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by Mary Sykes Wylie
Psychotherapy's preoccupation with personal troubles can seem like a self-indulgent luxury in the harsh Irish countryside near Conamara, where poet, philosopher, and former priest John O'Donohue makes his home. According to a commonly told local story, one day during World War II, two German fighter planes circled overhead. One pilot radioed the other asking, "Should we bomb it?" Looking down, the other pilot radioed back, "I think it's been bombed already." As O'Donohue, a tall, rangy man with amused eyes and a sudden, piercing laugh, puts it, "This landscape absolutely minimizes any kind of supposed significance of human words or thought; your pet ideas unravel very fast. It can be so desolating that it makes you feel how nomadic and transient you are--all this was here hundreds of millions of years before humans-come-lately arrived. It makes you aware of our own arrogance, human orphans as we are, who think the whole of existence is all about us."
His Irish upbringing among rural, traditionally reserved people, has enabled O'Donohue to bring an outsider's perspective to our therapy-obsessed culture's insistence on revealing all the intimate details of our own lives and uncovering those of other people. "Americans have a sweet and touching need to personalize everything," he remarks with affectionate irony. "I found that, in America, if I put too much sincerity into the question, 'How are you?' I could unleash an entire biography. In my village, you wouldn't ask a full-frontal question to anybody--you'd read the signs in the person, take stock of him or her, keep your distance, and then, maybe, you might get a glimpse of what was going on inside." For good measure, he adds, quoting poet Rainer Maria Rilke, "I won't go to a psychologist because I'm afraid that if my demons leave, my angels will as well."
Nevertheless O'Donohue has begun to build up a small but devoted following in the therapy world, a following that mushroomed dramatically at last spring's Networker Symposium in Washington, D.C., where, in spite of the fact that few people had ever heard of him initially, his appearances became the talk the meeting. His poetry reading on the meeting's opening day in particular became such a word-of-mouth sensation that it later sparked a run on the conference taping service. When O'Donohue's new fans discovered that the reading hadn't been taped, the occasion itself became something of an instant legend: afterward, stories about it passed along from those who'd been there to those unfortunates who hadn't been so lucky, leaving the latter feeling they'd missed the biggest event at the conference. Fortunately, Symposium attendees will have another chance to hear John O'Donohue, who'll be a keynoter at the 2006 conference.
This said, the reasons behind O'Donohue's impact are a bit mysterious. He spoke about beauty, creativity, poetry, the divine. He delivered exuberant lyrical riffs--"blasts" he calls them--on the meaning of true identity; the holy power of language; the divine gift of imagination; the dialectic between visible and invisible, presence and absence, longing and belonging; the fundamental mystery of the self. He laced his almost incantatory flow of words with his own luminous poems, though the line between his poetry and everything else he said wasn't easy to draw. It wasn't even always entirely clear afterward what O'Donohue had been talking about--these were less logical discourses than extravagant wordfests. So how did he so deeply move an audience usually impressed far more by practical clinical tools than rhapsodic flights of the imagination?
Therapists in the audience had less to say about the information O'Donohue conveyed than about how he managed to open their inner beings to an entirely new way of perceiving the world. "He said such astonishing things, like 'When we move away from our houses, do our houses miss us?'And the shift he created, literally, smacked you in the face, demanded that you go somewhere in your mind you hadn't been before," says Richard Goldberg, a clinical social worker in Bethesda, Maryland. "It's as if he's come from some different, remote place, and he somehow touches you in that same remote place that you'd forgotten you had inside yourself," said Virginia psychologist Charles Cerutti. Lisa Tillman, a therapist in Baltimore, Maryland, thought that "something happens in people's brains when they hear language so precisely tuned into the soul. He has the ability to make that happen." Of course," she added, echoing several other people, "it didn't hurt that he also had an Irish brogue."
O'Donohue seemed to tap into a yearning in his audience not often addressed in today's therapeutic culture. At a time when the pressure is on to do ever briefer, more technical, symptom-focused, "evidence-based," standardized therapies, to make ever greater use of psychopharmacological agents, to slavishly follow DSM diagnostic categories, and to rationalize every moment of a clinical encounter, he reminded his listeners what a noble, even sacred, calling therapy can be. Quoting Plato's Symposium, he said that "one of the greatest privileges of the human being is to become a midwife to the birth of the soul in another person." This is what therapy is about, he added--"helping people retrieve what has been lost to them; wakening and bringing home their fundamental wholesomeness." Therapists are like poets or priests, he noted: they draw on the power of words in the profoundly creative work of bringing people fully alive to themselves, awakening in them the human capacity for divine imagination that "dreams our completion."
But perhaps most of all, O'Donohue reawakened his listeners to the fundamental mystery that surrounds our existence. "In focusing on how people work, we've lost a sense of reverence for the deep mystery of who they are. We have lost sight of the mystery in the primal fact of human presence--that we are here at all." He suggested that the most important dimensions of human experience are those we can't see and grasp and measure, which demands the most reverent attention from a therapist. "I'd love a return to that old way of considering human identity not just as biographical drama, but as sacred mystery."
A scholar, bestselling author, internationally known speaker, and corporate consultant, O'Donohue is clearly both successful and comfortable in the 21st century. And yet he also seems to be something of an historical throwback--like a 19th-century nature poet or 13th-century mystic, living in an 18th-century cottage, surrounded by 1st-century Celtic ghosts. Although he resists our modern tendency to reduce personal identity to the mere external facts of biography, we can't help but wonder how this interesting human anomaly came to be.
The Making of a Poet
O'Donohue grew up in a premodern world of rural peasantry that would be almost unrecognizable to most Americans or Western Europeans today. The oldest of four children, he was born on a farm in Conamara--his father was a farmer and stonemason--surrounded by animals, in a community that probably hadn't changed much in hundreds of years. His family had no electricity until he was nearly 10, and, in the evening, the oil lamps and candles created a small island of softly flickering light encircled by a penumbra of shadow fading off into deep, mysterious darkness. "It seemed to me, as a child, that the area of light was really an abbreviation of the dark presence of the house, and that there was a huge interim world between where light ended and true darkness began."
Outside the house where O'Donohue's family lived, nature was a constant, living presence, both intimate and vast, in which it must have been easy to imagine the existence of whole colonies of primal, wayward spirits, not at all submissive to human schemes and intentions. Although O'Donohue's family wasn't overtly "religious" in any rigidly doctrinaire way, he says, there was a great sense of spirituality in the house, along with a family ethic of nonjudgmental kindness. His mother was humorous and often irreverent, "with a wild kind of mind, very sharp, very bright," while his father seems to have been something of a mystic himself. "My father was the holiest man I ever knew; more in the presence of God than anyone I've ever met," recalls O'Donohue. "He could be great fun, and was very attentive, but his spirit was tuned into the divine, his mind and heart lingering there. If he was working in a field alone in the mountain, or on one of the open gardens we had, when you brought him up a tea or that, you'd often hear him praying before you'd see him. Being with him, you knew he had it--his presence was like a doorway opening to the divine. He also had a great sense of the transience of things, and a wariness of getting entangled in the world, which I guess kind of came over me, too. 'Life is like a mist on the hillside,' he used to say, 'look, and it's there. Look again, and it's gone.' "
O'Donohue went away to a boarding school at 12, and then, at 18, to St. Patrick's College Maynooth, Ireland's national seminary--one of the largest and most celebrated learning centers in Europe--where he began training for the priesthood. Why the priesthood? Certainly, it wasn't something his family had pressured him to do. "The idea of making money never appealed to me," he explains. "Ever since I was very young, like my father, I had the same informing intuition of transience--that everything is passing--and I wanted to do something that would make things eternal in some way. I considered medicine, but then thought that if I didn't have a go at the priesthood, I'd always be kind of restless about it; it would always follow me."
But O'Donohue almost gave this path up during the first year of seminary, when he faced "six months of complete aridity," as he calls it. "I was there studying to be a priest because I wanted to participate in the huge, infinite intimacy with the divine, but I fell into a state of feeling complete, terrifying nothingness. I began to doubt that there was any divine at all--there was just nothing there. I began to believe I'd been duped." He now remembers this terrible trial as one of his first great lessons in the tough struggle of true spiritual growth, which isn't necessarily a feel-good course in personal uplift. "I learned that there's a huge difference between feeling and presence Â in the world of the mystical," he says. "When you feel absolutely nothing, or only absence, that can be actually the most refined form of presence. While I was going through it, I just knew it was a desert, but revisiting it, I begin to see it as a huge pruning of the spirit--like a false skin of protectiveness falling away."
While O'Donohue was never exactly a docile parish priest, he never thundered his rebellion against what he disliked. Instead, he staged a quiet, determined, persistent campaign in opposition to what he felt were some of the church's most egregious failings, including its rigid hierarchy, its fear of the feminine, and its hostility to sexuality. "I thought that sexual morality was people's own business, not the church's, and never believed in the demonization of the body," he says. "The most honest thing in human presence is the body--more honest than the mind, which is often twisted. I spoke in sermons about the lyrical beauty and innocence of the body, and tried to help people get away from the idea that sexuality was sinful, arguing instead that, for all the ambivalence we feel about sexuality, it was a creative, beautiful, and good thing in life."
Four years after he was ordained a priest, he went off to Germany to get a Ph.D. from the University of TÃ¼bingen, where he wrote a dissertation in German on the notoriously difficult philosopher Friedrich Hegel. "Through the grace of ignorance, I had no idea when I began just how difficult it was going to get," he recalls. "It was pure work, total work, work and work and work. That we don't know the future is our greatest protection. If I'd seen the amount and depth of the work I'd have to do, both learning the language and writing about Hegel, I don't think I could have done it." Nonetheless, after four years inside what he calls "the white monastery of Hegel's thought," he completed the dissertation and saw it published in 1993 and favorably reviewed by a slew of German, French, Spanish, and English critics.
In 1990, he took up the more quotidian concerns of leading a parish in County Clare. He also threw himself into a 10-year, ultimately successful, struggle to save Mullaghmore, a beautiful, unspoiled mountain in the Burren area from development as a major tourist site. At the same time that he was working to protect this ancient, natural place, he was also rediscovering another ancient birthright--Celtic culture and mythology--which, itself, was echoed and reflected in the Gaelic language, and even in the stories, anecdotes, references, and expressions used by his family and neighbors. Many people in this part of Ireland (including O'Donohue) still speak Gaelic, a language freighted with historical and social significance. Even regulation English, when spoken by the local people, reflects, says O'Donohue, "the colorful ghost of our real language, which was stolen from us by our colonizers." Furthermore, the souls of these Celtic forebears, their descendants still living in the villages, working in the fields, all somehow belonged to and seemed to have emerged from--even merged with--the palpably living, breathing, perhaps conscious and watchful, landscape itself.
During the 1990s, O'Donohue began putting this vision of Conamara's people and landscape to words, publishing his first book of poetry, Echoes of Memory, in 1994, and a second, Conamara Blues, in 2000. In both books, human love, longing, grief, memory, and faith are witnessed through the prism of, and haunted by, the brooding, timeless presence of nature. O'Donohue had begun writing poetry at about 18 or 19 on an impulse, he says, "stirred by experience too rich for normal words." It seems fair to say that, for him, language itself is in some sense holy. He cites the famous passage from the gospel according to John--"In the beginning was the Word, and the Word was with God, and the Word was God"--adding that he feels that poetry is as close to divinely inspired utterance as human beings can produce.
O'Donohue describes his own fraught encounters with the ungovernable muse of poetry as something like wrestling with angels. "I have a great terror of the white page. I hate going to my desk in the morning, because it's all or nothing when you sit down. When you submit yourself to this kind of rigor, of finding the form for something, what absolutely begins to emerge is something you'd never anticipate, something you can't control-- it knows it needs to come through. In some sense, everything you've ever experienced knows more about itself than you ever will. When I'm touched by a certain experience and start trying to go after it by writing it down, I often find it goes off in another direction completely, and, frequently, I find another experience is concealed there behind the first, but only now just showing itself. There's wildness, passion, spontaneity, and freedom in it. Poems are the most sublime individualities, living actualities. They aren't about anything, they are the thing itself--they just are ."
By 1995, O'Donohue began what he calls the "long journey to resignation from the priesthood." He now says that the best decision he ever made was to become a priest, and the second best decision was to resign from the priesthood. The priesthood refined and directed his inherent sense of reverence and spirituality, opened new intellectual worlds, made him lifelong friends, and introduced him to the work of thinkers and mystics that would help shape the contours of his mind. But by the mid-'90s, he was finding it ever harder to openly and honestly represent church positions he found increasingly untenable. He also crossed swords with a new bishop, who, O'Donohue says delicately, "wasn't overburdened with hospitality toward the kind of vision I had." Specifically, he insisted on assigning O'Donohue to full-time duties as a parish priest, which wouldn't allow him any time to write, and there was no possibility of compromise.
Even though O'Donohue could see no other path but to leave, it was a wrenching break. "I made the decision very slowly, over a long time--and it was a very lonesome time. What I loved most was celebrating the Eucharist. That's where the action is--the place where divine and human meet in ultimate togetherness. Sacrificing that was, for me, the loneliest, most forsaken thing."
But shortly after taking this portentous step, he was freed to write, and write he did. His book Anam Cara, about Celtic spirituality and its relevance for the postmodern era, was published in 1997. It became an international bestseller and has been translated into 20 languages. Another book, Eternal Echoes, was published in 1998, and it, too, became a bestseller in Europe, Australia, and America. In his most recent book, Beauty: The Invisible Embrace, published in 2004, O'Donohue explores the physical, emotional, and spiritual experience of beauty and protests the commonplace notion that beauty is an extraneous luxury, which "practical" people can do without.
An Unlikely Friendship
O'Donohue's introduction to the therapy field came through his unlikely friendship with neuropsychiatrist Daniel Siegel, known for his book Â The Developing Mind and his pathbreaking efforts to help therapists develop an understanding of how the brain develops and changes in response to human relationships. As Siegel was working on his book, an intricately constructed synthesis of evolutionary biology, neuroscience, and developmental psychology, with forays into attachment research, cognitive science, the study of emotion, and complexity theory, he came across O'Donohue's poetry. Recalls Siegel, "It seemed to me that he described, in a beautifully poetic way, the human mind in a state of inner coherence or neural integration--which is my subject--and how both solitude and relationship can act in tandem to bring a sense of mental and emotional wholeness."
Siegel cited Anam Cara in his own book and tried to contact Donohue directly, without success. Several years later, he saw a poster for a 10-day retreat O'Donohue was giving in Ireland and, as a birthday present, sent his wife--who's of Irish descent--to the retreat. She came back exhilarated, saying that it had changed her life. A few months later, she returned the favor and sent Siegel to a week-long conference led by O'Donohue, this time, on the coast of Oregon. Between O'Donohue's talks, the poetry jam sessions, the meditations and long walks together on the beach, O'Donohue and Siegel got to know each other. Each seems to feel he's found in the other a true "soul friend"--the meaning of the Gaelic words Anam Cara --a teacher, affectionate companion, and spiritual guide who completes the other's unfinished self in some way.
As the two men talked, they discovered a common interest in "poetry and the brain, poetry Â in the brain, poetry of the brain"--the details of which weren't entirely clear. It was clear, however, that Siegel's insights about interpersonal neurobiology dovetailed with O'Donohue's lyrical and mystical sensibility, and that both recognized intuitively the connection between the hard facts of neurobiology and the more illusive reality of emotion, imagination, creativity, and spirituality. For Siegel, O'Donohue is "living poetry," the walking incarnation of profound neural integration of the "logical, linear, literal left brain and the somatic, visual, emotional, ambiguity-loving right. Listening to him evokes a profound state of integration in us."
For his part, O'Donohue has been amazed to discover from Siegel just how inherently mystical and poetic the physical brain actually is. "In my ignorance, I presumed that the brain was a fixed, closed object of control, execution, and measurement--a kind of central headquarters for thought and so forth," he says. "But, actually, I learned from Dan that your experience shapes the kind of brain you have, and the brain you have shapes your experience. There's this amazingly intimate and subversive mutuality between your mind and brain. All the mirroring you do of the world--your gathering of information and communications, your sense of yourself--all occurs within this huge poetic, organic matrix. The brain is actually a poetic reservoir that loves possibility and makes connections we normally think would never be made. It's a lattice of subtle meshing that holds the fragile dust of spirit together to make the 'whoness' of who we are."
Both partners in this unusual pairing of brain scientist and poet-mystic share a disenchantment with the usual rigid dualism assumed to exist between the hard, objective logic of science and the soft, subjective imaginings of spirituality and art. They've begun to take their joint show on the road, giving workshops together, each spinning curlicued improvisations off the thoughts and insights of the other. For Siegel, speaking as a therapist and scientist with his own lyrical sensibility, the essence of good therapy is to establish with clients a deeply attuned, responsive relationship that helps a brain state of neural cacophony become a harmonious polyphonic choir, which is "flexible, adaptable, coherent, energized, and stable." For O'Donohue, the therapist, like the poet or priest, doesn't "fix" people, or "manage" them, or make them more "functional," but inspires and guides them on journeys only they can undertake into the deep territory of their unknown selves.
"The idea isn't to give people answers, or lead their bark of longing into a safe, dull, protected harbor," says O'Donohue, "but to make them aware of the depths of possibility in their hearts and lives; help them remove the barriers that keep them from being the people they were meant to be. In therapy, people tend to ask the 'how' questions-- how do you express anger, how do you deal with others, how do you show your personality, how have you become who you are. What's more interesting is the question of who. HASH(0xcafa0f8) Who are you really? The essence of who you are is ultimately mysterious, ungraspable and numinous--completely different from every other structure of matter. When people get into therapy, or when they need healing, their real hope is that they'll come to the secret frontier in themselves, some unknown source of energy and healing in themselves, where the divinity of 'whoness' is protected. This is a spiritual quest." O'Donohue clearly yearns for an era that seems to have just about vanished from the Western world--except perhaps in the Irish equivalent of Brigadoon where he hangs out. "I was born in a rural, peasant community and grew up in the midst of a folk consciousness, rooted in the land, which had taken hundreds of years to emerge and was much more subtle and mysterious than anything in Freud's Introductory Lectures. If you live in a community like this, people don't show themselves to you directly, but only in an oblique, suggestive way." He feels that the lack of respect in American culture for true privacy, for the fundamental ineffability of the deep self, has spawned an obsession with surface appearances that feeds our ravenous celebrity worship. Says O'Donohue. "I think that the pervasive loneliness of our times is related to this obsessive adoration of ever-changing surfaces--the computer screen is a good metaphor--and an addiction to keeping up a bright facade. People look so good on the surface that you'd never suspect how lost they are underneath."
Remembering the mysterious shadowy space between light and dark in his childhood home, he wonders if the momentous shift to electrical lighting, with its severe, glaring, unshadowed light, has transformed the way modern people actually view the world and each other. This "neon consciousness," as he calls it, can't tolerate ambiguity, darkness, mystery. But trying to shine a glaring, blinding flashlight into the deep center of a person's being will not, in the end, reveal anything worth seeing. "Severity of light banishes all shadows. In terms of human interiority, if you bring an electric neon band of light to shine on the inner world of thought and imagination, you'll never write a poem or compose a piece of music or paint a picture or make a sculpture. If you try to see through to the bottom of a person's being, all you'll find is a false bottom, an ersatz kind of depth, with no nourishment in it, no fecund darkness; the real depths won't show up. The excitement of creativity is something that emerges from the darkness quite mysteriously. If you completely wipe out the darkness, nothing can come forth."
