over and over: most neuroscience researchers agree that the brain acquires new habits through repetition. One of the most enduring concepts in neuroscience is Hebb's Law, named after the pioneering McGill University neuroscientist Donald Hebb, who stated that brain processes that occur together over and over again become grafted together, and are more likely to occur in conjunction in the future. According to Hebb's Law, if my clients engaged in new thinking processes while they were upset, and did this enough times, the new thinking processes would begin happening spontaneously each time they became upset.

Audio-Facilitated Change

Then one of my clients, a registered nurse named Judy, who kept struggling to tame her tendency to get enraged with her husband, said to me, "If only I could take you home with me!" When she was furious, she was in the grip of the delusion that her anger was her empowering friend, only to find that her outbursts actually disempowered her. She asked me to make an audiotape for her to listen to precisely at the moments when she became upset with her husband. In this audiotape, I offered encouraging words and reminded her repeatedly that she was far more influential and powerful when she stood up for herself in ways that didn't put her husband down.


She loved the tape and listened to it not only when she was upset, but also when she was driving in her car and on a Walkman, while she was doing the laundry and cleaning house. Within three weeks, she experienced a dramatic shift in a lifelong destructive pattern.

I made more elaborate tapes for Maria and Tony, who trudged into my office one crisp October evening for their fourth session. Maria was so upset that she refused to speak to Tony. She'd had elective surgery the previous week, and had gone into rage mode when Tony left her alone in the hospital one night to go home and get some sleep. I asked Tony to stay in the waiting room while Maria told me how incredibly selfish he was for thinking of himself when she was in so much distress. In the grip of her amygdala-driven cascade, she couldn't see that her attack was sending Tony into disgusted withdrawal as usual. I sympathized with her feelings, and then simply suggested that although her attitude was perfectly understandable, she'd need to drop the idea that he'd done something wrong, and simply tell him how she felt. She struggled inside for a moment and then relaxed. Her eyes moistened and she said softly, "Okay, I think I can do it." When Tony joined us, Maria spoke from a different place inside, and Tony responded instantly with an apology.

I then made an audiotape that essentially repeated the words that had helped Maria shift during this session, and asked her to listen to it each time she became upset with Tony during the following week. The next day, she got off work early, pulled into the driveway, and saw her children playing at the neighbor's house, even though Tony had agreed that he wouldn't let the kids go out to play after school until they'd finished their homework. She felt a surge of anger, but as she reached for the car door, she remembered the audiotape in her purse. She paused for a split second, torn between the urge to vent and the desire to avoid going down the same old path.

Reluctantly, she plugged in the tape and listened in the car. After 10 minutes, she realized that she was in no frame of mind to talk to Tony, and decided to take a walk around the block. After 20 minutes, she felt calmer, and by the time she saw Tony, she was able to keep an open mind and simply ask him why the kids were playing, rather than accuse him of breaking their agreement.


What happened during Maria's walk around the block? Frankly, I don't know. In Maria's audiotape, I didn't tell her what to do or how to shift her attitude, I simply reminded her of a few reasons why she might want to try. The decision was hers. Clients often have difficulty describing how they get shifts to happen. Most report a willingness to let go of control and a momentary surrender to the fact that you can't make life go exactly according to your plans. The shift is usually accompanied by physical relaxation and a release from obsessive thinking. The client returns to the present moment, and is able to respond to what's actually happening, rather than what they fear is going to happen. The most important ingredient in getting an attitude shift to happen is desire. When clients decide they truly want to shift, they do.

Ancient Wisdom

What clients report helps them shift brain states has something in common with many repetitive religious practices--from praying "Thy will be done" to practicing mindfulness, kissing a St. Christopher medal before going up to bat, or making a list each night of things one is grateful for. All of these approaches help people create enough of a pause to free them from the grip of intense rage or fear and to generate states of generosity, acceptance, and trust. Like them, my audiotapes allow the body and brain to calm down, and they serve as timely reminders that it's in the client's best interest to try to shift.

Maria, for instance, used her tape as regularly as some people light candles at mass. She told me that she often could feel an attitude change beginning as soon as she heard my calm, confident tone. It reminded me of what attachment researchers speak of when securely attached children evoke images of their caregivers to soothe themselves. In her third week of using the tapes, Maria told me that she began to spontaneously hear my voice inside her head every time she got upset.

Some clients need little more than a verbal reminder. Others require vivid images or metaphors. Tony, for instance, once told me that when he reflexively defended himself, he felt like he was swatting Maria's complaints back at her with a baseball bat. In a minisession without Maria, I helped him imagine turning the bat into a pillow. The image worked, and when Maria returned, he was better able to absorb and digest what she had to say.


I put the pillow image on a tape for Tony. Then we got Maria to record a tape full of her complaints--a litany about how Tony didn't keep his word, didn't fix things around the house, and hadn't kept the kids quiet on Saturday morning after promising he'd let her sleep in. In a solo session, I had Tony listen. As soon as he began feeling defensive, we'd stop the tape and he'd focus on how his body felt; he'd tremble and go into a sort of disgusted shutdown. Then he'd practice trying to shift, seeing the pillows, relaxing physically, reminding himself that there might be some validity to her point of view. Then we'd start the tape up again and repeat the process. Tony used the tape regularly in his truck and became so adept at generating a state of acceptance and compassion that one of his employees remarked that he'd undergone what seemed like a spiritual shift.

I still love the drama of transformative experiences, and my favorite moments are still the tearful ones, when partners drop their defenses and exchange heartfelt expressions of love. But nowadays, I see these moments as just the beginning. They give clients the motivation for the real work of change, which is much less dramatic. I rarely get to see it because it doesn't happen in my office. It happens a little bit at a time, day in, day out, as clients practice letting go of the critical judgments that arise with the brain's self-protective mood states.

My happiest clients make shifting a daily practice, not unlike prayer. The tape recorder, and all my modern knowledge about neuroscience, have ended up supporting the practice of routine and ritual, largely ignored by modern psychotherapists, but intuitively known and practiced by sages since the beginning of time.


Brent Atkinson is the director of the family therapy program at Northern Illinois University, and is in private practice in Geneva, Illinois. Address: School of FCNS, Northern Illinois University, DeKalb, IL 60115. E-mails to the author may be sent to: Brent@thecouplesclinic.com.

 

Mirror Mirror

Emotion in the Consulting Room is More Contagious Than We Thought

by Babette Rothschild

Empathy is the connective tissue of good therapy. It's what enables us to establish bonds of trust with clients, and to meet them with our hearts as well as our minds. Empathy enhances our insights, sharpens our hunches, and, at times, seems to allow us to "read" a client's mind. Yet, vital as it is to our work, empathy has remained a rather fuzzy concept in psychotherapy. To many of us, it seems to arise from a kind of potluck stew of emotional resonance and insight, seasoned with lots of attuned presence and a generous dollop of luck.

Far from the therapy office, in the precisely measured environment of the research lab, brain scientists are discovering that a particular cluster of our neurons is specifically designed and primed to mirror another's bodily responses and emotions. We're hardwired, it appears, to feel each other's happiness and pain--more deeply than we ever knew. Moreover, the royal road to empathy is through the body, not the mind. Notwithstanding the river of words that flow through the therapy room, it's the sight of a client looking unhappy, or tense, or relieved, or enraged, that really gets our sympathetic synapses firing.

This news is both exhilarating and scary. The good news--for therapists, their clients, and the world at large--is that human beings may be more deeply capable of empathy than we ever imagined. If we're truly born to connect, perhaps there's hope for us all. The scarier news: if we're truly designed to mirror each other's feelings, we therapists may be exquisitely vulnerable to "catching" our clients' depression, rage, and anxiety, and succumbing to the ravages of "compassion fatigue." Given the hardwired nature of empathy, is it possible to say yea or nay to its effects on us? What steps might we take to harness and channel our natural-born empathy for the good of our clients--and ourselves?

I first recognized the physical force of empathy as a college student, with the help of my friend Nancy, who was studying to be a physical therapist. As we walked down a street together, she'd follow total strangers and subtly mimic their walking style. Copying a stranger's gait, and feeling it in her own body, gave her practice in identifying where one of her patients might be stiff, or in locating the source of a limp. Intrigued by this mysterious way of "knowing" someone, I asked her to teach me to do it, too. I began to surreptitiously mimic the walks of all manner of unsuspecting folk, from unsteady older people to cooler-than-thou teenage hipsters. What startled me was that not only did "walking in someone else's shoes" change the way I felt in my body, but it often altered my mood as well. When I copied the swaggering gait of a cocky young man, for example, I'd momentarily feel more confident--even happier--than before. I found this secret street life fascinating and fun, but I didn't think much about it until a few years later, when I started practicing clinical social work.

Breathless

On my first job in the mid-1970s working in a family service agency, I began to notice peculiar things happening in my body when I sat in my office with clients. Some of my responses could be blamed on newbie jitters, but I strongly sensed that there was more to it than that. I particularly remember my bodily reactions to a young client named Allison. As she recounted the crises of her week in a spacey, disconnected way, she kept her body very still, and I had to lean forward to hear her whispery, almost inaudible, voice. As we worked together, I began to notice that I often felt lightheaded. When I began to pay attention to what was happening in my body, I found that my breathing had become very shallow--in fact, nearly undetectable. No wonder I was feeling lightheaded and spacey: I wasn't getting enough oxygen!

Turning my attention back to Allison, I noticed that her chest was barely moving. I was taken aback: we were breathing alike! I remembered then how my mimicry of walking patterns in college had often affected my bodily sensations and moods. Were my lightheadedness and general feelings of disconnectedness just the result of new-therapist nervousness, or the direct result of my imitation of Allison's breathing? If our breathing had actually become synchronized, I realized, it was totally unconscious on both our parts.

In all of my graduate-school discussions on the therapeutic relationship, including the fine points of transference and countertransference, I couldn't remember anyone who'd ever mentioned the possibility of "catching" bodily behaviors. Intrigued and a bit bewildered, I took my observations to my supervisor. I still remember her look of startled skepticism. "What an odd hypothesis," she finally remarked, her cool tone clearly implying that my experience wasn't to be taken seriously. I was dumbfounded by her lack of curiosity, but I never doubted my own sensations. On the contrary, increasingly fascinated with the role of the body in relational and emotional life, I began a serious study and practice of body psychotherapy.

In contrast to my suspicious supervisor, my body psychotherapy colleagues and teachers seemed to accept readily that their bodies were "in tune with" or "resonating with" those of their clients. Like actors, they regarded their bodies as essential, finely honed instruments of their craft. From these practitioners, I learned "postural mirroring," a technique instigated by dance therapists, wherein I'd attempt to get a reading on a client's emotional state by copying the way he sat, stood, or moved. There wasn't a lot of debate about the usefulness of such a technique: body psychotherapists simply assumed that "the body doesn't lie."

Tracking Down the Source

While I was heartened by the confirmation of my own observations, I was concerned about body psychotherapy's uncritical acceptance of a link between a therapist's and client's body states and emotions. I needed to know more: Where does our ability to resonate with each other, with such stunning immediacy and accuracy, come from? What core processes drive the dancelike synchronizations of movement and mood that I kept encountering?

Throughout the 1990s, I became a voracious student of neuroscience--at first, as a way to learn about the physiology of trauma. In the course of those studies, I discovered the term "vicarious traumatization" and documentation that therapists could actually suffer symptoms similar to their traumatized clients. At once, I was both concerned and excited. I wondered if the physiological and emotional reactions that accounted for this might have any relationship to my earlier gait experiments with Nancy, the incident with Allison, and my body psychotherapy colleagues' enthusiasm for client mimicry. I'd need to dig further.

I nurtured my curiosity at the library, on the internet, and through the PsychInfo and Medline databases. From the vast literature of social psychology, I learned that facial expressions were contagious--when baby smiles, Mom usually does, too--and that such synchrony affects the nervous system and can convey emotions. I also learned that people commonly, if unconsciously, copy each other's posture and synchronize breathing patterns.

As exciting as that research was, I still felt something was missing. The writings of neurologist Antonio Damasio, attachment specialist Allan Schore, interpersonal neurobiologist Daniel Siegel, and others told me that scientists could locate the effects of empathy in the brain. But, astonishingly, until the mid-1990s, no one had looked for a source of empathy in the brain. And, as I was to find out, the later discovery of the source of brain-to-brain empathy happened by accident.

Monkey See, Monkey Do

In 1996, an Italian neuroscience research team led by Giacomo Rizzolatti and Vittorio Gallese was studying grasping behaviors in monkeys. They attached electrodes to the monkeys' brains to observe precisely which neurons fired when a monkey grabbed a raisin with its hand. The research was routine: monkey grasped, specific neurons fired.

Then, during a break, one of the researchers hungrily reached out for a raisin. His fellow researchers coincidentally noticed something extraordinary on the monitor: neurons in the monkey's brain fired-- the exact same neurons that had fired earlier when the monkey grasped a raisin itself!

 

The team was astonished: nothing like this had ever been seen before. Their serendipitous finding was the first clue to the existence of what scientists now call "mirror neurons," so called because they appear to actually reflect the activity of another's brain cells. The monkey's response wasn't just simple recognition, as in "I know what the researcher is doing." That kind of observation activates other areas of the brain. What happened between monkey and researcher required a brand new concept, an altogether new theory of behavioral interdependence. The monkey's neurons fired as if it had made the same movement itself. This was a genuine brain-to-brain connection. In an instant, the definition of interconnectedness, the notion of empathy, changed forever.

Subsequent neuroimaging research in humans suggests that we, too, may have a similar mirror-neuron system that allows us to deeply "get" the experience of others. When people watch other individuals drumming their fingers, kicking a ball, or biting into an apple, the sectors of their brains that turn on are the same sectors that activate when they perform these behaviors themselves. Meanwhile, in a paper published last year entitled "The Roots of Empathy," Gallese pushed the envelope further by hypothesizing that "sensations and emotions displayed by others can also be 'empathized,' and therefore implicitly understood, through a mirror matching mechanism" in the brain. Soon, he believes, scientists will discover a mirror-neuron network that establishes, beyond a doubt, that we're born to resonate with one another at the deepest emotional levels.

Orchestrating Empathy

While neuroscientists continue the slow work of confirming these promising findings and theories, therapists can begin to apply them now to empathize more strategically and effectively with their clients. Because empathy is rooted in the body, the more mindful therapists are of their own somatic responses, the more skillfully they can choose to engage mirror neurons to gain valuable information about a client's emotional state. Equally important, a therapist can choose to slow down, or even halt, the brain's rush to empathize when it might overwhelm the client--or the therapist.

Let's begin with the body's gift for sleuthing. When you want to get a literal feel for what it's like to be in your client's skin, you can consciously mirror some aspect of his or her behavior or expression. I tried this when I worked with Fred, a new college graduate who'd come into therapy to address his anxiety about dealing with authority in his first "real job." Though he'd grown up with a tyrannical father who'd beaten him regularly as a child, Fred couldn't see or feel any relationship between his childhood trauma and his current fear of standing up to his boss.

 

One afternoon, Fred arrived for his session deeply depressed. He'd been thinking about suicide, he said, but had no idea why. I wasn't sure either. As I asked him to describe what "suicidal" felt like in his body, I tuned in by copying his flat facial expression and slumped posture. Almost immediately, I began to experience in my own body the sense of deadness he'd just described to me. It reminded me of the "freeze" response that's an instinctive reaction to inescapable threat.

All at once, a light bulb flashed in my mind. "Fred," I asked, "have you ever seen a mouse that's been caught by a cat?" He nodded yes. "What does the mouse do?" I prodded. "It plays dead," he replied, his face beginning to brighten with interest. We then discussed the protective function of freezing for all prey, both animals and people. Finally, I asked Fred if he'd ever reacted that way himself.

"Yeah," he said softly, "when my dad beat me." As his father hit him, he told me, his body would lose all power and "go dead." For the first time, he made a felt connection between his childhood horrors and his current emotional state. It seemed a light bulb was also flashing in Fred's mind. As he began to talk thoughtfully about his own "internal mouse," his body posture gradually became more upright and animated, and by the end of the session he reported that his thoughts of suicide had receded.

Could I have helped Fred make this breakthrough with talk alone? Perhaps, but it would likely have entailed several more sessions full of the usual conversational roundabouts, byways, and detours. Instead, by mirroring him, I could quickly feel and then understand Fred's deadness.

While purposefully synchronizing with your client can often provide added insight or even jump-start a stalled session, be aware that the data you pick up isn't "pure" information. Just as gaps can occur between speaker and listener in verbal communication, so can somatic communication be distorted by your own filters. If, for example, you mimic your client's head tilt and get a feeling of anxiety in your chest, your client may indeed be anxious. But it also could be that you habitually tilt your head when you're anxious, so that repeating this action triggers the emotion. So be sure to check out your bodily hunches with your clients, as I did with Fred.


The Risks of Resonance

Mirroring a client can be a bit of a tightrope act. You can easily lose your balance and crash to earth, especially if you fail to stay focused. I learned this lesson the hard way.

A few years ago, my client Ronald was angry with me because I was leaving town for a few weeks. He was so full of fury that, for the first hour of a double session, he wouldn't talk at all. He sat half-facing away from me, tense and seething. From time to time, his eyes would fill with tears. Repeatedly, I tried to make verbal contact with him, using such standard gambits as "You seem very angry" and "This looks very difficult for you." But I had the unmistakable feeling that my words projected about a foot from my mouth, and then thudded heavily to the floor.

Finally, I decided to hold my tongue and let Ronald work it out himself. With my mind emptied of fix-it schemes and nothing much else to do, I began to consciously copy my client's hypertense posture. I clenched my jaw, clasped my hands tightly in my lap, and scrunched my shoulders forward.

Two things happened. The first was that within a minute or so, Ronald's posture began to loosen up a little and he began to talk about his feelings of impending abandonment. (I've since learned that mimicking another's posture can nonverbally convey understanding.) As he aired his rage and hurt, I was able to acknowledge his feelings and let him know that I could understand and accept his anger. By the end of the session, he reported feeling somewhat calmer.

But not me. After Ronald closed the door behind him, I realized that I was very uncomfortable. Actually, that's an understatement: I was practically unhinged with fury. But why? Was I angry at Ronald? Had the session triggered something from my own life? I tossed around a half-dozen possibilities in my mind, but nothing seemed to fit. Only later, when I talked it over with a colleague, did I remember: I'd copied Ronald's infuriated posture! My mirror neurons had done their job too well. Once I made this crucial connection, the "infection" began to drain--I could almost feel the fury leaking out of me. I returned to myself again in a matter of seconds.


To some therapists, what happened between Ronald and me may look like a textbook case of projective identification--a case of Ronald's "putting" his uncomfortable feelings into me and thereby "inducing" my fury. I couldn't disagree more. I was a full participant in the process: only after I actively mirrored Ronald did I begin to feel angry. But while my mimicry was entirely conscious--if later forgotten--I believe that this kind of brain-to-brain communication occurs at an unconscious level between clients and therapists all the time. The next time you feel that you may be suffering from the impact of a projective identification, you may need to look no further than your own body to discover whether you've mimicked your client's posture, facial expression, or breathing pattern. Routinely adding such a simple step could eliminate the blaming of clients for feelings that are, in fact, rooted in our own, naturally responsive, neural circuitry.

There's liberation here, particularly for therapists who often find themselves on the edge of emotional overload. Active awareness of your own neurally-mediated role in absorbing clients' feelings can help you control the contagion. Once you become aware of your mimicry, any behavior that brings you back to the sensations and feelings of your own body, and out of synchronization with the client, will help you to apply the "empathy brakes." You might stretch, take a drink of water, get up to fetch a pen, or write some notes. These steps won't short-circuit empathy, but rather will allow you to return to yourself--to a place of clarity, presence, and helpful attunement to your client.

When a Client Feels Your Pain

Empathy, of course, is a two-way street. Our clients often unconsciously mimic our body patterns and take on our corresponding emotional states. Many therapists instinctively foster this process. When, for example, you slow your own breathing and your anxious client subsequently slows his, you're engaging his mirror neurons. No words need be exchanged for the client to gradually match your slower respiration and begin to calm down.

But if clinicians' serenity is contagious, so, too, is their agitation. One morning, upon returning to Copenhagen (my then home) after a long visit to the United States, I was suffering from a particularly nasty case of jet lag. Though exhausted and headachy, I jumped right into my usual work schedule. At the end of my afternoon session with Helle, I asked her, as usual, "How are you feeling?" Helle proceeded to describe my jet lag in precise detail. "I feel very tired, and there's a feeling of pressure in my forehead," she said, rubbing her eyebrows. "I also feel an odd heaviness in my chest. And I'm hungry, though I shouldn't be: I ate a good lunch just before I came."


I suggested to Helle that she stand up and walk around the room, hoping that the physical activity would move her out of my somatic sphere of influence and back into her own body. After pacing for a minute or two, she returned to her chair, noticeably more energetic. "My exhaustion and hunger have disappeared!" she reported. I then told her how I was feeling, that she'd described my sensations precisely.

Since consciousness is an important part of the process of controlling the neuronal dance, we spent a few minutes tracking how Helle had "caught" my state. In retracing her postures, she realized she'd rested her head on her hand as I'd tiredly done. That ordinary act of unconscious mimicry was enough to make her vulnerable to feeling my jet lag and the untimely hunger that accompanied it.

Psychiatrist and early attachment expert Daniel Stern calls the moments of true meeting in therapy a "shared feeling voyage." Though each voyage may last but a few seconds, we've all experienced its potent rush--the sudden throb of feeling not just for but with a client, a sensation of jolting connectedness that can be both exhilarating and fearsome in its intensity. What we've always imagined to be a resonance born of voice, smile, tears, or touch is encoded in us, it turns out, far more deeply and inexorably than we ever knew. It may be that our mirror neurons, those tiny and inescapable vessels of empathy, encapsulate one of the most exciting challenges of psychotherapy--that of attuning two brains, and two hearts, so that they warmly vibrate together without melting into one.

Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles and gives professional trainings worldwide. She's the author of The Body Remembers:The Psychophysiologyy of Trauma and Trauma Treatment and The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. Website: www.trauma.cc. E-mails to the author may be sent to: babette@trauma.cc.

Resources

Gallese, Vittorio. "The Roots of Empathy: The Shared Manifold Hypothesis and the Neural Basis of Intersubjectivity." Psychopathology 36 (2003): 171-80.Hatfield, Elaine, John T. Cacioppo, and Richard L. Rapson. Emotional Contagion: Studies in Emotion and Social Interaction. Cambridge, England: Cambridge University Press, 1994.

Rothschild, Babette, and M. L. Rand. Help for the Helper: The Mind and Body of Compassion Fatigue, Vicarious Trauma, and Burnout. New York: W. W. Norton, forthcoming.

 

Mindsight

Dan Siegel Offers Therapists a New Vision of the Brain

by Mary Sykes Wylie

In 1999, a few months after child psychiatrist Daniel Siegel's book The Developing Mind: Toward a Neurobiology of Interpersonal Experience was published, Siegel received an e-mail, purporting to be from a representative of Pope John Paul II, asking him to come to the Vatican to talk to the Pope. Thinking the e-mail was a prank, Siegel ignored it--why would the Pope invite an expert on the neurobiology of childhood attachment over to the Vatican to schmooze? Nevertheless, one enigmatic detail of the message stuck in Siegel's mind as he deleted it: the Pope, according to the message, wanted very much to know why "the mother's gaze" was so critical to the growth and emotional well-being of a baby.

As it turned out, the e-mail was legitimate. An official letter soon followed from the Pontifical Council for the Family, formally inviting Siegel to be the main speaker at a Vatican conference for church leaders and Catholic social services providers and missionaries, to be followed by a private Papal audience for Siegel and his family. Siegel accepted the invitation with one caveat: he wanted the Pope to know ahead of time that the all-important loving gaze could come from either parent or from another attachment figure--it didn't have to originate with the mother.

Reading John Paul's biography before he left for Rome, Siegel discovered something he thought might explain the Pope's request. When John Paul was asked by the biographer if he remembered much about his mother, who had died when he was a young child, he said no at first. Then, a bit later, he backed up, saying he did recall one thing--"I remember my mother's gaze." Could the Pope want Siegel to explain what happened in the brain that made this ephemeral moment in the life of a young boy still resonate, like a lost dream, many decades later in the heart and mind of a frail, elderly man?

What drew the Pope to Siegel's work was apparently the search for some illumination about the small, everyday miracle of that gaze--what novelist George Eliot called "the meeting eyes of love"--that every child yearns for and must have, literally, to survive. Repeated tens of thousands of times in the child's life, these small moments of mutual rapport serve to transmit the best part of our humanity--our capacity for love--from one generation to the next.


For many therapists, what Siegel has done is to show just how, from the moment we're born, our most important relationships fire into being the neural circuits of the brain that allow us to understand and empathize with others and feel their feelings. But beyond that, he's gone on to link his interest in both science and the nuance of relationship with the almost unfathomable complexities of neuroscience to generate a field he calls "interpersonal neurobiology," which has brought the latest findings of brain science directly into the therapist's consulting room. As much as any figure in the mental health field, he's taken on, as both a professional challenge and a personal quest, the task of showing his clinician colleagues how the objective, physical matter of the brain--its lobes, modules, folds, lumps, tubes, and fibers--creates the possibilities for the subjective life of the mind, heart, soul, and spirit that is the glory of our species.

While still only 47 and not a formal brain researcher himself--certainly not the originator of the massive, accumulating body of theory regarding the processes of human attachment-- Siegel has displayed a unique ability as a synthesizer, weaving together strands of knowledge from a variety of fields. Through his highly influential book and hundreds of workshop presentations he's given around the globe in recent years, he's tried to bridge the previously disconnected worlds of neuroscience research and clinical practice. "Dan is the right person at the right time," says Pat Love, a noted couples therapist and workshop presenter who's devoted the past several years to integrating neuroscience into her own clinical work. "His work cuts across disciplinary lines to bring together neuroscience, developmental theory, evolutionary psychology, systems theory, psychiatry, medicine, and psychotherapy and point us toward the integrated thinking that will shape the future of our field."

Siegel is by no means the first clinician to have talked about the role of attachment and brain processes in clinical work. For more than 50 years, attachment theory has been a significant feature on the landscape of childhood development research. But until recently, how attachment research might inform knowledge about adult psychology was virtually ignored by psychotherapists. For example, Los Angeles psychologist Marion Solomon recalls traveling with a group of associates to England in the early 1980s to visit pioneering attachment researcher John Bowlby and enthusiastically bringing back tapes of his works. When she returned, however, she found that "no one was interested in considering the clinical implications of attachment theory. They just weren't buying the ideas." According to Solomon, however, "There's something about the way Dan has put this material together that makes the lights go on for people. He's propelled attachment theory and neuroscience beyond the tipping point within the therapy world."


Considered a tour de force by reviewers from the worlds of clinical and research psychology and psychiatry, The Developing Mind --a densely packed synthesis of childhood attachment research, cognitive science, the study of emotion, and complexity theory--has definitely established Siegel's credentials as a major expositor and interpretor of neuroscience esoterica to nonspecialists. But even the book's critical success doesn't, in itself, explain the excitement he's been able to generate within the field. After all, it's a daunting read that probably won't be chosen anytime soon for the Oprah book club.

Explaining Siegel's impact, students and colleagues again and again cite the distinctive personal electricity he conveys. "Dan is a born connector," says Marion Solomon, "whether it's one-to-one or with an audience of thousands." His friend Alan Schore, known for his groundbreaking research and theoretical work on childhood attachment, still remembers his first meeting with Siegel 10 years ago at a dinner party. "We just started talking, and before I knew it I was intellectually and emotionally in synch with him," recalls Schore. "The only other person with whom I'd ever clicked like that was my wife."

"Even if you're listening to him in a large audience, you have the sense that Dan is speaking directly to you," adds Schore. That seems to be part of the mesmerizing effect that Siegel's public lectures have. Take the 2003 Psychotherapy Networker Symposium at which Siegel delivered a 45-minute keynote loaded with high-end neurospeak, sprinkled with references to the orbitofrontal cortex, anterior cigulate, hippocampus, the intricacies of neural transmission, synaptic plasticity. and gene expression. Clearly, it wasn't the kind of thing calculated to electrify an early-morning crowd. But from the first moments of his talk, when the soft-spoken, boyish-looking Siegel, apparently dressed by L.L. Bean, ambled on stage without notes to address an audience of 3,000, he had the mostly neuroscientifically challenged crowd on the edge of their chairs with enthusiasm.

Hundreds of shoulders in the hall palpably relaxed as he drew a laugh admitting that, as a medical student, the task of trying to remember the multisyllabic names for different brain parts "made me nauseous." Like a class of born-again biology fans, the crowd happily imitated Siegel as he repeatedly referred to his "hand puppet" model of the brain--balled fist, with knuckles representing the prefrontal cortex and the middle of the palm standing in for the brain stem. "Dan can take complicated ideas and put them into everyday language," says Marion Solomon. "He just conveys a driving curiosity that's irresistible to audiences."

It isn't just Siegel's skill as a communicator that enables him to connect so well with an audience, but the message he brings about the nature of the brain. Most of us who had any exposure at all to the human (rather than, say, the frog) brain in our biology classes were taught about the "single-skull" version. Translating his thorny subject for nonspecialists, Siegel enthralls audiences with his vision of the brain as an exquisitely social organ. From birth, it's not the relentless unfolding of a genetic plan that determines the shape of our adult minds, Siegel explains, but what happens between different brains that largely shapes what happens inside our individual brains. He opens up unexplored vistas of a plastic, self-renewing brain, with capacities to rewire itself in response to changing circumstances that go well beyond assumptions about our innate, hardwired limitations prevalent in neuroscience circles until only a few years ago.

For those inspired by the synthesis Siegel offers, his contribution transcends a particular concept or a set of change techniques. "In recent years, the therapy field has been dominated by theoretical eclecticism and a lot of attention to techniques and practical interventions, as if you can believe anything you want theoretically," says Sue Johnson, an originator of Emotionally-Focused Couples Therapy, one of the most empirically supported marital therapy approaches. "What Dan Siegel has done is give us a bridge to science and a much clearer idea about the organizing brain structure of relationships," adds Pat Love. "For the first time, Siegel is offering a neuroscientific paradigm for understanding how all kinds of psychotherapy work. He's taking us beyond anecdotes and metaphors and vague theories and 'it-works-because-I-say-so' into a measurable science of human nature."

DSM 'n Drugs

But the ability to connect disparate disciplines didn't come easily. Soon after enrolling at Harvard Medical School in 1978, the young Siegel, still unsure of his own career path, found himself plunged into a professional culture focused on diseases and pathologies. It jarred him to listen to doctors and his fellow medical students refer to patients as isolated body parts--"I saw an incredible kidney today," or "There's a very interesting liver in room 415." He soon found himself regularly being dressed down for spending too much time listening to his patients' stories. "If you want to listen to people's stories, go to social work school--that's not what doctors do!" one irate supervisor told him.


Disillusioned, he dropped out of med school and spent a vagabond year considering various "careers," including professional dancing, carpentry, documentary filmmaking, and salmon fishing. It was a fellow fisherman who turned Siegel away from that particular career choice, pointing out that fishing was all about "getting up at 3 a.m, bending over the side of a freezing boat for hours, your back killing you, throwing fishhooks out and pulling them in until your hands are too crippled to do much else." This de facto career advisor told Siegel that he himself was quitting fishing and going back to graduate school in psychology, and that Siegel should go back to medical school. Soon after that, working on a film interview of a man writing a book about the left and right sides of the brain, Siegel had a mini career epiphany and decided he, too, was fascinated by the brain and the mind. But since it would have taken him too long to get the credits he needed for psychology graduate school, he decided to return to medical school at Harvard and focus on psychiatry.

Academic psychiatry during the '80s, it turned out, was exactly the wrong place for someone eager to develop a holistic, integrated view of the mind and brain. An increasingly reductionistic biological (i.e. psychopharmaceutical) psychiatry had just begun its relentless push for dominance. With the advent of DSM III and the torrent of new medications pouring out of the pharmaceutical pipeline, psychiatry grew ever more inclined to define emotional and mental problems as purely medical illnesses reflecting biochemical imbalances in the brain. Diagnosis became a game of parsing DSM categories and subcategories, and treatment a matter of prescribing meds to amp up or dampen down the synaptic exchange of neurotransmitters. The last thing that interested these scientist-psychiatrists was a vaporous, 19th-century concept like mind. "There was no understanding that subjective human experience--feelings--was an objective scientific reality," recalls Siegel. "Psychiatrists were supposed to be experts on the brain, and all they were interested in was knowing how neurons fire--they weren't interested in feelings."

Siegel found the emerging infatuation with the DSM 'n Drugs combo deeply distasteful and a betrayal of what he considered the deeper mission of psychiatry. "I hated to see colleagues and trainees seeing patients for half an hour for a meds check, then sending them off until their next appointment three months later," he says. For him, the self-conscious scientism of the new psychiatry was a crabbed, distorted version of real scientific inquiry: "The only brain mechanisms we ever really talked about were neurotransmitter receptors."


One case from this frustrating period that underscored biological psychiatry's lack of imagination sticks in Siegel's mind. He was seeing a young woman in therapy who was suffering from unresolved grief and guilt at the loss of a parent. Eventually, she got better, and when she was ready to leave, Siegel asked her what had been most helpful about her treatment. She thought for a minute and then said, "When I'm with you, I feel felt. " Her remark about what is a perfectly commonplace experience in good therapy contrasted for Siegel with the indifference to relationship that he saw all around him. "She could see that my inner emotional state was affected by her inner emotional state, and that profoundly changed her experience of herself, which gave her hope that she could change." But the scientist in Siegel also wanted to know what exactly the objective brain mechanisms were that resulted in this profoundly healing interpersonal experience.

At the time, the psychiatry department at Harvard was a war zone of mutually antagonistic factions, each speaking its own language, sunk in its own pet paradigms (biological psychiatry, psychoanalytic psychiatry, descriptive psychiatry, social psychiatry) who, Siegel recalls, "all bad-mouthed each other." But whatever his feelings about the shortcomings of biological psychiatry, the field of psychotherapy offered little attraction for Siegel. Its most influential models didn't exhibit the barest interest in neurobiology or, in his opinion, even a decent regard for ordinary intellectual consistency. And despite his humanistic inclinations, he still wanted a disciplined, scientifically plausible explanation of the core phenomena therapists dealt with--human personality, emotion, memory, and identity. But none of the "explanations" offered by various psychiatric denominations, or the deceptively-neat DSM taxonomy, actually explained anything to him. Siegel regarded them as "ever more complicated definitions of observations--they all seemed about as substantial as plumes of smoke."

It seemed to Siegel that any explanation worth its salt must incorporate both the biological and the personal; it must somehow include the physical brain, the individual story of the particular human being, and the evolutionary story of the whole species. It had to reflect the tough-minded objectivity of science and the "soft" subjectivity of ordinary human experience. Neither "scientific" psychiatry, which reduced an individual to the ebb and flow of brain chemistry, nor a Tower of Babel of contending psychotherapies, which completely ignored the living brain, even came close to meeting these apparently impossible goals.


No Axe to Grind

During the late '80s, Siegel found something approaching the kind of theoretical connective tissue he was looking for when he discovered attachment theory. In the previous 40-odd years, attachment researchers following the pioneering work of John Bowlby and Mary Ainsworth had built up a formidable body of empirical research to show that a young child's sense of security, safety, and well-being depends largely upon the emotional quality of his relationship with his primary caregivers. And it was this secure base in early childhood, the theory continued, that enabled a child to grow into an emotionally stable adult and become a good parent to his or her own children.

For Siegel, attachment researchers, with their careful attention to measurement and moment-by-moment interaction, "seemed beautifully nonpartisan and unbiased, without any clinical or theoretical axe to grind." He also found in attachment theory something he'd missed in other explanatory models--a rigorously scientific field that focused on something more emotionally compelling than the synaptic vicissitudes of neurotransmitters. Here was a field that posed the most fundamental questions about the small miracle by which we actually become human beings: How does a coherent sense of self emerge from the turmoil of fluctuating sensations that is a baby's mind? How does early experience shape our personalities? How do we learn to love? Why do we tend to treat our children the way we were treated? Why does parenting matter?

In 1988, Siegel heard one of the pioneers of attachment theory, Mary Main, give a talk about her work on what she called "coherent narrative." Main and her colleagues had devised an instrument called the Adult Attachment Interview (AAI), in which parents were asked about their recollections of their own childhoods. What Main's research indicated was that the way these parents told their own stories--how they made sense of their past lives, or didn't--was the most powerful predictor (85 percent accuracy) of whether their own children would be securely attached to them. If adults could create a reflective, coherent, and emotionally-rich narrative about their own childhoods, they were likely to form a good, secure relationship with their children--no matter how "insecurely attached" they themselves had been as children or how inadequate or even abusive their own parents were. It wasn't what happened to them as children, but how they came to make sense of what happened to them that predicted their emotional integration as adults and what kind of parents they'd be.


The narrative material struck Siegel "like a lightning bolt," extending attachment research beyond the nonverbal attunement of "the mother's gaze" into the realm of memory and language. As much as we need the wordless love and the creaturely comfort of our parents and caregivers, we also need to acquire the ability--the mental and emotional wherewithal--to put our experience into words in order to fulfill our biological potential as human beings. For Siegel, the idea of narrative became the key to a bigger, more coherent, "story" than either psychiatry or psychology had so far been able to produce. "Anthropology shows us that every culture on earth tells stories. For the last 40,000 years we, as a species, have been trying to bring what's inside of us out--to make sense of what we see and put it out there for other people to hear," says Siegel. "Stories bring together the external, observable, objective world and our internal experience of our minds. The capacity and need to tell stories is not only part of our culture, but part of our evolutionary heritage, built into our genetic code and embedded in the circuits of our brains."

Furthermore, the findings on narrative were a real beacon of hope, empirically reinforcing the commonsense notion that people can change--their lives are not determined by their bad beginnings. In fact, according to the attachment researchers, a person can earn her emotional security and ability to create a coherent narrative about her past through personal growth and involvement in positive, healthy relationships with teachers, friends, lovers, mates, and, of course, therapists. "I loved the way attachment research showed that fate (having less-than-perfect parents) isn't necessarily destiny," says Siegel. "If you can make sense of your story, you can change it."

Of course, most therapists share Siegel's interest in the transformative power of narrative, but not his need to ground his beliefs in scientific principle. For him, however, it was as if he'd opened one of a set of nested Chinese boxes--discovering one powerful explanatory system in the connection between narrative and attachment theory--only to come across another, smaller, but even more intriguing box. What, he wondered, were the neurobiological mechanisms that made attachment so important? How does coherent narrative "happen" in the brain?

Of Coherence and Incoherence

The question of how we develop a coherent narrative was becoming clinically relevant for Siegel because he had a number of patients with PTSD, and one of the most striking symptoms of his traumatized patients was their inability to construct a coherent story about their past. If asked to talk about what happened to them as children, they became disorganized and incoherent, couldn't remember major events of their own life histories, and frequently became emotionally distraught just making the effort to recall the past. These patients remembered traumatic incidents while in one state of mind and then had no memory of the same incident when in another state of mind. They confused the past and the present and experienced highly charged, intrusive flashbacks that didn't seem like "normal" declarative memories. To Siegel, there was clearly some connection between their traumatic past--what was called their "disorganized attachment"--and something going on in their brains that prevented them from making sense of their own stories.

As a clinician, Siegel knew that PTSD was assumed to be related to dissociation, but what did that mean? How could clients both not remember enough to tell a coherent story and at the same time remember all too much, all too vividly? Psychiatrists still described these symptoms in the archaic and inadequate language of psychoanalysis--conscious versus unconscious or repressed memory--which was too schematic and narrowly sectarian to make sense of phenomena that, literally, burst the bounds of standard theories and models.

To find some more promising answers, Siegel began studying neuroscience in earnest. While exploring the complexities of memory, he learned from some of the leading authorities in the research world about the fascinating difference between implicit and explicit memory, and the newly discovered role of a horn-shaped region of the brain called the hippocampus. Implicit memory is a form of nonverbal, unconscious memory, present at birth, which lays down neural pathways encoding emotion (via the amygdala), behavioral patterns, and learned habits (like driving), perceptions, and probably bodily memory. We may experience very strong feelings or body sensations triggered by an implicit memory, for example, but have no subjective awareness of consciously recalling anything--we just feel something powerful. About a year after birth, the hippocampus comes online and begins to encode explicit memories, including consciously recalled facts--"Richard Wagner was married to Franz Liszt's daughter"--and the countless past experiences, feelings, and thoughts that make up our awareness of our autobiographical past.


Discovering the division between implicit and explicit memory and the role of the hippocampus in turning the former into the latter was, for Siegel, like finding a trail after hacking his way through a dense jungle. "The timing was wonderful, coming just when I was learning about attachment narratives and desperate to understand trauma," Siegel says. It dawned on him that the disruption of the hippocampus and the processing of explicit memory might have something to do with why both PTSD clients and "disorganized" parents in the attachment research couldn't relate a coherent story about the terrible past. What if trauma shut off the hippocampus, so that horrible sensations and experiences flooded the amygdala and were laid down as implicit memories, but were blocked from becoming explicit memories? That might explain the odd fact that people with PTSD experienced their memories in the here and now without having the sensation of remembering them. Today, this theory is old hat among trauma therapists and researchers (though still surprisingly unfamiliar to many other clinicians). Even so, however, when the discovery of what the hippocampus did was itself brand new, nobody seems to have made that connection.

Siegel first publicly floated his idea at a conference in 1992, attended by famous heavyweights from the trauma and neuroscience communities (including Eric Kandel, later winner of a Nobel prize for demonstrating how experience creates new neural connections in the brain). During one session, somebody in the audience asked, "How do you explain traumatic repression in terms of the brain?" Nobody had an answer. Siegel, still considered a junior colleague by many of the prominent figures in attendance, daringly raised his hand. "I was just this punk kid, but I threw out my idea--Is it possible that if the hippocampus is blocked during a trauma, you could be vulnerable to flashbacks and dissociation because, while you'd have the implicit memory of the event, you'd have no explicit, declarative memory of it?' Then I sat down."

At the break, an intrigued mob surrounded Siegel and asked him to amplify on this extremely interesting and radical idea of his. "It was the first experience I ever had of going to the brain to find out how people's mental processes work and coming up with an answer that might pave a way to better treatment," Siegel remembers.

Brain and Mind

Siegel was soon feverishly exploring anything else he could find out about how the brain worked and what light neurobiological research might shed on the problems of his patients. From 1991 to 1995, while the head of training in child psychiatry at UCLA, he led a study group, a multidisciplinary dream-team loaded with experts--anthropologists, evolutionary biologists, linguists, geneticists, psychiatrists, and heavily weighted with neuro-types, including neurobiologists, neurologists, and neurosurgeons. "I was realizing that the brain held the secrets to the mind," he says now.


He focused, for example, on the clinical implications of the fact that the right and left hemispheres work in dramatically different ways. By then it was commonly understood that the left brain is associated with logic, cause-effect reasoning, verbal processing, and linear thinking, while the right is associated with nonlinear, holistic (big-picture) thinking, intense emotion, body sense, social awareness, and nonverbal communication. What Siegel became interested in was that a coherent narrative about the past requires both hemispheres to be fully online: the right holds the images, themes, and sense of personal self existing across time, while the left holds the drive to make logical meaning and put words to these wordless feeling states and perceptions. Right away, this seemed to explain the difficulties many people had in creating coherent narrative: if the two sides of the brain weren't working together, the story would either be chaotic and confused--overwhelming feeling, overwhelmed thought--or superficially logical but lacking the emotional oomph of a good, coherent autobiographical story

He decided to try out the theory that integrating brain function could be beneficial therapeutically with clients who had an impoverished sense of their own past and couldn't really feel or express emotion: "I'd worked out a hypothesis that this type of patient might respond to therapy that explicitly stimulated the development of the right hemisphere." And it worked. A lot of the patients, who usually intellectualized their way through talk therapy, responded very well to guided imagery, sensate-body focusing, and practice in using and picking up on nonverbal cues.

Simply telling patients what might be going on in their brains, he discovered, could also be both deeply comforting and therapeutic. He explained to patients with PTSD the difference between implicit and explicit memory and the function of the hippocampus, and they felt less crazy. "You're telling me I'm not nuts," said one greatly relieved patient, who thought she was going insane because of the flashbacks and intrusive images that hounded her. As she put it, "It's just that the bad things that happened to me got fragmented in my mind and were never put together into my regular memory by my hippowhatsis."

Soon, he was spiking his therapy with brief, neurobiological vignettes that helped clients understand why they were so prone to sudden rages, or had such rotten love lives, or felt so anxious all the time. Siegel became adept at explaining the role of the unbridled amygdala, the self-calming talents of the neocortex, the heroically integrative properties of the orbitofrontal cortex, the amazing system of mirror neurons that allows us to pick up and feel the feelings and intentions of others--the remarkable capacity for "mindsight." He even started keeping a chalkboard in his office to draw rough sketches of the brain and its parts, which helped ground discussions of subjective mental experience in the world of physical reality. "Unlike most psychological concepts, the brain is a three-dimensional object that you can hold in your hand," he says. "It's also a visual entity, and we're very visual creatures--a lot of our cortical real estate is devoted to vision. So when I sketch the brain on the board, people can really 'see' it."


His patients loved it. Far from making them feel that their lives were completely determined by physiological processes beyond their control, they felt empowered. They discovered that their negative feelings weren't them, but originated from one part of their brains, which could be controlled by another part, actually altered by what they think . "Connections in the brain shape the way you think, but the flip side is true, too," says Siegel. "The way you think can change your brain. Neural firing changes neural connections--if you pay attention." We often have the idea that we have no power to control our own attention. Not so. "You can harness the power of your mind," says Siegel. "You can sit in your prefrontal cortex, where self-regulation is mediated, and simply notice, just notice, the mental processes emanating from different neural circuits of the brain--without locking onto them."

By now, the concept of mindfulness--detached attention to one's own feelings and thoughts--has acquired the fuzzy quality of overfamiliarity among therapists, becoming something of a New Age platitude. But Siegel gives it a fresh dimension by grounding it in the realities of neurobiology. His interest is in how mindfulness works in the brain and how it can, literally, change brain function. "Mindfulness promotes the integrative function of the prefrontal cortex," Siegel says. "It allows brain circuits to fire that have perhaps never fired before, giving people a sensation of inner awareness that they may never have had before." In short, it brings about neural changes that Siegel alternately calls "integration," "coherence," or "self-regulation."

At first glance, "self-regulation" is a mildly soporific term reminiscent of the psych lab, but from Siegel's perspective it defines the basic goal of all psychotherapy. "When you think about it, you can understand almost every mental health problem--anxiety, depression, eating disorders, personality disorders, thinking disorders--as an issue of self-regulation," Siegel remarks. Self-regulation, in the Siegel lexicon, is the balanced and integrated "flow of energy and information" through the major systems of the brain--brain stem, limbic circuits, neocortex, autonomic nervous system--and between one brain and another. When we're in this secure, stable state of mind-brain-body equilibrium, we can face life's vicissitudes with some measure of emotional calm, flexibility, self-awareness, and reason. Our relationships are good, and we're "mindful" almost as a matter of course.


But, according to Siegel, "self-regulation" is really something of a misnomer. What should by now be blindingly obvious is that our capacity for self-regulation depends so much upon our interactions with other people that it might well be called "other-regulated self- regulation." We're not born knowing how to regulate ourselves--in fact, we're alarmingly, chaotically, un -self-regulated creatures at birth, more so than most other newborn animals on earth. Loving parents, if we're lucky, begin the long process of teaching us how to organize and regulate our inner selves--encoding their care and attention in the pliable neural fibers that integrate various regions throughout our brains. No matter how good we had it in the beginning, however, we'll need reinforcement of these early lessons throughout life, and much remedial work if we were shortchanged early on.