In fact, it's at the threshold between knowing and not knowing, between complete mystery and full disclosure, between invisibility and visibility, at the boundary between dark unconscious and the light of awareness, O'Donohue suggests, that imagination has its fullest play. He describes a mountain near his home, with fog hiding its summit. "You know it's there, but you cannot see it with the eye. This is a wonderful living metaphor for the imagination. Around every life are these adjacencies--these huge, invisible presences that you can't pick up with the human eye, but that you can connect to viscerally and affectively through the power of imagination. This is the threshold where polarities can enter into conversation with each other, and take us to new levels of complexity, differentiation, and integration."
The Old Becomes New
Essentially, all John O'Donohue is doing is asking us to reflect on some of the same old questions mystics and spiritual guides have asked throughout the ages: Who are we? Where have we come from? Why are we here? What do we truly want? These are the grand, old chestnuts of philosophy and spirituality. We may still even vaguely remember them, like faint echoes from an earlier, more archaic time. And yet, somehow, through his astonishing way with language and incandescent presence, O'Donohue makes these old echoes ring again; makes the questions seem urgent, critically important, not only to our happiness, but to our very existence. Listening to him, we feel something stirring inside, something quickening, as if some buried yearning were being awakened. "There are certain rhythms and sounds of language that have their own atmosphere," he says. "What affects you is the atmospherics of language. The weather of language gets inside you. It's something intangible and illusive, but intimate and transforming." Lightly, even gaily, with what seems like no effort whatsoever, he creates a kind of climate change within every person whose heart and mind isn't terminally climate controlled.
How does he do this? The short answer is that John O'Donohue is an artist and this, to the extent of their talent, is what artists do. As an artist, he spins straw words into golden language, delivers them with all the brio of a born performer, enables us to experience the archaic world in a new, thrilling way. Perhaps one key to his appeal to therapists is that he does them the honor of suggesting that, at their best, they, too, have the power to be artists, midwives of the imagination, guides to the lost beauty their clients can no longer see in themselves. The other key may be that in a field increasingly focused on solutions and influenced by positive psychology, O'Donohue expresses an unflinching belief, deeply embedded in all the great spiritual traditions, that suffering isn't only inevitable in human life, but may also be a great opening to transcendence. He quotes again from Plato, "'All thought begins with the recognition that something is out of place,'" and adds, "Arriving into conception, into the womb, and then into birth is a primal act of rupture and disturbance, and all through human experience, that fracture doesn't let us be completely ourselves." If this is true, then the inherently human state of being "out of place" in the universe is the source of all our suffering, but also of the human imagination--born of the need to repair or transcend the primal rupture.
At the heart of O'Donohue's appeal is his ability to evoke the astonishing mystery of the human presence on earth--our peculiar, difficult place between earth and heaven. "We humans are the strangest creatures," he says. "Outside my window, all the time, this raggle-taggle group of white mystics known as Conamara sheep wanders back and forth, showing no level of metaphysical disturbance at all. They're as completely at one with the places they're in as the stones and lakes and mountains. We are the only creatures who are in-between. We're of the earth, but don't belong to it, because we strain after the heavens; and yet the heavens aren't fully in us. So this wonderful, restless, eternal longing in us has us always on a quest."
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .
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.
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.
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.
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.
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.
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.
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!
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: firstname.lastname@example.org
by Richard Simon and Mary Sykes Wylie
In 1966, Jon Kabat-Zinn, a graduate student in molecular biology at the Massachusetts Institute of Technology, was walking down one of MIT's endless, pallid-green corridors when he spotted a flyer advertising a talk about Zen by somebody named Philip Kapleau. A former reporter at the Nuremburg War Crimes Tribunal, Kapleau had spent years practicing Zen in Japan, and was about to publish a book, The Three Pillars of Zen, that would become a classic text for American students of Buddhism. Kabat-Zinn was a very bright, hard-driving, 22-year-old kid from New York City, the son of a distinguished research immunologist, who was just starting out on his own promising scientific career. He had no idea what Zen was or who Kapleau was, but, in a sea of notices posted on one of the huge bulletin boards lining the corridor, this flyer somehow called out to him.
There were only five or six others at the talk, Kabat-Zinn writes in his new book, Coming to Our Senses. He doesn't remember much about what Kapleau said, except that conditions in a traditional Zen monastery sounded basic to a fault--primitive, no central heat, and freezing cold in winter. But Kapleau explained that within six months of moving into the monastery, his chronic ulcers went away, never to return. Kabat-Zinn was startled to hear that ulcers--a physical ailment--could clear up without medical treatment. This fact seems to have sparked in him some barely-conscious surmise about the mind's power to affect the body that would later form the nucleus of his own vocation.
More important to Kabat-Zinn at the time, however, was something he remembers about the way Kapleau himself demonstrated the power of paying attention as if it really matters . This orientation to being in the moment, embodied by Kapleau and at the heart of the ancient Buddhist practice of mindfulness meditation, sounds pretty mild today--taught as part of meditation and yoga classes in every "Y" in America--but it was radical stuff in 1966. It apparently evoked in Kabat-Zinn a deep curiosity about the possibility that simply being fully aware of each moment as it happens could subtly but profoundly transform the entire quality of life. As he began his own daily practice, Kabat-Zinn started to discover for himself how meditation can take you deeply into the living, pulsing heart of reality, the bodily, down-home feel of your minute-by-minute, second-by-second existence.
Today, nearly 40 years after that portentous afternoon talk, Kabat-Zinn is acknowledged as one of the pioneers in mind-body medicine--a field that integrates ancient spiritual traditions like yoga and meditation with mainstream medical practice. In 1979, Kabat-Zinn established the Stress Reduction Clinic at the University of Massachusetts Medical Center, the first center in the country to use meditation and yoga with patients suffering from intractable pain and chronic illness. Since then, the clinic--now housed in the Center for Mindfulness in Medicine, Health Care and Society (CFM) in the Department of Medicine--has treated about 16,000 patients and trained about 5,000 medical professionals, 30 to 40 percent of them M.D.s. More than 250 similar programs have been set up at other major medical institutions around the country. At least 1,000 research studies on mindfulness-based stress reduction (MBSR) are in print in peer-reviewed journals, showing it can reduce chronic pain, high blood pressure, serum cholesterol levels, and blood cortisol, and alleviates depression, anxiety, post-traumatic stress disorder, and eating disorders. MBSR can also change the way emotions are regulated in the prefrontal cortex and alter the immune response to an influenza vaccine. In short, Kabat-Zinn has been instrumental in bringing a body of practices and beliefs, once the considered a fetish of spiritualized hippies, right into the mainstream of contemporary medical practice.
Finding A Calling
At the time of his first exposure to Zen, Kabat-Zinn was very much on the intellectual fast track and engrossed in the pursuit of scientific knowledge. Nevertheless, he was beginning to question the entire edifice of academic science and the hyperintellectual, highly abstract, amoral worldview it spawned. Like thousands of other students of the era, he was deeply embroiled in the movement opposing the Vietnam War then beginning to inflame campuses all over America. And, like them, he was becoming disenchanted with what the best scientists of his era were actually doing with their sharp intellects--creating the next generation of highly sophisticated and lethal weapons systems.
He was dismayed that the world's most brilliant scientists, many of whom were on his own campus, could be so sophisticated about science, yet so unsophisticated about the nature of the mind that produced the science. "We use all these fancy instruments, which are extensions of the senses--electron microscopes, radio telescopes, spectrophotometers--to study the world, but we haven't paid much attention to who's doing all this studying. Who's doing all this knowing? What's the mind of the scientist? We were, and are, smart in a lot of ways, but idiotic in a lot of other ways," he says.
By the time Kabat-Zinn finished his dissertation, he'd been studying Buddhism and yoga for about four years and knew that the standard life of an academic scientist wasn't for him. His academic advisors got a hint that his career trajectory might be a tad unorthodox when they saw that the first page after the title page of his Ph.D. thesis on molecular biology contained only the aphorism, "He who dies before he dies does not die when he dies." He spent about half the time allotted to the defense of his dissertation answering the committee's questions about what he meant by those 12 words, delivering an earnest and high-minded exposition on Buddhist thought in the process.
It was all very well to get hooked on Buddhism and mindfulness, but a young Ph.D. still has to go out and make a living. If, after years of studying with the world's biggest brainiacs, he didn't now want to take his appointed place among them, what, exactly, did he want to do? Kabat-Zinn would spend the next eight or so years trying to figure that out.
He taught science as a substitute junior-high-school teacher--occasionally teaching classes from a yoga headstand to keep his students' attention--then taught biology to nonscience majors at Brandeis, did research on anesthetics at Harvard Medical School, and, finally, secured a post-doc in cell biology and gross anatomy at the University of Massachusetts. Part of the reason he took the position was to apply what he learned dissecting cadavers to increase his yoga students' understanding of how yoga postures affected the inner structures of the body.
All these years, he focused on the question of what he was meant to do, what job--"with a capital 'J'"--he was supposed to have on this planet. He never felt that his training as a scientist had been a waste of time; on the contrary, he believed that, somehow, science would figure into whatever he ended up doing--but what might that be? He'd heard architect-visionary Buckminster Fuller say that the seeker after a vocation should ask him- or herself, "What can I do that isn't going to get done unless I do it, just because of who I am?" This question obsessed him, becoming the subtext of all his meditations, the koan he lived with for 10 years.
The answer finally began to come to him while he was working in the U Mass anatomy department, where he had the opportunity to talk to doctors and go on rounds with orthopedic surgeons. What did the surgeons do to help their patients deal with intractable pain that drugs didn't help, he wanted to know. Send them for physical therapy, was the answer, though it didn't usually work very well. Patients tended to passively accept physical therapy, the way patients generally accepted drugs or any other medical treatment, as something being done to them to make the pain go away. In difficult and longstanding cases, when these interventions didn't work, patients felt themselves progressively ground down by their chronic pain. And Kabat-Zinn soon found that most of the doctors, of whatever specialty, had patients they could no longer help, didn't know what to do with, and secretly hoped would just go away.
At about the same time that he was discovering this little-advertised fact about the limitations of high-tech medicine, Kabat-Zinn embarked on a two-week Vipasana meditation retreat getting up to practice in the cold at 3:00 a.m., suffering the all-consuming discomfort of sitting cross-legged and motionless for hours and days. One morning, an idea serendipitously struck him with all the force of a keisaku --the wooden stick used by Zen teachers to administer a bracing, but physically harmless, whack on the back to wake up sleepy or daydreaming sitters. As he recalls, "It was on the 10th day, or something like that, and after all of those years meditating on what my job on the planet was, I suddenly thought, 'Oh my God, I could bring all this stuff--meditation, mindfulness, yoga--into the hospital!'" In a sudden epiphany, Kabat-Zinn could see the entire plan unfolding in his head--how these techniques could be taught to chronic-pain patients in a hospital setting and to healthcare workers from other hospitals and clinics, who could teach them to their own patients. Mindfulness training wouldn't necessarily relieve pain, but it could transform the experience of pain, help people change their relationship to it and thus soothe their suffering, even when no drug or medical treatment made any real difference.
But would these peculiar ideas fly back at U Mass Medical? There was already a relatively small, but nicely growing, body of literature suggesting that meditation and yoga could influence physiology. Studies in the early '70s by Harvard medical professor Herbert Benson, for example, had shown that practicing Transcendental Meditation promoted physiological relaxation and lowered blood pressure. So, when Kabat-Zinn broached the idea of teaching meditation to pain patients, the head of the pain clinic, the assistant director of the orthopedics department, and the director of the primary-care clinic, all agreed to send in patients right away. Soon after Kabat-Zinn began his one-man, two-day-a-week program in an office borrowed from a physical therapist, the chief of medicine (royalty in the hierarchical world of the medical establishment) came down and asked him if he wanted to run the program through his department--a vote of confidence, if there ever was one! Kabat-Zinn soon began gathering together a pool of "interns"--anybody in the hospital who wanted to learn about this new thing--developing in the process a small core team to run the rapidly expanding program.
How was it that Kabat-Zinn was allowed to try a decidedly fringy approach on patients in the absence of any professional credentials in this line of work? Or as he puts it, "How the hell did somebody with no training in clinical medicine or psychology, no credentials, and no license, get to work with medical patients?" He was given carte blanche partly because he was passionate and articulate, and also because his Ph.D. in molecular biology from MIT with a Nobel Laureate dissertation advisor provided an entrÂ´ee in professional circles, even if it didn't have much bearing on his new job.
While the program was a "clinic," in name only when it began, today, it stands proudly housed in its own spacious quarters, with the full staff of directors, instructors, administrators, receptionists, and bureaucratic billing procedures of any self-respecting hospital department. Still, the basic content of the program has hardly deviated from what it was at the beginning. While patients are greeted with open-hearted kindness and authentic presence, they're also asked to commit themselves to full participation in the eight-week program--go to weekly classes, meditate for at least 45 minutes six days a week (using tapes provided), and attend a day-long, silent retreat in the sixth week.
The results patients experienced in the new clinic were almost immediate. One doctor told Kabat-Zinn, "You did more for my patient in eight weeks than I've been able to do in eight years." People with all kinds of medical and emotional conditions reported that they slept better, were more relaxed, and were less anxious. Persistent headaches went away, blood pressure dropped, and pain often decreased. What Kabat-Zinn had done for them was "astounding," they told him, "a miracle." To which, Kabat-Zinn, ever the stern empiricist, constitutionally allergic to both mysticism and hero worship, would reply, "Don't use that language. I didn't do anything for you. You did it yourself. All I did was arrange the conditions and give you enough support and encouragement and tools to do it."
The skills the clinic taught patients were hardly the stuff of science. Nonetheless, from the get go, science counted for Kabat-Zinn, who realized that if he wanted to have any impact on the world of medicine, his clinical cases would have to be backed up by solid research. So he quickly began learning how to do outcome studies in behavioral medicine. By 1983, he and his colleagues were publishing research papers and monographs on treatment outcomes related to chronic pain, anxiety, cancer, immune function, heart disease, and trauma. In a 1988 landmark study, he and Jeffrey Bernhard, chief of dermatology at the U Mass Medical Center, demonstrated that patients undergoing ultraviolet-light treatment for psoriasis--a chronic and unsightly skin disease--healed four times faster if they'd been meditating in the lightbox. The study powerfully suggested that, at least in some circumstances, the activity of the mind could speed healing of the body and save money in the bargain; in some cases, the meditating psoriasis patients needed many fewer treatments than did their nonmeditating cohorts. Meditation also reduced the incidence of skin cancer caused by the UV treatment.
A Well-Kept Secret
During the next decade, the clinic quietly went about its operations, attracting little fanfare in the wider world. As Kabat-Zinn recalls, "The work was a really well-kept secret. Nobody knew what we were doing, and no one cared. It was just fabulous--a kind of golden era, without all the challenges brought by notoriety or fame or whatever you want to call it." Then, in 1990, Kabat-Zinn published Full Catastrophe Living, a book describing the program at the Stress Reduction Clinic and his experience with the power of mindfulness training to help people cope with stress, pain (physical and emotional), and illness. With a preface by Buddhist monk Thich Nhat Hanh and plenty of testimonials from physicians and medical professors on the cover, the book blended ancient tradition, modern science, and Kabat-Zinn's own reassuringly commonsensical approach that appealed both to experienced students of meditation and people who'd never heard of it. It almost immediately began to attract a devoted readership, and has gone on to sell about a half-million copies.
HASH(0xc8dee0c) Full Catastrophe Living also caught the attention of celebrated television journalist Bill Moyers, who included Kabat-Zinn's Stress Reduction Clinic in his five-part PBS television series Healing and the Mind. The film crew shot about 54 hours of film for a 45-minute segment featuring the clinic, an improbably riveting piece of filmmaking, particularly considering that a great deal of the "action" consists of one chronic-pain patient silently meditating. "The film was its own guided meditation on television," says Kabat-Zinn, "and captured the feeling and tone in the room in a way that, I think, entrained the 40 million people who saw it to intuitively resonate with what they were seeing and feeling."
If the book made waves, the PBS special started a deluge. The hospital had to set up a special phone bank to deal with the onslaught of inquires about the clinic, which numbered well over a thousand calls in the month after the show. As many as 40 percent of the callers were doctors, many of whom said they didn't know what they'd seen, but whatever it was, they wanted it. Within six months, Kabat-Zinn and his staff set up a larger, more accessible training program for doctors and patients.
In 1994, Kabat-Zinn published Wherever You Go, There You Are, a kind of meditation on meditation, which has sold, to date, 800,000 copies. This January, his new book, Coming to Our Senses, about the power of mindfulness as a means to social change, will be published.
Although retired from his position as professor of medicine and executive director of the Center for Mindfulness in Medicine, Health Care and Society, Kabat-Zinn continues to be involved with his colleagues in pursuing a range of studies on the impact of mindfulness-based stress reduction on such conditions as prostate cancer, hypertension, asthma, fybromyalgia, chronic fatigue, and irritable bowel syndrome. They have also just completed, but not yet published, a paper on the impact of mindfulness training in Spanish and English on inner-city residents, and are writing a paper on a project looking at the practice of mindfulness in prisons.
In all of this blizzard of work and work in progress, one fact stands out: Kabat-Zinn is as much a scientist who also meditates, as he is a meditator who does science. In a world that prefers its distinctions to be clear-cut and mutually exclusive, he's someone who's successfully built bridges between different worlds and worldviews.
And a bridge-builder between wildly different ways of looking at the world inevitably embodies certain paradoxes. A student and practitioner of an ancient spiritual tradition, he's suspicious of the word spiritual, because he thinks it obscures and mystifies more than it reveals. In his view, while meditation may ground people in the fundamental reality of their being, in another sense, it's nothing special. In fact, practicing mindfulness may be the most democratic of skills. "Anybody can meditate," Kabat-Zinn says. "You don't have to be a college professor." And you don't have to be a Buddhist. Although many people assume that he's a Buddhist, he prefers to describe himself as a student of Buddhist meditation.
His entire career has been devoted to bringing this practice home, into the life of anybody who wants to find some peace of body and mind, some sense of clarity and calm, even in the midst of enormous challenges. "My interest has been to find a way to make mindfulness available to regular people, people who are suffering in one way or another, and who may benefit from mobilizing inner resources they may not even know they have."
In the following interview with Networker editor Rich Simon, Kabat-Zinn, who'll be a keynote speaker at the Networker Symposium in March, discusses the "science" of meditation, the nature of inner freedom, and the distinction between mindfulness and psychotherapy.
--Mary Sykes Wylie
Psychotherapy Networker: In Coming to Our Senses, you try to show the connection between the Eastern knowledge tradition of meditation and Western science. Could you start off by explaining what one has to do with the other?
Jon Kabat-Zinn: Western science, for the most part, has devoted itself to studying nature and what's observable in the outer world. Basically, meditation is about bringing the same kind of systematic discipline to understanding inner phenomena, and that, too, is a legitimate field of investigation for science. You could call it the science of subjectivity, of first-person experience, of interiority.
For example, my colleague and friend Richie Davidson is involved in inviting Tibetan monks who've devoted their entire lives to meditation practice into his laboratory of affective neuroscience at the University of Wisconsin to be studied by various means while they're meditating. What he's found is that these monks have an extraordinary ability to describe the inner terrain of subjective experience with reliability and objectivity. They can tell you exactly what's going on inside them when, for example, you're picking up changes in the fMRI scanner. When one of these monks says, "My mind is stable," you can actually see stability on the brain scan in that moment. And when the scan reads a shift activity associated with a particular meditation practice, they're able to reproduce the shift voluntarily in almost no time.
This isn't a question of having them meditate for an hour and then measuring the change in the brain pattern. They can shift into very different states and corresponding brain patterns every 90 seconds. By contrast, if you ask college students hooked up to the same equipment what they're experiencing in the mind, as a rule, they just don't know. They're not such reliable reporters on inner experience, and show much less coherence in their brain patterns or the ability to change them at will.
PN: In Coming to Our Senses, you also shoot down a number of what you consider to be popular misconceptions about meditation. What are these misconceptions?
K-Z: First of all, I wouldn't say "shoot down"--that's a little violent for my taste. But people do have a lot of misunderstandings about meditation. As it's become more popular in the West, it's also become loaded down with a lot of images, associations, and connotations that aren't necessarily useful. One common misunderstanding is that meditation is some kind of interior maneuver into a special state of relaxation, as if you're throwing a switch in the back of your mind and then you're in the "meditative state." But mindfulness is really about bringing awareness to virtually any situation or any circumstance or any mental state. It's not about staying in any one particular state. You practice it just to be awake.
Now we all have the capacity to be awake, but that wakefulness is usually so fleeting because we're so used to distracting ourselves or propelling ourselves or repelling ourselves that we normally don't do very much to feed that tiny little flame of recognition that awareness is.
PN: I remember years ago seeing Bill Moyers nonplussed on his PBS special when, after he asked you whether the purpose of meditation was to slow down the mind, you answered, "There is no purpose to meditation. As soon as you assign a purpose to meditation, you've just made it just another activity to get someplace or reach some goal." What did you mean?
K-Z: What I was emphasizing there was the nondoing element of meditation, getting away from the goal-oriented thinking that takes up so much of our lives. But, of course, in a larger sense, the purpose of meditation is really just to know yourself. In our everyday lives, we're not really aware of knowing as the fundamental organizing principle of who we are. So we're always trying to get stuff to complete ourselves, without recognizing that we may already be complete. And even if we need to work everyday to get food or problem-solve or handle the other stresses of being a human being, we can do that best by bringing the entirety of our being to bear on whatever we may be doing.
Most of us are usually out of touch with the present moment to some extent. We all create a certain kind of story about ourselves, and then proceed with our lives without realizing that, in doing that, we've removed ourselves from the actuality of living itself. We're so caught up in the story of "I," "me," and "mine" that we lose what's best and deepest in ourselves. That creates a huge amount of suffering and alienation. And, basically, meditation says that's unnecessary. The Buddha, who you could say was a great scientist of the mind, taught, based on studies in the laboratory of his own experience, that it's possible to liberate ourselves from many of the habits of mind that contribute to that suffering and alienation. Meditation offers us a chance to taste or feel or smell the actuality of our experience without all the stories we usually associate with it.
PN: But how do you live without a story? Are you saying that meditation is opposed to what modern neuroscience is telling us about the brain's apparent predisposition to organize our experience through story?
K-Z: What I'd say is that meditation enables us to reconstruct the stories we live by to make them more accurate and larger than they'd be otherwise. Of course, meditation doesn't give you different parents. Your mishigas (this is a technical Buddhist term) is going to be your mishigas the rest of your life. But meditation helps us to recognize that we're bigger than we think are. And it helps us to come to our senses, to wake up, to realize what's actually going on in the realm of experience.
Let's say we take the sense of our own breathing--because so many meditative traditions start with the breath for a variety of reasons. It's part of the body. It's close to home. You can't leave home without it. So you start to pay attention to the breath. You don't need to be "mystical" or "spiritual" to do that.
So, if you start to pay attention to something as simple as the breath, you all of a sudden notice some really dramatic and shocking things. You can do this as an empirical scientist. The first thing--never mind for the moment who's the "I" that's watching--but the first thing that happens is that "someone" notices that it doesn't take long for the mind to go off someplace else and lose the breath completely. Breath is still going in and out, but there's no awareness of the way it feels. That then gets noted because some corner of the awareness sooner or later remembers or detects, "Oh, wait a minute. I was supposed to be on my breath for these five minutes as if my life depended on it, and here I am emphasizing something or other or obsessing about this or that. What just happened?"
So then you notice what's on your mind, whatever it is. But instead of beating yourself up and saying, " I'm a bad meditator," the exercise would be more like, "That's interesting. I said I was just going to stay with the feeling tone of the breath, not thinking about breath, but just the sheer sensation of the belly rising and falling, or the feeling of the air passing by the nostrils, and five seconds don't go by and I'm off someplace else." Noted. Back to the breath. There you go again. Another five seconds go by. You're off someplace else. You rapidly come to realize this is a habit. "This is part of the way my mind is wired. Holy smoke. I can't even focus." Well, that, in itself, is very interesting data.
PN: Thus the "inner scientist."
K-Z: Yes. Life itself becomes your laboratory. This little experiment of observing your own breathing for five minutes can be quite revealing, and humbling. It's like, "Oh, I may think I'm free, but actually my mind is at the mercy of whatever crosses my field of vision, my hearing, or smelling, or whatever." There's nothing wrong with that. I'm not judging it. I'm just saying it's interesting to notice. It's not about good or bad.
So what we're saying is, for a moment, let's just see if we can be with our direct experience and not label it all. Just note it. Just see. The mind wanders. You bring it back. The mind wanders. You bring it back. The mind wanders. You bring it back. The mind wanders. You don't want to bring it back anymore. You're bored with it already! A minute has gone by. I get the idea. I'm not interested in meditation. Or, I'd rather be thinking whatever. I'm busy. And then something strikes you. "Holy smoke. This is kind of like the native space of my mind. When I want to bring it to something really important, say an emotional issue, relationships, work, or anything else, I'm bringing that same mind. It's like it has no capacity to get out of its own way or be more spacious, be more stable, more calm and open, or be less reactive and judgmental."
As I say, that's interesting. You know how long it takes for you to realize that? Less than five minutes, because in five minutes, the mind will wander an infinite number of times, or close to an infinite number of times, especially if you're living a busy life.
PN: At the same time that meditation has become so popular, I know so many therapists who insist that it does nothing for them. For whatever reason, they don't get what you're trying to describe here. How do you convey to people like that what meditation has to offer?
K-Z: Certainly, I hear from people all the time who say things like, "I just sat there and it was just nothing. Why would I waste my time doing that?" One of the best lines was from one of my patients at the clinic who said, "I might as well be ironing the couch."
Now I don't like to "sell" meditation or give people a sense of "Just meditate and these are the things that you'll feel." From my point of view, that's much too goal oriented. But I'd say that, at the most fundamental level, meditation can show you how to cultivate intimacy with your own body and be in what the Buddhists might call "right relationship" with it.
Many of us are just really encapsulated in our head and in thought, while our bodies are kind of on their own. Then when we experience pain or disease, we may realize that we're actually in an adversarial relationship with our own body. We may be obsessed or preoccupied with its appearance. Or when our body does something we don't like--like come down with disease--we want to drive it to the hospital and have it fixed, as if it were an automobile.
In our clinic, many people learn through meditation that the body is the fundamental ground of our relationship to the world, even if, most of the time, we're not paying attention to it. Through meditation, they learn to call on deep inner resources for healing that are biologically available to all of us.
I, Me, Mine
PN: What about how meditation shifts our experience of personal identity?
K-Z: Moment to moment, we're usually flitting around, living inside our heads. You might think about it this way: if you wanted to look at the moon, for instance, and you put your telescope on a waterbed, you wouldn't really have very much success focusing on, or even finding, the moon; your instrument of observation would first need to be stabilized. In the same way, if you want to understand something about the nature of your own life, then you have to learn to stabilize your mind.
But when you begin to meditate, you soon realize that your major instrument for understanding both your relationship with the outer world and your relationship with the inner world is so much more unstable and chaotic than you usually notice in everyday life. Pretty soon, you come up against this basic mystery that some people can spend a lifetime ignoring: who is this "I" who's doing all this experiencing? After all, if you ask biologists looking at how the 100 trillion cells in the body interface with each other, they'll probably tell you that it's an impersonal process--there's no "person" in there. Yet, somehow, out of this three pounds of meat we carry around inside our heads, we get the idea that there's an "I" involved in all this. Yet you can't find that "I" anywhere by looking at all those cellular interactions. It's an emergent phenomenon, so to speak, that comes out of the complexity of it all.
Maybe because it's all so complex, lots of people develop some reified notion of themselves and live their life based on some kind of diminished story of who they are. You can live a great deal of your life in delusion of one kind or another and miss altogether the larger mystery of being human. What meditation does is help us find a way to embrace our interconnections with the outer and inner worlds. It's what Whitman was talking about when he wrote, "I am large, I contain multitudes." Yet most of us feel small, and, if we contain multitudes, they're often at war with each other.
We're all out of a painting by Marc Chagall--figures floating in the air, twisting in this huge spaciousness that surrounds our lives. There's no solid, reified, absolute "me" that we can build a fort around. Meditation teaches us how to become at home in this groundless domain, like a fish in the water. We discover that we don't need to have the usual artificial props of our "identity" to ground us, when we realize that the ground actually is itself also floating.
PN: As you say this, I keep thinking of where we started this conversation and the connection between meditation and the scientist's drive to find order in the world.
K-Z: What I'd say about that is that meditation helps us find the relationship between the chaos and order that are both part of our lives. As we were saying earlier, the mind is chaotic: our focus keeps shifting, seemingly uncontrollably, from moment to moment. But inside of that chaos, at any and every level, you also find order. And then if you look inside that order, you find some other level of chaos. The interesting thing isn't to be too ordered--that's actually a state of stasis or death. But if the body gets too chaotic, you'll be in atrial fibrillation or a complete state of mania. Living systems are continually at the edge of chaos. That's why meditation can teach us the deepest lessons of what it means to be alive. It shows us how to surf the wave between the chaos and the order. Even when it's very, very turbulent, meditation helps us find the sweet stillness inside the wave. That's what I call being awake.
Ultimately, meditation teaches us that if you bring mindfulness to the present moment, you have more ways of seeing that are fresher, and you're less likely to be caught in conditioning. Then, of course, the next moment you'll get caught again. So that moment's already gone, and there's another one for you to experience. The question is always, "How am I going to be in right relationship, or wise relationship, to this moment at the level of the body, at the level of the mind, at the level of feelings, at the level of perception?" And it's all one piece: it's not fragmented. And that's why I say meditation isn't a technique that you deploy to get to some kind of special state. It's a way of being in your life that's embodied and awake, and without agenda. It's not about trying to get somewhere. I guess the way to put it is that you are where you are.
Therapy and Mindfullness
PN: As the man said, wherever you go, there you are.
K-Z: Exactly. Then your luggage is another story.
PN: What's the difference between the kind of mindfulness that you're describing and what therapists are trying to accomplish in their work?
K-Z: I know many therapists who are incredibly empathic with their patients and extremely good at listening and not being judgmental. They know how to make things spacious and cultivate calmness in the relationship, but they sometimes don't admit that they themselves haven't come close to dealing effectively with their own suffering. And their own therapy doesn't help all that much. Perhaps this is why many therapists are drawn to the interface between mindfulness and therapy as much for themselves as for their patients. In therapy, there's a huge amount of the compassion perspective, but the wisdom perspective--the ability to get beyond the psychological story of "me"--can be a long-term challenge, or even an obstacle.
PN: Can therapy provide anything that mindfulness doesn't?
K-Z: I think there is something that only good therapy provides: the opportunity for a relationship with someone who's honest and loving, yet recognizes the sovereignty of the individual other. That's a huge difference. In our clinic, we see 25, 30, 40 people at a time in our classes. We don't have the resources to spend hours a week talking with people about their personal issues, although we do to a degree, as required.
People who've been badly harmed may need that kind of attention at a much more in-depth level than we can provide; others may not. But the primary relationship in Mindfulness Based Stress Reduction is actually their relationship with themselves, not with us. That's why we start with the body and the breath. The challenge is, "Can I befriend myself?" In that sense, the therapeutic aspect of meditation doesn't start with the therapist: it starts with your relationship to your own experience. And if you hold that in a way that's benign and compassionate, some people might say you can serve as your own therapist, although putting it that way seems to pathologize something that's only a natural part of being human.
PN: From the viewpoint of mindfulness, what happens in the "relationship" that you're referring to? What is it exactly that the therapist offers the client?
K-Z: The therapist is trying to help the patient cultivate a kind of autonomy that's already here, that's at his or her core, even though the patient might not be able to experience it yet. Holding that kind of space for the other person is probably the most compassionate thing one human being can do for another. That's what I'd call love. But what's most important for therapists, in my view, is to approach what you do with real caring, and not just as a job to get done. That means truly recognizing that every single person is different, even though you've seen a million cases that may seem the same. That means experiencing each moment with them as unique--and that may mean reminding yourself, "This is a human being, who's always more than any small story she may be telling herself at any moment."
PN: What you're describing is what some therapists might call bringing a "spiritual awareness" into their work. But in your books, you seem to go to great lengths to avoid using the term spiritual.
K-Z: You're right. I almost never use it. In fact, in Wherever You Go, There You Are, the last chapter is called, "Is Mindfulness Spiritual?" There tends to be a lot of confused thinking about spirituality that comes perhaps out of a natural hunger we may have for some kind of transcendent experience. When I hear another person describe someone as "very spiritual," I often just find myself laughing inside. Who isn't "spiritual" when it comes right down to it?
Usually, it's just a projection. I prefer to use the term "fully human," rather than talk about "spirituality." For me, it's a way of speaking about waking up to what's deepest and best in all of us, and already here, if only sometimes in seed form, undeveloped.
PN: You don't need to go to some magical, rarefied place. We're already there.
K-Z: Not "there." There's no "there." We're talking about "here." What's happening right here is what it's all about. It's about realizing, with a hyphen-- real-izing --making real, what's actually already so. We're largely ignorant of those dimensions of our being that tend to be bigger than our thinking. As I ask in Wherever You Go, There You Are, is having a baby a spiritual experience? Is being a father a spiritual experience? Is chopping vegetables a spiritual experience? Is taking a crap a spiritual experience? If they're not, then what's a spiritual experience? Anything can be a spiritual experience. It depends on the quality of the being that's in the experiencing.
So if you're thinking, "Oh, now I'm having a spiritual experience. I can't wait to tell people about it," it's really just another way to show how accomplished you are--another advertisement for yourself, to yourself, more clinging without awareness to those knotty personal pronouns I, me, and mine. Acquiring new "spiritual experience" can be just another addition to one's CV, as opposed to actually becoming more aware of one's being and the obstacles to wisdom, compassion, and the ability to be balanced and helpful in the world. To me, it's utterly simple: the most spiritual people I've ever met don't look "spiritual." They're not trying to be spiritual. They're just who they are, whatever the costume.
by Michael Ventura
Till change hath broken down
All things save Beauty alone.
-- Ezra Pound
In Brooklyn, circa 1957--when doctors still smoked cigarettes while examining their patients in small stuffy rooms--I was in a hospital, 12 years old, dying. If I hadn't been fever crazed I might have known I was dying, for we were poor, we lived in what was then called "slums" and what was I doing in a private room? In those days, before health insurance as we know it now, and before federal programs, my family had no possibility of paying the bill. I was a "charity case," and, with true charity, the hospital had given me a private room to die in. My diagnosis had something to do with "acute malnutrition"--in other words, hunger--complicated by a seemingly untreatable fever. Though nobody told me what was going on, I should have known I was dying when my aunts (my father's sisters) visited. For my aunts to be in the same room as my mother was an event; they did not often speak. In a Sicilian family, grudges go deep, so when my aunts and my mother treated each other tenderly . . . well, I must have been dying. But my family and the doctors, and even my skinny fever-wracked body, all seemed then, and in memory seem now, like figures in a dream. What was most real to me, and what remains vivid even now, was the window.
For several days and nights, too weak to lift my head, all my attention was fixed on that window. It was . . . just a window. Nothing remarkable about it. But pigeons would alight on the sill, suddenly, as though out of nowhere. They would make their clucking and cooing sounds. Occasionally, one would simply sit very still for a long time. Then, just as inexplicably, fly off. Through that window I would watch the changing light of the sky, and the clouds--I had never noticed how many shades of light inhabited the sky. And sometimes a flock of pigeons would sail across my field of vision, high up and far away; I would wait for that, wish for that. Sometimes, too, their wings would catch the sun as they banked all together at some unseen mutual signal, and that flash of many- winged light thrilled my heart.
I think I remember that window so well because it was my first consciousness of beauty--that is, my first independent, deeply inner meeting between the beauty of the world and my own soul. All my former contexts had been shattered, I could hardly even move, I was in a sense utterly on my own, yet even in this state (or because of this state?) I was being touched directly by a sweet and transforming force, or feeling, for which I know no other word but beauty. I was many years away from the concepts of contemplation and meditation, but I believe now that those were the fundamental elements, or activities, of my enthrallment, my rapt attention, as I focused upon that window. It's impossible to prove, but I believe that my intake, my inspiration (literally, my breathing in) of the elegance, the beauty, of the birds and the sky, gave me strength and saved my life. This, at least, is sure: from that time on I have been extraordinarily, gratefully susceptible to, and conscious of, the beauty of the physical world, even in the bleakest of places--like Brooklyn.
I do remember one fragment of conversation from that hospital bed. My Aunt Anna, in a way that was hardly typical of her, commented to my mother that I had "pretty hands." My mother said in response, "He has an artist's hands." This was the first time it occurred to me that anything about me might be beautiful. After they said this, when alone in that room, I often looked at my hands, and, yes, thought them beautiful--as though, like the pigeons and sky, and unlike anything else about me or my life, they were a part of the beautiful world. I can still hear the soft proud way my mother spoke those words. I believe now that she somehow sensed or grasped what was going on; for it's clear to me, 40-odd years later, that in that hospital bed, my soul took its first, wondering and gloriously unselfconscious steps (steps more unselfconscious than they would ever be again) toward being an artist--for not very long after I left the hospital I began to write. By the age of 14, writing became, consciously, all that I wanted to do with my life--became, that is, my devotion, the calling to which I intended to devote my life.
The illness had stripped me down to the core of my being, which, like the core of anyone's being, feels itself most intensely when at the meeting-point of life and death.
And the window--the window!--had poured beauty into me at just that terribly vulnerable moment. And everything changed; or, to put it more accurately and less dramatically, many disparate and not-yet-coherent elements in me coalesced and found their focus.