For Siegel, therapists are the remedial attachment experts and rescuers of the chronically un-self-regulated, and it is their job to, in effect, help rewire the frayed neural connections, reintegrate (or sometimes integrate for the first time) different areas and functions of the brain--implicit and explicit memory, right and left hemisphere, neocortex with limbic system and brain stem. From Siegel's viewpoint of interpersonal neurobiology, here's how a therapist influences a distraught patient reliving a past traumatic event that hasn't yet been consolidated and turned into an ordinary memory.

Imagine you're such a patient sitting in your therapist's office. She sees that you're not in good shape--pale, shaky, agitated--and knows that your sympathetic nervous system is clearly running in overdrive. She listens to you try to explain what happened and realizes right away that your story isn't coherent--your left brain is struggling to make sense of this past event, but your words are being swamped by waves of intense right-hemisphere emotion. You stutter, forget things, swallow nervously, feel nauseated, and have to keep starting your story all over again. Something about what you're trying to say is still locked in your amygdala, in your implicit memory--still hasn't been processed by your hippocampus so it can become simply part of your explicit memory, and then incorporated into your consciously remembered autobiographical story. How can she help this neural integration happen?


Listening closely to you, your therapist lets you know that she's really there with you, she feels some of what you're feeling. She picks up your fear, confusion, despair, but without being overcome by them as you are. As a result, you "feel felt" through nonverbal signals and mirror neurons and you "see yourself" in her, allowing you to realize that you're authentically in her mind, and this changes your experience of the moment. You take a deep breath and feel a little safer, more grounded, calmer, almost as if her strong, steady mind is embracing your fragmented, chaotic one.

Knowing the brain is an associational organ, your therapist tries to elicit what it was about the recent triggering experiences that might have reminded you of something from the past. She sees how the past event affects you in the present and she joins you in this mental time travel, carefully probing your past and your present life. This helps bring the two into a more stable, integrated relationship with each other--allowing you to put a past event in the past, so you can viscerally distinguish the present moment from it and move forward into the future without fear that it will continue to haunt you. By doing this, she helps you increase neural integration between differentiated areas of the brain--the consolidation of memory via the hippocampus into the neocortex, and the synthesis of left-brain logic and right-brain emotion, so that the past event becomes no more and no less than an aspect of your conscious autobiographical story.

And so it goes. With her as your guide, you go back and forth with her between mind and brain, using your capacity for conscious thought and reflection on the buzzing activity within that neural hive beneath your skull. And as you do so, your immediate experience--your sense of yourself and your story--gradually changes. You begin seeing the past event in the context of other events, other times, relationships past and present, and you can weave it into an ongoing narrative of your life. As the implicit memories from years back are turned into part of a more coherent and inclusive autobiographical story, you feel relieved, somehow lighter. You also feel deep gratitude and affection for your therapist, as you would for someone with whom you've been through a life-or-death struggle and emerged victorious. In a sense, nothing has changed-- the past is still what it was--but everything has changed, because, in concert, your mind and this other sensitive, deeply attuned, intelligent mind have changed your brain. The gradual improvement in your capacity for "self-regulation" hasn't been a solo performance, but a duet sung in counterpoint.


Night Vision

For all his curiosity about the brain and its workings, Siegel professes himself largely indifferent to the subject of therapeutic technique. He doesn't seem to care particularly what methods therapists use, and consistently avoids telling them what they should do in treatment. "You can shape and harness synaptic connections in the brain by giving patients medications or doing therapy," he says. "You can also do it just by teaching them to meditate and get in touch with their bodies, go jogging, play music. Or you might use the fact that the self is defined by interpersonal communication to form reparative attachments with them." He doesn't even try very hard to sell the idea that all good therapists must know about neurobiology. "If you're doing great work, I suppose you probably don't need to know about the brain," he says. In fact, he readily admits that, at this stage, many of the tenets of interpersonal neurobiology remain hypotheses, not scientific fact. Nobody really knows what exactly is going on in the brain during therapy--how a clinical encounter or two or seventy actually affect synapse formation. But he's convinced--and has convinced many thousands of others--that learning about the brain and the power of relationship to create and change neural circuits is the most important challenge the therapy field will face in the years to come.

Forty years ago, family systems theory transformed psychotherapy by forcing clinicians to see beyond the single psyche to the interlocking circles of relationships that also make up the reality of the "individual" self. It might be said that Siegel's system brings into every therapy encounter an even bigger system, which includes the entire psychological, biological, and genetic history of the human species. This awareness of the fact that every human being contains multitudes and carries within him- or herself a lineage extending back to the origins of life on this planet may not immediately change what a therapist does, but it almost certainly will change the way she understands her work and its impact on her patients. And as Pat Love says, describing the way neuroscience has transformed her own work, "Information is intervention."

At this point, what Siegel offers therapists in his synthesis of evolutionary biology, neuroscience, and developmental psychology has more to do with a way of seeing than practical clinical advice. To explain the effect of this way of looking at ourselves and others, he likes to describe a walk he recently took on a deserted Oregon beach late one night, with his flashlight turned off. It took his eyes a while to to pick out of the darkness the vague outlines of rocks, the billions of stars, the serpentine border of the sea and sand. Unlike the familiar reality that we see by the light of day, the world revealed to us by this kind of night vision, he notes, can be disorienting, even surreal, possibly menacing, but often magical. We feel our capacities for perception sharpened and transformed as we become more attuned and attentive to the smallest, most subtle, variations of shape and shadow. In some way, by seeing less, we see more.


For Siegel, night vision is a metaphor for the world of subtle processes that interpersonal neurobiology opens up for our investigation. It awakens us to the everyday marvels of the human brain--our ability to transcend the quotidian boundaries of space and time, to "see" through the barrier of the physical body into the invisible precincts of another's mind, conceive of imaginary worlds that never did and never could exist anywhere else except in the imagination--in short, to shatter the laws of ordinary reality. Interpersonal neurobiology not only gives us some idea of how these impossibilities really do happen in the physical world, it makes us more aware of them inside ourselves and in our relationships with others, taking us into unsuspected realms of consciousness. "We can see ourselves connected to other human beings, belonging to the whole planet, and even a part of the entire universe in a way that extends our own dimensions far beyond our merely mortal selves," says Siegel. "In this state, we become part of something that has existed long before we were born and will continue long after we die."


Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. E-mails to the author may be sent to mswylie@maineline.net.


Visionary or Voodoo?

Daniel Amen's Crusade Has Some Neuroscientists Up in Arms

by Mary Sykes Wylie

Psychiatrist Daniel Amen is a trim, elfin figure with a puckish smile and the staccato delivery of a stand-up comic. The winner of a Distinguished Fellow Award from the American Psychiatric Association, a clinical professor of psychiatry and human behavior at the University of California, Irvine School of Medicine, the author of 20 books and as many peer-reviewed papers, and a hugely popular public lecturer and workshop leader, he sounds, somewhat paradoxically given his own sum, a bit like a wiseacre underdog impudently challenging a reactionary establishment. He cheerfully rails against the self-satisfied stuffed shirts from the worlds of academic psychiatry who, in defiance of reason and good sense, don't accept his view that a brain-imaging method called SPECT is an invaluable tool for understanding and treating psychiatric disorders.

"I just don't get it. Why are we the only medical specialists who never look at the organ we treat?" he asks, his voice rising in exasperation before a jam-packed audience of 500 therapists drawn to a full-day workshop on his work. "Why is it controversial to get more information on people who suffer? The images are really easy to understand. What's the problem with having more data?"

And then the "piece de resistance". We're always being told that the brain is so terrifyingly, irreducibly complex that nobody except Nobel-caliber neuroscientists could ever begin to understand how it works. But Amen says, in effect, that it really isn't that hard for anybody--with a little training--to get a good sense of what all those brain modules are actually up to. "The images are really easy to understand--you don't need to make it any harder than it is," he says, as if explaining a new recipe to an insecure cooking student. "All SPECT does is measure three things--areas of the brain that work well, areas that are underactive, and areas that work too hard. Then you just gear the treatments to rebalance these areas."

So why not just take a look? What's the harm? His case is helped by the elegant, crisply articulated, brain images he shows that, in concert with his simple explanations, seem to luminously reveal what's actually going on upstairs.

Amen flashes two computer-reconstructed, three-dimensional, exquisitely tinted color scans, each of a different brain. One, a "healthy" brain, is a smooth ovoid shape, with some softly modulated rises and depressions; if it were a landscape, it would be a gently rolling pastoral scene. The other brain looks an awful mess. With its deep fissures, crevices, and "holes"--areas of severely low activity--it looks as if uneven chunks of it have been eaten away by a voracious rodent. This latter brain, Amen dramatically announces, is the brain of Kip Kinkel, the 15-year-old boy from Oregon who, in 1998, shot to death his mother and father and then drove to his high school, where he shot 24 more people, killing two.


Kinkel, Amen explains, had been seeing a psychotherapist and taking both Ritalin and Prozac, which only made him worse--more volatile and unreachable. His demoralized parents had taken him off his meds, after which he went on his murderous spree. "If a scan had been done on him before the killings, it would have shown an extraordinarily abnormal brain," says Amen. On the SPECT scan, he tells the audience, Kinkel's prefrontal lobe--associated with impulse control, judgment, and planning--exhibits extremely low activity. At the same time, his temporal lobe, controlling such functions as temper and mood stability, also showed abnormal patterns of blood flow, which can make a person more prone to aggression, emotional volatility, and violent suicidal and homicidal thoughts.

"If his therapists had actually seen his brain, they could have put him on mood stabilizers, and the odds are they'd have diminished his violent thinking dramatically." Amen pauses to let this sink in. "But because the current 'state of the art' in psychiatry is not to look at the brain, his doctors were simply throwing darts in the dark. Today you can try to kill yourself or kill other people, and nobody will look at your brain. But if your brain's not right, you won't be right."

Amen has a vast fund of salvation stories about people misdiagnosed and mismedicated, often for years, whose real problems are only finally revealed through the combination of intense clinical detective work--the kind any good therapist would do--and the nuclear magic of a SPECT camera, which, literally, casts light into the hidden recesses of the brain. "Giving a diagnosis of 'major depression' or 'ADD,' is like giving a diagnosis of 'chest pain,' or 'belly pain,'" says Amen with some asperity. "These are symptoms with many, many possible causes. And one treatment will not fit every person with similar symptoms. We need to start looking at the brain, to begin seeing the underlying physiology of what's going on. Scans aren't the answer, but they're certainly part of the answer. A psychiatric profession that doesn't look at the brain is archaic, dated, and stupid."

Amen now has the audience in the palm of his hand, laughing at his jokes, moved by his stories of troubled little kids whose lives were either saved or ruined, depending upon whether their underlying brain problems were discovered and treated. He seems to be as much on a personal crusade as a professional quest. But, periodically, a note of unabashed salesmanship and self-promotion intrudes--the repeated references to his "cool" books and their worldwide distribution; his bestseller, Change Your Brain, Change Your Life ; his column for Men's Health ; his media appearances on The Today Show, The Leeza Show, CNN ; his recent gig at the National Security Agency. For some in the audience, it's enough to induce emotional whiplash: are we hearing from a fearless pioneer dedicated to transforming the mental health field or a salesman whose most important product is himself?


To be sure, Amen has acquired a small, but growing, crowd of supporters and colleagues in psychiatry, psychology, and nuclear medicine--he says more than 1,000 professionals refer to him--who consider him a trailblazer and believe SPECT scans will revolutionize the practice of psychotherapy. "I think he's a real pioneer, making an enormous contribution to the field of psychiatry and helping to change the paradigm of how people think about the brain and psychiatric symptoms," says Joseph Wu, professor of psychiatry and clinical director of the brain imaging center at the University of California, Irvine. "Daniel Amen introduced me to a whole new universe of subcortical brain structures that we in nuclear medicine had only looked at casually before. He helped me realize that SPECT can be very useful for evaluating complex, difficult cases in which comorbidities are present," notes Dan Pavel, professor of radiology and nuclear medicine at the University of Illinois. "I came away from Amen's clinic convinced there is a place for SPECT in clinical psychiatry," writes AD/HD expert Edward M. Hallowell, coauthor with John J. Ratey of the bestselling Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. "It is obviously helpful to be able to look at the brain before you try to treat it. Perhaps SPECT will prove to be the most practical way for psychiatrists to do that."

But utter the name Daniel Amen to some of the leading members of the psychiatry and neuroscience research community and the reaction ranges from dismissal to derision and denunciation. "He's made a mountain of money doing scans [a two-scan evaluation at one of Amen's clinics costs $3,250, which also includes, a history, physician evaluation, and follow-up visit], but never, to my knowledge, published any data, or provided one shred of evidence that an independent investigator would be able to reproduce," says George Bush, psychiatry professor at Harvard Medical School and psychiatric neuroimaging researcher at the Martinos Center for Biomedical Imaging. "Amen is extremely successful, has many franchises and is a wickedly good salesman, but what he's doing isn't supported by scientific evidence. Where's his data? What does he know that all the other practitioners and researchers don't know?" asks Helen Mayberg, psychiatry and neurology professor and brain-imaging researcher at Emory University. In fact, so exercised is much of psychiatric officialdom by Amen's approach that, last January, the American Psychiatric Association's nine-member Council on Children, Adolescents and Their Families felt moved to issue an independent position paper opposing the use of SPECT in the clinical practice of child and adolescent psychiatry.

It seems strange that a person so disarming and apparently eager to please, who's clearly distressed by the uproar he's caused and seems like the last person who'd mount a Rambo challenge against entrenched power, would arouse such hostility. Or that his cause--the incorporation into psychotherapeutic and psychiatric practice of SPECT scans, a technology that's been around for decades--should be so contentious. So what is it about Daniel Amen and his mission to get therapists to use brain imaging, and SPECT in particular, as an aid to diagnosis and treatment that makes him such a lightning rod?


The Man Behind the Cause

Daniel Amen's personal and professional biography is a palimpsest of the odd and extraordinary, which may help explain why he's never found a home in the clubby atmosphere of the psychiatric and research establishments. His entrepreneurial success seems to particularly gall them--it adds insult to injury that he's not only doing something totally beyond the scientific pale, but making pots of money at it.

His talent for business seems almost foreordained by his background. His parents, the children of poor Lebanese immigrants, went to the West Coast during the 1940s. There, Amen pere began clerking in a relative's grocery store and then, embodying both the American dream and the ancient Phoenician talent for trade, worked his way up to become chairman of the board of Unified Grocers (a position he still holds), one of the largest wholesale grocery businesses in the country. Amen's family was large (five sisters, one brother), loving, but strict and Roman Catholic, headed by a tough, authoritarian paterfamilias. "I grew up with an extraordinarily successful father, who always expected the most from us," says Amen. "Our family honored work, and our lives were centered around work--I worked from the time I was 10. And nobody ever thought it was a bad thing to be successful."

Amen joined the Army at 18, partly because he had a low draft number, but also because his father told him not to. It was 1972, and the Vietnam War was in full swing, but Amen believed the recruiter who told him he'd be assigned as a vet's assistant. (He'd always loved animals and, as a teen, considered becoming a vet.) "I thought that the odds were good that nobody would be shooting at a vet's assistant." Instead, he ended up as a combat medic in Germany, where he got himself retrained as an X-ray technician, mainly so he could work in a nice, warm dispensary, rather than a chilly tent. But he became fascinated by X-ray technology and found that he loved studying the ghostly images of people's insides. "I looked at kidneys, lungs, skulls, thigh bones," he says now with remembered relish. "That's where the imaging story really begins."

Because of his religious background, Amen had seriously considered becoming a priest, but, as he says sardonically, "I couldn't stand the idea of being called 'Father Amen.'" He declined the priesthood, but certainly not religion. In Germany, he found himself drawn to the wholehearted, emotional expressiveness of Pentecostalism--shouting, praying in tongues, healing ceremonies, and all--so different from the restrained solemnity of the Roman Catholic mass. He was sufficiently moved by his new religious tack that, when he returned home, he got off the plane dressed in a "Jesus loves you" T-shirt and carrying a Bible, much to the consternation of his blindsided mother. By this time, 1975, he knew he wanted to go to a small school, and a religious one, so he finished his college education at Vanguard University, a small Christian college. Then, in 1978, he became a member of the first class of a newly opened medical school (since closed) at Oral Roberts University.


The nexus between capitalism and religion appears to have shaped Amen's life. In Healing the Hardware of the Soul, his book about the connection between a healthy brain and the capacity for morality, conscience, and faith, Amen writes that he felt "led by God to pursue this [SPECT] work." These days, he uses his training and skills as a kind of reverse mission to churches, in an effort to persuade Christians and Jews that much "sinful" behavior may be due to brain problems, rather than evil motives. Some of his critics haven't looked kindly on this sense of religious mission. "He's a true believer, and evangelical medicine is scary," says Mayberg.

After medical school, Amen took a residency in psychiatry at Walter Reed Army Medical Center. In 1987, the Army sent him to Fort Irwin, California, as the chief psychiatrist--the only psychiatrist in the middle of the desert for thousands of soldiers and their families--a population rife with drug abuse, depression, anxiety, domestic violence, psychosomatic ailments, and stress. This new gig would have been a daunting job for any psychiatrist, let alone a young, newly minted, and relatively untried one.

Serendipitously, in the old World War II building that housed his office, he found an antiquated biofeedback machine (an instrument that measures physiological responses, via electrodes or sensors attached to various parts of the body) left by his predecessor. He found that, even as a novice, he could use the machine to train people to warm their own hands by using their imaginations--thinking about burying their hands in hot sand, for example. He could also use it to help them reduce their anxiety or relieve their migraine headaches, while gaining a sense of self-control and personal mastery. Enthusiastic about his new toy, Amen convinced his dubious commander to pay $30,000 for an up-to-date model and send him for 10 days' training in biofeedback.

The biofeedback training program in San Francisco was, Amen remembers, a revelation: "The best, most exciting, training I'd ever had. I was just stunned by what I learned." It was the first major introduction he'd yet had to the powerful interaction of brain, body, and mind, and he was hooked. He discovered that people could learn how to control their own autonomic nervous system--relax their muscles, calm their breathing, reduce their sweat-gland activity, lower their blood pressure and heart rate--to relieve both physical tension and mental anxiety. Moreover, through neurofeedback (a form of biofeedback in which electrodes are attached to the scalp), they could learn to change their own brain-wave patterns, and thus their mental states. "I was so excited to have this cool new technology that I went back to Fort Erwin and started using it on everybody."


Amen was particularly anxious to try out this new brain-mind technique on kids with AD/HD. "Standard psychotherapy, as I'd been trained to do with AD/HD kids, made me crazy--they just never got any better," he recalls. Medications helped, but not nearly often enough, and there was no way to predict whether or not they would work. So Amen began using neurofeedback with his AD/HD patients to encourage more normal brain waves and reduce their symptoms. While not exactly the fast-track cure he'd have liked (it could take from one to two years to produce significant improvement), neurofeedback did work encouragingly well, with the side benefit of helping many kids avoid or lessen medications. In 1989, when he opened his private practice in northern California, he equipped it with his own biofeedback equipment.

Amen's clinic was an immediate success, no doubt partly because of the workaholic habits, business acumen, and marketing skills he says he inherited from his father; but also because he was the only child psychiatrist for 300,000 people in the county. During this period, he worked six- and seven-day weeks, building up his practice, directing the dual-diagnosis unit of a local hospital, lecturing in the local community, and writing a news column (he'd already published two self-help books on getting ahead in school and in work).

In March 1991, Amen attended a lecture on SPECT imaging at the hospital where he worked. If learning about neurofeedback had been a revelation to him, seeing SPECT scans was an epiphany. SPECT is the acronym for single photon emission computerized tomography, a nuclear-medicine imaging technique that measures an organ's blood flow or activity level--its function . An MRI, by contrast, looks at brain structure or anatomy, just as an ordinary X-ray does (but provides far more detailed images). A patient being SPECT-scanned is injected with a "radiopharmaceutical" and then lies on a table for about 15 minutes while a multiheaded camera rotates around his or her head picking up gamma rays (which are like pulses of light) from the radioactive material taken up by the brain cells. The data obtained by the camera are processed by a supercomputer to produce a series of two-dimensional cross sections of the brain. Different activity levels--relative blood flow--show up as shades of different colors or gray tones, depending on the color scale of the software program chosen by the imager.

These cross sections are then reconstructed into three-dimensional images. Notwithstanding Amen's suggestion that brain scans "aren't that hard to read," it's definitely not a simple process, requiring real skill and judgment to do well. To a lay viewer, the cross sections that first come out of the computer look like a meaningless kaleidoscope of colors and patterns. It takes an expert in reading, understanding, and manipulating the scans to tweak them into an accurate but elegant form--the dramatic, 3-D pictures of the kind Amen shows his audiences.


The Society for Nuclear Imaging officially recognizes only four common indicators for the clinical use of SPECT: to detect and evaluate strokes, brain trauma, and suspected dementia (a recent article says that brain scans like SPECT can predict Alzheimer's disease nine years before people have symptoms), or to locate focal points of epileptic-seizure activity. But SPECT has been used in a huge and highly eclectic number of research studies on almost every conceivable psychiatric and neurological condition, as well as some nonpsychiatric studies, like measuring the impact of meditation and prayer on blood flow to different brain areas.

The lecturer at Amen's hospital, a local nuclear physician named Jack Paldi, showed brain images of patients with depression, dementia, schizophrenia, and head trauma, comparing them with normal brains. Using these amazing images, Paldi tried to demonstrate that one could actually see the differences between brains that worked well and those that didn't, see how medications changed the way brains functioned and where those changes occurred. In this rush of graphically astonishing images, Amen thought he could begin, finally, to understand why some of his patients just couldn't seem to benefit from therapy or get their lives in order, no matter how hard they tried. It wasn't psychological resistance or personality type or deep-seated unconscious motives that kept them from getting better: it was simply that the software of their brains wasn't up to speed!

"I was absolutely blown away," remembers Amen, who took up Paldi's offer to do no-cost SPECTs on interested physicians and, six months later, got one himself. Shortly after the lecture, however, he ordered 10 scans on particularly difficult patients, which, according to Amen, resulted in "literally miraculous changes" in five of them. One patient was a 12-year-old boy with a nasty temper, a history of aggression, and school failure, who'd been hospitalized three times, prescribed assorted drugs (including Ritalin, which made him hallucinate), and treated with two years of psychoanalytic therapy. The scan showed low temporal-lobe function (associated, as in Kip Kinkel's case, with anger, violence, and mood swings), as well as frontal-lobe problems (which kept him from being able to concentrate in school). Amen placed him on mood stabilizers and a different stimulant, and voila! Within three weeks, he became milder tempered, began making friends, and, says Amen, "turned into the sweetest boy you'd ever want to meet." His school performance improved dramatically as well.


Another woman had been diagnosed with Alzheimer's after she'd nearly burned down her own home and lost her driver's license. Amen scanned her and found no signs of the characteristic abnormalities associated with dementia. But he did see that her deep limbic structures were "on fire" (a favorite bit of Amen-speak to describe brain areas of severe overactivity). This suggested depression, which can sometimes mimic Alzheimer's symptoms of memory loss, apathy, indifference, and disorientation. Amen prescribed Wellbutrin--an antidepressant and stimulant--and voila` again! Within weeks, she'd regained her memory, and her mood was much better. Within six months, she got her driver's license back.

"How many experiences does a psychiatrist have like these in a whole career?" Amen asks. "I had five of them in the space of a few weeks."

By Amen's lights, SPECT was not diagnosing new conditions. The scans didn't remotely correlate with DSM diagnostic categories, but they often revealed the inaccuracy of previous diagnoses and suggested functional anomalies that shed light on otherwise unexplained symptoms. Nor were his treatments miraculous, radical, or novel; they apparently just hit the target better than earlier interventions. In short order, he was a true believer in the modality. "I thought, 'How can I do psychiatry in good conscience without using scans when I don't really understand what is going on? How can I just continue to rely on guesswork when I have this tool at my disposal?'"