Many walk into the therapist's consulting room exactly at the moment, and because of the moment, that they have been stripped to the core of their being. While not at the physical meeting-point of life and death, they are often at its emotional and spiritual equivalent. One element they seek and are desperate for, one element they usually feel they've lost, is beauty; they present a situation that's cut them off from experiencing beauty. They may not articulate it that way, but that's what's going on. Yet, beauty has not still been sufficiently recognized as both a healing balm and a necessity--something without which we may die, and through which we may live.
In Carl Jung's Memories, Dreams, and Reflections, he relates a dream in which he went into the center of a darkened city--Liverpool. It does not take an analyst of Jung's caliber to know that a dream that takes you to the center of your liver (an organ that cleanses the blood of toxins) is a journey to where your innermost self deals with the poisons you've ingested from the world. Jung's "Liverpool" was very dark except for its centermost point, where a tree glowed all on its own. "A single tree, a magnolia, in a shower of reddish blossoms. It was as though the tree stood in the sunlight and was at the same time the source of light." That tree was one of the most beautiful things Jung had ever seen. He wrote, "I had had a vision of unearthly beauty, and that was why I was able to live at all."
He had found in a dream what I had found in a window. His movement toward the sustenance of beauty was from the inner (his dream, his soul) to the outer (his life); mine was from the outer to the inner; but the result was the same: "that was why I was able to live at all." Every day these movements of beauty happen in many small ways to many people; and almost everyone, except the most severely damaged, remembers at least a few events that, whether dramatic or everyday, are startling in that they suddenly open the soul, the self, the psyche, to beauty. While it is difficult to define what beauty is, because different people find so many different beauties, the experience of beauty is not as hard to define: one's soul and one's world are connected in an engagement of wonder. Sometimes we experience this with others--while listening to music, perhaps, or in an intimate moment with someone we love. Sometimes the experience is solitary, and can even come in a dream. But the singular quality, however fleeting, is an awakening of, and a connection to, wonder. The experience of beauty is always one of expansion, of opening, of inclusion--a moment of connection, often mysterious, that extends the possibilities of all connection.
So beauty isn't merely decorative; its primary function is to connect--beauty connects our innermost being to the world. It is precisely this lack of connection that afflicts so many. And while suffering usually has its source in the personal life, it's reinforced by the ugliness we live amidst. Much depression is a symptom (James Hillman might call it a healthy symptom) of resistance to ugliness--a holding-back of the spirit from an aggressively ugly environment. In most urban neighborhoods, there is only an immense and slowly deteriorating sameness of brick, building after building, street after street--a relentless and unforgiving sameness, a dull labyrinth in which to struggle for the basics. The suburbs are only slightly more benign; they have become a culture of malls, the same franchises and signs and structures everywhere, and houses built without distinction, without excitement, without inspiration. Millions go from dull ugly rooms on dull ugly streets, on clogged roads, to dull ugly workplaces where they do work that has little or nothing of the saving grace of beauty. It's impossible to overestimate how Americans have come to take this extent and degree of dull ugliness for granted; but it is not surprising that, taking it for granted, we have become too dulled as a culture to ask what this ugliness does to us.
As beauty opens us, ugliness closes us. We shut down. We blunt our perceptions, our sensitivities. We stop seeing, because seeing gives us no sustenance. We enclose ourselves in our own bodies, the personal circle of our own bodies, because it is unpleasant, unrewarding, to see, feel, scent, and touch what's around us. We become resigned. That is what ugliness, or a continual lack of beauty, conditions us to do. I have seen, more than once, a magnificent rainbow over a city, with thick bands of brilliant color, and no one on the crowded street was looking at it, no one else seemed to notice it. Not because they were insensitive dolts, but because they were so accustomed to the absence of beauty that they'd conditioned themselves not to see anything but what was directly in front of them, not to see anything they didn't have to deal with directly. So much shutting down, done so automatically and done by so many that it's taken for "normal," can't help but have consequences. It makes a certain dullness-of-spirit, a certain boredom-of-perception, seem commonplace and therefore "right" and "normal." So it is no surprise that when we try to address problems in our intimate lives, whether in our homes or in the consulting room, the insensitivity we've conditioned ourselves to accept and practice is an invisible but potent factor. How can people so conditioned to dullness-of-perception by the absence of beauty in their world--how can they ever really see each other? It is crucial to realize that this insensitivity, this reluctance to see, cannot be attributed only to a childhood or familial situation, and still less to a genetic or otherwise "natural" lack of intelligence; whatever our personal situation, for many of us, the reluctance to see, to feel, has literally been "built in" to our environment, and is reinforced every day by that dull ugliness, the attack on beauty, that is the environment for so many.
The result is that an assumption of dullness and ugliness has become an unconscious psychic foundation for many of our feelings, thoughts, perceptions. Only this can explain America's need for continually more sensational entertainments--ever louder music, ever cruder sexual depictions and the loutish popularity of wrestling, shouting-matches on political "discussion" programs, effusive and argumentative talk shows where people willingly give up dignity to get attention and nothing gaining wide public notice unless it is extreme. The root of these phenomena is in large part aesthetic: an ugly dull environment in which brutish behavior becomes a positive value because it at least has the force to cut through, momentarily, our shielded, blocked ability to perceive.
All of which leaves us, each of us, facing one piercing question: What is beautiful in your life?
The therapist-client relationship is just about the last functioning shared space in this country where this question can be asked and, more important, heard. Which is why it's so crucial that therapists find a way to ask it. Directly or by implication, that question leads to others, questions that would make any of us squirm--and so they need to be asked all the more. Questions such as: Your children, your friends--do you find them beautiful? But what, exactly, is beautiful about them, and do you contemplate it much, does it shine in your behavior? In theirs? Your wife, husband, lover, what is their beauty in your eyes? But how does it play in your life, how does it nourish or inspire or challenge you? How do you acknowledge, salute, and cherish their beauty? And if you don't, why don't you? Your home, your city, your town, are they beautiful? How do you enter and celebrate and preserve their beauty, or do you? And if your surroundings are not beautiful or, more to the point, if you can find no beauty in them--what is there to do about this? What is the beauty in your work? And if this question stops you in your tracks, what does that say about your work--and about what your work gives to you and to others? And: What is your beauty? And does that question embarrass, frighten, annoy, or depress you? Why?
In an ugly world, beauty is a revolutionary idea. Which is why these questions strip us of comfortable and/or evasive language, cut through our technical professional language, and demand responses that are specific, concrete, immediate. Psychotherapy is in a unique position to ask these questions, to introduce these questions into our cultural life once more, for people seek therapy in that state of vulnerability in which the discovery of beauty is desperately needed--especially the beauty of relationship. Psychotherapy has forged a precise and immensely useful language for dealing with the negative and problematic aspects of relationship, but it has no corresponding language for the beauty of relationship. This is because problems between people are reducible; we can break them into pieces, concepts, and deal with them. But beauty between people is irreducibly itself. A rose is a rose is a rose. Jose Ortega y Gasset said, "Why do I love this woman? Because she is this woman." We can't be abstract about the beauty of one another, or that beauty flees. My wife Hannah has a marvelous laugh. When I feel and hear and see the beauty of her laughter, I experience as natural a beauty as the flash of sunlight on the wings of those birds I first noticed in that hospital, or the changing light upon the clouds that I learned to watch for in the sky. When I look into her eyes, I see a depth, a glow, a presence, to which I cannot give a name, not even hers. "I had had a vision of unearthly beauty, and that was why I was able to live at all." A psychology of beauty must somehow grope its way toward experiencing the Other as part of the beauty of the natural world--a beauty to which, in relationship, we have privileged access.
So the question, "What is beautiful in your life?" goes beyond analysis and into what was always intended as the end result of analysis: experience. Beauty doesn't matter much as an idea, it only matters, it only gains force, as an experience. A psychology of beauty is a psychology of experience, a psychology that appreciates and teaches an aesthetics of experience. For our very lives depend upon the beauty that we are capable of experiencing in each other and ourselves.
Another hospital, some 40 years after my view from that window: In my father's 81st year he was on a gurney about to be wheeled into the OR for a serious operation, a procedure that might well kill him. I held his hands, and their grip was still strong--his small, thick, deft peasant hands, that had earned his living all his life, hands that had an intelligence of their own, so precise were they in work. He looked up at me, and I was astounded by his eyes. I had never seen such eyes. So deep and calm, so full of an all-encompassing love--so unlike him! Had he been waiting all his life to muster the incredible focus of love with which he now looked at me? But not just at me. It was as though I were a representative for all of life, in that moment, in his eyes. In that moment we were all we had both been, and far more than we had ever been--the love in his eyes, for me and for life itself, was that overwhelming. It was, and remains, the most beautiful face I have ever seen. That it was my father's face is almost incidental. It was a face of humanity, looking upon the world with unalloyed adoration. You'll have to trust that I am not exaggerating--for, believe me, no one could have been more surprised than I that this man had that look in him. His beauty, and the beauty he could see, had been his best-kept secret, revealed only now at the end of his life. If this bitter, failed, enraged human being could achieve that look--then perhaps it was a gaze inherent and waiting in all of us. As they wheeled him away to what might be death, I stood in that bleak hospital hall stunned with joy. I had seen nothing less than pure human beauty--a beauty within, reaching out to bless and beautify all it saw. How can we leave beauty unaddressed, when so many long for beauty and are withering for the lack of it; and when so many keep the beauty they feel secret, and never reveal it, or reveal it only in extreme situations, perhaps at the very end?
Beauty is specific, personal, intimate--for it is experienced, in tiny but crucial ways. In dreams, in a child looking out a window, in hearing a lover laugh, in an old man taking what could be his last look at life. Which is precisely why beauty is in the terrain of psychotherapy--an as-yet-undiscovered country at the center of psychotherapy. "What is beautiful in your life?" is a question psychotropic drugs can't answer.
Our eyes go dead for want of a connection with beauty. And deadness, dullness, of the eyes is the very death that psychotherapy is dedicated to resurrecting.
I remember my very first therapist. I was about 13, and New York City had instituted some sort of program--through the schools? I don't remember--enabling emotionally disturbed street kids like me to receive help from "uptown" shrinks on an individual basis. His name was Dr. B.T. Lassar or Lasser. He was a portly, very dignified gent with deeply serious yet sweet eyes. His office on Central Park West was the most well-appointed, monied room I had, at that point in my life, entered--a plush room, not very well lit, full of portent and shadow, but I found the dimness appealing. The strange thing was . . . I was comfortable in that room. Lasser couldn't have been more different from the adults I'd known--for one thing, he was quiet and patient, and I hadn't seen much of that in the adults of my family. Perhaps because I was a child, he was careful to speak in words I understood, though now I remember almost nothing of what he said. What I remember most was the long subway ride from my tenement to his office--for the ride had the quality, going and coming, of a passage into and out of another world, a world that valued what my world didn't or couldn't. And that, I know now, was the healing power of his therapy for me: he put a value on qualities in me that my world mostly didn't notice, didn't want to notice. On the subway, I journeyed to and from a space where different things were valued, cherished, nurtured--which meant that there was such a space to be journeyed to, even if it was only one dim room in which sat one attentive person, attending to what the world devalued and ignored.
The consulting room has the power to be such a space--in it, value can be placed on what one's world will not or cannot consider. And in that space, that value can grow and become strong. In that space, in addition to dealing concretely with dilemmas, it is possible to value beauty--it is possible to make that space a place where the maligned and attacked beauty of the world and of humanity is emphasized, explored and made more real to whoever seeks that space. If the question "What is beautiful in your life?" can root itself in that space, then from that space, beauty will radiate, exert itself, find itself in the only way that beauty finally matters: in the experience of a soul that is, by degrees, less and less afraid to ask that question of itself.
Michael Ventura's biweekly column appears in the Austin Chronicle .
by Barry Duncan
Imagine a future in which the arbitrary distinction between mental and physical health has been obliterated; a future with a health care system so radically revamped that it addresses the needs of the whole person--medical, psychological and relational. In this system of integrated care, psychotherapists collaborate regularly with MDs, and clients are helped to feel that experiencing depression is no more a reflection on their character than is catching a flu. This new world will be convenient: People will be able to take care of nearly all their health needs under one roof--a medical superstore of services. It will be great for therapists, too, providing them with a seemingly inexhaustible stream of client referrals from the enormous pool of patients who, in earlier times (today), would have mistakenly identified their complaints as primarily physical.
Now, imagine a future in which every medical intervention in a patient's life is a matter of quasi-public record; in which therapy is tightly scripted and only a limited number of "approved" treatments are eligible for reimbursement. A future in which recalcitrant patients can be tracked and forced to undergo treatment, and in which therapists must serve as compliance cops for health management organizations and insurance companies. In this brave new world, integrated care actually means a more thoroughly medicalized health care system into which psychotherapy has been subsumed. Yes, therapists will work alongside medical doctors, but as junior partners, following treatment plans taken directly from authorized, standardized manuals.
These are not two different systems; rather, they are polarized descriptions of the same future, one that draws nearer every day. Make no mistake: A seismic change is coming to the American health care system. The age of integrated care is upon us, and psychotherapy may soon be incorporated in a way that will profoundly affect how and where it is practiced. But what will this new system really look like? How will therapists--and the therapeutic process--fit into it? What values will lie at its core? Although there is no question that a new system is coming, the nature and structure of this new system are still very much up for grabs. And this means that, for therapists, the future poses both tremendous opportunity and grave threat.
One version of the future--the one envisioned by such advocates of "reform" as the American Medical Association and the leading managed care companies--is of a seamless web of services that quickly identifies patients' true needs and efficiently delivers patients to the right professional for the correct treatment. The other vision--therapists' vision--has yet to be fully articulated, largely because most of us are still adjusting to the changes wrought by managed care and unaware of the implications of what's coming.
We have the opportunity now to present our vision, to argue for the holistic integration of medical and psychological services in a way that is true to the core principles of psychotherapy. We must resist the inevitable attempts to define therapy as, in essence, a treatment that gets dispensed by a professional to a patient and argue instead for therapy as a process of change that is entered into by client and therapist working together as allies. And it is critical to do so now, when psychotherapy is on the brink of another tectonic shift that could well discredit the majority of approaches therapists use today.
Carving In, Carving Out
To understand what lies ahead for the field of psychotherapy, we must first review some basic principles of health care economics. To state the matter in accountants' terms, mental health services have traditionally been "carved out"--handled and paid for separately from general health care costs and considered to be distinct from patients' medical needs. Most of us have grown accustomed to the idea that the point of entry for taking care of our medical needs is different from that of our mental health. Currently, 88 percent of the mental health cases are handled in this way. But experts such as noted psychologist Charles Kiesler--whose critical commentary on the accuracy of psychotherapy research and the expense of inpatient psychiatric care has been a springboard for policy discussions for more than 30 years, and who, in the mid-1980s, predicted that fledgling MCOs would soon dominate the American health care industry--see another sweeping change in the offing. Soon, they say, behavioral care, like most other medical specialties, will be "carved in"--that is, mental health services will be treated as an integral part of medical patient care and administered accordingly, with all the advantages and liabilities that entails. According to Kiesler, the changes to be ushered in by carve-ins will be "as dramatic as the computer revolution."
The reason for this coming change, of course, is the tremendous pressure on health care administrators to reduce spiraling costs, especially those that are racked up by patients who repeatedly seek medical treatment--often expensive specialty consultations--for complaints that are at least partly due to undiagnosed psychological issues. A typical scenario goes like this: A patient visits a physician or emergency room with a physical complaint, say neck pain. Doctors treat his physical symptoms, but don't refer him to a therapist, who might help him tackle the stress contributing to his symptoms. As a result, his neck pain flares regularly and he frequently seeks treatment from doctors. This pattern may repeat for years unless and until his behavioral problem is identified.
Over the last four decades, studies have repeatedly shown that as many as 60 to 70 percent of physician visits actually stem from psychological distress that finds somatic expression. Advocates of carving in behavioral care say it will not only save money, but will bring real advantages to therapists and patients alike. Imagine that before even meeting a client you could open a computer file and learn that her doctor put her on Prozac some years ago when her mother died of congestive heart failure. Curious about the mother's mental health history, you could click on the link to "familial predisposition" and find that the mother, too, had been treated for chronic depression. If such information were available to you in advance, argue advocates for carving in care, you'd obviously be better prepared to meet this person, and you'd have a deeper understanding of her situation.
And here's another apparent advantage of bringing together the medical and psychological disciplines: It becomes easier to provide care for people with disorders like chronic pain and insomnia that don't clearly fit into DSM categories; for people whose disorders are medical but clearly have psychological or relational components, such as irritable bowel syndrome and high blood pressure; and for people who fit into multiple categories, such as alcoholics with renal system problems.
The advantages of this new, collaborative system are evident in the case of a woman I'll call Kathy, a 23-year-old retail worker. Kathy was a client of family therapist Tom Mahan at the innovative Marillac Clinic in Grand Junction, Colorado--a model of how the integrated health care system of tomorrow can function at its best. She went to the clinic complaining of nausea, fatigue, feelings of helplessness and a constant burning in her chest. Kathy had seen six doctors in five years, and each one had told her she had no medical problem. Most recommended that she see a therapist, but she had rejected the idea that she had a "mental problem" and never followed this advice.
Then she visited the Marillac Clinic. She was seen first by a doctor, who conducted a sophisticated assessment of her biomedical, psychological, social and even spiritual life. At the end of the interview, the doctor told her that while she might have gastroesophageal reflux disease (GERD), psychosocial factors, such as high stress, relationship difficulties and perhaps depression, exacerbated her illness. He asked if Kathy would be willing to meet with "a behavioral care specialist" for some additional input and Kathy gave a tentative "maybe." So Mahan joined the interview and, in the course of an amiable chat, was able to demystify psychotherapy and explain the relevance of Kathy's emotional state to her physical complaints. By the end of the session, Kathy had agreed to meet with him to work on managing her "stress."
They met for three sessions. Kathy liked Mahan and felt she was finally making progress. While she responded positively to the treatment for GERD, which included medication and dietary changes, as well as to an antidepressant prescribed by the intake physician, she also began examining the psychosocial stressors in her life. Kathy talked about her dead-end job as a retail clerk, her frequent arguments with her boyfriend and her wish to move out of her parents' home. With Mahan's coaching and support, Kathy became more assertive in managing her own health: She learned more about GERD, formulated questions for her physicians and transformed from docile observer to active, informed consumer.
Her newfound confidence manifested itself in other areas of her life as well. She became more assertive in her relationship with her boyfriend and her family, as well as in her job. She moved away from home, started a walking regimen and finally got the wire-haired fox terrier she always wanted. In short, Kathy learned to speak up for herself and to act more decisively in her own interests. During a follow-up interview, she told Tom she was in better health and was paying more attention to her own needs. Kathy's new confidence also helped land her a more responsible position at work.
Integrated care was a godsend for Kathy. Aided by medical and behavioral professionals working in concert, she made changes in every facet of her life. Had Kathy not entered an integrated system, she might have continued to show up in the emergency room or the cardiologist's office, receiving costly, ineffective services. If she had encountered integrated health care from the beginning, she might have gotten the help she needed earlier and avoided the frustration of repeated but futile visits to doctors.
This is the beauty of an integrated system, its supporters say. Patients get a reliable diagnosis from a properly trained professional and no longer need to diagnose themselves. They get the medical and therapeutic care they need quickly and cost effectively. The system becomes more coherent--with mental health services easily available, but only through the primary care physician. The bottom line: Carve-ins--done right--increase collaboration, improve care and make psychotherapy more central to health care. And save insurance companies a lot of money.
The Nightmare of Integrated Care
So if carving in offers all this, why do many therapists fear it could undermine our relationship with clients, rob us of our creativity and challenge the fundamental values that underlie good psychotherapy? While the case of Kathy and the Marillac Clinic represents integrated care at its best, such success stories can lull us into underestimating the insidious and deeply ingrained mind-set of the traditional medical model--the idea that proper diagnosis plus prescriptive intervention equals effective treatment. What is obscured is the very real danger that in the name of "integration," psychotherapy will become ever more dominated by the assumptions of the medical model. At issue here is not the theoretical advantages of greater collaboration among health care professionals or bringing more of a therapeutic perspective to bear on medical conditions, but whether we will lose our bearings--and our autonomy--as a profession by becoming immersed in the powerful professional culture of biomedicine today.
To understand the potential danger of carving behavioral care into an integrated system, consider the case of a 15-year-old girl we'll call Carrie. Each morning, she would say goodbye to her mom and walk toward the bus stop near her home in one of the pleasantly named, planned communities that form the suburbs of a large southeastern city. But instead of getting on the bus, she'd walk to a friend's house, where she would spend the day, returning home just as the afternoon bus drove down the street. If not for the notices the school eventually mailed home, her family might never have learned what was going on.
Perplexed about her aversion to school, weary of her rebelliousness and her contentious attitude and frightened by her profound sadness, Carrie's mom took her to the family's HMO. A doctor there noted Carrie's depression, prescribed an antidepressant and recommended psychotherapy. During her visit the next week to the therapist to whom she had been referred, Carrie revealed that she'd been going into the kitchen late at night and making scratches on her arms and legs with a knife. The alarmed therapist admitted Carrie to the hospital. After three nights, she was diagnosed with depression and sent home with orders to take her meds, see the therapist regularly and come back to the hospital psychiatrist on a monthly basis.
In this case, the early referral for psychotherapy was no panacea. Carrie's therapist saw a collection of symptoms rather than a person and focused on alleviating those symptoms with the most efficient intervention at hand--medication. What happened next reflects the pitfalls of applying the medical model to complex interactional problems--when people don't respond to prescribed treatment, they are seen as "resistors" and, when in doubt, a hierarchical, medical system is likely to escalate its "treatments" in ways that compound, rather than resolve, problems.
Carrie didn't want to take the antidepressant prescribed--she said it "made her skin crawl." But in the face of the authority of the medical system, and at the insistence of her mother and the therapist, she took it anyway, and continued to feel bad and cut herself. Once, she even ran into traffic in an attempt to still the tumult inside her. Her friends ran after her, calmed her down and made sure she took her next dose of medication. But when her mother saw the scratches and the continued despair, she called the therapist and, in the next stage in the escalation of her treatment, Carrie again found herself in the hospital. At the hospital, the doctor diagnosed a Bipolar Disorder and added an anticonvulsant to her medication regimen.
But Carrie didn't want more medication--she hated the way she felt when she took the pills, and she wanted to "rule" her feelings without drugs. She just wished she didn't feel so sad. But the therapist and other health care professionals involved with her believed they knew the root of Carrie's problem--Bipolar Disorder--and were emphatic about the importance of the medication, reminding Carrie's mother that it was her legal responsibility to ensure that her daughter never missed a dose. Responding to the therapist's warning, Carrie's mom continued encouraging her daughter to take her pills and Carrie persisted in cutting herself to relieve her distress. All told, she was admitted three times to the hospital, was variously diagnosed with depression, Bipolar Disorder and Borderline Personality Disorder and was prescribed several antidepressants, lithium and an anticonvulsant.
Fortunately for her, Carrie's story doesn't end here, but let's pause to contemplate the mental health care she received in a system insidiously dominated by diagnostic thinking and a hierarchical treatment model. Even in an HMO in which therapists were closely involved early on in treatment, just as is proposed in the integrated care model of the future, Carrie was first required to be a patient; second, to see her problems as medical; and third, to listen and follow orders--her own capabilities and perspective on her problems were never enlisted in her treatment. No one ever really asked her what she wanted, or formed a personal connection with her.
Integrated care, in and of itself, does not provide safeguards that would prevent the kind of treatment Carrie received. In fact, the monolithic power of such a consolidated system, becoming, in effect, a court of last resort for health care, should alert us to its possible dangers. Of particular concern should be an element that its proponents consider a cornerstone of the health care of tomorrow--the integrated data base. With such a comprehensive, computerized record-keeping system of a patient's entire medical and psychiatric history, Carrie's treatment would permanently follow her, available to anyone with access to the system. Ten years from now, she might be unable to get insurance or join the military. And her history of suicide attempts and diagnoses of Bipolar and Borderline Personality disorders could easily affect her career prospects and even her personal relationships. Employers and colleges routinely question applicants about medical history. DSM disorders hardly qualify as preferred credentials on such applications, nor is a history of mental treatment usually included on a resume. In fact, background checks for any reason would take on ominous overtones in a system that would document "mental illness" as part of the medical record.
As it was, Carrie's treatment took an unexpected and fortuitous turn. Her truancy triggered involvement by juvenile authorities, who ordered her to receive treatment from a home-based therapist. Now outside the domain of the medical system, the focus of treatment shifted from Carrie's individual symptoms to understanding the fuller context of her life. The new therapist's first step was to include all Carrie's family members, not just her mother, in treatment. With their help, she began to develop a more complete picture of Carrie--that she was everyone's pet, and everyone's headache. The therapist learned about her karate class, about her love for the horses she cared for on the weekends and about her passion for Egyptian archaeology. The family began a home-schooling program and Carrie's mother took on responsibility for helping her daughter with her daily schoolwork. The therapist also learned, for the first time, that Carrie had been sexually abused by a friend's father.
After three months, and many intense family meetings, Carrie argued less, had stopped cutting herself and had decided to go back to school. At one point, after Carrie broke up with her boyfriend, the therapist worried that the scratching might go deeper and enlisted Carrie's family and friends in a 24-hour support network. They scheduled "check-in" points throughout the day, and Carrie and her family weathered the crisis. After six months of gradually less frequent visits with her therapist, Carrie experienced fewer periods of depression and returned to school.
In short, Carrie was finally helped by good old-fashioned therapy--the kind that entails listening to clients, meeting them in their own worlds and on their own terms and supporting them as they construct a life based on renewed confidence in their own capacities. But how would one translate this kind of treatment into medical terms? A health care system organized by traditional diagnostic thinking that addressed Carrie's symptoms had trouble grasping the larger context of her life.
Clearly, the initial involvement of a therapist in this case was no guarantee of the engagement of Carrie and her family that proved to be pivotal in the work with her. But it would be a mistake to simply write off the treatment Carrie initially received as simply bad therapy. In fact, it may closely resemble the kind of experience patients will receive within many integrated care systems. Why? Because this initial approach is far more consistent with the traditional medical-model thinking that permeates our health care system at all levels--match the right clinical method with the correct diagnosis.
And, in what is perhaps the most disturbing development that may determine the nature of "integrated" care in the future, the major professional associations have begun to position themselves as champions and adjudicators of a distinct set of "approved" interventions for targeted diagnostic groups that, in fact, ignore much of what we have learned makes therapy work in the first place. It is this fundamental misconception within the discipline itself about what constitutes effective psychotherapy that poses the gravest danger for our field.
The Myth of Evidence-Based Practice
In spite of the call to provide a bridge between therapeutic methods and scientific findings, the growing ascendancy of evidence-based practice may also be understood as the product of increasing competition among the mental health professions. Since the 1980s, the number of mental health practitioners has jumped by some 275 percent. Consumers can currently choose among psychiatrists, psychologists, social workers, counselors, marriage and family therapists, psychiatric nurses, pastoral counselors, addiction counselors and many others advertising their services under a variety of job titles and descriptions. In response, the various professional groups have felt an urgent need to document the scientific efficacy of their preferred approaches. In the early 1990s, members of the American Psychiatric Association (APA) decided that they should take the lead in determining the best treatments for the various diagnostic subgroups. So in 1993, the APA established the Steering Committee for Practice Guidelines to prepare guidelines designating specific treatments for specific disorders.
Beginning in 1993 with guidelines for Major Depression and Eating Disorders, the committee has produced guidelines for 10 disorders ranging from Bipolar Disorder to Alzheimer's Disease to Nicotine Dependence. Practice guidelines cover everything from treatment planning to psychiatric management and treatment selection for each of the disorders. More recent guidelines, issued since 1997, also include "practice parameters," ranging from "standards" (should be followed with few exceptions), to "guidelines" (exceptions are not rare, but require justification) to, finally, "options" (where there is no preference between choices). Yet, despite the committee's claim to strong empirical support for its recommendations and reliance on overwhelming clinical consensus, these guidelines have been criticized for treating open therapeutic questions about treatment effectiveness as though they have been definitively settled. For example, the guidelines for the treatment of depression are heavily skewed toward pharmacological intervention, despite the questionable evidence of the efficacy of drug therapy and the fact that studies show that psychotherapy with depressed people provides at least as much--and perhaps longer-lasting--symptom relief. However, the APA's imprimatur has given an aura of scientific legitimacy to what was primarily an agreement among psychiatrists about their preferred practices, with an emphasis on biological treatment.
The other APA, the American Psychological Association, was quick to follow psychiatry's lead, arguing that clients have a right to proven treatments. In 1993, a special APA task force, deriding psychiatry's approved treatment list as medically biased and unrepresentative of the clinical literature, set forth its conclusions about what constituted scientifically valid psychological treatments. Instead of clinical consensus and comprehensive guidelines, the task force concentrated its efforts on research demonstrations that a particular treatment has proven to be beneficial for clients in well-controlled studies. To be considered well established, a treatment must have demonstrated that its benefits exceed those of an alternative treatment or a placebo condition that controls for attention and expectancy. Additionally, this efficacy must be demonstrated by at least two independent research teams.
Since then, the task force has cited 71 empirically supported approaches for an ever-expanding list of disorders. Perhaps believing more is better, the list not only covers conditions like depression and anxiety, but also addresses marital discord, health problems and sexual dysfunction, to mention a few. While the psychiatry association's guidelines focus on a thorough delineation of psychiatric treatment for a few disorders, relying extensively on clinical consensus among experts, the psychology association's list emphasizes specific treatments with replicated empirical support.
There is a certain seductive appeal to the idea of having a specific psychological intervention for any given type of problem--the psychological equivalent of a pill for emotional distress. But, in fact, a closer look at the research literature on therapy clearly reveals that the whole idea of empirically supported treatments (ESTs) is critically flawed, especially as any kind of mandate for what should be done in therapy.
To start with, the criteria for the clinical procedures used to validate a treatment contain a fatal bias. Standard research design requires that the treatments being assessed not contain the inevitable improvisations of therapy as practiced in the real world. Instead, the approaches studied are all required to follow a script so that the "variable" presumably being examined--a precisely defined and structured form of treatment--can be strictly controlled. But while certain kinds of therapy can be scripted--cognitive-behavioral therapy (CBT) being the most prominent--most cannot. So it should come as no surprise that CBT and other behavioral approaches dominate the list of treatments that have received the imprimatur of the task force, amounting to about 80 percent of the list. Is this because these treatments are more effective? No, it is really because they are the easiest to duplicate and, therefore, have been the ones chosen to be researched. This privilege does not extend to some 250 other approaches around today.
Besides the issue of what determines whether a treatment is chosen for study in the first place, questions have also been raised about whether the specific methods associated with an EST really constitute its "active ingredient." One of the most provocative of the studies that raise doubts about this assumption was conducted by Louis Castonguay and Marvin Goldfried, two prominent cognitive-behaviorally oriented researchers who set out to compare the effects of the therapeutic alliance with the effectiveness of a highly structured cognitive approach with depression. Surprising to many who carry the banner for ESTs, their study concluded that the more emphasis a therapist placed on cognitive-behavioral techniques, the worse the treatment outcomes for clients. In their study of 30 depressed clients, Castonguay and Goldfried compared the impact of a treatment technique specific to cognitive therapy--the focus on correcting distorted cognitions--with two other, presumably, non-specific, treatment variables: the therapeutic alliance (agreement between therapist and client on treatment goals and methods) and the client's emotional involvement with the therapist. Results revealed that while the two so-called common variables were highly related to therapeutic progress, the technique unique to cognitive-behavioral therapy--eliminating negative emotions by changing distorted cognitions--was negatively related to successful outcome!
Although the American Psychological Association's intention in adopting ESTs was to demonstrate that psychiatrists had not cornered the market on empirically verifiable treatments, in effect, its task force has responded to the myth of the magic pill by propagating the myth of the magic method. In fact, the uncomfortable truth for advocates of these verified treatments is that there is no solid evidence demonstrating that specific treatment models have unique effects, or that any single therapeutic approach is superior to another. Of course, there have been studies that purport to show that a particular therapy is especially effective. CBT is an example of this. But studies have yet to show consistent differences in effectiveness among therapies developed to address a particular problem despite the Herculean efforts of legions of researchers to do just that.
The results of any attempt to rate the effectiveness of clinical methods--as opposed to the individual effectiveness of practitioners--is best summed up by the dodo bird in Alice's Adventures in Wonderland: "Everybody has won and all must have prizes." In 1936, Saul Rosenzweig invoked the dodo's words to describe the equivalent success of diverse psychotherapies. It has since been called the "dodo bird verdict" and has proven to be one of the most replicated findings in the psychotherapy literature--no approach can reliably make a greater claim to effectiveness than any other.
Perhaps the best publicized study to confirm this idea that all techniques are created equal is the landmark 1989 Treatment of Depression Collaborative Research Project, widely viewed as the most ambitious and methodologically sophisticated outcome study ever undertaken. This NIMH-funded project, which involved both psychiatrists and psychologists at multiple cites around the country, randomly assigned 250 depressed participants to four different treatments: Aaron Beck's cognitive therapy--an approach that seeks to reduce depressive symptoms by challenging irrational and distorted attitudes; Gerald Klerman and Myrna Weissman's interpersonal therapy--which focuses on developing more effective strategies for dealing with "here and now" interpersonal problems; treatment with antidepressant medication; and, finally, a placebo approach called "clinical management," which included a pill placebo plus support and encouragement. After all the effort that went into designing a study that represented the state-of-the-art in outcome research, the investigators were stunned by their own findings. Overall, the four treatments--including placebo--worked with about the same effectiveness.
Recent advancements in statistical methodology, particularly metanalytic studies, which allow researchers to comb through the vast clinical literature and draw conclusions from huge collections of data, lend even further credence to the dodo bird verdict. In psychotherapy researcher Bruce Wampold's comprehensive 1996 review of the therapy-outcome literature, some 277 studies conducted from 1970 to 1995 were analyzed--with particular attention given to the presumably more methodologically sophisticated research of recent years--to determine which therapeutic models have yielded the most robust results. This comprehensive review once again verified that no approach has reliably demonstrated superiority over any other. "Why," Wampold asks, "[do] researchers persist in attempts to find treatment differences, when they know that these effects are small?"
The Client as Partner
So, if empirically supported treatments aren't what makes psychotherapy beneficial to clients, what is? Even though Rosenzweig addressed this question 65 years ago, his conclusion still applies today. Writing in the American Journal of Orthopsychiatry, he argued that all approaches appear to be equally effective, so there must be some larger common factors in operation that overshadow any presumed differences between techniques. What are these factors? The answer isn't really a mystery. The real key to the success or failure of therapy, as Rosenzweig and many other therapists over the years have argued, is the resources a client brings into the room.
Why should it be a surprise that the very factors that were operating in a client's life before counseling also have a crucial effect on therapy? Clients who are, for example, persistent, open and optimistic, who, for that matter, have a supportive grandmother or are members of a religious community are more likely to make gains in therapy.
What else is important to therapeutic success? Researchers Alexandra Batchelor and Adam Horvath argue in their comprehensive 1999 review article that the client's perception of the therapeutic connection is the second most important ingredient of successful therapy, accounting for 30 percent of the outcome. In other words, therapy is much less about method than about the quality of the bond established between therapist and client. To many clinicians, this may seem obvious, but partisans of models and manuals too easily ignore this basic truth: The nature of a client's relationship with a therapist is more important than our cherished theoretical schools, our favorite techniques or our most worshiped gurus.
As we approach a far-reaching transformation in the way mental health services are delivered, it is more important than ever that we recognize that the very foundation of our work is the tailoring of our approaches to the unique needs and circumstances of each client. When you try to do therapy by a book, research tells us that things may not go according plan. For example, researcher Hans Strupp's classic studies, collectively known as the Vanderbilt II Psychotherapy Training Project, conducted in the early 1990s, demonstrated the dangers of overprogramming therapy. Strupp compared the work of therapists before and after they were trained with a manual on psychodynamic therapy. The results: Those who followed the manual were less approving and supportive of their clients, less optimistic and more authoritarian and defensive. Before health care systems organize themselves according to the recommendations of the APAs about what constitutes effective treatment, we need to heed such findings, as well as the previously mentioned study by Castonguay and Goldfried--practitioners of standardized therapy are in danger of developing better relationships with their treatment manuals than with their clients.
Nevertheless, within the medical world, the concept of empirically supported standardized treatments has tremendous appeal. Today, we may stand on the brink of a misguided system of "integrated care" in which manualized therapy will reduce clinicians to mere technicians. And, to make matters worse, integrated data bases will make it easier than ever for managed care organizations to keep track of whether our clients are adhering to the standardized regimens prescribed for them. Lists of approved treatments will give health care bureaucrats a potent weapon to use against those of us who don't order off the menu. This could even leave us in the ethically dubious position of enforcing compliance with treatments we don't endorse, and reporting our clients' lapses to the HMOs.
When our services are provided without a partnership with those receiving them, the client can easily become a cardboard cutout. Moreover, as the trend toward evidence-based practice picks up steam, therapists and clients uncomfortable with this market-driven standardization will find themselves under enormous pressure to conform. So before carved-in care becomes the only game in town, those of us who envision a different future for psychotherapy must step forward to make the case for therapeutic multiplicity.
No matter how invested we are in our own particular clinical methods, we first need to acknowledge that there are many ways to respect our clients' values and perceptions, many ways to be effective and many ways to maintain our clinical integrity. This isn't as easy as it sounds. We have all worked hard to establish our own distinct identity as therapists. We've invested heavily in our own methods. But if we do not unite behind methodological pluralism, we will be easy targets for medical-model ideologues, the proponents of empirically supported treatment and the bean counters of the HMOs.
Clinicians today must take stock of both the values that underlie our practices and our responsibility for professional accountability. Each of us must do his own soul searching about these issues. So what follows is not meant as a blueprint for how therapy should be practiced, just my own conclusions (along with my colleagues Scott Miller and Jacqueline Sparks) about how to extend to clients the same therapeutic freedom we must defend for ourselves and some alternative ideas about what the empirical literature can teach us regarding accountable practice.