Between 1991 and 1995, he became something of a SPECTomaniac, reading everything he could find, attending meetings about SPECT, and ordering SPECT scans on hundreds of patients at the local hospital. He was asked to talk about SPECT at hospitals and at the University of Colorado medical school. He wrote a research paper comparing SPECT brain images of ADD children to those of normal children. He became an enthusiastic promoter of SPECT.

But there were signs of smoke from an impending firestorm almost from the beginning. In 1992, at a meeting of the American Psychiatric Association (APA), where he attended an all-day course on the use of SPECT in child psychiatry, he went to a lecture by National Institute of Mental Health child-psychiatry researcher Alan Zametkin. This would-be colleague used PET scans (a form of nuclear imaging with higher-quality resolution than SPECT, though more difficult and expensive to use) in a groundbreaking study of what ADD brains look like. Zametkin, says Amen, was one of his heroes, so he went up to him after the talk in the spirit of a fan approaching a star. "I told him that, partially based on his work, I was using SPECT in my own practice," remembers Amen.


But if he'd expected an avuncular smile of approval, he was mistaken. Zametkin angrily barked at Amen that these techniques were strictly for research and in no way intended for clinical use. In no uncertain terms, he told Amen, in effect, to cease and desist what he was doing.

"But why do you do these studies if you don't intend this technology to be used clinically?" Amen asked, baffled.

"I do them just to learn more; it's interesting basic science," Zametkin replied loftily.

This is an attitude foreign to Amen. "I really have no interest in science for science's sake," he admits. "I'm a clinician through and through--it's my reason for living. I get my juice from my practice, from relationships with patients, not from research."

Back home in California, the natives were also getting restless. A local pediatric neurologist, after calling three or four researchers around the country and hearing that SPECT wasn't ready for clinical prime-time, complained to hospital officials about Amen's heterodox behavior. "The neurologist told me that my reasons for ordering scans weren't empirically proven, and that I should quit doing them. He said, 'The brain is for neurologists, not psychiatrists,'" Amen recalls, even now incredulous. "I told him he was nuts." At a meeting of the hospital authorities, Amen was given permission to continue getting SPECT scans for his patients, but he was now required to have the medical director sign off on his requests.

In 1993, he was asked to help teach a brain-imaging course at the APA annual meeting, but when the program came out, a Dallas SPECT researcher wrote the APA program chairman demanding to know why such a controversial figure was included. The program committee chair sat in on the presentation and supported Amen's work, but many others were openly hostile to him, making a point of telling him he was a fraud and a mountebank and ought to be drummed out of the medical profession. It had gotten to be too much, so he decided to retreat from the public field, help his patients in the relative privacy of his clinical practice, and let other people do the research and fight the battles.


It's hard to imagine as restless and driven a figure as Amen ever really settling for a quiet, low-profile practice in suburban California, so he'd probably have taken up the gauntlet again sooner or later. But a crisis involving his 9-year-old nephew, Andrew, launched him back into the fray.

Amen's sister called him in tears one day early in 1995, telling him that her son--his nephew and godchild--had attacked a little girl on the baseball field for no reason. Over the preceding year, this friendly, active, outgoing little boy had become surly, angry, mean, and depressed, and had begun drawing pictures of himself shooting other children or hanging from a tree. Amen told his sister to bring the boy in the next day and, after a lengthy interview, personally took him to the hospital to be scanned. "When I looked at the image, I saw he had no left temporal lobe at all!" recalls Amen. This was, again, a part of the brain associated with violence, aggression, and suicidal and homicidal feelings. Andrew was almost immediately given an MRI scan, which showed a cyst about the size of a golf ball where his temporal lobe should have been.

But Amen couldn't find anybody willing to remove the cyst. Three pediatric neurologists--one at Harvard--told him that Andrew's behavior was probably not related to the cyst and that they wouldn't remove it until there were "real symptoms." Amen was beside himself. "Hearing this made me nearly psychotic, I was so angry." He remembers shouting, "What do you mean, 'real symptoms?' You don't think suicidal and homicidal thoughts and behaviors in a 9-year-old are real symptoms?" Real symptoms, the Harvard neurologist coolly informed him, meant seizures and speech problems. Period.

Finally, he located a pediatric neurosurgeon at UCLA who said he'd operated on three other children with the same problem--a temporal lobe cyst resulting in aggression. This doctor performed the operation on Andrew. When the boy finally woke up after the surgery, he smiled at his mother--the first smile from him she'd seen in more than a year. Shortly afterward, he became, once again, the youngster he'd been before his problems began.

This event changed Amen's life, he says. "From that moment on, I felt I could no longer be shy, or allow myself to be hurt by criticism, or fearful that people wouldn't like what I was doing. I just thought of all the kids who are in residential treatment facilities or end up in prison because they've done terrible things, and nobody ever even knows whether or not it's because they have something terribly wrong with their brains."


Now a newly energized Amen charged full-steam ahead. He completed the 1,000-hour training and supervision program to obtain the license in handling radioactive material that's necessary to do scans, bought SPECT equipment, and became, as far as he knows, the only psychiatrist in the world who had then incorporated brain imaging in his own practice. He once again took up the SPECT gospel and began spreading the word, and once again was met with virulent attacks.

In 1996, after Amen gave the State of the Art Lecture in Medicine at the Society of Development Pediatrics, a San Francisco pediatrician stood up and excoriated him for using brain imaging to justify giving drugs to children for AD/HD--in effect, accusing him of shilling for Big Pharma. Shortly after the meeting, he was anonymously reported to the California Medical Board for practicing outside the generally accepted standards of care. The state medical board began an investigation, which took a full year--of lawyers, interviews, questions, reviews of his articles, office visitations. "The worst year of my life," Amen calls it. Finally, after his work was sent to the departments of neurology and nuclear medicine at UCLA, he was exonerated and became an expert reviewer of psychiatry for the California Medical Board.

Amen and His Critics

Today, about eight years later, Amen has no doubt succeeded as a medical entrepreneur. He has two clinics in California, one in Washington State, and one in Reston, Virginia. By any measure, he's a huge success. Besides founding his clinics and cranking out books (another is on the way), he's produced a "Clinician's Toolbox" of brain-related materials for therapists, a brain-scan atlas, and assorted CDs and videos. He's given more than 100 presentations in the United States and abroad, written or been the subject of numerous articles in the popular press, appeared on scores of radio and television shows, testified at numerous trials, and developed a 12-week high school course on the brain to be piloted in 30 schools this fall. There are perhaps 15, mostly for-profit, psychiatrist-run clinics around the country that now use SPECT--a fair number of the proprietors trained by Amen himself. In addition, an indeterminate number of psychiatrists around the country quietly, but regularly, refer their own patients for brain scans.


Nevertheless, most of the research community and the psychiatric establishment remain deeply unimpressed. Indeed, there isn't anything about Amen or what he does that his critics do like. Following the back-and-forth between them and him is like watching a bunch of increasingly infuriated boxers all trying to knock down an inflatable punching doll--the harder they hit, the faster he bounces back. They argue that Amen isn't competent to use scans because he's not board certified in nuclear medicine, didn't train in radiology (his several hundred hours of imaging training don't count), and doesn't follow science-based methods of differential diagnosis (using appropriate tests to differentiate systematically between distinct diseases with similar symptoms). He counters that he has the proper licenses to do his studies, teaches SPECT at a major medical school, has written or cowritten chapters about SPECT in three professional textbooks, has produced nearly two dozen peer-reviewed papers, instructs nuclear-medicine doctors who come from far away to spend weeks at his clinic, has chaired workshops on SPECT at the APA annual meeting, and, finally, just a year ago, received a Distinguished Fellow Award from the APA. "I have more experience with SPECT than anybody else in the world, and there are mountains of scientific literature backing up my clinical work--1,500 such studies are on my website alone."

They argue that he sits on a proprietary stash of 27,000 scans, like a miser sitting on a pile of gold bullion, and won't give researchers access to his data because he's afraid an independent look will undermine his claims. He contends that researchers are perfectly welcome at his clinic, to talk to his doctors, see how they interpret scans, and look at his database. But one leading researcher he invited out to see his scans hasn't followed through, and no one else has ever asked to see them.

They say, to quote Harvard's George Bush, that "he's unethically subjecting people, including children, to potentially dangerous ionizing medication in a diagnostic test of no proven benefit." He cites Michael Devous, a leading nuclear-medicine expert, who writes that "there are no data that have ever demonstrated any harm to humans by radiation exposure at diagnostic imaging levels." The average radiation exposure for one SPECT scan, Amen points out, is similar to that of an abdominal X-ray, which is routinely ordered for common childhood medical conditions, including constipation.


They say, repeatedly and maddeningly in Amen's view, that he claims to diagnose psychiatric illnesses from the scans. He just as repeatedly insists that he never uses SPECT to "diagnose" anything, but looks at the scan within the context of the person's life and after a full psychiatric evaluation to get more information that might shed light on puzzling, difficult, or anomalous symptoms. "I've never said the image is 'the answer.' We use it when we don't know what's going on, when we think it might supply a piece of the puzzle--it's like radar that helps us better target the problem. The alternative to doing scans is blindly putting kids on meds or multiple meds without looking at their brains either before or afterward."

Finally, and most damagingly, they say that what Amen is doing is totally unsupported by the facts--that he hasn't remotely demonstrated the scientific validity or reliability of using scans as he does. They argue that it isn't yet possible to identify subtle distinctions in single subjects that reliably correlate with specific symptoms. "When a radiologist looks at a chest X-ray, he recognizes pneumonia, or an enlarged heart or liquid at the base of the lungs that correlate with disease because he's compared these abnormal scans to thousands of normals and other abnormals," says neuroscientist Bush. "Maybe in 50 years, when someone comes in looking as if he or she has a certain syndrome, we'll be able to refer them to a radiologist who'd be able to interpret that individual scan. But we're not yet, as a field, in a position to distinguish one brain scan from another. Right now, you can look at any individual scan and what you'll find is color blobs across a screen. What separates science from nonscience is the ability to pick out quantitative, statistically reliable, patterns [in those blobs] based on large numbers of scans--set certain criteria for a disorder, show it in 50 cases compared with 50 normals, for example. Amen isn't doing that. Essentially, all he's doing is 'blobology.'"

To this, Amen responds that factoring in the individual variability in each brain, rather than drawing general, statistical inferences from a large base of cases, is a strength of his method, not a weakness. Researchers look for signature features in a scan that will reliably correlate with specific DSM categories, which do not reflect the complexity and heterogeneity of psychiatric disorders as they're experienced by real people, Amen argues. " DSM diagnoses are artificially derived from symptom clusters," he says. "But they don't explain why people are having these symptoms--why one person's depression or anxiety or AD/HD may be entirely different from the same formal diagnosis in somebody else. Only by looking at each person's individual scan can you get some insight into the underlying physiological pattern in the brain, so we can target treatment specifically to what that person needs."


In addition, he says, researchers study "pure" cases--people with one supposed diagnosis without the confounding variables of comorbid conditions (i.e., drug addiction along with their depression, AD/HD symptoms along with their anxiety). This approach simply doesn't reflect the complexity, variability, and individuality of real people and real patients.

Finally, researchers compare people with a DSM diagnosis to presumed "normals," but Amen doubts that there's such an entity as a "normal" brain. Recruiting people for a database of normals, his office screened 1,500 people and found only 72, who met the criteria for "normal"--no signs of head injury, no history of substance abuse, no psychiatric illness, and no first-degree relative with a psychiatric illness. "'Normal' is a myth," he says flatly.

Whatever the specifics of his critics' objections to Amen's work, it's hard not to suspect that underlying the intensity of their response is their objection to Amen himself--his persona, his style, his modus operandi. Most scientists lead comparatively monastic, inconspicuous lives (though not necessarily impecunious--many act as paid consultants to pharmaceutical and medical-device companies). Even those few who achieve eminence do so largely within the circumscribed universe of their peers. How many people can name a recent Nobel laureate in any scientific field? They have their own worldview, and what they consider Amen's heavy-handed promotion of high-tech gimmickry is as far from it as earth is from Pluto.

"The nature of science is agnosticism," says Helen Mayberg in a passionate defense of the way researchers do things. "Our job is to ask questions, measure data, continue doing the research until we find out what's real, what isn't. I've devoted my entire professional life to using imagery to understand depression, and the more progress I make, the more complicated it gets. As a clinical neurologist, I see patients die all the time. I don't have to have anybody tell me how much people suffer. But no matter how much, as a doctor, I want some idea for a promising new treatment to be true, as a scientist, I have to remain an agnostic. We all know the system isn't as good as it should be, but it's the best we've got. We get accused of living in ivory towers, but we do what researchers do--we can't leapfrog over the process."


For researchers like Mayberg, Amen is anathema--a leap-frogger to the nth degree. His disregard for professional politesse can make even his friends and defenders cringe. Jerry Rodos, a psychiatrist in the Chicago area, who regularly refers difficult patients for scans, remembers taking a younger colleague to hear him lecture. "We walked into the conference room, my friend took one look at the Amen concession--tapes and books and CDs, advertisements for his clinics, posters, etc.--and was completely turned off before he even sat down. I think Dan has done a lot of neat work, and what he is saying is very valuable, but he's not a traditionalist and hasn't spent a lot of effort trying to get refereed journals to review his material. If you have something important to say, you submit it to peer-reviewed journals, rather than just run off and start four clinics and write popular books about it. Dan Amen is a big promoter of Dan Amen, and that offends many of his colleagues."

Partly in response to critiques like this, even from allies, Amen has hired a statistician-researcher and is preparing several studies, including one on predicting treatment response in AD/HD patients based on their different scan subtypes. But Amen doesn't believe his opponents will come to like him anytime soon, no matter what kind of studies he publishes. "A friend of mine told me I was like somebody under an old Romanian curse--doomed to know something that's true, but nobody believes him," he says gloomily.

The Client's Experience

Meanwhile, anathema or not, Amen's clinics do 400 to 500 scans a month, and, according to follow-up questionnaires given one month and six months after treatment, 85 percent of this patients think they received "significant benefit" from the process. According to therapy researcher Jay Lebow, however, this isn't unusually high--about 90 percent of psychotherapy users report being satisfied with their treatment, which can simply mean they liked the therapist and felt understood and cared for.

At least some of Amen's patients, however, clearly feel that the experience transformed them, even saved their lives. Whole families get scanned, and then refer their friends and acquaintances and fellow church-members. Some of Amen's most convinced champions are evangelical Christians, who believe that Amen is doing God's work and want to help him do it. Linda and Gaylen Bronson, a California couple who are committed Christians, were so delighted with Amen's treatment of their family that they started the Recovery Assistants Foundation, a tax-exempt, charitable organization that helps people who couldn't otherwise afford it to get and pay for SPECT scans, therapy, and medications.


To get some idea of how the Amen phenomena can build on itself, consider the Woodmansees--Jack, a retired general and businessman, and his wife Patty--who live in a suburb of Dallas. The Woodmansees heard about Amen a decade ago from a friend who felt the SPECT scan and his treatment had dramatically improved her life. Because the Woodmansees had a grandson diagnosed with AD/HD, who was doing very poorly on Ritalin, they sent for an Amen video about AD/HD. Watching it as a family, their adult son (the father of the AD/HD child) came to the conclusion that he probably had AD/HD, too. The senior Woodmansees made appointments for the son and grandson to get scanned, and then decided to take their granddaughter, who had behavioral problems. Eventually, three different branches of the family trooped out to California to be scanned.

Soon they were all talking about the temporal lobes, cingulate gyrus, prefrontal cortex and noting the interesting family resemblances in their brain-perfusion patterns. They also became advocates for Amen, sending along friends, neighbors, and members of their congregation, and even financing scans for people who couldn't afford them. They brought Amen to Dallas to give lectures, and have been trying to convince him to open a clinic there.

Two years ago, Richard and Sarah Mitchell took their 10-year-old daughter, Terry, in for a scan. Always a difficult child, Terry was now throwing herself on the floor in explosive temper tantrums, harassing her siblings, causing classroom disruptions, and failing in school. Diagnosed with AD/HD and oppositional defiant disorder, she'd been prescribed a stimulant, which she vociferously fought taking, and which only made her worse. After the scan, Amen prescribed an antidepressant, a mood stabilizer, and a handful of supplements. He also recommended several therapists. But not one of the three therapists worked out, and the drugs didn't help much, either.

So Amen shifted course. He took Terry off meds, cranked up the supplements, including large doses of over-the-counter omega-3 fatty acids, GABA, and other amino acids (believed to reduce anxiety), recommended a high-protein diet, and helped her parents learn some techniques for handling their daughter better. Now, about two years later, Terry still tends to be bossy and overbearing, has a hard time picking up on social cues, and is emotionally immature. But she's much better than she was--her grades are now high Bs, she likes school, and her mood has generally improved. "She isn't raging anywhere near as much," her mother reports, and she clearly feels more at peace with herself.


Terry's case points to a paradoxical and perhaps misunderstood aspect of Amen's approach. However radical the use of SPECT may seem, his treatment is unconventional only in that it's far more heterogeneous and informed by alternative-healing methods than the Johnny-one-note pharmaceutical orientation of most psychiatrists. While not shy about prescribing medications, often in twos and threes, he also recommends nutritional and herbal supplements, cognitive therapy, EMDR, biofeedback, parenting-skills training, diet, exercise, meditation, and abstinence from alcohol.

How does treatment with Amen compare with what another psychiatrist might recommend? Might not Terry, for example, have done just as well if she'd found a reasonably creative and open-minded therapist willing to try a variety of different approaches and hang in with the family for as long as it took? Of course. Did the SPECT scan speed up the process? Possibly. Does Terry's family believe that scans are magical keys to the kingdom of the inner brain and that Amen is the sorcerer who, essentially, saved their child? Completely. "Without Dr. Amen, she'd probably be in some military school now," says Terry's mother. "I feel blessed to have met him." Among the Amenophiles, this attitude isn't unusual.

For all that people say about what most mattered to them about their experience at one of Amen's clinics, it would be a mistake to underestimate the weight of the old saw that a picture is worth a thousand words. People believe they're seeing an actual picture of something empirically real, fundamentally true, and undeniably revealing about themselves. This apparently incontrovertible glimpse of reality can be unwelcome, even shocking, but it has to be taken seriously. Before the scan, Terry Mitchell had furiously refused to take medications, and felt her parents were disciplining her unfairly. When her scan was shown to her and explained, she looked at it quietly and somberly for a long time, and said, "I guess I really do need medications." It's easy to believe Amen when he talks about the power of these scans to convince even adolescents that the drugs they ingest really are hurting their brains--there's the evidence.

Critics might argue that this troubled child has been conscripted into a possibly false sense of her personal pathology by a misused and misleading test. But, paradoxically, scans that show something amiss can be oddly reassuring. "Do you know what people's biggest worry is about seeing their scan?" Amen asks. "That the scan will show nothing ; that it'll look normal, which means that they're suffering because they're weak or bad." After her scan, Terry felt relieved, her mother said, because the scan explained why she was having so much trouble and removed her sense of self-blame for not acting like a "normal" girl.


Brain and Soul

This peculiar, but almost universal, sleight of thought--"it's not me, it's my brain "--helps explain Amen's appeal and, for that matter, the appeal of all "biological psychiatry." Whether or not we're religious, spiritual seekers, or hard-nosed materialists, we feel intuitively that our real selves, our souls, if you will, aren't the same as the soft "hardware" of the brain. And unlike many drive-thru drug dispensers, as psychiatrists have too often become, Amen actually seems to care about the soul, perhaps even in some way believes he's doing his part to save souls, or at least free them from the malign influence of a sick brain. And clearly, Amen and his staff do everything they can to make the people who come to them feel like real people with basically whole souls, whatever is wrong with their neurophysiology.

Recently, Ted, a nonprofit administrator who'd seen Amen at the Networker Symposium, decided to get his own brain scanned in Amen's clinic in Reston, Virginia, which is directed by psychiatrist Charles Parker. Now in his mid-fifties, Ted says he's been depressed since his late thirties. He describes his emotional state not as sadness so much as apathy, lack of energy, zest, and motivation. "Nothing's wrong in my life. In fact, I think I have a great life. I just don't enjoy it very much," he says. He also has a hard time concentrating and, while he used to read a lot, now just zones out in front of the TV. He was in therapy many years ago, though not since becoming depressed, and has tried a number of medications--Prozac, Wellbutrin, Cymbalta, Paxil--and acupuncture, all to no avail.

Ted loved his whole experience at the Amen clinic. The staff seemed entirely made up of young, attractive, extraordinarily pleasant women with big smiles who, Ted was intrigued to see, all wore very high heels. "It was a little like the Stepford Wives, only they seemed genuinely nice." He filled out a 15-page questionnaire, went through a lengthy interview with the "historian," and then underwent a concentration scan. Two days later, he went in for his resting scan, and a day or two after that, Dr. Parker reviewed the scans with him.

Ted found Dr. Parker to be the nicest person of an amazingly nice staff, scoring about 110 on a 100-point friendliness scale. "The psychiatrist I go to for my meds checks is a nice enough guy, I guess, but he's like an iceberg compared to Dr. Parker, whom I liked much better. He really seemed to want to spend as much time with me as I needed."


As for the scans and what emerged from them, things get a little murky. The report was long, complicated, and somewhat confusing to Ted, who said that, as he listened, "after five minutes or so, I kind of glazed over." The scans showed less than normal perfusion in areas of the prefrontal cortex, temporal lobes, and parietal lobes; increased, or excessive, perfusion in the basal ganglia and limbic system; and "scalloping," or dehydration, on the outer surface. Altogether, all of this signifies . . . well, a lot of possibilities--including, but not limited to, short attention span, low motivation, memory problems, abnormal perception, impulsivity, disorganization, distractibility, anxiety, irritability, depression, and mood cycles.

In this somewhat jumbled mass of findings, what fascinated Ted the most was the pronounced indentation in his left prefrontal cortex, consistent, said Parker, with past brain injury. Amen contends that many psychiatric conditions may result from undiagnosed, and even apparently mild, brain trauma without unconsciousness, and he makes it a practice to ask his patients at least five times if they've ever experienced head injuries. Ted was also interested to learn that several of the patterns picked up on in the scan are often seen in people with AD/HD.

The upshot of all this was that, according to Parker and Amen (who read the scan), Ted had been taking the wrong medication--Cymbalta only exaggerates symptoms of AD/HD and concentration difficulties. He was to begin taking Effexor right away, and Adderall a few weeks down the line. Besides this, he should begin exercising and take various supplements. Ted was given a list of books and referrals to holistically trained MDs specializing in nutrition and brain-injury recovery, neurofeedback experts, and brain-health websites. He was also told to make a follow-up appointment. For a technique that's supposed to provide the focus for well-targeted, specific clinical interventions, Ted's SPECT scan seems to have resulted in something of a hodgepodge of generic recommendations.

But Ted came away from his adventure feeling elated--less like somebody who's had a high-tech medical procedure with no very clear prognosis, and more like somebody who'd won the lottery and been given a new lease on life. "I thoroughly loved the whole thing. I'm very glad I did it. It was uplifting and made me feel so hopeful." And the scans? "They're interesting to look at--very pretty. It's neat to have somebody show you what your brain looks like. And then to be shown this big indentation that's not supposed to be there; well, it's concrete evidence that something really did happen to you. I do think I understand my own brain a little bit better."


Whatever the outcome for Ted's case, or for Amen's crusade overall, it seems inevitable that his work, or some variant of it, represents a glimpse into the future. With the development of revolutionary new technologies permitting a direct look inside the brain, people will be increasingly dissatisfied with the clinical guesswork and serial medication trials that constitute so much of psychiatry today.