Not long ago, I worked with Erica, a woman in her mid-thirties who came into therapy searching for an identity that she believed she had lost. All her life, Erica had wanted to be a police officer. As a teenager, she rode with state troopers, and as a young woman, she became the first female to graduate from the police academy.
Erica lived her dream as an officer for several years, until a car accident plunged her into a coma that lasted for two years. In a triumph of biomedicine, an experimental drug revived her, although she was left with some brain damage and a seizure disorder that made it impossible to work as a police officer. Without this identity she had devoted her life to achieving, she was no longer certain who she was.
How might a medical system of care address Erica's concerns? Although her quest for a new identity does not neatly fit into DSM categories or empirically supported treatments, there is a good possibility that Erica would be reduced to a collection of symptoms and interventions. She might well be diagnosed as depressed and prescribed cognitive-behavioral therapy and an SSRI, along with additional skills-training for deficits left by her brain injury. In the process, the fullness of Erica as a person could easily be lost and she could be reduced to a description of "illness."
My first contact with Erica, as with all my clients, was founded not in just giving lip service to being respectful of clients and collaborative with them, but in using the set of empirically supported findings that I have found most useful in making my therapy as effective as possible. In all the research literature, perhaps the most clinically relevant finding I've discovered is that client's improvement early in treatment is one of the best predictors of successful outcome. So, instead of regarding the first few therapy sessions as a "warm-up" period or a chance to try out the latest brief-therapy technique, I believe it is crucial to be accountable in the very first contact with clients. And given all we now know about the importance of the therapeutic alliance, I approach such initial sessions as a chance to discover how to make the best possible match between myself and my prospective client. Our burgeoning alliance is monitored by clients' session-by-session evaluations of their satisfaction with and progress in treatment. In other words, the guiding principle behind my work with clients is recognizing that all my decisions as a therapist must be guided by my clients' engagement in the treatment process, their view of the quality of the therapeutic relationship, their expectation for change and--the gold standard--their assessment of whether change occurs.
When Erica first called our clinic, she was given the opportunity to structure her therapy, including a choice about whether to meet with an individual therapist or a team. She chose to see me individually, and I first met with her outside the consultation room and told her that I wanted her perceptions to be the light that guided us through the coming process. At my request, she filled out a brief form about how she felt she was progressing individually and socially. Only then did we walk to the consulting room.
She then explained that she felt at a dead end in her life. Having recovered enough to go back to work of some kind, she could not even imagine a back-up dream now that her career in police work seemed over. To complicate matters, Erica was also wrestling with the idea of being "disabled," a word she despised. She recognized that she had some limitations and could not perform the strenuous duties she had once dispatched with ease. Still, the word stuck in her craw. As we explored her experience on the path to recovery, I found myself amazed by her courage, resilience and wisdom. Here was a woman who had it all and lost it--who defied others' expectations of what she could and could not do many times--early on, when she became the first female police office, later, when she unexpectedly came out of a coma, and now, once again. Despite her problems with seizures, vision and balance, she was fighting the expectations of her "disabled" label. She knew there was much more to her than any description of her disability could begin to capture. I knew it, too, as would anyone who spent any time getting to know her. I told Erica that one of the things I liked most about her was her refusal to accept her disability.
A few minutes before the end of our meeting, I asked Erica to fill out another short form, evaluating the progress of therapy to that point. Here, the key clinical information for me was that she felt that I took her problems and ideas seriously, and that she felt hopeful about her situation. Reflecting on how impressed I had been by her, I jokingly asked her if she had ever thought about pursuing a career as a motivational speaker. It was an offhand tribute to the power of her story, but, as I learned later, it struck a deep chord. As we discussed our meeting, Erica told me that she enjoyed the process we had begun--she liked telling her life story and fielding questions about her experiences. Just as the conversation was about to end, she declared that it had occurred to her that she might pursue a career teaching police officers.
That pronouncement was a key step in Erica's journey toward reclaiming her life. She did not end up as a training officer, but was able to reestablish her relationship with the work she loved by becoming a dispatcher. This satisfied Erica's itch for reconnecting with police work, which, for her, was a key to a meaningful life. It allowed her to move on and address other issues, such as her loneliness and her current living arrangements. Erica reported improvement on the outcome measure, and therapy ended a few sessions later.
I don't mention my experience with Erica as an example of a one-session therapeutic miracle, just the reverse. In fact, it is the ordinariness of this kind of interaction that addresses the core of what we have to offer as therapists--the forming of partnerships with clients that makes therapy effective and accountable. I offered Erica no irresistibly powerful interventions, just a relationship structured around her goals and values, that showcased her talents and fortitude. And my repeated requests of Erica to tell me whether the therapy was serving her needs involved a kind of accountability that is very different from the accountability that HMOs increasingly demand from therapists, and that we may expect even more of under integrated care. It stands in sharp contrast to a decision-making process predicated on psychiatric diagnoses, "approved" therapeutic modalities or treatment plans.
As is true of most therapeutic interventions, standardized treatments can be helpful with many clients. But we need a health care system that recognizes that many clients are unlikely to be helped by a medical model of treatment. And that means that if the emerging system of integrated care adopts evidence-based practice as its standard, they may not be helped at all. It is our responsibility as therapists to lift our voices and to advocate on behalf of our clients and our profession. We must make sure that the integrated care system is truly integrated and that it draws from the best of the vast range of approaches that therapists currently tailor to their clients' needs, not the limited number of techniques that are most easily studied. As we are about to enter the next stage in the evolution of our health care system, we need to draw from the accumulated wisdom in our field that teaches us that not all of our clients' struggles fit within diagnostic categories and that therapy can never be reduced to a set of prescribed interventions, no matter how "empirically" supported they may seem to be.
Barry Duncan is professor of family therapy and psychology in the Graduate School of Humanities and Social Sciences at Nova Southeastern University (NSU) and coauthor of 10 books, including The Heroic Client (Jossey-Bass, with Scott Miller) and the forthcoming Heroic Client, Heroic Agencies:
Partnerships for Change (NSU Press, with Jacqueline Sparks). He can be reached at: www.nova.edu/~blduncan. HASH(0xb895f6c) Letters to the Editor about this article may be sent to Letters@psychnetworker.org.
Batchelor, Alexandra, and Adam Horvath. "The Therapeutic Relationship. In The Heart and Soul of Change: What Works in Therapy . Edited by Mark A. Hubble, Barry L. Duncan and Scott D. Miller. Washington: APA Press, 1999.
Castonguay, Louis R., et al. "Predicting the Effect of Cognitive Therapy for Depression: A Study of Unique and Common Factors." Journal of Consulting and Clinical Psychologys 64 (1996): 497-504.
Chambless, Diane L., et al. "Update on Empirically Validated Therapies II. The Clinical Psychologist 51 (1998): 3-16.
Elkin, Irene, et al. "National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments." Archives of General Psychiatry 46 (1989): 971-982.
Kiesler, Charles. "The Next Wave of Change for Psychology and Mental Health Services in the Health Care Revolution." American Psychologist 55 (2000): 481-487.
Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2000. APA Clinical Resources. Washington: American Psychiatric Association, 2000.
Rosenzweig, Saul. "Some Implicit Common Factors in Diverse Methods of Psychotherapy." American Journal of Orthopsychiatry 6 (1936): 412-415.
Strupp, Hans H., et al. "Effects of Training in Time-Limited Dynamic Psychotherapy: Changes in Therapist Behavior. Journal of Consulting and Clinical Psychology 61 (1993): 434-440.
Wampold, Bruce, et al. "A Meta-analysis of Outcome Studies Comparing Bona Fide Psychotherapies: Empirically, "All Must Have Prizes." Psychological Bulletin 122 (1997): 203-215.
by Barry Duncan and Scott Miller
There was a time when therapists, and much of our larger culture, saw depression and other human troubles as complex conditions of mind and heart, influenced by many subtle inner and outer forces. But in the last decade, a vast intellectual and emotional sea change has taken place. We now inhabit a culture where many people hold the view that their emotional pain is "biochemical" and can be cured by simply taking a pill.
Emotional suffering, according to this new view, is a genetic glitch, successfully treatable by drugs. Depression is no longer thought to be shaped by such diverse forces as a sedentary, lonely or impoverished life;
the loss of love, health or community; "learned helplessness" or feelings of powerlessness arising from unsatisfying work or an abusive relationship. Its resolution no longer requires anyone to get meaningful support from others, to establish a collaborative relationship with a good psychotherapist, to draw on community resources, or for communities to address conditions that breed depression. No, depression is now publicly defined as a purely biological illness, treatable--thank heaven--by the miracle antidepressants.
Consider, for example, this interview, which ran on the CBS news program 60 Minutes in 1991, three years after Prozac began its meteoric rise to therapeutic dominance:
Lesley Stahl: [voice-over]... For 10 years, Maria Romero has been suffering from depression, a serious illness. Sometimes she spends weeks on an unmade bed, in a filthy apartment. She told us that she didn't care about anything, and she often thought of suicide. . . . Most doctors believe chronic depression like Romero's is caused by a chemical imbalance in the brain. To correct it, the doctor prescribed Prozac . . . and two and a half weeks later, we paid her another visit.
Stahl: I can't get over it. You're smiling.
Romero: Thank you. Yeah.
Stahl: How do you feel?
Romero: Great. I feel great. I feel like--like I'm a different person, somebody else. Somebody--something left my body and another person came in.
Stahl: She no longer spends her days in a filthy apartment. So two weeks after you started on this drug, whammo? . . . You stopped being depressed?
Romero: I stopped being depressed.
Stahl: Got out of bed . . . fixed your apartment, fixed yourself, and are losing--
Romero: --Fixed my life --
Romero: Yeah. Mmm-hmm. Yep. I'm happy about it. I think it's great.
In the eight years since this segment was broadcast, hundreds of stories like Romero's have been whispered between close friends, described by journalists and repeated in books like Peter Kramer's bestseller, Listening to Prozac. They have become our culture's conventional wisdom. The grinding despair and helplessness of depression is, these stories imply, just a "chemical imbalance" somewhat like diabetes or high blood pressure. The treatment of choice, we are told, is always a drug: Prozac, another Selective Serotonin Reuptake Inhibitor (SSRI) like Zoloft or Paxil, or perhaps another, newer antidepressant like Wellbutrin or Serzone. These miraculous drugs, the story goes, are effective with 75 to 85 percent of the people who take them. In this prevailing cultural script, therapy, like an old character actor, is sometimes ignored altogether, and never given more than a minor supporting role. Only one solution, apparently, is needed, and only one is offered: the passive consumption of a pill.
These views have taken on the luster of scientific truths. But they are not truths. They are myths. They have not been confirmed by the latest discoveries of neuroscience, nor are they supported by outcome research. They seem true because they have been repeated and reinforced by mass-market advertising intended to make taking antidepressants seem as normal and pervasive as swallowing aspirin: Zoloft's logo smiles from long-distance calling cards, coffee mugs, luggage tags and complimentary pens and pencils. A commercial during the World Series trumpets Paxil's power to cure social anxiety disorder. And the sides of colorful tissue boxes in physicians' offices proclaim: "Sue's playing with her kids again," "Walter's fishing again" and "Just like normal--thanks to Prozac!" SSRIs, these advertising campaigns imply, are simply the best first choice for treating depression.
The message is seductive and it works: if these drugs were books, they would be runaway bestsellers. More than 130 million prescriptions were written for them last year alone, and more than $8.58 billion was spent on them. And while most mental health professionals would acknowledge that the explanation given to clients is a gross oversimplification of actual brain functioning, few reject the biochemical model altogether. Fewer still question the effectiveness of the drugs, and virtually no one challenges the idea that combining medication with therapy is the best of all treatment options. At least it includes what talk therapists have to offer. The problem with these common beliefs and practices emerges, however, when they are examined in the light of scientific research.
On a level playing field, antidepressants would be regarded as one valid therapeutic choice among many--one with risks far more grave than those usually attendant on therapy. The awareness of many side effects is just beginning to make it into mainstream consciousness, and the future may reveal further unanticipated consequences: witness the silent epidemics of drug addiction among American women in the 1950s, produced by the widespread prescribing of "mother's little helpers"--amphetamine diet pills and Librium.
Not only are side effects underrated and underreported, outcome research does not confirm the miracle status these drugs have been accorded in the popular imagination. Our culture's exaggerated faith in these psychiatric medications rests not on science, but on brilliant marketing by a profit-driven industry. Outcome research--even outcome research funded by the companies that manufacture pharmaceuticals--has not found these drugs to be any better than therapy, and only marginally better than placebos. Knowing what the research really says will empower therapists to challenge the myths our culture holds about psychoactive medications, reinvigorate their belief in therapy and offer their clients choices based on fact, not superstition masquerading as science.
The first and perhaps most pervasive myth about SSRIs and other newer antidepressants is that their effectiveness is a matter of scientific record, conclusively demonstrated in strict, controlled, double-blind, placebo studies--the gold standard in medical research. According to this myth, the development of SSRIs was a pharmaceutical watershed and the drugs are "magic bullets" far more effective than the older tricyclic antidepressants like Elavil. This message is not only retailed by drug companies, but by the mass media and professional journals: in October 1995, for instance, the American Association for Marriage and Family Therapy's (AAMFT) Family Therapy News cited "overwhelming evidence" in support of antidepressants and their undisputed effectiveness with all but 25 percent of people suffering from unipolar depression.
This is a gross overstatement. Last year, a federal research review of hundreds of clinical trials found that the newer antidepressants were effective with only half of the depressed people who took them and outperformed placebos by only 18 percent. The finding came from the federal Agency for Health Care Policy and Research (AHCPR), a branch of the Public Health Service that promotes "evidence based" health care practices. The AHCPR reviewed all 338 relevant clinical trials of antidepressants conducted between 1980 and 1998, including 206 that directly compared SSRIs and other new antidepressants with older tricyclic antidepressants like Elavil. It found "no difference in overall efficacy" between SSRIs (costing about $66.41 a month) and tricyclic antidepressants (costing less than a tenth as much, or about $5.50). About 50 percent of trial subjects responded well to either drug, while 32 percent responded equally well to placebos; thus, all drugs helped only 18 percent more people than did sugar pills (plus hope and regular contact with a researcher or clinician).
Even at the anecdotal level, miracle stories like Maria Romero's are more rare than we have been led to believe: an online survey of 1,400 depressed people by the National Depressive and Manic-Depressive Association (NDMDA) in November 1999 found that 25 percent reported that antidepressants had no effect on their symptoms, 40 percent reported no improvement in fatigue and loss of energy and 35 percent reported no increase in their ability to experience pleasure.
Leaving aside the question of effectiveness, we turn to another major myth about Prozac and other newer antidepressants: that clients are more likely to tolerate them because their side effects are relatively mild compared with older tricyclic antidepressants like Elavil. In reality, the SSRIs' advantages are marginal; it's more a question of picking your poison. According to the AHCPR review, takers of tricyclics complained more of dry mouth, constipation, dizziness, blurred vision and tremors. SSRIs and other new antidepressants, on the other hand, produced more diarrhea, nausea, insomnia and headaches. Another side effect well known to clinicians went unmentioned by the AHCPR: SSRIs cause sexual problems, including pain during intercourse and difficulty reaching orgasm, in somewhere between 30 and 70 percent of the men and women who take them. SSRIs are also associated with rarer, but much graver, side effects, including bleeding, liver damage, seizures and akasthisia, an almost unbearable jitteriness that can escalate into suicidal thoughts and violent impulses: more than 200 lawsuits have been filed against pharmaceutical companies contending that SSRIs helped precipitate murders and suicides (see the Networker, September/ October 1999).
A third widely held myth is that tolerating even severe sexual side effects is worthwhile, because SSRIs are so much more effective than therapy for depressed people. This myth, too, is junk science, and is not supported by any large-scale methodologically sound study. According to the AHCPR review, the only known, well-controlled research study directly comparing antidepressants and therapy gave a slight edge to therapy. The 1996 study, involving 31 subjects and published in the journal Â Depression, found that Prozac and cognitive therapy were both effective, with no statistically significant differences between them. But a full third of the Prozac group dropped out of treatment or were unavailable for a final assessment, while only 3 of the 13 who received cognitive therapy dropped out.
The myth that SSRIs have proven their superiority to therapy echoes the belief held earlier about tricyclic antidepressants, which were also, in their heyday, thought to be a therapeutic watershed. But in 1989, another large federal study found that therapy was just as effective in the short run, and more effective in the long run, than tricyclics. This finding came from the landmark Treatment of Depression Collaborative Research Project (TDCRP), a National Institute of Mental Health (NIMH) study led by psychologist Irene Elkin. The four-month project involved psychiatrists and psychologists in Washington, D.C., Pittsburgh and Oklahoma City who treated 239 patients diagnosed with major depression. Patients were randomly assigned to one of four groups: Aaron Beck's cognitive therapy; Gerald Klerman and Myrna Weissman's interpersonal therapy; treatment with the tricyclic antidepressant imipramine; and, finally, treatment by placebo. After four months of treatment, the talk therapies had narrowly outperformed the drug: 39 percent of those receiving cognitive therapy, 34 percent of those receiving interpersonal therapy and 32 percent of those receiving drug therapy were rated as recovered. (In the placebo group, 16 percent had recovered.)
In the 18 months following the conclusion of the study, however, the people who had taken part in talk therapy did much better than those who had been given drug treatment. Psychologist Tracie Shea, of Brown University, and her colleagues found that about 24 percent of the therapy clients had recovered without a subsequent major depressive relapse, compared with only 16 percent of the pharmacotherapy clients and an equal percentage of the placebo group. Those receiving the antidepressants did worse on practically every outcome measure: they sought treatment more often during the follow-up period, were more likely to relapse and experienced fewer weeks of minimal or no symptoms than members of either of the two therapy groups. Shea did not speculate on why this was so. But her provocative findings dovetail with the findings reported by outcome researchers Michael Lambert and Allan Bergin in 1994, that clients who attribute change to their own efforts are more likely to maintain positive changes. One plausible hypothesis is that the therapy clients gained the tools and confidence to draw on when other life problems arose, while those who had been given drugs had nothing new to draw on.
But wouldn't the best of all possible worlds be one in which medications were combined with therapy, giving clients enough stability to make use of therapy and creating a sort of double-whammy treatment effect? The idea that both together must be better than either one alone for treating depression has become the newest orthodoxy among many professional groups. In fact, this sensible-sounding "compromise" solution actually promotes the use of medications, by implicitly suggesting that virtually anybody who enters therapy for any reason could usefully take them. Many managed care funded practices now routinely require all therapy clients to undergo medical evaluations as a prerequisite to reimbursement for treatment. But neither outcome studies nor clients themselves offer much support for applying this two-is-better-than-one approach.
In one of the broadest surveys ever conducted of therapy under real-life conditions, Consumer Reports in 1995 tabulated the responses of 4,000 members who filled out a questionnaire on their experiences with therapy. On the whole, their self-reports of both therapy and drug treatment were positive: 54 percent of those who said their state of mind had been "very poor" said treatment made things "a lot better." But people who received only psychotherapy reported as much improvement, on the whole, as people who tried drugs-plus-therapy. Given the additional expense of medication and the risks of side effects, we think therapy alone should be the treatment of first resort rather than drugs-plus-therapy.