Nor will psychotherapists, the workhorses of the mental health industry, be content to wait until the last peer-reviewed, double-blinded study demonstrating SPECT's empirical validity and reliability has been published before making use of these technologies in their own practices. They've never been willing to delay using what seemed useful to their patients until they've gotten the okay from the higher orders of scientific inquiry. EMDR and many forms of body-oriented trauma therapies, as well as a host of other therapeutic methods, are still considered fringe by research psychologists, but that isn't stopping therapists from using them. Whether one considers Amen a devil or a new messiah, his use of SPECT visionary or voodoo, it seems likely that time is on his side.

Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. Contact: maswylie@midmaine.com.

 

A Week of Silence

Quieting the Mind and Liberating the Self

By Daniel Siegel

I'm flying from Los Angeles to Boston for a week-long meditation retreat, and I'm feeling nervous. For the next seven days, I'll be sitting in silence with 100 other scientists at the Insight Meditation Society in Barre, Massachusetts, at an event sponsored by the Mind and Life Institute, an organization devoted to the scientific study of mindfulness and compassion. The event is unique: when before have 100 scientists, most of whom specialize in studying the brain, gathered together to sit in silence for a week and learn "mindfulness meditation"?

I know that teaching mindful awareness to people can markedly improve their physical and mental well-being. At the UCLA Mindful Awareness Research Center, we recently conducted an eight-week pilot study that demonstrated that teaching meditation to people, including adults and adolescents with genetically loaded conditions like attention-deficit/hyperactivity disorder, could markedly reduce their level of distraction and impulsivity.

Still, I have no background in meditation, my mind is always busily running on at least 10 cylinders, and I've never been known for my taciturnity.

I told a friend about the silence coming up and he said that talking with other people is his "life's blood," and that connecting with others--the talk, the eye contact, the closeness--was what gave his life meaning. Me, too, I said. How will it be to sit completely still for long periods of time, not communicating either verbally or nonverbally (part of the deal) with anybody else for seven days? Why am I doing this? I wonder if it's too late to back out of the whole thing.

Scientists in Silence

There wasn't much for me to do in preparation except pack up warm clothes and shoes for this occasion to be in New England in the dead of winter. I was advised the best thing I could do to get ready was to tie up all the loose strings at home and work so that in the silence of the retreat, I wouldn't feel the urge to call, e-mail, or write anybody back in my ordinary world. As a psychiatrist interested in the brain and relationships, I can't help wondering what will take over the language-processing areas of my left hemisphere when they, presumably, become silent during meditation? Words are digital packets of information that convey to ourselves and others our models of conceptual reality--how we see and think about the world. They're part of the brain's top-down apparatus for ordering and making sense of incoming sensory information.


But then I think of poetry--a different use of language, which inhibits the strictly hierarchical, top-down, left-brain processes organizing our raw experience into a preconceived grid. Poetry, like silence, creates a new balance of memory and moment. We see with fresh eyes through the poet's artistry, which illuminates with words a new landscape that before was hidden beneath the veil of everyday language. Our ordinary language can be a prison, locking us in the jail of our own redundancies, dulling our senses, clouding our focus. By presenting ambiguities, by using words in unfamiliar ways, by juxtaposing elements of perceptual reality in new combinations, by evoking imagery, poets and their poetry offer us fresh, novel possibilities for experiencing life.

Perhaps the silence of this week will do the same for me.

Day One

I arrive at the Insight Meditation Society, where we'll be spending the week together. After a brief dinner, tour, assignments of daily cleaning duties, and an introductory talk, we've already begun the silence. The idea is to immerse ourselves in the subjective reality of our own minds. With some direction from the insight-meditation faculty here, we're to dive deeply into the waters of our own internal sea. The form of mindfulness we'll be learning this week comes from the 2,500-year-old Buddhist practice of Vipassana meditation, which is often translated as "clear seeing."

On the first day, we learn to sit in the meditation hall with the brief instructions to merely "watch our breathing." This capacity to focus attention is the first step of mindful-awareness training. When we notice our attention has wandered away from the breath, the instructions tell us, we're to gently return our focus of attention to the breath. That's it. Over and over again. I feel relieved. How hard can this be?

But by the end of the first day of practicing this concentration aspect of the meditation, my confidence level has definitely plummeted. I thought I had what the instructors call "good attention," but, in fact, my mind is repeatedly not cooperating with the instructions to "just focus on the breath." After a few moments, it seems I can barely make it through an entire breath without having my mind pulled toward different thoughts like a dog zigzagging on a walk, drawn this way and that by enticing scents along the path.


Our instructors tell us that this continual wandering is a totally natural part of the mind itself, and suggest we try just to focus on half a breath at a time: the in-breath, then the out-breath. This helps a bit, but my mind still goes strolling off in all directions. This is sometimes called a "proliferation of the mind," we're told--the way the thoughts generate more and more conceptual thinking. The "solution" to this dilemma, once we become aware that our minds have been hijacked by stray thoughts, is to calmly return to focusing on our breath, over and over and over--at least a million times, it seems to me, during the 45-minute session of sitting meditation.

After each sitting period, we do walking meditation that lasts from half an hour to an hour. While walking, we're to focus on the sensations in our feet and lower legs, step by step. When we notice our minds wandering from the sensation of the steps, we're to bring our focus back to the walking. Same deal: my mind has a mind of its own and goes where it wants to, not where "I" intend for it go.

Our instructions are expanded more as this first full day goes on. We learn that concentration on the breath will enhance the first step of mindfulness, which is to aim and sustain our attention. By learning to keep our attention focused, we can prevent the constant stream of wayward thoughts, the concepts that comprise our mental processes and get in the way of truly experiencing sensations. Sensation is the gateway to direct experience they tell us. When we can "just" see, or smell, or taste, or touch, or hear--our first five senses--then we enter the realm of being in the moment, a distant realm from where I am with all of the clutter in my mind, as I just sit, and walk, and sit, and walk. Getting close to sensation, it seems, is intended to enable us to just experience without the interference of thinking.

This first day has been both odd and stressful. Being in silence and out of direct communication with anyone makes me feel a bit stir-crazy. I'm driven to connect, but we're "forbidden" from communicating with anyone, with words or gestures, eye contact or facial acknowledgments of connection. This is the rule that precludes us from joining in any way, and I feel some part of my brain is aching to reach out to the many who are here. I'm beginning to talk to myself, not just in my head, but out loud. I'm even telling myself jokes and laughing. Then I say "Shhh!" to myself, remembering the rule about the noble silence: no communication with anyone. But how about with myself?


During the practice I try to remember what I told myself before this began: Make every breath an adventure. Now I say to myself, "Every half breath an adventure." But I'm saying this with words, and somehow words have become an enemy, those proliferative concepts that keep me from direct sensation. I'm trapped. I feel confused. I'm feeling the sensations directly, I feel, or I think, but I'm also not giving up the conceptual, word-based dialogue in my head--the words that summarize what I'm doing, like taking a walk, eating an apple--instead of just letting me be doing it. I've got some narrator in me that just won't quit. "Go ahead, try to just drink that soy milk: S-O-Y M-I-L-K I read on the carton. The letters jumping into my sight like a long-lost friend. I even have the words active in my mind when sitting and walking in our sessions. This makes me feel I'm not "meditating mindfully." Maybe I'm just too intellectual and filled with ideas and questions, words and concepts to be doing any of this.

Day Two

Something shifted today. We get up at 5:15 every day and are in sitting meditation by 5:45. At the end of the first 45-minute session, I had the startling feeling that no time had passed at all. I sat down, began watching my half breath, and before I knew it, the bell had sounded for our 6:30 breakfast. I hadn't fallen asleep, as I was still sitting bolt upright, my head straight, legs still folded beneath me. Then I went for a long, mindful walk in the snow in the forest outside the main building. At one point, I saw this gorgeous vista of a white-blanketed valley framed by the snow-covered limb of a tall pine, icicles dangling down from a nearby boulder. To my surprise, I burst into tears at the vivid sights and smells and cool air on my face, the sound of the wind in the trees and the crunching snow beneath my boots. And then, just as quickly, I heard a thought in my head say, "You'll die one day and none of this will be here for you." My exhilaration vanished in an instant, leaving me distraught. I felt defeated and deflated. It was as if an ancient war were being waged, magnified in my isolated head, between thoughts and sensations.

Later, during a brief group meeting, I described this experience to the teacher and wondered if their mindfulness teaching was playing favorites, as if sensations were better than thinking or anything else we might do, perhaps even than talking with each other. Why were sensations being privileged over thoughts? A teacher said that we'd soon learn that anything arising in the mind, from sensations to thoughts, is to be accepted as it comes without judgment. Her instruction was deeply helpful, making me feel there didn't have to be a war in my head between direct sensation and conceptual thinking anymore. Perhaps I could broker a truce between the two. But I was surprised that such a simple instruction could produce such a huge shift in my experience.


With this new perspective in mind, at dinner, I had a remarkable experience eating an apple. At each of the meals, in fact in all of our activities besides just the formal sitting and walking practice, we're to be "mindful." What this means is to be awake and aware of what's happening as it's happening. I decided to eat an apple for dessert. Feeling free to think as well as sense, I decided to do a mind experiment of enhancing the experience of eating the apple. I cut a piece and looked at its texture. I felt the skin, the pulp, and the edge where they met. I smelled the aroma and drank in its wafting, expanding scent. I even decided to put the piece of apple to my ear and see how it sounded (yes, I know, ridiculous, but molecules vibrate and that's exactly what sound is, so why not try?). All I could hear was the sound of others in the room, no whirring atoms shaking my ear drum. When I placed the apple slowly in my mouth, I could hear the crunching, taste the burst of flavor, feel the pieces against my tongue and teeth, and then sense the shift as the mashing pieces got smaller, and then moved down my throat, into my esophagus, and down into my stomach.

Feeling free now to allow conceptual thoughts into the picture, I allowed my mind to expand and play with images and sensations of the apple's making its way through my digestive system, being absorbed into my body, and becoming an integral part of me. Then I thought about where the apple had come from--the people in the kitchen who (hopefully) washed it, the staff who bought it, the orchard from which it was picked, the tree on which it grew, and the seed from which that tree sprouted. With the freedom to enjoy this imagery, I suddenly felt a sense of wholeness and oneness with everything--the earth, the chain of people, my body.

I floated out of the dining room and wanted to speak to someone, but remembered the silence. A friend had been in the room, but we couldn't talk. I went outside and gazed at the almost-full moon in a cloud-strewn evening sky. I felt a presence next to me and found my friend had come out also, on his way to the sleeping area, and paused a moment by me in the silence under the stars. In that silence, a million words couldn't have said what that shared moment in the moonlight felt like.


Day Three

Today I met with another teacher for a one-to-one meeting. I tried to describe the apple experience. I said that I felt as if there were a flowing river creating my awareness, and this meditation practice was enabling me to go up the current to visit the individual streams flowing into that river--one stream of sensation, one of concepts. This image made me feel more at ease with whatever arose in my mind. He answered by telling me that he often felt that he'd "finally gotten it," only to realize that there was always something new to experience in awareness. He suggested that I might not want to hold on to any fixed idea of "how things are," but just see what happened.

I felt dismissed and irritated by his response. After this ten-minute meeting, my head was filled with worded-thoughts and the next few sessions were "difficult." A difficult session feels as if it were going nowhere; as if instead of feeling the spaciousness of a calm and stable mind, I'm simply spacing out. Spacing out instead of "spacing in." I get lost in thoughts easily and somehow don't come back to the breath.

But in the end, this teacher was right. It would get quite a bit more complicated and would be forever changing. No matter how illuminating some experiences have been, you can never predict what the next session will feel like. The mind is always in flux, and nothing seems to predict anything. The idea is to give up expectation and let whatever happens, happen.

In our group instructions, we've gone from being told to just watch the breath to also being told to notice sounds and feel our bodies. The breath is like an anchor point, a place to start, but noticing sounds gives us a wider expanse. The body scan--sensing each part of our body, one area at a time--enables us to open our awareness intentionally to the predominant sensations in our body. We just drop into awareness of the body or our senses and take in whatever arises.

Day Four

We're now expanding the field of awareness to move from the concentration on the breath to becoming mindful and receptive to all that arises, including the experience of mindfulness itself. Nothing is excluded. But the receptive mind isn't a passive mind. There's a quality of active engagement, not just with the object of attention, but with awareness itself. Yet this active sense isn't strained--it has a flowing, grounded, and intentional quality to it.


An insight that emerged on a walking session today came into my awareness without words. This insight was that deep in mindfulness, it isn't possible to get bored. Words portray a concept, a verbal thought that may articulate even a nonverbal idea. But an insight, like this one, feels more like a shift in internal perspective than a conceptual idea.

There's a strange change today. It feels as if some part of my mind that was aching to connect with others has given up aiming for them and has turned inward toward myself. I feel a surge of awareness of each step, a kind of connection to myself that wasn't there before. No moment is like any other, even step after step after step. I feel with each step the pressure on the ball of my feet transitioning to the sole and then the heel. And then the shift in weight in my legs as the next foot takes on the pressure of my body. Each step is unique. There's no place other than here, no moment other than now. I'm filled with excitement. I feel a floating sensation on the walking meditation, each moment inflated with a kind of helium from my mind.

I want to tell someone, so I tell myself.

Day Five

We've been working on full mindfulness in experiencing our sensations, feelings, mental activities, and states. One practice is to start with grounding yourself in a focus on the breath and then move into a more open, expanded, and inquiring state of awareness, which feels something like "bring it on." Whatever comes, will come. We're told that it helps some people notice a thought or sensation or mental state (without getting sucked into it) to imagine it emerging from a mouse hole in the wall. Others imagine the thought appearing on a video screen that they can turn on or off.

Neither of those worked for me. Instead, my awareness of the present moment emerged in my mind's eye as a valley. Thoughts and feelings and images would float like clouds into this valley, where I could see them, name them ("thinking" or "feeling" or "imaging"), and just let them float off, out of my valley of the present moment. Sometimes a thought would arise without my awareness that it had come and, in an instant, I'd be "lost in thought." There'd be no separation between the thought and me. I'd not only be lost in it, I'd be the thought. At those moments, I was no longer in the valley, but had been swept up into the clouds.


When I became aware of my unawareness of my breath, the key wasn't to get mad or frustrated or feel like a failure, but to just take note of this experience. It also helped to remember what our teachers told us: that no matter how many decades people spend practicing mindful awareness, there's always the regular "getting lost in thought" experience. This is just how the mind works. But building mindful awareness helps you see a thought as just arising and floating away. The thought loses its power to kidnap you, make you its captive.

We've been also working on ancient meditative practices for the cultivation of "loving-kindness." Loving-kindness is a fundamental part of mindfulness meditation and aspires to imbue us with a positive regard for all living creatures, our selves included, and the world at large. A set of sayings is repeated, beginning with a focus on the self. These are the particular articulations of those sayings taught by Sharon Salzberg: "May I be safe and protected from harm. May I be happy and have a peaceful and joyful heart. May I be healthy and have a body that supports me with energy. May I live with the ease that comes from well-being." Having an image of your self in mind can deepen these practices. As these statements are made, the mind's awareness of the body can focus on the heart region, the area just beneath the chest, as one breathes in, and breathes out. Beginning with loving-kindness for ourselves is necessary, because if we can't feel it for ourselves, how can we feel it for others?

After focusing on the self, we focus on others. We wish safety, happiness, health, and ease first on a benefactor (someone who's supported us and our development in life), then on a friend, followed by someone about whom we feel neutral. Often an image of that person is useful to have in mind as these wishes are expressed. The next step is harder--wishing these blessings on a "difficult" person in our life, one with whom we may have a challenging relationship. And the next step can be even harder: we're asked to offer and ask for forgiveness. "I ask you for forgiveness for anything I've done or said that's caused you harm or painful feelings." Then, with the same words, one forgives this person.

I chose a friend with whom I've had a long-standing relationship that had ended with confusion and hostility recently. I pictured his face, saw the troubles that led to our rift, and asked his forgiveness for what had happened between us. It was hard, as he hasn't been forthcoming in trying to make a reconnection. But the exercise, including forgiving him for what had happened, helped me feel a sense of resolution.


I personally found this deeply moving, but several in the group during evening lectures expressed difficulty forgiving those who'd done them harm. For others, this entire "metta" or loving-kindness practice was uncomfortable, and some even stopped coming when this was the guided-meditation topic of the session. A number of people later would say that they had a hard time forgiving someone who'd wronged them and hadn't apologized for the transgressions.

Day Six

I'm feeling as if I now have three palpable streams of awareness flowing into my river of consciousness. One is direct sensory experience. These sensations of my body or of my perceptions feel raw and bare. When I walk, I feel the pressure on the heel of my foot, the transition to the ball, the distribution of weight unevenly onto my toes, the movement of my hips as my other leg slowly swings over the center of gravity and my body leans forward, the next heel touching earth, my other foot's toes releasing and taking flight. I'm not observing this as a perception; I'm sensing it. As it's happening in real time, I feel there are no words to describe these sensations, no concepts to analyze and cluster them. They just are their sensory fullness--sights and sounds, inner gurglings, tensions, pressures. I also become quite aware of the second stream--the conceptual stream in the idea of walking. I can almost hear the thought--"walking"--in words that aren't quite audible in my mind. But now there's also a third stream flowing that I call the "observer"--the sense that I'm watching myself from afar, out of my head, floating in the hall above me or in the trees above the path where I'm walking.

Each stream--sensation, concept, observer--seems to coexist in the valley of the present moment. I note them, even observing the observer. How odd. At some point, I feel as if I'm losing my mind as my sense of reality crumbles, unraveling before my mind's eye, literally. Or am I actually finding it? I walk on. Step by step, I watch my mind. I feel my steps. I observe my feeling and even feel my observing.


I haven't had a conversation with anyone besides brief moments with my teachers in almost a week. No interactions, no speech, no reciprocity. I'm surrounded by others, but am far away, yet so close. I've been carrying out the assigned job of cleaning our hall's bathroom each day. I dreaded this routine at first, but somehow have come to enjoy it, to even relish the task. There's a kind of connection I feel with the mop, scrubbing the toilet, washing the sink. Day by day, I've come to expect the same sort of reaction from the cleaning fluids, the sponges, the rags. It feels comforting to know that somewhere in all this there's some sort of predictability. I scrub, the dirt disappears. Magic. But in the open valley of the present moment, I never know what will arise.

Needing some kind of anchor point during the walk, I think of a mnemonic for the whole thing. I know we've been told to say to ourselves, "not now" or "no thank you" to acknowledge an interesting idea and not get swept up in it. But I can't help myself. Or perhaps I am helping myself. Step by step my shoeless feet are floating over the wooden floor of this walking room. Step by step. I think: Sensation. Okay. Observation. Fine. Concept. Good. Each of these three streams gives me a sense of knowing the present moment, a knowing paradoxically without words, without concepts, without sensations. This knowing is a kind of subterranean stream beneath this valley of the present moment, a formless Knowing : K. How will I ever remember this amazing vision? Then I think, " S. O. C. K." So a sock is around the sole of my feet and SOCK is surrounding the soul of mindfulness, step by step, moment by moment.

Earlier I'd described a three-stream awareness in a question-and-answer period and asked if I was losing my mind. When the observer becomes excessively active, I said, it seems to destroy the direct sensory experience, just as the conceptual thoughts used to do. Do I need to get rid of the observer? I asked. No, the teacher responded. The idea is balance. I can live with that. In fact, I can float with that. And, of course, on the following walk, another mnemonic emerges--the ABCDE of mindfulness: A Balance of Concept and Direct Experience. My left hemisphere just won't quit!


Day Seven

This is the day we "break silence." They've planned a brief, three-hour period of formal discussion, followed by an evening meal full of chatter and social connections, during which we won't be aware of the taste the food, I imagine, and then a silent evening meditation before going to sleep until tomorrow morning's final meditation and discussion. We first meet in pairs, and I'm dying to describe my experience. I tell my partner about these mnemonics and he likes the YODA one best: You Observe and Decouple Automaticity. This describes the role of reflection in waking us up into mindful awareness: observation disrupts being on automatic pilot. We laugh about the idea of "Yoda's Socks." Mindfulness may involve more than just sensing--it may include that capacity to be aware of awareness, to observe experience. When we observe, we can disengage the automatic chatter and less obvious filtering that our emotions and habitual schema create as they distance us from direct experience. Observation feels like the key that ironically unlocks the doors for direct sensation: we observe and note our conceptual mind, and free ourselves to enter the valley of the present moment more fully.

As we emerged from silence, a strange phenomenon seemed to occur that I've subsequently been informed is common, not just with scientists: there was a frantic sense, a kind of party atmosphere, once we could speak after our lonely, silent sojourn. But when we later returned to silence, I felt surprising relief, and an open, spacious sense of my mind's coming back to me. I could feel a clearing of my awareness when I knew I wasn't to speak to anyone. That lack of contact freed my mind to be open again, to connect to itself. There's some kind of clarity that comes with silence.

Still, that night, when I called home for the first time in a week, I was glad to connect with my wife and children. And yet, even though things were fine at home, my mind couldn't stop thinking about our conversation, the plans, the tones of voice, things to be done. For the first time all week, I had a hard time falling asleep and awoke several times, just thinking of various things that had evaporated from my awareness during the week. The pull of my regular life made me realize that I hadn't been aware of how much quieter my mind had become.

I'd been drinking hot tea all week long without a problem. After calling home, moving out of mindfulness and back into the frenzy and hustle and bustle of "civilian" life, I burnt my tongue. I was thinking of something else instead of being aware of the tea as I was drinking it. Without mindfulness, we can get harried, and burnt.


During the brief science discussions about our ideas and experiences on the last night of the week, I couldn't get my head in gear. What struck me was how utterly conceptual the conversations felt, and I just wasn't in a frame of mind to reengage in that way. I welcomed the return to silence that last night. On the ride to the airport the next day with two friends, though, I felt we could go into our experience deeply, slowly, without interruption. It felt satisfying to try to put the week into words and share that with one another. I said that it had felt as though some part of my mind that usually connects with others had, by the middle to end of the week, turned its focus onto the only person available: me. As I described my experience, I could feel that they were attuning to me in a way that I'd felt I was attuning to myself during the week. My science mind imagined it was the mirror neurons that enabled us to resonate with one another. That resonance of internal and interpersonal attunement felt deeply gratifying.

Now, many months later, I find myself still riding the current of those four streams of awareness--sensation, observation, concept, and knowing--that seem to create my experience of the present moment. Having had a week of a silent retreat feels, for me, like a gift of getting to know myself in a new way. Even as a therapist and someone who engages in nearly nonstop reflection, being alone with my own mind during that time somehow brought out a new sense of myself that stays with me to this day.

How have I changed? One way is that the stream of direct sensation seems much stronger and less vulnerable to being crowded out of my life by conceptual thoughts, or even by observation. There's been more than a "truce" created among these distinct ways of knowing now--I feel a new sense of harmony since the retreat. I no longer become locked on any judgment that one way of being is better than another. Each has its own role to play in the spectrum of life.

In my professional world, I've found that teaching mindfulness has taken on a new dimension with my patients. There's a sense of a central "hub" within my mind that's become more spacious and holds more of the moment of being between us. It's hard to describe, but perhaps the feeling is best expressed like this: Being is just this. Whatever is here, we--you, me, relatives, friends, our patients, our students--can contain the fullness of the experience and ride the waves of our awareness streams together. That spaciousness can be shared. A wheel of our awareness can become a collective, group experience, filled with awe, and the illusion of our separateness revealed for what it is: a creation of our minds, a neural invention.

Somehow I feel an open access to a core self beneath identity from the week of silence. This core way of being, underneath the clutter of personality, is something we all have. The simplicity of attuning to our breath, to ourselves, perhaps permits us to gain access to a deeper self that's the common ground that we can share as we bring mindfulness to each other. At that core place, there may be a path toward healing our global community, one mind, one moment at a time, since kindness is to our relationships what breath is to life.

Daniel Siegel, M.D., is the author the forthcoming book The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being , from which this article was adapted. He's codirector of the UCLA Mindful Awareness Research Center. Contact: danieljs@ucla.edu

 

 

Appointments With Yourself

Don't Mistake Your Schedule for your Life

By Michael Ventura

Now is an obvious word, but a tricky concept. As soon as you say "now," the now in which you said it has passed. Where did it go? It went that-a-way. Just like the now in which you said "Where did it go?" Thinking about "now" can make you dizzy.

We speak about "the present moment" and the ability to be fully present, and we claim a sort of smudgy understanding of what that means. But what is "the present moment? Seriously! "Be in the now." "Be here now!" "Be present." "In family life be completely present," says Laozi's Tao Te Ching (in Stephen Mitchell's New Age-ish translation)--a sentiment echoed in one way or another by every marriage counselor alive.

Americans have heard and used these phrases for about 40 years, as Eastern and New Age concepts influenced psychology and other ologies. We're all familiar with expressions like "right attention," "mindfulness," and family therapy's emphasis on what's happening in this room right now.

There have even been attempts to quantify the present. In Daniel Stern's The Present Moment, he states that "present moments last from 1 to 10 seconds with an average around 3 to 4 seconds," and submits this definition: "The present moment is structured as a micro-lived story with a minimal plot and a line of dramatic tension made up of vitality effects." Obviously, once you delve into it, now isn't as exact a word as it appears.

Finding the Present


The primary definition of now in the Oxford English Dictionary is "at the present time or moment," which, as we've just seen, isn't very useful. There's more utility in the dictionary's second definition: "in the present circumstances"-- that spreads out "now" comfortably. We're not talking about one moment, or one perception, or 10 seconds; rather, we're talking about a kind of place within time, a "here," these present circumstances. "Here" as in: what we're presently engaged upon, in the place that we are.


So you're taking a walk, and the entire walk is "now." You're having a conversation, and the entire conversation is "now." You're making love, writing, cooking, telling a bedtime story--the entire act is "now." That's a manageable present, something that can be discussed without requiring the capacities of a Zen master.

A manageable present, but also complex and variable. You're taking a walk. In a park, say. And let's say you're an attentive person--you're not one of those people who walks staring down at their shoes. You notice birds, trees, clouds, kids playing, an aged person sitting on a bench, a couple walking hand-in-hand. It's nice, it's sane, you have the gently relaxed feeling that the world isn't ending at the moment; maybe soon, but there's time enough yet for a walk in the park. Also, something worrisome and/or interesting is going on in your relationship, and you're chewing on that.

The mind is a nonlinear organ: while you're mulling your thoughts and you're attentive to the comparative sanity of the park, something you see reminds you of something else and takes you away from your primary thoughts. "Now" you're in three places at once, at a leisurely pace: the park, the relationship, and the fact that kid over there is doing just what you used to do as a kid, or that you once had a dog like that dog this very pretty lady is walking, and you notice the lady, too. Thus "now" is continually expanding and contracting on your walk. It's a bird, it's a kid, it's a memory, it's your girl- or boyfriend, sometimes one at a time and sometimes kind of all at once--assuming, again, that you're having a decent sort of day, there's no particular crisis, and you aren't obsessing. Various things are going on all around you and within you, and you're walking in the park.

I take this walk-in-the-park kind of activity to be the state that the Zen poet Ikkyu described when he said: "so many people know but don't know they know / walking to work talking to themselves" (Stephen Berg's translation, Crow with No Mouth ). What do they know? They know how to be in the now. The trick is knowing that you know, which doesn't necessarily require years of meditation. The great mystics are always saying (infuriatingly) that the very big things are actually very simple. In this case, knowing that you know is simple. It doesn't require "enlightenment" (whatever that is); it requires only appreciation.


Add appreciation to this "now"--add, that is, a bit of consciousness, the awareness that, "Hey, this right here is pretty nice"--and your "now" expands to the whole walk, the whole park, the entire present circumstance. Presto, you're in the now! If you can appreciate it. If you can't, you may also be in the now, but you don't know it; that is, you don't appreciate it--and if you don't know it, don't appreciate it, you're not fully there.

So say you're walking in the park and appreciating it--it isn't over-the-top happiness, it isn't profound awareness, but it's pretty good. Then your cell phone rings. (We're assuming that, like many of us, you're foolish enough to take your cell phone on a walk in the park.) It's the significant other you've been thinking about, calling from another state where she (for the sake of argument) has been for a week on business or whatever, and she isn't due back for two more weeks. You're glad to hear her voice. She says she misses you. You sense that she expects you to say, in return, that you miss her. But what if you aren't missing her? That doesn't mean you don't love her. It's just that on this pleasant walk in the park, you aren't particularly missing her. It might be better if she was there, but she isn't, and she can't be, and she won't be, and it's still a good walk in the park without her. If you say, "I miss you, too," you're lying, and there's a flat dullness to that kind of little lie--it sours the moment; enough lies like that, and it sours the relationship. (As someone once said to me--a line I later stole--"Never say 'I love you' when what you mean is 'Good morning.'")

So she says "I miss you" and you don't want to say "I miss you, too" because, at the moment, you don't. But if you say, "I don't miss you," you're in trouble, and you're hurting a person you don't want to hurt. What's "missing" anyway? It's a feeling that leaves a hole inside; it's a feeling that says, "The present circumstance isn't enough, even though it's all you have."

Missing is usually a sense of incompleteness, a lonely insufficiency of the self; when acute, missing can even feel like a kind of panic. Either way, missing arises out of a feeling that's more profound: longing. But longing--if you allow yourself to long for someone, if you appreciate the depth of the feeling--can be a lovely sensation. Missing leaves a hole; longing can feel full. You feel the longing filling you up, expanding your heart. And "I long for you" is so much more romantic than a perfunctory "I miss you, too." (If you actually do long for her, as a sort of constant undertow when she isn't around.)


It's difficult to appreciate missing, but not as difficult to appreciate longing. Missing whisks you out of the present circumstance; but a recognition of longing deepens and nuances the present circumstance. Again, it's that small thing, appreciation--to appreciate the moment you're actually experiencing, instead of faking a feeling you aren't having or allowing yourself to be preoccupied with missing a moment you aren't experiencing.

"Be here now" is pretty vague. "Appreciate, and don't fake," that's concrete. You may or may not be able to do it, but at least you know what it is. It may take time and trouble to learn how to do it, but at least you know whether you're doing it or not. "Do I appreciate my circumstances? If not, why not?" That's at least a starting point. "Do I do a lot of faking?" That's at least an answerable question. It may take a lot of work to answer it thoroughly, but it can be answered. Maybe you need the help of a therapist to answer it. Maybe you can figure it out, sooner or later, on your own. Either way, through these questions, you enter a mental and emotional territory the poet Rilke described: " Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer."

Frenzied Schedules

But it isn't so easy to "live the questions" in a multimedia, interactive era of cell phones and pagers in which we're expected to be constantly available--I've called it "The Age of Interruption." We've even devised nifty gadgets for interrupting ourselves, and never letting the present speak to us on its own terms. The iPod supplies a constant soundtrack wherever you are--background music to force the present into whatever mood, or pastiche of moods, you programmed into it. (We may not experience this as a form of interruption, but that's what it is, albeit self-induced.) For many of the young, cell phones and iPods are taken for granted, almost as biological appendages, and their concept of "the present" involves instant electronic connection to their friends and family at all times. Meanwhile, in our big cities, it's hard to be out of sight of some ad that exists for no other reason than to wrest your attention from the present to something you can buy. Life now is a kind of cacophony that's difficult to turn down and almost impossible to turn off.

The daily round has become frantic, for workers and homemakers alike--we need Day Runners just to keep track of what we're supposed to do! Each task interrupts the last, nothing one does feels fully completed, and many live their lives always a little panicky, as though late for an appointment. (The appointment they're really late for is an appointment with themselves.)


Jungian psychologist James Hillman told me once that in his clinical practice, he found that nothing was harder to "treat," to do therapy with and upon, than peoples' schedules. He said it was very difficult to get people to see that their schedule was their life --the skeletal structure of their existence. You're not going to change your life much unless you change your schedule: open it up so that the unexpected may enter. Else how can the present be a presence instead of just another goal--or just something else you don't have time for?

So when I write of a walk in the park, someone might be saying, "What are you talking about, who the hell has time for a walk in the park?!" Your weeks may be so oppressively scheduled that you never, or rarely, take the time for something like a walk in the park. In such circumstances, your inner life, which no one can avoid having, can get in the way and become something to be suppressed, not explored. Your self becomes a burden--a danger to the marriage, the children, the job. Ask questions like "Do I do a lot of faking?" "Do I appreciate my present circumstances, and if not, why not?" and truthful answers could bring your life down around your head.

People in these circumstances rarely want to be "in the now," in the sense that we've been speaking of. Rather, they seek to lose themselves in their tasks so that they don't rock the boat. Their schedules become not something to be addressed and changed, but something in which to hide.

Living with Courage

Often the price of success, or the price of simply fitting in, demands not only conformity (the suppression of self) but passivity. And we can lock ourselves into conformity and passivity simply by, as the saying goes, "working hard and playing by the rules." For example, the average college student goes into massive debt to achieve a masters or doctoral degree. It's the work of a decade to pay off that debt, a decade during which one willingly accumulates many other obligations. Often by her mid-thirties, that Ph.D. recipient has a family and children. Sometime in her late thirties or early forties, the desire to be more her own person, more in charge of her own time, more "in the present moment" becomes urgent. How to do it? The possibility of breaking free, of fulfilling herself, seems slim to nonexistent. For many, the obligations they've bought into have compromised their inner lives beyond hope, and a genuine appointment with themselves can never be kept.


It's difficult, if not impossible, to appreciate your circumstances if those circumstances imprison. It's tough to learn not to fake if you're living a lie, or many lies, and if those lies have become the terms of your survival. For many people, that's "normal life." Therapy can help you cope, and coping is better than nothing, but no one mistakes it for fulfillment.

For some, "the present moment" is nothing less than terrifying, when faced full on, without blinders, without apologies. The marriage is sunk in compromise, the job sucks, the children are an endless worry, and God doesn't respond. If even one of these aspects goes well--the marriage is alive, or the job is full of interest, or the kids are alright, or God is a comforter instead of a terrorist--then we are (as Southerners say) shitting in high cotton. Who wants to face "the present moment" in most circumstances? Better to watch TV, videos, or Jeopardy. Anything becomes better than an awareness of where you are. Anything becomes better than not faking.

But this is really nothing new. In a world far milder and more orderly than ours, Thoreau observed that "the mass of men lead lives of quiet desperation."

The odds have always been against any individual who desires to live a free inner life--and a free inner life means not being afraid of, indeed relishing, the present moment. To buck the odds takes courage. To determine to find one's way through the societal maze to a place where "the present moment" can blossom requires not one but many small acts (perhaps large acts!) of courage. But "courage" isn't a fashionable word anymore; I can't remember the last time I heard anyone use it in conversation.

We don't tell each other, or ourselves, something our great-grandparents assumed: if you don't have a certain amount of courage, you can't live worth a damn in this world. Psychology, philosophy, religion, money--they won't help if you don't have any courage. But courage isn't necessarily something innate that one has or doesn't have; for most of us, courage is something that you learn, cultivate, grow into step by step, mistake by mistake--like love. Courage, like love or freedom, is something you have to want. Certainly, if you won't cultivate your courage, "be here now" is forever beyond your grasp.


"This was about courage," writes Doris Lessing in her Golden Notebook. "It's a small painful sort of courage which is at the root of every life, because injustice and cruelty is at the root of life. And the reason why I have only given my attention to the heroic or the beautiful or the intelligent is because I won't accept that injustice and cruelty, and so won't accept that small endurance that is bigger than anything." We aren't speaking of anything grand. It takes courage to admit that you're unhappy, and still more to address that fact. It takes courage to decide you need therapy, and more courage to go through the process. It even takes a kind of courage to say, "Today, come hell or high water, I'm taking a slow walk in the park."

Blessings from the Past

All I can offer as a guidepost to the present moment is something that happened to me--an element that helped me be "in the now," as that grating saying goes. And, for me, this step took what Lessing calls "a small painful sort of courage."

It involved memories. Memories "come up," as we say, all the time, in every kind of situation. The past adheres, in the form of memory, to most present circumstances. And, except when we're actually trying to remember, we're usually not in control of what we remember. Something reminds you of something and zap: you're remembering. A scent, a sight, a song can take you back decades.

As a writer, I'm perhaps especially susceptible to memory because there's a sense in which writing is memory. It may be argued that a writer works in the medium of memory even more than in the medium of language. For a writer, often the prime function of language is to serve, preserve, and transmute memory--as fiction, poetry, nonfiction, or even as thought. So I'm often preoccupied with the meaning of memory itself, and with the significance of specific memories.

Like anybody, I have many bad memories. Gradually, by hook or by crook, most of us learn to live with that. But I began to be bothered by this question: Why do good memories, wonderful memories, sometimes cause me intense pain?

Not all good memories, of course, but gorgeous memories like: when I was falling in love with Z (and with several other letters of the alphabet); or moments of great happiness in my first marriage and my second (both long past); or a good memory of a dead or lost friend; or a rare good memory from childhood--excellent moments, rich with life. So why should they cause pain--so much pain, sometimes, that, lacking courage, I'd shut the good memories down?


I began to wonder why these good memories, memories that shouldn't be avoided but cherished, should wrench me away from an appreciation of this moment--from the courage to be in this moment? The events evoked were anything but depressing or sad, so why should the memory of them depress and sadden me "in the now"? Because the romance or friendship or marriage later went bad. Because one good childhood memory brings up a dozen that were awful. What happened later colors the good memory and leaves a bad stain--the awful and ever-present fear of loss.

Even the good things that didn't go bad: a great bunch of kids I taught, whom I'll never see again; a marvelous adventure that I'll never have again; the sensation of being young (for I'm not young anymore and will never be again). Excellent times! Why should the sudden thought of them cause pain, and the fear of pain, in the present?

Because those times, those adventures, those loves are gone forever. And I seem particularly sensitive to that, not in a sentimental or nostalgic way, but simply with a sense of irrevocable loss. That sense of loss, and fear of further loss, was clouding my present.

Then one day, something changed. I can't tell you why it happened or how; it just happened. On a street where I'd once walked with someone precious to me, someone whom I'd since lost, I "saw" (in my mind's eye) the two of us walking ahead of me, as we used to walk, smiling as we used to smile, with our old radiance. And instead of feeling the pang of loss and fear of memory, I felt something very different, and I said softly but aloud: "Go well, my beauties."

The memory didn't wrench me out of the present, nor did it cause sadness and fear--it was poignant, yes, but in a sweet way. I knew everything that was going to happen to those people, some of it good, some of it not. I knew that, contrary to what they felt and thought then, one day, their paths would diverge forever. And what I felt was to wish them well. Both of them. He would one day turn into me, and she--I can't know whom she's become. But I wished them well. "Go well, my beauties." And that felt good in that present moment. And the memory faded, and the fear of loss faded, and I was right there on that street, in the present, with no past burden.


From that time on, when a memory arises, I see it clearly, and I say, softly or to myself, "Go well, my beauties." And the memory passes without wounding. I'm doing something in the present that relates to the past but isn't gripped by the past. My ghosts are welcome, and, being welcome, they quickly go elsewhere--they still have much to do. Because of this, my present feels vastly expanded. Memories are no longer interruptive or fearsome; they're part of the present, and I've found that when I've blessed them--"Go well, my beauties"--good and bad alike leave a loveliness in my present air. It's as though the past is saying, as Jacob said to the angel, "I will not let thee go except thou bless me."

We cannot be in the present until the past lets us go. It'll never leave entirely; it must always return. I suppose it needs a lot of blessing. But, blessed, it'll let us go . . . and the blessing, because it occurs in the present, also blesses the present.

Just Being


In a life running from one sort of appointment to another, space must be made for appointments with oneself. This, too, takes that "small courage," but all talk of being "in the now" is pointless without unspecific appointments with oneself.

Some time ago, my friend and teacher, George, asked if there was any moment of the day when I wasn't doing. I said, "I meditate." He said, "That's doing. It's a specific effort with a goal." "Well," I said, "occasionally I'll just pour myself a cup of tea and stare out the window." He said, "Drink more tea."

It was a concrete suggestion; a way for me to spend some unscheduled time with me, in the present. A walk is good, too. (Not for exercise. Exercise is doing. ) There are days when I'm all jangled with doing; when being in the present seems a distant memory. I suddenly remember George's "Drink more tea," and I make myself a cup of tea and just sit and sip a while. You sit and sip, the mind wanders (which is its natural state--the mind is a wanderer). It wanders back to itself, always. I find that I suddenly, again, really am where I am. In the present. And much more easeful about whatever comes next.

In Hillman's terms, George was "treating" my schedule.

Our schedules are enemies of the presence of the present--"officiating devils," to steal Heinrich Zimmer's term. "But," he also said, "the officiating devil is not very difficult to trick." You can trick it with a cup of tea, a walk, a question, a blessing, appreciation. It isn't that complicated. The really important things are simple, the sages like to say. It simply takes attention. Even the most harried person can sit a little while with a cup of tea. To be "in the moment" is within anyone's reach.

I've found that many people don't like to be told that. Makes them cranky. Nevertheless, it's within anyone's reach, the now, the true present, the expansive moment in which one meets oneself and does . . . nothing. "Just visit," as they say in Texas. Be with the moment, which (the Zen guys are right) is yourself.

You can do it. Have a cup of tea.



Michael Ventura's biweekly column appears in the Austin Chronicle
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The Precarious Present

Why is it So Hard to Stay in the Moment?

By Robert Scaer

"I just can't seem to stop my mind," Linda told me. "I try to relax, but after a few moments, my brain starts to buzz again with a jumble of thoughts and feelings. I can't seem to turn them off." As she spoke to me during our second visit, she was visibly distressed. She had the pinched face and hunched shoulders of someone who felt at once threatened and helpless.

"Lots of times, it's the same old thing, just the same old negative thoughts and worries and blaming myself," Linda went on. "Sometimes I try to head them off by going out for a run, but they come back later. When they really get ahold of me, I get kind of shaky, dizzy, and sick to my stomach. If they go on long enough, I actually get a stiff neck, and eventually a headache."

A client's negative, intrusive thoughts are a therapist's stock and trade. Ditto the accompanying roster of bodily complaints, from stomach pains and neck tightness to headaches and back problems. In my 20 years as medical director of a multidisciplinary chronic-pain program, I've found these body-mind intrusions to be a sort of generic marker for significant emotional disorders, including depression, anxiety, post-traumatic stress disorder (PTSD), and adjustment disorder.

But if Linda's distress seems familiar, it isn't just because we see this kind of client so frequently in our offices. It's also because her complaint rings true for "healthy" people like ourselves. All of us ruminate, bringing up the cud of old memories and unresolved problems, in the process experiencing a sinking feeling in the stomach or perhaps a tightening in the throat. As we well know, these experiences usually arise unbidden and often at inopportune times, such as when we're reading a book, eating a meal, or even, God forbid, making love! And when we're interrupted in this way, we basically lose it: we forget why we went into the bedroom, we lose track of our place in the book, and, if the intrusion is upsetting enough, we may even lose the wherewithal to continue with what's going on right now. We've experienced that most insidious of insults to our mind--the corruption of the present moment by emotion-linked memory.

When we catch ourselves in this state of nonpresence, we're likely to chalk it up to "mind chatter." When a client reports these repetitive intrusions, we may wonder about a tendency toward obsessiveness or the possibility of depression and/or anxiety. While all of these interpretations may have some validity, I believe that much more is at stake. I propose that in many of these moments of body-mind intrusion, our brain is trying to protect us from mortal danger arising from memories of old, unresolved threats. In short, we're in survival mode.


"Ordinary" Trauma

To understand the meaning of these everyday emergency responses, and to transform them into opportunities for healing, we first need to rethink our fundamental assumptions about trauma. I propose that the sources of trauma are far more complex than the standard Diagnostic and Statistical Manual (DSM) definitions. Under Criterion A, the DSM-IV defines trauma as the result of having "experienced, witnessed or been confronted with . . . actual or threatened death or serious injury . . . to self or others" and responding to that event with "intense fear, helplessness or horror."

This definition isn't wrong, but it's woefully incomplete. In fact, any negative life event occurring in a state of relative helplessness--a car accident, the sudden death of a loved one, a frightening medical procedure, a significant experience of rejection--can produce the same neurophysiological changes in the brain as do combat, rape, or abuse. What makes a negative life event traumatizing isn't the life-threatening nature of the event, but rather the degree of helplessness it engenders and one's history of prior trauma.

Let's look at the first criterion--the person's relative state of helplessness in the face of a threat. We can often avoid being traumatized by an actual life threat if we remain in control of the situation, either by effectively fighting back or escaping the situation. If we've adequately defended ourselves, our survival brain doesn't need to store the body-mind messages of a trauma as an ongoing warning signal. But if we haven't prevailed--if we couldn't avoid the oncoming car or fend off the mugger--the brain remembers that experience as mortally threatening.

The second precondition for the development of trauma is one's storehouse of prior trauma. If you endure a relatively minor negative life event that somehow reminds you of a prior event in which you were helpless, trauma can result. Let's say you're facing surgery of a fairly safe and common sort--say, a cataract removal. For many people, the procedure would be relegated to the category of "unpleasant but bearable." But for you, this situation brings back memories of having your tonsils out when you were 6. Your parents weren't allowed in the operating room with you, and you briefly saw a scary, sharp instrument, and, all in all, you felt helpless and terrified. (You may be conscious of these memories, or you may simply be aware of a tightening in your throat or the desire to scream when you think of the upcoming cataract procedure.) Because your survival brain still thinks it's in danger from that tonsillectomy, it'll store this new, similar experience as dangerous by association. Not only will you experience the cataract operation as traumatic, but you'll also be even more vulnerable to trauma during the next medical procedure you undergo.


All of us, clients and professionals alike, will continue to set ourselves up to be retraumatized until we recognize that many of our negative intrusive thoughts and sensations are, in fact, symptoms of trauma. They may not be identified as such in the DSM-IV, but these more commonplace body-mind invasions assume the same meaning, if not the intensity, as the trauma-related thoughts and flashbacks of full-fledged PTSD. In both PTSD and what we might call "ordinary" trauma, conscious and unconscious memories brutally intrude upon and corrupt the present moment. Not everyone suffers from PTSD, but each of us has sustained many of these smaller traumas, setting us up for being continually shoved out of the present moment into a frightening, helpless past.

Who Cares about the Present?

In psychiatrist Daniel Stern's model, the "present moment" is a brief period--lasting perhaps 1 to 10 seconds--that represents our conscious experience of the here and now. Only in the present moment can we fully live. If our "nows" are perpetually interrupted by intrusive memories, we're essentially stuck in a time warp formed by those stored perceptions. We can't problem-solve, we can't experience a daffodil or a sunset, we can't relate to other people, resolve old conflicts, or form new attachments. Only in the here and now can we directly experience, and move ahead with, our lives. The present is indeed a precious commodity.

Yet we repeatedly squander it. Therapists most readily witness this dissipation of the present moment with certain clients, the ones who focus obsessively on ancient complaints and worries to the exclusion of creative or productive ideas that might help them move forward. Many of these clients also complain of various aches and pains, most commonly gut symptoms, such as acid reflux or irritable bowel, or chronic pain in the head, neck, or back.

But if we're honest, we also recognize this corruption of the present in our own lives. How often do we find ourselves ruminating about this or that familiar resentment or well-worn worry? How often do we truly notice where we are, whom we're with, or what's actually happening--that is, experience our own precious moments? It's as though some dark, implacable entity invades our minds and bodies and fills them to the brim, leaving little space for pleasure in our aliveness, much less for growth or healing. That entity, I believe, is the total body-mind experience of a past trauma.


Remembered Horrors

Let's take a moment to look at the two primary types of memory that contribute to trauma. One type is emotion-linked conscious memory, which gives rise to the intrusive, troubling thoughts we keep experiencing. These thoughts arise from some little cue in the environment that reminds us of an unresolved conflict. For example, you may be balancing your checkbook when your mind suddenly jumps to the letter you received years ago from your ex-wife's lawyer demanding an accounting of your income and threatening to haul you into court if you didn't comply.