The Consumer Reports survey has obvious limitations: those who filled it out had sought therapy for many problems besides depression; the results were based on self-reports by a self-selected group of members willing to discuss therapy on a questionnaire; and the sample was not randomized or demographically balanced. But its conclusions echo those of a research metareview by Yale University psychiatrist Bruce Wexler published in the Journal of Nervous and Mental Diseases in 1992. Wexler examined seven well-controlled outcome studies of 513 patients treated for depression. Therapy alone, he found, helped as many people as therapy-plus-drugs, with fewer dropping out of treatment. The review concluded with this simple summary: out of 100 patients with major depression, 29 would be expected to recover if given drugs alone, compared to 47 given therapy alone and 47 given combined treatment. On the other hand, 52 drug-only patients would be expected to drop out or have a poor response to treatment, compared to 30 therapy-only patients and 34 patients getting therapy-plus-drugs.
Â In all of the healing arts, there is no single explanation or simple, infallible remedy for any of the problems that beset humankind. Yet the growing power of the biological perspective in mental health discourse and practice suggests not only that there are solely biological explanations, but perfect, fail-safe biological solutions as well--simple pills that mark finis to everything from mild depression and nervous tension to panic attacks, bipolar disorder and full-blown psychosis and schizophrenia. How did this scientifically anomalous, weirdly simplistic point of view come about? If the science behind the advertised superiority of psychotropic drugs is so lacking, how did medications come to hold almost unchallenged sway over both public and professional opinion?
In the days of the Watergate investigation, the government informant known as "Deep Throat" met with Washington Post reporters Carl Bernstein and Bob Woodward in an underground garage and advised them to "follow the money" if they wanted to find who was really behind the break-in at Democratic National Committee Headquarters. The same advice can help explain why psychiatric medications have permeated every aspect of our culture. Follow the money, and you will begin to understand the growth of the pharmaceutical behemoth.
In March 1992, Consumer Reports estimated that the $63 billion drug industry spent $5 billion a year on promotion and publicity, and it spends at least as much today: advertising in medical journals, on television and in women's magazines; helping fund "public awareness" efforts like the National Depression Awareness Day; giving grants to organizations like the Anxiety Disorder Association of America (ADAA), the National Depressive and Manic Depressive Association (NDMDA) and even the American Association for Marriage and Family Therapy (AAMFT.) The American Psychiatric Association confirms that at least 30 percent of its budget is now underwritten by drug companies through grants, glossy paid advertisements in its journals and paid exhibits at professional conferences. Psychotherapy organizations cannot begin to compete with this billion-dollar promotional machine, even though the data upholding the value of therapy are clear.
Drug companies also fund much of the drug research that supports, however weakly, the myths that have taken hold of almost everyone from psychiatrists and journalists to therapists and the average client in the street. Because of the shrinking of federal grants and the privatization of research funding that began in the Reagan years, pharmaceutical companies now pay for the majority of clinical trials of drugs. The AHCPR metareview, for example, noted that out of 315 published clinical trials of 29 antidepressant drugs, every study that identified a sponsor had been funded by a drug company. The ubiquity of drug company funding may also help account for the dearth of research comparing the effectiveness of therapy and medication: why would drug companies fund research that might prove a competing product (such as therapy) was equally or more effective?
In the broader field of nonpsychiatric medical research, those who pay the piper tend to enjoy the tune: researchers with financial ties to drug companies usually publish results friendly to their funders, and friendly researchers, likewise, tend to get funded. An October 1999 study of 44 journal articles on anticancer drugs, for instance, published in The Journal of the American Medical Association ( JAMA ), reported that only 5 percent of drug-company funded research found that the drugs were not cost-effective, while 38 percent of the research sponsored by universities, foundations and other nonprofit organizations found the drugs not cost-effective. A study in the January 1998 New England Journal of Medicine produced similar results: of researchers whose published studies supported the use of calcium channel blockers to treat high blood pressure and angina, 96 percent had financial relationships with the manufacturers; only 37 percent of researchers whose work did not support the use of calcium channel blockers, on the other hand, had received drug company funding. Thus, like a flower opening itself to the sun, published research results tend to be skewed in the direction of the money source.
Our exaggerated sense of the efficacy of psychiatric drugs may also be colored by the fact that drug companies are under no obligation to publish the results of failed clinical trials. Thomas J. Moore, a health policy analyst at George Washington University, for example, recently found, in a search of FDA files, the results of two identical trials of the antidepressant Serzone. The one showing a marginally positive result was published, but Moore found no indication that the other trial, showing no measurable drug effect, was ever published.
While drug-neutral and drug-negative research is underplayed, drug-friendly research is sometimes overplayed and made to serve the purposes of marketing. In February 1999, for example, JAMA published a study showing that as many as 40 percent of American women and 30 percent of men suffered from some form of sexual dysfunction. "I think it gives us a base for explaining why we had this enormous response to Viagra," one of the coauthors, sociologist Edward Laumann, told The New York Times at the time. The article, widely reported in the popular media, was actually a recalculation of data first published in 1994. The JAMA article did not disclose that two of the coauthors, Laumann and Raymond Rosen, had served as paid consultants to Pfizer, the makers of Viagra.
Closer to home, the American Association for Marriage and Family Therapy (AAMFT) recently took part in a major public relations campaign focusing on depression, intimacy and antidepressants. The campaign was primarily funded by Glaxo-Wellcome,Â makers of Wellbutrin, an antidepressant notable for its lack of sexual side effects. With the help of a $50,000 grant from Glaxo-Wellcome,Â the AAMFT 1998 national conference in Dallas featured a panel on intimacy and depression at its opening plenary--a session historically reserved for one of the real movers of the family therapy field. The slick, Oprah-style session featured clips from the television series Party of Five Â and a five-member panel that included three speakers with financial relationships with Glaxo-Wellcome: psychologist Martha Manning; her husband, social worker Brian Depenbrock; and psychiatrist Anita Clayton, associate professor in the University of Virginia's Department of Psychiatric Medicine.
Over the next hour and a half, the audience of 2,000 therapists was reminded 11 times of the tragic sexual side effects of some antidepressants. Although Wellbutrin was never mentioned by name, Clayton mentioned several times that someÂ antidepressants don't deprive clients of a sex life. She did not disclose that she is a member of Glaxo-Wellcome's advisory board and speakers bureau, nor that Glaxo-Wellcome has funded her research. Nor didÂ Manning, who has written widely about her own depression, disclose that she has sometimes acted as a paid consultant to Glaxo-Wellcome and has cowritten a brochure for them on intimacy and depression.
The plenary was part of a larger public relations effort funded by Glaxo-Wellcome and cosponsored by AAMFT and the National Depressive and Manic Depressive Association (NDMDA)Â a private non-profit "public education" organization that gets the bulk of its funding from pharmaceutical companies. The campaign included a brochure for the public on intimacy and depression, bearing the AAMFT and NDMDA logos, but copyrighted by Glaxo-Wellcome and written from the point of view that drugs are the treatment of choice for depression. Nearly four full pages are devoted to the nuances of antidepressants, while individual and couples therapy rate a few sentences. ("Antidepressants are usually effective . . . psychotherapies developed specifically for the treatment of depression can be useful. . . .") Wellbutrin is not mentioned by name, but the point is prominently made that consumers should consult their physicians about medications free of sexual side effects. The campaign also took a panel that included two AAMFT officials, plus Manning and her husband (and on occasion, actors from Party of Five and John Gray of Men Are from Mars, Women Are from Venus fame) to three well-publicized and advertised "town hall meetings" on intimacy and depression held in New York, San Francisco and Seattle.
Psychiatrist Anita Clayton told the Networker that her airfare and lodging expenses for her participation inÂ the AAMFT 1998 plenary had been paid, but she had not receivedÂ an honorarium. She also noted that she has received research funding from, and is on the speakers' bureaus of, other pharmaceutical companies beside Glaxo-Wellcome.
We the authors were so concerned about AAMFT's involvement in the depression and intimacy campaign that we organized an e-mail protest to AAMFT before the plenary, leafleted the event and spoke in opposition to it at an AAMFTÂ "town meeting." Although AAMFT did not violate the ethical standards of any group with which it is affiliated, the failure to prominently disclose the speakers' relationships to Glaxo-Wellcome at an event presented for continuing education credit would violate the standards of other professional groups, including the American Psychiatric Association and the Accreditation Council for Continuing Medical Education.
Manning says that she routinely discloses that she is sometimes a paid consultant to Glaxo-Wellcome, but was never asked by the AAMFT to do so for the 1998 plenary; her involvement with the drug company's campaign, she says, resulted in far more focus on therapeutic and relational issues. "We cannot afford to isolate ourselves from the medical approach to depression, which has been enormously useful in my own experience, as has psychotherapy," she said. "Depression is such a horrible thing that we have got to be involved in all kinds of cross-fertilization." We do not argue that her views, and those of other consultants, aren't sincerely held. But what therapeutic school can afford to fund its advocates to put on an equivalent national public-relations road show?
This magazine, likewise, has never routinely asked its authors to disclose financial ties to pharmaceutical companies. In March 1999, the Networker published "Rx for Passion: Antidepressants Needn't Depress the Libido," about the sexual side effects of antidepressants, by Valerie Davis-Raskin, M.D, in which she recommended Wellbutrin. The editors were not aware that Davis-Raskin was also a member of Glaxo-Wellcome's speaker's bureau. The ubiquity of nondisclosure of financial ties, like these, makes it impossible for the general public, including therapists, to critically evaluate the objectivity of so called medical experts.
Marketing masquerades not only as research, but as public education. Take National Depression Screening Day, for example, a public relations and marketing extravaganza riding on the back of a public service campaign. On October 7 every year, volunteer mental health workers offer simple screening tests for depression (as well as counseling and referrals), at more than 3,000 hospitals, mental health clinics, doctors' offices, libraries, grocery stores and shopping malls across the country. Public service radio spots publicize the day. The American Psychiatric Association and the National Institute of Mental Health (NIMH) lend their names to the event, which is administered by a private, not-for-profit organization called the National Mental Illness Screening Project (NMISP) of Wellesley Hills, Massachusetts.Â NMISP also sponsors screening days for other mental illnesses.
According to information provided by NMISP to the IRS, Eli Lilly, the makers of Prozac, gave the group $1.75 million between 1993 and 1997--nearly half of the organization's $3.6 million income for those years. Almost all of Depression Day's largest funders (giving $50,000 or more) are pharmaceutical companies, as are six of the seven major funders named on the web site for the event. The director of NMISP told the Networker that revenue from other sources has since increased, and that only 25 to 30 percent of Depression Day's funding now comes from pharmaceutical companies.
Some marketing connected with Depression Day has been directed specifically at children. In 1995, for example, The Washington Post reported that several students at Walter Johnson High School in Bethesda, Maryland, complained after sales representatives of Eli Lilly spoke at a school assembly on Depression Day and then passed out free pens, pads and brochures touting Prozac. One student said she had been forced to listen to "a 45 minute plug for Prozac," and her mother told the Post that no other alternative treatment for depression, such as counseling, had been presented. These campaigns have a predictable effect: more than 453,000 prescriptions for Prozac alone were written last year for kids under the age of 18. Another recent Depression Day initiative focused on primary care physicians, teaching them how easily their patients could take screening tests in the waiting room, to be later scored by staff without imposing on the doctor's time.
Adrift in this cultural sea of overprescription and overpromotion, what is the responsible therapist to do? The solution is not to dismiss SSRIs and other antidepressants out of hand, but to put them in their place. Therapists should stop kowtowing to their supposedly superior powers and think of them as one choice among many--and certainly not as the treatment of first resort.
In our own practices, we never suggest medication as the treatment of first resort. Instead, we begin therapy on the assumption that if we follow the client's lead, ask about the client's own theory of how change takes place and strengthen the therapeutic bond, we will enhance therapeutic outcomes of all kinds--with and without medication. When clients believe that medication will help and are "in the driver's seat" in making an informed choice, we have found that SSRIs can be helpful at times. Whatever approach evolves from the dynamic, moment to moment synthesis of ideas, it is the client who judges its helpfulness. Finding something that fits is facilitated by routinely inviting each client's feedback about the treatment he or she is receiving. Whether the approach is medication or one of the 400 available therapy methods and techniques, we think therapy should be a partnership that involves the client's voice at every juncture and in every decision. And if talk therapy has not produced results in three to six weeks, we brainstorm options with our clients; one of them may be antidepressants, while others include switching to another therapist or another approach. But SSRIs are never our first choice unless the client suggests them.
Guidelines like these don't make the treatment of depression simple. Nor can guidelines--or any drug--fully prepare any of us for those horrible moments when we sit face to face with the smothering despair of our clients. Not long ago, one therapist at our clinic at Nova Southeastern University worked with a weeping, financially desperate woman named Alina. The therapist listened with growing concern as Alina talked about her inability to leave her emotionally abusive husband, her worry about her four children and her humiliation at her new job, where her boss mocked her Spanish accent in front of customers. "I can hardly get up in the morning. If I had the guts, I'd just crash my car into a tree and be done with it," she said. Her tears, anguish, and despair were so palpable during the session that the therapist found herself having to fight her own feelings of hopelessness and fear for Alina.
It was this painful resonance that permitted the therapist to connect with her client, and that helped create the possibility that Alina and she could be part of some kind of change together.
But this very resonance also made the therapist vulnerable to finding herself, like Alina, in momentary despair. For many therapists, this is the moment when the voice of bad research and great marketing emerges, whispering of the superiority of "modern science" over primitive "talk therapy." It leads many therapists to reach for what looks like a sure thing to give their clients (and themselves) hope and relief. The medication solution is like fast food: it takes the work, time and anxiety out of answering "What's for supper?" But the introduction of the topic of medication in therapy carries numerous messages, among them, "Your problem is so severe, and you are so biologically damaged, that we have to look at something other than what we are doing together, or what you can do on your own." These messages serve to abort most clients' naturally occurring search for solutions and to block access to their own innate resourcefulness that lies at the heart of good therapy.
Reaching for that sure thing, the therapist thought as she faced Alina, would have predictable results. She would refer Alina to a physician who could prescribe drugs, and he or she would inevitably focus on Alina's mental state, her fragility and her potential for suicide. The therapist also considered the implications of the fact that 70 percent of all antidepressants are prescribed to women. Other paths were far more uncertain. As the therapist struggled internally, Alina volunteered that she didn't like pills, and wanted to solve her problems herself. Knowing that other options could be introduced at any time, the therapist trusted in Alina's direction and in the power of the therapeutic relationship.
At the end of the first visit, the therapist pointed out Alina's strengths and all she had done to extricate herself and her children from unbearable situations. Alina concluded the session by emphatically stating that she had no plans to hurt herself. Over two months of therapy, the therapist met with Alina every week, encouraging her concrete efforts to deal with the circumstances that were distressing her, and Alina's life and mood slowly improved. When federal funding for the therapy program ended, Alina was no longer desperate, validating the therapist's faith in her client's innate resourcefulness. Alina was going out with girlfriends more, she had conquered her job and was getting praise there and she had much more confidence in herself. She had even begun saving money for an independent future without her abusive husband. She and the therapist had weathered the storm together, with Alina, not medication or the therapist, at the helm.
Some people, like Alina, struggle with despair and oppressive life circumstances over time; others, including the severely depressed, sometimes make stunning turnarounds within the course of a single therapy hour. If the option to try something different is not at least as attractive as the medical option, the magic pill will win every time. What is required is a reconnection to what good therapists already know: that most people can and will develop solutions to even the most daunting dilemmas, given support and encouragement.
At the core of this approach is our faith that change occurs naturally and almost universally: the human organism, shaped by millennia of evolution and survival, tends to heal and to find a way, even out of the heart of darkness. When we hang on to this belief in our hearts, we level the playing field and can compete with the noisy medical ideologies promoted by profit-making drug companies and championed by factions within our own professions.
Every good therapist knows that each case is as different as the faces we greet each hour. Each experience of depression will take its own course. Rather than being hostage to the notion that "it's all biochemical," we can remind ourselves that every emotional human experience--including hope, reassurance, trust, love, faith and rapport--affects the body's chemistry and has neurochemical correlates in the brain. Rather than turning to the magic pill, therapists can access the real magic: the connection created by listening to and exploring their clients' stories, experiences and interpretations of their problems. That rapport, as the sustained power of the much misunderstood and underrated "placebo effect" suggests, can positively affect not only clients' bodies and brain chemistries, but their willingness to act and their sense of who they are and who they can become. A mountain of outcome studies conducted over the last 40 years has shown that forming a therapeutic alliance is not a prerequisite to successful treatment--it is Â the real treatment. In study after study, therapies in which the client perceives a helpful therapeutic bond and a mutual agreement on goals are the most successful. Finally realizing that psychiatric drug therapy is a profit-driven industry, built on flimsy science, may be the bad tasting medicine we've needed. Although it may be hard to swallow, empowered with the knowledge, therapists can regain their voices, trusting what they have known all along about depression and other human travails: there is no better medicine than a good therapeutic relationship.
Barry Duncan Psy.D., is an associate professor at the School of Social and Systemic Studies at Nova Southeastern University in Fort Lauderdale, Florida, and Scott Miller, Ph.D., is a therapist and an international workshop presenter based in Chicago, Illinois. They are cofounders of the Institute for the Study of Therapeutic Change (ISTC). Jacqueline Sparks is a member of ISTC and a doctoral candidate at Nova Southeastern University. This article is adapted from Duncan and Miller's latest book, The Heroic Client: Doing Client Directed Outcome Informed Therapy . The authors can be reached at: www.talkingcure.com
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Elkin, Irene, et al. "National Institute of Mental Health Treatment of Depression Collaborative Research Program: General Effectiveness of Treatments." Archives of General Psychiatry 46 (1989): 971-82.
Murlow, Cynthia D., et al. Treatment of Depression: New Pharmacotherapies. Evidence Report/Technology Assessment Number 7. AHCPR Publication No. 99-E014. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, February 1999.
Shea, M. Tracie, et al. "Course of Depressive Symptoms Over Follow-up: Findings From the National Institute of Mental Health Treatment of Depression Collaborative Research Program." Archives of General Psychiatry 49, no. 10 (October 1992): 782-87.
Wexler, Bruce E., and Domenic V. Cicchetti. "The Outpatient Treatment of Depression: Implications of Outcome Research for Clinical Practice." Journal of Nervous and Mental Disease 180, no. 5 (May 1992): 277-86.
by Pat Love
Late on a chilly spring night several years ago, my husband inquired when I would be coming to bed. "Mmm, a little later," I replied. Translation: "Do you want to make love?" Answer: "Not a chance." The dialogue was familiar, but this time it was edged with a quality of brooding tension that distinguished it from the hundreds of similar invitation-and-refusal scenes we'd enacted before. When I finally came to bed that night, my husband was still awake, bristling with outrage and hurt. "Every night, it's the same routine," he stormed. "Aren't we ever going to have sex?"