At other times, intrusive thoughts may pop up from a purely internal cue. You may be thinking about vacation plans for a trip to Hawaii when you flip to the memory of losing your luggage, includi­ng all of your money, in the Honolulu airport on a prior trip. Since you often don't consciously notice these cues--they can flit through the mind in a millisecond--you often find yourself bewildered by a sudden change in mood. You'd been feeling perfectly fine; why, now, do you feel so scared or so oddly dispirited?

And why, for that matter, are you clenching your teeth so hard your jaw hurts? Another kind of memory is at work here: the hardwired recollection of what the body experienced in trauma. Acquired in a flash and stored for a lifetime, these unconscious, procedural memories serve as survival mechanisms, ready to be unleashed instantly in the face of present, perceived danger. The clenched teeth that kept you from crying when you lost all your luggage now sets in whenever you plan a vacation; the spasm in your neck that started after a long-ago car accident now occurs whenever you're stuck in traffic; the cramping you felt in your gut whenever your father harshly scolded you now hits whenever your boss gives you feedback about your work performance. All of these bodily reactions serve as warnings from your survival brain that an old danger has resurfaced. It signals: Watch out! You're in big trouble! Right now! In these everyday circumstances, we experience a terrifying past exactly as though it were the present.


The Trauma Capsule

It's vital to recognize that our memories of a traumatic event reflect that event precisely. So what we've got is a sharply defined and bounded state, or capsule, containing all of the pertinent stored memories for each traumatic experience we've endured. My patient, Linda, for example, can't stop the loop of negative memories of the gender discrimination she experienced on the job last year. Although she came to the job with management experience, she was assigned menial tasks, such as running errands to the office supply store. Worse, she was repeatedly the target of sexual innuendos from her older male boss. When she complained, the harassment ceased. Briefly, she felt empowered, but not for long: Linda was passed over for her next promotion, one she'd worked hard for and knew she deserved. Because she was paying back a college loan and had minimal savings, she couldn't quit--at least not right away. She felt trapped and helpless.

Now, memories of the experience intrude on her consciousness in a host of situations--whenever she's short of money, whenever she gets into an argument with her boyfriend, whenever she has to deal with any male authority figure. She experiences intrusion on the present moment by a kind of internal "capsule" reflecting all of the conscious and unconscious memories of her job experience--cognitive, emotional, and bodily. Simultaneously, she's assaulted by thoughts of her mistreatment, feelings of shame and anger, and a host of unpleasant physical sensations--the same tight neck and gut cramps she experienced at the time of the original trauma.

When these kinds of memories arise, they corrupt the present moment by inserting past events into present perception. If the original trauma was severe enough, such as assault, it can feel as though one's actually reliving a horrifying past event, as in a flashback. For "ordinary" trauma, such as repeated job discrimination, it can ignite the volatile compound of distressing thoughts, emotions, and autonomic states that Linda experienced. Because I view dissociation as the perception of past as present, I call this phenomenon the dissociative capsule.

The Body under Siege

We often misunderstand the physical symptoms of the dissociative capsule as somatization disorder, which is defined as the intrusion of persistent somatic symptoms that don't reflect an actual physical disorder. But the symptoms I've been describing are genuine physiological disorders. The more clearly we understand this reality, the better able we'll be to help our clients in distress. Let's look at how these physical symptoms are produced.


In the traumatized person, the muscle spasm that causes the neck pain and the abnormal motility of the gut that causes the cramps are actual physical phenomena triggered by the somatosensory and autonomic procedural memories of the original traumatic experience. Somatosensory memories include all of the sensations and the exact pattern of muscle activity that accompanied the trauma, such as the tightening of neck and jaw muscles. Autonomic memories, both sympathetic and parasympathetic, are often experienced as visceral sensations--a pounding heartbeat, cold sweaty hands, and pressure in the chest. Initially transient, these bodily changes can eventually lead to chronic disease. Numerous studies suggest links between early trauma and the development of fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chronic back pain, and a variety of autoimmune diseases. The body remembers, and keeps on remembering.

Dissociation by Degrees

Each of us has our own, distinctive cache of dissociative capsules. The number of life traumas one has sustained will determine the number of capsules stored in procedural memory: there may be a few or there may be dozens. Many factors determine the size and intensity of each. A large, complex capsule created by severe and repetitive childhood trauma may intrude on the present moment repeatedly. In such cases, the present moment may be obliterated most of the time, causing maturational arrest at the age of the most severe trauma. This situation may explain the remarkable maturational suspension seen in such syndromes as borderline personality disorder and other severe attachment disorders in which the "self" may be stuck in the first decade of life. But it's important to remember that these dissociative states may form even in cases of "ordinary" trauma. Recall Linda's experience of gender-based job discrimination: because she suffered not merely shame, but shame in the context of helplessness due to her low rank in the corporate pecking order, her experience was genuinely traumatic.

Viewed from this perspective, one can see how many of the "little" conflicts associated with cultural and institutional bias can assume the dimensions of traumatic stress. In my own medical practice, many female patients who've struggled with persistent job discrimination have developed chronic fatigue syndrome, physical collapse, and even PTSD. Other patients have developed PTSD following their experience with an adversarial justice system during a plaintiff lawsuit following an auto accident.


For those who bear an existing burden of childhood trauma, even more "trivial" incidents can cause new trauma. I've treated hundreds of patients with full-blown PTSD following auto accidents occurring at speeds under five miles per hour. For these highly sensitized individuals, it isn't the accident per se that caused trauma, but the triggering of a dissociative capsule of earlier, unresolved trauma that transformed an unpleasant hassle into a genuine catastrophe.

Treatment: Mere Words Aren't Enough


Trauma healing, in essence, is the recovery of the purity of the present moment. This concept has vital implications for trauma therapy (which, from here on in, should encompass treatment for "ordinary" as well as extraordinary trauma). The bottom line: therapy must adequately address the body-based procedural memories that form a large part of the trauma structure.

Unless we can expunge the somatic contents of the dissociative capsule, they'll continue to emerge with every triggering event, contaminating the present moment and promoting further sensitization to trauma. But if we can find a way to extinguish these somatic cues, the accompanying emotions and autonomic feelings will also be neutralized, rendering the capsule inoperative. Emotions and autonomic states are inevitably associated with "feelings"--the body sensations directly linked to those states. Without the "feelings," the emotions and autonomic state have lost their threatening meaning for survival. The declarative memories of the event will remain, but in the absence of sensations and emotions, they'll be experienced as past events--period. The present moment will be liberated.

So, how do we get from here to there? The royal road to the present moment, I believe, is through the emotional brain. We know that the limbic nucleus, the right amygdala, evaluates the emotional content of incoming sensory stimuli. If stimuli imply threat, the amygdala triggers arousal, unless, somehow, it can be persuaded to go off duty. In his book The Feeling of What Happens, noted neurologist Antonio Damasio describes a woman with bilateral injury to the amygdala. Via personality and psychometric tests, Damasio discovered that while she remained functionally normal, she'd lost the capacity to experience fear or rage. Is it possible, then, that someone without a functioning amygdala would be incapable of being traumatized?


This hypothesis seems well worth exploring. If we can find a way to shut down the right amygdala while a client is exposed to the contents of the dissociative capsule, we should be able to extinguish its contents. With the amygdala "off-line," the traumatic memory would no longer be associated with the somatic cues of arousal--the tight chest, the pounding heart, the constricted throat. These symptoms would no longer intrude on the present moment. Procedural memories of the trauma--both bodily sensations and emotionally linked memories--would no longer convey threat in the here and now, because they'd accurately be perceived as old memories. We'd find ourselves restored to the present moment, in all of its richness and possibility.

Retraining the Brain

What therapeutic processes might convince the amygdala to "down-regulate?" I'm not touting any specific approach. But what we know about the neurophysiology of trauma suggests that some of the so-called somatic and energy therapies, such as Somatic Experiencing, EMDR, Emotionally Focused Therapy (EFT), and Thought Field Therapy (TFT), may be particularly well equipped to escort a traumatized person from the past back to the present. Let's look at how these approaches might fulfill some fundamental needs of trauma healing.

Integration of the cerebral hemispheres. The functioning of the left cerebral hemisphere is a brain state that's normally inhibited during arousal. Theoretically, bringing the left brain back "online" and integrating the left and right hemispheres would interfere with, and inhibit, the independent function of the right amygdala. Alternating visual, tactile and auditory stimulation might well integrate the two sides of the brain and down-regulate the right amygdala while the patient imagines the traumatic event, thereby removing the arousal charge.

Brain integration may explain why some of the seemingly bizarre repetitive behaviors of energy therapies seem to produce dramatic results for some patients. The alternating sensory stimulation of EMDR, as well as the eye-rolling, counting (left hemisphere) and singing (right hemisphere) employed by EFT, may help to integrate the brain hemispheres and thereby relegate traumatic memories to the past. The EFT practice of repetitively tapping acupuncture meridian points, which promotes autonomic homeostasis, may also put the brakes on brain arousal.


Ritual. This is often part of the healing process in non-Western and especially indigenous societies, where it's often practiced by tribal healers or shamans. Rituals often involve repetitive behaviors, such as drumming, dancing, or singing, and frequently induce hypnotic trance states. The use of hypnosis in healing trauma may have its roots in this process. In addition, social rituals may activate the anterior cingulate, the part of the cortex that's known to inhibit the amygdala. We know that the anterior cingulate plays an important role in mother-infant and social bonding, a state that may be replicated by social ritual. The potency of ritual also may explain the impact of the eye movements of EMDR, the tapping procedures of EFT and TFT, and the repetitive affirmative statements of the latter two approaches.

Empowerment. This is the ultimate goal of all trauma therapy. To heal, an individual must recover from the state of helplessness that defines the trauma experience. During a traumatic event, a person experiences physical helplessness and effectively freezes into that state, leading to all manner of pain and illness. To recover, one needs a way to thaw out the body.

This "melting" process is at the heart of Somatic Experiencing, a body-based therapy in which one accesses the felt sense of the trauma and allows the failed motor defense to emerge in the form of a "freeze discharge," wherein the individual moves out of immobility into an effective fight or flight response. This ability to achieve discharge can be facilitated via a number of other somatic approaches, including dance, balance, equestrian therapy, and art therapies. What these approaches have in common is their capacity to access the freeze discharge and extinguish somatic procedural memories through completion of the bodily act of defense or escape. This completion at once permits and celebrates reempowerment.

Making meaning. Talk does play an important role in trauma therapy, but not as the first order of business. Once the contents of the dissociative capsule are extinguished, client-therapist conversations can help to provide the client with conscious, cognitive meaning and perspective. Talk can empower a client with the knowledge that the occasional recurrence of residual somatic symptoms--a sudden bout of nausea, a strangled feeling in the throat--actually represent an event from the past, and not an imminent threat that wipes out the here and now.


All in all, perhaps this is the most important lesson of trauma recovery: we never do quite fully recover. After all, our trauma memory capsules are nothing less than survival mechanisms, working in tandem with the amygdala to try to keep us alive. As one would expect from a primitive survival mechanism, it can never be totally extinguished. (Recall that after many years, Pavlov's dogs were reconditioned to the bell with just one trial.) Our stored memories of personal danger are fierce, focused, and highly motivational.

Of course, we can make enormous strides in discharging the contents of our trauma capsules, especially via approaches that address our body-based memories. But as we make our vital journeys back to the present, we'd do well to cultivate an attitude of gentle acceptance. For it's quite possible that all the body-based therapy in the world, plus regular infusions of meditation, running, yoga, and other mindfulness practices, won't be enough to keep us permanently anchored in the here and now. It seems we just aren't wired to live there fulltime. But we can make extended visits. And when we do, we can explore the lush landscape of the present moment with more wonder, wisdom, and pleasure than ever before.

Robert Scaer, M.D., was formerly associate clinical professor of neurology at the University of Colorado Health Sciences Center in Denver, Colorado. He's published numerous articles and two books addressing the neurophysiology of trauma, diseases of trauma, and concepts of healing: The Trauma Spectrum and The Body Bears the Burden . Contact: scaermdpc@msn.com

 

 

 

The Art and Science of Love

Can the Gottmans Bring Empirical Rigor to the Intuitive World of Couples Therapy?

By Katy Butler

Throughout the 1980s and 1990s, in a specially outfitted studio apartment in Seattle that reporters nicknamed the "love lab," mathematician-turned-psychologist John Gottman videotaped ordinary couples in their most ordinary moments--playing solitaire, chatting, kissing, disagreeing, watching TV, cooking dinner.

Sometimes Gottman, then a professor at the University of Washington, asked them to discuss an area of conflict while monitors strapped to their chests recorded their heart rates. Sometimes he sat them on spring-loaded platforms to record how much they fidgeted. He looked at how they brought up painful subjects, how they responded to each other's bids for attention, how they fought and joked, and how they expressed emotion.

Funded by the National Institute of Mental Health, he and his colleagues studied newlyweds, men who battered their wives, couples who shouted a lot, and others who beat around the bush and never raised their voices. He used an elaborate coding system to track not only their verbal exchanges, but less obvious indicators of emotion: flickering facial expressions, sighs, clammy hands, rolling eyes, and galloping heartbeats. He followed some of the couples for more than two decades, recording who got divorced, who established parallel lives, and who stayed together--more or less happily.

He then took his data and translated them into numbers, quantifying an area of human life usually relegated to the psychotherapist and the novelist. Using complex computer models, he found that he could predict divorce with 91-percent accuracy, simply by analyzing seven variables in a couple's behavior during a five-minute disagreement. What he discovered made him famous. He appeared on network television and was immortalized by Malcolm Gladwell in Blink. Most of what we reliably know about marriage and divorce in its natural state comes from his work.

In the course of studying more than 3,000 couples, Gottman discovered that most of them fought, and that even the most happily married couples never resolved 69 percent of their conflicts. When they returned to his lab at four-year intervals, the issues and even the phrases were essentially the same. Only their clothing and hairstyles changed.

 

What was crucial, Gottman learned, wasn't whether a couple fought, but how. Among those couples whose marriages survived well, whom Gottman and his colleagues came to call the "masters of marriage," wives raised issues gently, and brought them up sooner rather than later. Neither husbands nor wives regularly became so upset with each other that their heart rates rose above 95 beats a minute. They broke rising tension with jokes, reassurance, and distractions. They didn't escalate their arguments.

Faced with a request or complaint from their wives (and 80 percent of the complaints did come from wives), the successful husbands didn't play king or cross their arms like rebellious teenagers. Instead they changed their behavior--doing more dishes, working fewer hours, giving more than lip service to their wives' dreams, or taking an older child to the park to give an exhausted new mother a break. When news of these findings hit the newspapers in the late 1990s, my boyfriend at the time called it the "yes, dear" path to marital harmony.

Perhaps most notable, the master couples made at least 5 positive remarks or gestures toward each other for every zinger during a fight ; in calmer times, their positive-to-negative ratio was an astounding 20 to 1.

The "masters of disaster" in Gottman's study group--those who eventually divorced--fought differently. Wives raised issues harshly--especially when their husbands ignored them or put them down. (He named the wives' openers "harsh start-ups.") The husbands got upset more easily during arguments like these and had a harder time calming themselves down. And 94 percent of the time, conflicts that opened harshly didn't get any better as they went along.

Rather than complaining about specifics, the wives frequently globalized their criticisms, using phrases like "you never" and rhetorical questions like "What's wrong with you?" The husbands, for their part, frequently shut down, playing emotional possum or becoming as blank as a cement wall. The reverberation between them was so toxic that Gottman named criticism and stonewalling as two of his Four Horsemen of Marital Apocalypse. (The other two are defensiveness and contempt.) The presence of the Four Horsemen alone, he found, combined with pulse rates that rose above 95 beats per minute during a disagreement, were highly reliable predictors of divorce.

The background music of the less successful relationships, not surprisingly, was halting. In both happy and unhappy couples, partners made plenty of subtle bids for attention, closeness, or reassurance. But the partners headed for divorce responded to each other's bids only 33 percent of the time, while the happy couples' response rate was 86 percent.

 

Finally, Gottman's research showed him that it wasn't only how the couple fought that mattered, but how they made up afterward--what he called a "repair," echoing the language of engineering. In a longitudinal study of 130 newlywed couples published in 1998, Gottman found that 83 percent of marriages initially exhibiting the Four Horsemen became stable over time, as long as the couple learned to reconcile successfully after a fight.

Then in 1994, John Gottman went canoeing in Puget Sound off Orcas Island with his wife, Julie Schwartz Gottman, an experienced clinical psychologist in her own right. Mindful of the dismal showing of most existing couples therapies in outcome studies, he suggested that they combine his research and her therapeutic wisdom to fashion a science-based couples therapy.

They began writing a manual that night. Later they organized weekend workshops and started a Seattle clinic eventually staffed by 16 clinicians. In 1998, they began leading advanced trainings for therapists. By 2004, 4,000 couples had gone through their workshops or their clinic. By 2006, more than 3,000 therapists had taken a basic training workshop with them, 65 therapists had been certified in their approach, and 600 more were well on their way to certification.

The Gottmans call their new approach Gottman Method Couples Therapy. It braids together classic therapeutic skills with two new elements: scientific dispassion and scientific authority. The dispassion comes from their extensive use of assessment and feedback, a legacy of John's research training. More than 30 pen-and-paper questionnaires are methodically administered to each partner before therapy begins; videotaping and heart-monitoring are part of therapy itself. The authority comes from the research showing that therapists using this approach can decisively stop their clients from exercising the Four Horsemen of contempt, criticism, defensiveness, and stonewalling. They can teach their clients the behavioral skills used by Gottman's "masters of marriage," including little kindnesses that build a strong marital friendship, and tools to regulate conflict. Perhaps most important, the dispassion, structure, and authority of the approach act as counterweights to the discouragement and chaos often generated by couples in trouble--emotional storms that blow many a therapist into taking sides or losing control altogether.

Last April, Brian, my almost husband, and I flew from San Francisco to Seattle to attend a two-day weekend couples workshop with the Gottmans called "The Art and Science of Love."

 

Starting Out

An old joke says that women marry expecting men to change, and men marry expecting women not to. Even though we aren't yet married--we're both long divorced from other people--Brian and I fill that bill. I want him to dress better, set limits with his adult sons, and change his job. He wants me to lighten up. After seven years together, he still leaves me notes saying how much he loves me, and I still bring coffee and the newspaper up to our bedroom on Saturday mornings. But much as I hate to admit it, if John Gottman installed a video camera in our home, he'd sometimes catch us cohabiting with the Four Horsemen. I'm a master at the harsh start-up. I've ambushed Brian with pressing concerns when he's still half-asleep, rolled my eyes contemptuously during arguments, and couched my complaints as variants of "What's wrong with you?"

Brian, for his part, has often promised to consult me before inviting his sons to stay with us--and hasn't. I moved into his house six years ago, and I still sometimes feel perched there, overwhelmed by free-floating testosterone. He doesn't always keep agreements, and when I want a straight answer, he can fend me off with stonewalling and an evasive Irish-American jokiness that drives me up the wall. By the time we flew to Seattle, we'd begun avoiding some of our most tender differences rather than risk a fight.

That, in a nutshell, is our shared emotional climate at 9:40 a.m. on a windy Saturday last spring. We sit together in the front row of a huge conference room, packed with couples in similar straits, not far from the old Seattle World's Fair Space Needle. John and Julie Gottman are standing in front of us, warning us about the Four Horsemen, and suggesting that instead of tackling our most upsetting issues head-on, we start obliquely, building a "culture of appreciation" for each other. In sum, they want us to improve our background music.

"If you make a very small correction," John Gottman says, "doing stuff that seems natural and small, over time, it'll make a big difference." The idea is to fiddle with thousands of tiny daily interactions--things so seemingly trivial that it's hard to imagine they'd make any difference at all--as if we're fine-tuning a complex carburetor.

 

"You build romance and passion and great sex through little moments," he goes on, citing tidbits of his research showing that unhappy couples often respond positively to each other--just not often enough. He's 64 and slight, with a white beard and luminous eyes. He's wearing a bright-red tie and a yarmulke, but there's something about the way he sometimes throws out terms like "vasoconstriction" and "chance levels of prediction" that makes it easy to imagine him in a white lab coat.

I wonder if Brian is getting bored.

John's wife Julie, who's the copresenter of the workshop, is 55, zaftig, humorous, and easy, with long, curling, black-gray hair and the full, low, soothing voice of a practiced psychotherapist. She wears sensible shoes and a therapist-as-priestess black and white kimono, banded with images drawn from Haida Indian totem poles.

Joining Brian and me in the audience are about 200 other couples from many states in the union, in varying states of wedded bliss and distress. Most have paid $600 to be here. Some women lean forward, their expressions hopeful, rapt, or desperate. Some men sit back with their arms crossed, like attendees at a weekend traffic school.

Sometimes I poke an elbow into Brian to underline a point. Every now and again he whispers to me, "Let's acknowledge the men!" amazed that so many have agreed to be here on the opening weekend of the NBA basketball playoffs.

On our laps are melon-colored, three-ring binders entitled "The Art and Science of Love." What differentiates this workshop from others on the market, the binder says, is that it's grounded not in idealistic notions of what marriage ought to be, but on "solid research on what actually works in relationships that are happy and stable."

Embedded in this sentence is a clinical hypothesis: that unhappy couples can be taught to do what happy couples do. This assumption underlies not only this workshop and Gottman Method Couples Therapy, but also aspects of cognitive-behavioral therapy, the Positive Psychology movement, and Marsha Linehan's Dialectical Behavior Therapy.

 

The hypothesis assumes that unhappy couples have the maturity and the emotional wherewithal at least to try to treat each other differently. I wonder if that's true for me.

There's another difference between this and other couples approaches that the binder doesn't mention: the Gottmans' work is men-friendly. Some of the language that their therapy uses--"relationship repair," "overrides," and "harsh start-ups," for instance--could have come from a car-repair manual. It's a dirty little secret that men are often dragged to couples therapy, and feel emotionally illiterate or ganged-up-on once they get there. The exercises in our binders, however, look doable, practical, and circumscribed, rather than like an endless dive into the amorphous emotional depths.

The workshop's goal is to help us learn to imitate Gottman's long-married master couples. The bedrock of their successful relationships, it's explained, is marital friendship, built granule upon granule, through tiny rituals of courtesy, kindness, humor, and appreciation. Successful couples, have large "cognitive maps" of each other's worlds. They're curious about each other's inner lives, and they don't stint on expressing their appreciation for each other. When one of them makes a subtle bid for attention--something as simple as "look at the pretty boats"--the other one usually responds positively.

This system of mutual stroking, according to the Gottmans' model, produces "positive sentiment override"--an emotional tipping point that allows spouses to think, in tense moments, "My sweetie must be having a hard day" rather than "What a jerk!" or "He doesn't love me." And that makes it easier to disagree without being disagreeable.

It all seems eminently doable, but I'm not convinced. For me, the complex weather of human relationships conforms more closely to the dynamics of chaos theory than to Newtonian physics. The Gottmans' structure seems too linear and mechanistic. But maybe, I think with a glance at Brian, who's paying close attention, it's an image that works for men.

In unhappy couples, the presenters continue, the relative dearth of positive feedback engenders a destructive cognitive shift over time to "negative sentiment override"--essentially, assuming the worst about one's partner. This leads to what John Gottman calls the "fundamental attribution error"--a default setting of blame, in which all the problems in the relationship are the partner's fault. Fights escalate and become a contest of wills, replete with the Four Horsemen. Both partners get painfully flooded with emotion and sometimes withdraw. Over time, this can result in a cascade of isolation, distance, loneliness, parallel lives, and eventual divorce.

 

When I hear this, I think of the morning 15 years ago, not long before my marriage ended, when my former husband sat opposite me at our kitchen table and gently stroked my head with the tip of a three-foot dowel, like a lobster using his antenna to groom a mate he dared not touch.

But that was a long time ago. Today, in a series of unthreatening exercises, I have a chance to do things differently. During the weekend, the Gottmans explain, Brian and I will be taught how to put deposits in our joint "emotional bank account" and engender "positive sentiment override." We'll learn to soothe each other and ourselves. And finally we'll develop ways to manage the conflicts we can't resolve, honor each other's dreams, and create a life of shared meaning.

No longer drifting in a river of emotion, I find myself looking at our relationship dispassionately, with the mind of a scientist. I realize how often Brian pays me compliments, and how seldom I compliment him. I ask myself: Why not be nicer? Where's the risk? "I don't give as many small things," I write in my notebook. "I need to criticize less. I need to learn softened start-up. I need to listen when he's overwhelmed. I need to learn when I'm overwhelmed."

And when John Gottman says how important it is for men to make cognitive room for their wives' dreams and accept their wives' influence, I think of times I've felt run over or ignored, and I give Brian an elbow-poke.

A few minutes later, the introductory lecture concludes and the Gottmans send us out to adjoining breakout rooms for the "Love Map," our first partner exercise. We find two chairs facing each other and begin. One by one, Brian and I turn over cards we've taken from a plastic pocket in our binder and guess the answers to questions like, "Who is your partner's best friend? What are his or her dreams and aspirations? Who is his or her favorite poet?"

I miss his favorite magazine-- Mother Jones --but get both of his second choices right-- Rolling Stone and Time. He gets all of my magazines right except The New Yorker. I name his best friend and he names mine, but I realize there are two women whom I talk to daily whose names he doesn't even know. These women are aware that I dream of selling my house in Mill Valley and building a straw-bale house from scratch in the dairy country near Tomales Bay, and going there to write. I've never told Brian about this dream. Mired in our day-to-day struggles, I realize, we seldom talk about our larger hopes and aspirations.

 

I miss his favorite poet--John O'Donohue--but get the next two right--Uriah Mountain Dreamer and Mary Oliver. He misses my favorite poet--Mary Oliver--but gets the next one right: Jane Hirshfield.

We feel close and happy. This is fun. Brian loves the exercise. He says he wants us to do this once a month when we get home.

So the day goes. Every hour or so, after a minilecture and a role-play from the two Gottmans, we stream out of the auditorium with our binders into adjoining breakout rooms to do little exercises with our partners. Along the walls stand roving therapists certified (or close to being certified) in Gottman Method Couples Therapy. Every now and again, a distressed or confused husband or wife holds up a small red card--like the penalty card in soccer--and a clinician quietly moves in like a therapeutic AAA truck to coach them.

Now we pick from a deck of "opportunity cards" that suggest ways we can turn toward each other. Brian nixes the notion of spending an evening discussing what I'd like to change about the interior of the house, but promises to plan a weeklong getaway when we get home. He turns down my offer to bring flowers home, but asks me to surprise him with tickets to a concert. We look down a list in the binder and circle things like "doing a favorite activity together," "playing together," "taking vacations together," and "time to make love." It's shocking to realize how hard we work, how long it's been since we went biking together in the country, and how much we'd like to do it again some time.

We're working behaviorally, moving up stair-steps like the itsy-bitsy spider, building the foundation of what the Gottmans call our "sound relationship house." The structure resembles Abraham Maslow's hierarchy of needs--starting with a solid friendship, proceeding to negotiating conflicts, and then to higher-level relationship needs. The Gottmans' goal isn't for couples to achieve a relationship rivaling Antony and Cleopatra's, but rather to learn how to have a good-enough marriage. A marriage is good enough, John Gottman once wrote, "If the two spouses choose to have coffee and pastries together on a Saturday afternoon and really enjoy the conversation, even if they don't heal one another's childhood wounds or don't always have wall-socket, mind-blowing, skyrocket sex."

 

The day proceeds. Between exercises, we take breaks for tea and pile little paper plates with grapes and slices of cut pineapple. The Gottmans don't drag any of us onstage to open our hearts in front of strangers. They don't deliver any aren't-I-smart paradoxical interventions, tell us that men are from Mars, or teach us how to exchange quid-pro-quos, like "I'll do the dishes and stroke your back if you'll have more sex with me." They don't suggest that marriage is a sexual crucible, as David Schnarch holds, or that it's a God-given opportunity for deep emotional healing, as Imago's Helen Hunt and Harville Hendrix contend. They just want us to create small, gentle changes in the trajectory of our relationships--ones that might create big payoffs if practiced over time.

A good Gottman marriage, I start to think, is a bit like a 16-foot scale model of an ocean liner made from 194,000 toothpicks and seven gallons of glue. They don't want to us to remake ourselves from scratch. They're handing us toothpicks, some glue, and a blueprint.

Struggling to Open Up

The next exercise, after lunch, is a step more intimate. We turn to a checklist in our binders, choose three positive qualities we see in our partners, and tell each other about them.

Brian checks that I'm "thrifty," "creative," and "a great friend," and writes comments like "you know your limits . . . smart bright writer and teacher . . . I trust you."

I'm touched.

I decide he is "virile," "committed," "protective," and "playful," remembering how he took care of both of our airline boarding passes and insisted we squeeze in a ferry ride on Puget Sound before the workshop began.

He smiles.

Like many couples, we come back to the big room hand in hand.

Next, after Brian takes a break, hovering around the tables laid out with tea and cut fruit, comes practicing a "stress reducing conversation." Learning to buffer our relationship from the stresses of the world, the Gottmans say, is critical to maintaining closeness over time. This means being Brian's ally, his sympathetic ear, his cheerleader, and not his educator, coach, critic, or mentor--a big shift for me.

For once, I simply listen and accept when he tells me he's so stressed by his job that he doesn't have the energy to change it. Instead of giving him a checklist of things to do, I take in his exhaustion and fragility.

When it's my turn, and I talk about wanting to drop a work responsibility, he says, "What stops you from doing something about it?" I feel reprimanded. I ask him to just listen. Then I speak not only of my own driven work habits, but of my difficulty saying no and of the day long ago when my beloved father beat me badly when I was caught after running away.

Brian takes my hand, looks in my eyes, and tells me he's never before really "gotten" what my childhood was like. He has tears in his eyes.

What we've just done together sounds so innocuous--a standard-issue exercise in reflective listening. I've done things like it before, although never with someone I'm so close to. And we've gone deeper than I expected. This isn't territory the Gottmans warned us about. I wonder if there are hidden reasons why Brian and I don't treat each other better, and marvel at how easily intimate partnerships can reawaken the hurts of our first deep connections. For a long time--perhaps since the end of my marriage, perhaps since childhood--I've been Miss Hard-Boiled, making sure I didn't risk too much closeness. Now that I've been more open with Brian (and vice versa) my heart hurts.

As it turns out, I'm not alone. Others in the rooms here seem to have emotional reasons--far deeper than mere ignorance or lack of skill--for not being able to "act as if" and do what happy couples do. A man to my left spends big chunks of time either reading the New York Times sports section or sitting with his eyes half-closed. To my right, before another exercise, one woman stays behind in the auditorium, hanging onto her husband and sobbing inconsolably. I wonder about her story: what long-ago childhood betrayal or recent affair fuels her tears? Another man and woman stand outside smoking in the courtyard, not talking, not touching, just staring into space. Are they too far down the "distance and isolation cascade" to turn back? Around the breakout rooms, red cards fly up. Two sets of chairs away from us, a man points to his wife accusingly. "I saw it!" he says. "You rolled your eyes! That's contempt!"

 

That night, Brian and I have a lovely dinner at an Italian restaurant across from our hotel. We bemoan the fact that we didn't set aside a few extra days just for fun, and swear we're going to come back to Seattle again sometime without work obligations. As we look over the bill and recap the day, Brian casually says, "I don't know about the love maps. What difference does it make if I know who your favorite poet is?"

This strikes one of my enduring vulnerabilities: my fear of never being known or understood. Quicker than thought, I say harshly, "You're missing the point." In his eyes, I see reflected the altar boy he once was, being reprimanded by a nun. For a moment, the good feelings of the day are scattered like toothpicks.

We've been here before: what the Gottmans would call my "harsh start-up" has hurt what I'd call the little boy inside my man. Brian starts a slow, sustained, invisible burn. It's little comfort to me that Gottman found many couples like us when he did his research: sensitive couples who easily got hurt; men incurious about their partner's life; women who felt ignored and therefore hit their men over the head with a rhetorical two-by-four to make a point. Those were the couples who often ended up getting divorced.

Later that night, we lie side by side on a huge king-sized bed. We aren't touching. It's a smoking room: the little hotel is full of couples from the workshop, and by the time we signed up, this was the only room left. The smell of smoke is in the air, especially now that we've closed the windows against the evening cold. Brian is on his side, turned away from me, angry.

"Nothing's ever good enough for you," he says.

I think of the toxic effects of the Four Horsemen, and that gives me the wherewithal to tell Brian that's a criticism rather than a complaint. Then, borne on the stream of the workshop, I reach out my hand and stroke his back. I hear two sets of footsteps, and a door open and close down the hall.

 

I stroke Brian's back and shoulder for a long time, as the light in the room fades. I wonder whether his heart rate is over 95 beats a minute, remembering John Gottman's remarks not long before the workshop day ended about the physical flooding or "diffuse physiological arousal" that often occurs when couples fight: cortisol is secreted, the heart races and the blood pumps, perceptions narrow, and the processing of new information virtually ceases. Men respond more intensely than women to a stressor, like a gunshot; they're more likely to sustain angry thoughts after a fight; and their hearts take much more time to slow down again. Through the years, this recurrent neurological cascade can damage men's immune and cardiovascular systems. This gender difference may help explain why women often are more wiling to engage in emotionally upsetting conversations than are men.

As I lie there, I also remember Julie Gottman telling us, in her soothing, therapeutic voice, that it isn't the fight that matters so much as how the couple repairs things afterward. So I murmur, doing my best to own my part in things, and to nudge Brian gently to forgive me. I'm not in a rush, happy simply stroking him, simply feeling his skin. Finally he makes a joke--the kind of thing Gottman says that his master couples do to break tension. He turns to face me, and when he's naked like this, his bright eyes and grey beard somehow remind me of the battle-scarred Ulysses returning, almost unrecognizable after 20 years, to his faithful Penelope.

Finally, after hours of closeness, we sleep.

Learning How to Fight

On the morning of day two of the workshop, the Gottmans show us that they, too, fight, and not always gracefully. They've been married for 20 years. Both were married before, they've told me, and both came from painful, though decidedly different, family backgrounds.

John was born in the Dominican Republic to poor Jewish refugees from Vienna who had lost 24 members of their extended families to the Holocaust. Julie was raised in Portland, Oregon, where her father was a successful doctor and her mother a depressed incest survivor. Her early family life was so painful that she often slept in the woods.

 

John found a refuge at MIT, in the precision of mathematics and science. He admits he was "clueless" about male-female relationships as a teenager, and later decided that since he wasn't succeeding at relationships, he might as well study them. Over the years, he slowly learned to imitate what his master couples did. Julie, by contrast, had visions in the woods calling her to become a healer. She became a clinical psychologist, working with trauma survivors and Vietnam veterans, and she served long apprenticeships with two American Indian medicine women. I sometimes I wonder how they ever learned to respect, much less integrate, their different ways of being.

The fact that it's not always easy is laid bare on Sunday morning, when they reprise an old fight and role-play "repair." Julie begins by describing how she'd woken up one morning having dreamt that John had been flirting with other women. Already anxious about an upcoming speech, she'd wandered into the bathroom, where John was brushing his teeth. She'd told him her dream. He'd murmured reassuringly and hugged her for what seemed to her like a few seconds and what seemed to him like a long, long time.

He'd turned away--abruptly, Julie thought--and she'd gotten into the shower, feeling even more alone.

Now John takes up the thread, describing how he'd thought to himself, Wait a second! He'd apologized to Julie for things he'd done in a dream --things he hadn't actually done and wasn't thinking of doing. Hadn't he been cleaning up around the house lately, the way she asked him to, without much acknowledgement? Hadn't he been cooking her lots of great fish dinners? She has some nerve, having this dream about me being a louse, he said to himself. Don't we have enough problems during the day without her making up new ones at night?!

Then before he knew it, John said, he was snapping at Julie, and she was standing in the shower in tears.

I glance down at the page in my binder entitled "Aftermath of a Fight or Disagreement" and its subheads: Share Your Subjective Reality, Find Something in Your Partner's Story that You Can Understand, Are You Flooded? Admitting Your Own Role, and Making It Better in the Future.

 

I think of times, in my marriage and in long-gone relationships, when I, like Julie, wanted reassurance and had gotten none. At such times, I'd usually decided that I'd picked the wrong man to be with. The Gottmans don't go there. I feel almost naughty listening in on their argument, as if they've raised a black curtain and I'm watching them pole-dance or violate some other cultural taboo. In this culture, very little gets said about the years after the honeymoon, the years that fairytales call "Happily Ever After" and Joseph Campbell called the "spiritual ordeal" of ordinary marriage. If Brian and I had an interchange this painful--and we did just last night, and haven't fully recovered yet--I'd be tempted to tell nobody for fear of hearing, "What a jerk! Why do you put up with him?" or "Why does he put up with you?"

Modeling imperfection for us, the Gottmans show the normality of relationship angst--even recurrent angst. On the surface, they're teaching us behavioral skills and evidence-based techniques--how to understand your partner's equally valid reality, and how to reconcile. But on the metalevel, what they're teaching doesn't come from John's research. It's wordless and embodied--a normalizing of the fact that little things can set off surprising ambushes of hurt in intimate relationships. After watching the Gottmans in action, Brian and I don't look so odd to me.

"My subjective reality is that I come from a background where I was beaten up," Julie goes on as they model the process of repair. "I don't have a lot of self-confidence, especially when I have to give speeches to powerful people."

"I dream symbolically," she continues. "The person in the dream becomes the symbol of someone who's hurting me."

"So I become . . . .?" interjects John.

"You're not supposed to talk now," Julie says quickly. "As a good little psychologist ( Do I detect contempt, humor, or just anxiety here? I wonder fleetingly), I thought you'd understand that my dream is sym-bol-ic. I needed you to be by my side, and you couldn't be, and I felt very alone."

Then Julie softens, moving to find something in her partner's story that she can understand. "You try so hard to be a good husband--and you are a good husband." She starts to sniffle.

 

"Are you flooded?" John asks gently.

"Yes I am," she says. She turns away and takes a few deep breaths.

"I'm a little flooded, too," says John. "Let's take a minute to calm down."

"I have been taking you for granted," Julie goes on after a pause. "Perhaps I haven't made time for good things between us because we're both so darn busy. And you have been making some fabulous fish dinners"

Now it's John's turn to share his subjective reality. "Things haven't been going the way I wanted them to at work," he says, referring to a major federal grant that hadn't come through. He adds, "I haven't had time to play music, and when I don't, I'm mad at the world."

A little while later, as they move toward making it better in the future, John asks, "Next time, would you tell me that your dream is symbolic, so I'm not expected to be a psychologist all the time?"

"What if I say, ´I'm so raw, so vulnerable, I really need a good long hug?'" asks Julie.

John hesitates, pauses, and agrees, without enthusiasm.

"Okay," says Julie. "We're done."

"No we're not," says John. "What's one thing you could do differently?

Julie cocks her head.

"I could start by saying, ´This dream isn't really about you,'" she says.

 

"That's great!" says John, with apparently genuine enthusiasm and surprise. "Okay! Are we buddies?"

If only it were that simple, I think.

A Fight That Deepens Connection

Now it's our turn. We stream out to the breakout room again. Brian takes an inordinately long time getting slices of pineapple and tea.

Our assignment is to take a minor, resolvable conflict and process it the way the Gottmans did. The binder tells us "there is no absolute 'reality' in a disagreement but rather two ´subjective realities.' "We are to practice "softened start-up" and making I-statements.

I glance over the cheat sheet in the binder's back pocket called the Repair Checklist. It contains suggested lines: "I feel defensive. Can you rephrase that? How can I make things better? Let's compromise here." I'm game.

I fetch Brian from the refreshment table. It dawns on me that he looks pale, and that he's not quite as enthusiastic as I am to go on. In the middle of the night last night--after hours of touching--he'd jumped out of bed, having dreamt that I was part of a conspiracy to assassinate him.

I open my binder to the appropriate page and ask him to look over my shoulder at the Chinese-menu list of relationship differences for us to choose from. Yesterday we'd added "television" and "whether or not to get married" to the list, on top of "handling finances" (I'm more frugal), "how to raise and discipline children" (I have none and he has two), and "alcohol" (he likes it and I don't).

"Can we just cool the jets?" he says. It's too much, he goes on. He wants us to sit this one out.

I don't want to say yes.

 

We raise our red card. A therapist comes over and suggests we try "television." That seems too trivial to me, while everything else seems impossibly sticky. As we wander desultorily toward the breakout room, Brian hangs a few steps back.

I want to do the exercise. I'm afraid that if we don't, I'll miss out, we won't learn how to reconcile after a fight, and my article won't pan out well. I'm thinking, Okay, I get it, Brian, you're overwhelmed. Now can we just please go ahead and do the exercise, please?

But now I'm stuck in an Escher-like paradox. In order to do the exercise, I'd have to violate the spirit of the exercise, which is to honor my partner's reality and be willing to compromise. In the Gottmans' lingo, I need to maintain an up-to-date cognitive map of Brian's inner world. At this moment, his inner world is flooded by a neurohormonal cascade of cortisol and adrenaline spawned by last night's fight and his subsequent nightmare. I ponder the strange fragility of men, especially this one particular man. This bearded guy, six feet two inches tall, who loaded all my luggage into the car in Mill Valley, is now blanching at the notion of having a 15-minute argument? This guy who bicycles and jogs and took protective care of my airline boarding pass--he can't stand to look at a cheat sheet and try out expressions like "This is important to me. Please listen?"

Could it be that when it comes to emotional discussions, men are the ones who strain to lift the bags, and women are the triathletes? Could it be that men who tell us in so many words to back off are expressing their vulnerability, not their callousness?

These, of course, are afterthoughts. At the time, I wanted just to forge ahead, like the obedient subject in the Stanley Milgram experiment who continued to administer "shocks" to an allegedly helpless fellow subject who appeared to be in pain.

Not knowing what else to do, we recruit two more therapists, a man and a woman, from the back wall. Brian runs through his story of feeling overwhelmed again as if it belonged to us both. My stomach tightens, and I interrupt: I'm not overwhelmed. He is. I want to go ahead.

 

I wonder if we're too weird for this workshop.

The four of us sit down together, Brian and I facing each other with a therapist on either side, our chairs forming a rough square. The woman therapist turns to me and suggests we two take a break. The male therapist, who's "shadowing" the woman, as part of his certification process, says nothing.

I lean forward, my hands on my knees. I don't want listen to her. I open the binder. I decide to make this current disagreement--over whether or not to do the exercise --the subject of the exercise. At the top of a page I see, "Find something in your partner's story that you can understand." I ask Brian, a bit mechanically, to tell me how he feels. I say back that I hear that he feels overwhelmed, that he needs a break. Merely repeating back what he's saying makes me realize that it's true: he really is overwhelmed. The odd thing is, I'm trying to do that old therapeutic stand-by, reflective listening--this is something that John Gottman says successful couples don't do during fights.

Now I take a turn to share my subjective reality: how important it is for me to follow the rules, to move forward, to be obedient, to get things done. Saying this in the presence the two therapists, who essentially are just tracking what we're doing without commenting, somehow loosens my hold on having to get my own way. And this, in turn, makes it easier for me to do what John Gottman calls "accepting influence from one's partner"--realizing dimly that it's not only men who refuse influence from their partners, not only men who sometimes bullheadedly play the king and cross their arms like adolescents.

I feel heard by the two of therapists, whose names I barely know. And I've heard Brian. Although the exercise isn't officially over yet, I'm ready to stop even though it means not following the rules. Brian and I walk outside to the courtyard and breathe the fresh air until a bell sounds to bring us all back.

During the next minilecture--on how to handle "gridlocked" perpetual conflicts--Brian whispers to me that he's decided to leave after lunch, instead of taking a plane at 3 p.m. as he'd originally planned. I'm sorry, but for once I feel no need to push him or lay out all the good, logical reasons why he should stay with me.

 

It's a paradox: I feel far more connected to Brian, and yet my hands aren't clenched. Before the workshop, I'd assumed that I was a failure--and our relationship was a failure--if we didn't solve our conflicts, once and for all, the way I had in mind. I don't think that way anymore.

Flying home the next day, taking care of my own boarding pass and my own luggage, I remember the cautionary words of Wendell Berry in an essay on marriage that capture some of what I learned in the workshop. "Some wishes cannot succeed. . . . Because the condition of marriage is worldly and it's meaning communal, no one party to it can be solely in charge. What you alone think it ought to be, it is not going to be. Where you alone think you want it to go, it is not going to go. . . . When you unite yourself with another, you unite yourselves with the unknown."

I return to the chaos of the quotidian. Tulips touched with orange fire droop in a vase on our kitchen table and the weekend's newspapers are piled around it. In the living room, my 25-year-old stepson Zack is checking his email with his best friend, Ned, standing by, and both of them, to my surprise, are planning to spend the night. If I ever needed proof of one of the Gottmans' most basic propositions--that 69 percent of what couples argue about doesn't change--this is it.

In the months since the workshop ended, I've found such Gottmanesque statistics oddly comforting--and surprisingly therapeutic. When I raise something with Brian and feel awkward, I remind myself that women raise 80 percent of the issues in relationships, and I feel normal again. When I can't get a straight answer, I cite Gottman's research on the importance of men's taking influence from their wives. And when I'm irritated, I remember that 96 percent of the time, people who use a "harsh start-up" find the conversation doesn't go the way they'd hoped.

As I write these words, it's been four months since the night Brian and I lay on that impossibly wide bed in Seattle. For a month or so after we got back, we consciously had "stress reducing conversations" in the evenings, but lately we've slacked off. I haven't yet, as I promised, surprised Brian with music tickets. (He surprised me.) Brian didn't find us a place this summer for a getaway as he'd promised. (I did.) But he and I did go kayaking last weekend on Tomales Bay, much to our joint delight.

 

Things between us seem different--gentler, warmer, closer, more fun--and not so different, since we have the same old conflicts. But we discuss more and argue less. Brian never invites his sons over anymore without checking in with me (if I weren't typing this right now, my fingers would be crossed). If John Gottman had a hidden camera running in our house today, he'd see a lot less of the Four Horsemen. I wouldn't yet classify us as being among the masters of marriage, but I've become much better at the softened start-up. When I'm grateful or admiring of something Brian has done, I'm far likelier to say it out loud.

Describing things this way seems too pat, though. Not even the most complex computer model could disentangle the variables of our lives together, or even of our weekend in Seattle. When I look back, I don't remember statistics. Instead I remember leaning into Brian's arms and looking out at the dark blue of the bay on our ferry ride; I remember stroking his back in bed at the Hotel Marqueen; I remember the two therapists who sat and witnessed us.

In the realm of numbers and words, the world of the intuitive human community will always be at a disadvantage. Yet quantification always leaves something out. Our weekend was a union of science and intuition, and it's far easier to write about the science. But a mysterious alchemy takes place when a person lets go of old moorings and casts off into the unknown--as I did, when Brian showed me his vulnerable face and I didn't turn away. If he and I hadn't happened upon those two therapists that morning, I might not have dared do that. They held me while I moved into a new experience of accepting Brian as he is. John Gottman's research and all the weekend's little exercises may have prepared the ground for that experience, but they didn't take me there.

I look over my notes at Gottman's percentages and I still find them oddly comforting and reassuring. But it isn't the same comfort that I get from remembering how, in a smoky hotel room one Saturday night in Seattle, I reached across a huge king-sized bed and Brian turned to meet me.

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 . She's teaching creative writing at the Networker's Symposium West in San Francisco in October and memoir writing at the Esalen Institute in December. Contact: katybutler9@earthlink.net or www.katybutler.com

 

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