I began to marshal my usual arguments about being exhausted after a day of chasing two small kids when, suddenly, I felt myself go limp with dejection. I felt bone-weary of the years of conflict, guilt and crushing sense of inadequacy that pervaded my lack of interest in lovemaking. Turning my face to the wall, I said softly but entirely audibly: "I don't care if I ever do it again."
From the other side of the bed, there was silence.
How had it come to this? When I first began dating my husband, a rangy, dark-haired college athlete with a chiseled physique and a talent for making me feel like the only woman on the planet, I was plenty attracted. Saving sex for our wedding night only heightened my desire. But even after our marriage, we made love frequently, passionately and often for hours at a time. If, during those early years, he wanted sex slightly more than I did, the difference in our sexual setpoints seemed negligible. On the erotic front, we seemed about as perfectly matched as any couple could hope to be.
Until it all ended. Two years into our marriage, my libido began to wilt; after giving birth to our first child, it went permanently AWOL. Truth to tell, I didn't much care about the demise of our sexual synchrony. Furiously busy with the demands of an infant son, homemaking and church work, I rarely even thought about sex, much less craved it. My husband's desire for me, however, had dimmed not one iota. One evening he arrived home, full of hope, bearing a book on sensual massage for couples. When I glanced through the photos of smiling, nude women pleasuring their partners, I felt my inadequacy like a physical attack and threw the book into the trash.
Silently, I blamed my husband for being inconsiderate enough to desire me when the feeling wasn't mutual, and while he never explicitly said so, he must have felt profoundly unwanted. For years, we coped by simply repressing all of our anger and sorrow--each of us fearful to say out loud how desperately unhappy we had become in our marriage.Â Then, on the night I finally spoke the unspeakable--"I don't care if I ever do it again"--our mutual disenchantment bottomed out into despair. Like many people, my husband and I equated sexual passion with love, so we concluded that if I had lost all interest in sex, I must no longer love him. At the very least, it seemed that each of us was trapped in an unbearably incompatible marriage, a union that doomed one partner to everlasting sexual frustration and rejection, and the other to feeling perpetually invaded and, at the same time, somehow defective. These convictions led to an action that remains the deepest regret of my life--an unnecessary divorce from a thoroughly decent, loving man and the father of my two children.
I say "unnecessary" not because we didn't try to work things out. We sought therapy and got the best that was available. But the intensity of shame and hopelessness that permeated our mutual sense of sexual failure was beyond the usual therapeutic jump-starts. Rather, I believe our divorce was unnecessary because we did not understand then that our desire gap was rooted, to a large degree, in powerful, automatic, biochemical processes that had little to do with how attractive I found my husband or how much I actually cared for him. In fact, I did love him; the problem was that my body didn't know it.
If the idea that desire is orchestrated by our body chemistry hasn't yet found its way into the clinical conversation, it may be because the evidence is still largely buried in scientific journals, primarily from the emerging fields of behavioral endocrinology and psychophysiology. The provocative core of the new research is this: Each of us approaches our erotic encounters already primed by a premixed neurochemical and hormonal "cocktail" that influences both the strength and staying power of sexual passion. Having delved into this new biological evidence and observed its impact in my own couples therapy practice, I am convinced that as long as our clients remain unaware of these bodily processes, they are at high risk for making disastrous decisions about their intimate commitments. Some clients will misread their clashing desire levels as the death of love and lose faith in basically sound marriages, as my husband and I did. Others will choose badly to begin with, making lifelong commitments while under the influence of short-lived, highly irrational brain states.
But I believe that both catastrophes are largely preventable. The emergent data on the biology of desire offers therapists a potent new tool for helping troubled couples--a genuinely new kind of sex psychoeducation. This form of "desire ed," which I now use routinely in my work with couples, doesn't dwell on the usual sex therapy instruction about performance anxiety or the search for the elusive G spot. Instead, its objective is to help clients understand how their hidden neurobiological agendas may operate in the bedroom, so that they can make conscious, thoughtful decisions about their intimate relationships rather than ones that misinterpret the critical messages of the body.
But let me be clear: I am not proposing that the complexities of sexual desire can be reduced to Chemistry l0l. There is no question that problems of passion also can be influenced by relationship conflicts and a long list of other factors, from depression, stress and past sexual trauma to certain medications and a host of medical disorders. Likewise, it goes without saying that chronic sexual problems can contribute hugely to relationship difficulties. Nonetheless, the biochemical action of the human brain--the organ that nature writer Diane Ackerman calls our "three pounds of blood, dream and electricity"--may influence how often and how badly each of us wants sex more than we ever imagined.
To begin to understand the biology of desire, think back to the last time you fell fiercely, feverishly in love. He, or she, merely walked into the room and your body was zapped by a thousand-watt current, transforming you from a reasonably rational, functional adult into a trembling, mushy puddle of pure yearning. When the two of you were together, the most mundane activity--say, going to Wal-Mart for poultry scissors--became an exhilarating, deeply rewarding event. Not to mention the sex. Remember? The sex was amazing .
Most of us who have spent any time in infatuation's clutches also remember the sense of pure, utter helplessness that permeates this state. In the throes of new romance, there is something strangely involuntary about one's behavior--the workaholic misses deadlines; the penny-pincher blows his paycheck on plane tickets for two to Paris; the solidly married woman finds herself whispering on the phone, making furtive, high-risk plans with her paramour. Our culture speaks of "falling" in love. Other societies have compared infatuation to divine revelation, and to psychosis. We often say, in jest, that this experience of hurricane-force passion is "like a drug."
But that oft-quipped analogy may turn out to be no joke. Some scientists now believe that the frenzied euphoria of romantic love may well be a bona fide, altered state of consciousness, primarily brought on by the action of phenylethylamine (PEA), a naturally occurring, amphetamine-like neurotransmitter. Michael Liebowitz, a research psychiatrist at the New York State Psychiatric Institute, believes that when we come into contact with a person who highly attracts us, our brains become saturated with a "love cocktail" comprised of PEA and several other excitatory neurotransmitters, including dopamine. This chemical brain-bath theory explains why new lovers can talk till dawn, make love for hours on end, lose weight without trying and feel so outrageously, unquenchably optimistic. Their neurons are soaking in natural speed.
Thus far, much of what we know about PEA's action comes from animal studies. When mice are injected with PEA, they cavort and squeal in displays of rodent rapture, while rhesus monkeys dosed with PEA-like chemicals make pleasure calls and smack their lips, a courting gesture. While the brains of romance-besotted humans have yet to be directly studied, Theresa Crenshaw, a sexual medicine researcher and author of Sexual Pharmacology , reports that elevated levels of PEA have been found in the bloodstreams of lovers. Crenshaw also has found that women's PEA levels tend to rise at ovulation, which suggests a role for this potent molecule in the survival of the species.
Still, speed-spiked blood and the antics of small animals hardly prove a pivotal role for PEA in firing human passion. To date, the most compelling evidence comes from studies on a group of people suffering from a disorder known as hysteroid dysphoria, characterized by a desperate, boundless craving for attention and admiration, coupled with an acute hypersensitivity to rejection. Unlike most adults, who succumb to infatuation upon occasion, the hysteroid dysphoric is a kind of "romance junkie," falling in love constantly, violently and often with unsuitable partners. This person's usual pattern is to enjoy a brief, thrilling infatuation, followed by a traumatic breakup, often precipitated by his or her anxious, seemingly bottomless need for displays of love and affection. Upon rejection, the romance-hooked person predictably plunges into deep depression, which he or she tries to cure by falling in love all over again.
Research psychiatrist Liebowitz and his colleague Donald Klein suspected that such "infatuation junkies" might suffer from some kind of biochemical imbalance--perhaps abnormally low PEA levels. They wondered: Was it possible that these individuals jumped compulsively from lover to lover in order to keep their PEA sufficiently revved up to feel normal? To find out, Liebowitz and Klein treated a group of hysteroid dysphorics with the class of antidepressants known as monoamine oxidase (MAO) inhibitors, which block the action of brain enzymes that break down PEA. MAO inhibitors, therefore, act to boost PEA levels. Within weeks of starting their medication regimen, some of the lovesick subjects began to choose partners more judiciously, while others reported feeling reasonably comfortable without any love interest in their lives at all. Apparently, these individuals no longer craved the PEA jolt they once got from their euphoric, disastrous romances.
But one doesn't have to have a diagnosable love disorder to be influenced by PEA. Researchers propose that in the presence of a sufficiently intense sexual and emotional attraction, virtually everyone's neural lattices become marinated in natural speed. Given some of the dangerously delusionary thinking that accompanies new romance, the concept of an overstimulated brain makes compelling sense. If the frenzied action of lovers' neurons tends to render them maniacally optimistic, it is no wonder that they tend to discount patently alarming qualities in their sweethearts. You may gently remind a love-struck client: "Have you really considered the fact that she is a practicing alcoholic, has lost three jobs in a row and has been divorced only two months?" Your client sweetly responds: "We can work it out." Indeed, in a study of 400 men and women involved in a new romance, psychologist Dorothy Tennov found that while infatuated individuals had no trouble identifying shortcomings in their lovers, they tended to recast even the most serious liabilities as trivial, tractable and even charming.
What about sex? We don't need a slew of studies to convince us that with a new lover, sex is the Mount Everest of romantic peak experiences. Some neuropsychologists now think that the sexual euphoria that accompanies infatuation issues from brain secretions of both PEA and dopamine, a neurotransmitter that both stimulates libido and mobilizes people to actively pursue the pleasure of lovemaking. With two potent brain molecules working overtime, it's as though our erotic thermostat gets overwhelmed--we want scads of sex with our beloved, we get our fill, then in short order we're ready for more. It must be love.
Until it's not. For the universal and much-denied truth is this: Romance has no legs. Numerous studies that have measured the duration of infatuation--from the first moment of stuttering euphoria to the first feeling of neutrality for one's love object--have found that the state of romantic rapture predictably burns out after 18 to 36 months. And while the demise of infatuation certainly encompasses emotional components, such as the resentment that attends the inevitable discovery that our lover has other priorities besides keeping us happy, our wilting desire is also likely to be grounded in brain physiology. Liebowitz and others theorize that the brain cannot eternally maintain its revved-up, lust-crazed state of romantic bliss, either because the nerve endings become habituated to the brain's natural stimulants or because levels of PEA and related substances begin to drop. It certainly makes sense that if infatuation is a "high" that is chemically analogous to an amphetamine jolt, lovers would develop a tolerance for each other over a period of time. Whatever the precise mechanism involved, all of us have experienced this downshift in desire--slowly but predictably, euphoria sneaks out the back door while reality, that perpetually unwelcome houseguest, makes its sullen entrance.
If the sexual reality facing postinfatuation couples were limited to plummeting desire, it would be tough enough to cope with. But the dilemma of many disillusioned lovers is made far more difficult by a substantial desire gap between partners. To fully understand this element of a couple's sexual struggle, we need to introduce a second biological factor--testosterone. When most of us think of this steroid hormone, we reflexively think "male," and a pumped-up, perpetually horny one at that. We almost never think about the ways in which testosterone influences women--and consequently, we may be missing one of the biggest clues to the desire difficulties of many couples.
Scientists have known for decades that both sexes produce testosterone: men manufacture gobs of the stuff in their testes and adrenals, while women pump out smaller quantities from their ovaries and adrenals. But while testosterone has been conclusively shown to highly correlate with male libido, it was long dismissed as a nonfactor in the sex drive of women. Then, in 1987, Barbara Sherwin, a psychologist and psychoendocrinology researcher at McGill University in Montreal, published her now-classic study on the impact of hormone replacement therapy on women's sex lives. Sherwin divided her 43 subjects, all of whom had undergone surgical removal of their ovaries, into three groups, giving one group estrogen medication, a second group a regimen of estrogen and testosterone and a third group a placebo.
The results were swift and dramatic. The women who received the testosterone-estrogen cocktail reported a greater upsurge in sexual arousal, more lustful fantasies, a stronger desire for sex, more frequent intercourse and higher rates of orgasm than the women in either of the two other groups. Sherwin replicated these findings in several other carefully conducted, double-blind studies.
Subsequent research on women's naturally produced testosterone has yielded similar results. In the absence of infatuation, women with high baseline levels of testosterone--so-called "high-T" women-- tend to be significantly more sexually interested and responsive than "low-T" women. This now-substantial body of psychoendocrinological research has exploded decades of mythology about female sexuality by establishing that libido requires a goodly supply of testosterone in women as well as in men. But herein lies a key source of the postinfatuation desire gap. Both genders rely on testosterone for a robust sex drive, yet on average, men have 10 times more of the stuff circulating in their systems as women do. This doesn't mean that women are typically only one-tenth as lusty as men; many endocrinologists suspect that because women are exposed to lower levels of testosterone, they are more sensitive than men to a given amount. Nor does it mean that all men are the sexual equivalents of the Energizer Bunny. Testosterone levels drop gradually with age, and at any stage of life, the genetically determined sensitivity of androgen receptors in the genitals and brain influences how strongly testosterone pumps up male libido.
Nonetheless, the biological reality remains that, on average, men tend to be hornier than women--by quite a bit. Surveys show that, among both heterosexuals and homosexuals, men think about sex more frequently, masturbate more often and rank sex as more important in their lives than women do. Of course, there are millions of exceptions to this gender-typed scenario. I worked with one young couple in which the woman wanted daily lovemaking, while her husband felt the urge maybe once a week. Sharing a bed with him aroused her to such a pitch that she had taken to sleeping alone in a back bedroom. I also have worked with many lesbian and gay couples on problems of mismatched desire, indicating that passion quotients vary within as well as across gender lines.
Whatever the gender positions of this lust gap, it is a commonplace phenomenon: A survey of 289 sex therapists found "desire discrepancy" to be the single most common presenting problem of clients. Yet couples might be able to cope more sanely with their divergent desire levels were it not for the biochemical blinders they wear in the early stages of their relationship. It is during the infatuation stage that the two major components of the biology of desire--the time-limited PEA factor and T-level mismatches--collide to create sexual catastrophe for many couples. If the brains and bloodstreams of new lovers are awash in the aphrodisiac properties of PEA and other brain molecules, any disparity in libido is, at first, likely to go blissfully unnoticed.
Let us say, for argument's sake, that you are a "low-T" woman who has fallen fervently in love with a "high-T" man. You, a person whose needle on the sex meter usually points close to zero, suddenly find yourself fantasizing about sex in graphic, Omnivision detail, and approaching lovemaking with a level of gusto bordering on zeal. You think to yourself: "I am a sexual person--I just needed the right partner." Your naturally highly sexed new lover, meanwhile, finds himself in a state of erotic nirvana: "Finally, I've found someone as hot as me!" Over and over again, I have heard clients recall their mingled sense of exhilaration and relief at having finally found their "perfect" lover. Even if they had experienced a similar sense of sexual harmony in the early months of a past romance, infatuated people tend to discount history: It is this lover, at this moment, who satisfies me more deeply than any other. That is, until the tide of PEA begins to recede and preexisting T-levels emerge, unveiling for each person his or her "real" sexual partner.
At this juncture, the "high-T" person is apt to feel bitterly disappointed, even betrayed. For even though his or her brain may no longer be drenched in a PEA-dopamine cocktail, he or she typically has sufficiently high T-levels to still want plenty of action in the bedroom. The "low-T" partner, meanwhile, is likely to feel bewildered by the loss of his or her temporarily turbocharged libido, as well as sexually pressured by what now seems like an insensitive, even predatory, partner. A downward spiral of mutual anger, bad sex, more anger and still worse sex--or none at all--finally leads many couples into therapists' consulting rooms, raging with sorrow, shame and profound doubts about the future of their disappointing marriages.
At first glance, the proposal that something as fluffy-sounding as "desire education" could make any difference to dispirited couples sounds inflated, if not preposterous. As University of Washington psychologist John Gottman's research indicates, on average, couples straggle into therapy a full six years after their troubles first erupt. If anything is going to help at this late date, it seems as though it would have to be an intervention that does something fairly dramatic--something that packs a real emotional wallop or teaches potent relationship skills or both. Faced with the typical couple's end-of-their-rope discouragement, how is dispensing a bunch of facts on body chemistry going to make any difference?
In my experience, the difference is as profound as hope. For beneath the "dry" facts on neuronal and hormonal processes lies a radically normalizing, shame-reducing message: Sexual passion is rooted in our natural body rhythms. That means that if the thrill is gone or if the thrill is different for you than it is for me, I have not failed and you have not failed. Nor has our relationship failed. There may be plenty of emotional junk that is also mucking up our sexual connection, but that's not all that's going on. If our desire problems are at least partly innate--mirroring neither messed-up psyches nor a bankrupt relationship, but rather the pulse and flow of ordinary bodily processes--then maybe we don't need to feel quite so ashamed and despairing about the muddle we're in. Maybe each of us, and the embattled, fragile relationship we're trying to sustain, are even fundamentally okay. Maybe we've got a chance.
Of course, every therapeutic approach tries to engender hope. The particular potency of desire education is its capacity to plant seeds of optimism so early in therapy--sometimes as soon as the first session. Every clinician who works with discouraged couples understands that there is no time to waste: You need a way to show them, quickly and compellingly, that what they view as a sorry excuse for a relationship is even worth expending further energy on. The problem here is that the palpable rewards of most couples work--the profound emotional breakthroughs, the fruits of well-learned relationship skills, the mastery of new sexual techniques--take time to emerge. By contrast, the matter-of-fact, calming information of "desire ed" can be dispensed almost immediately to interrupt the furious, toxic, blame-shame cycle that sabotages so many sexually polarized couples at the very outset of therapy. As a potent, front-end couples intervention, desire education can make the difference between a willingness to plunge into relationship work with a measure of motivation and the decision to prematurely quit in despair.
When Eddie and Joyce, a couple in their mid-thirties, arrived for their first session with me, it quickly became clear that their sexual standoff was already calcifying into a kind of listless bitterness. Slumped in his chair, Eddie complained that Joyce was his "wife in name only"--that is, she had avoided sex with him as much as possible duringÂ the past five years. "Your basic ice queen," he quipped grimly. Joyce countered that Eddie made her feel ugly and invisible by openly flirting with other women, to which she often responded by collapsing into tears, panic stricken that she was losing her husband. Eddie made clear that this was a real possibility. "Do you know what it feels like to get down on your knees and beg for sex?" he asked me. Joyce snapped, "It's more like being cornered by a dog in heat." Twice before, they had tried therapy, which had focused on improving communication and injecting more novelty into their erotic repertoire, to little effect. In a last-ditch attempt to stave off separation, Joyce had dragged Eddie to see me.
In the past, I would have begun therapy with a couple like Joyce and Eddie by focusing immediately on communication about relationship issues, such as Joyce's anger and "withholding" of sex and Eddie's motives for his blatant attentions to other women. But my experience has been that sexually struggling couples can rarely focus on such efforts at relationship repair at the outset, because they feel too deeply flawed and full of shame to believe that genuine change is even possible.
Instead, I began by empathizing with each of them about how painful it must be to live in a relationship in which one partner wants sex more than the other. Then, gently probing about their desire history, I learned that both partners had experienced their particular passion level over time, with several different partners. This suggested to me that Eddie and Joyce's sexual problem wasn't purely relationship-driven, but probably also had a hormonal component. So I introduced some information about T-levels and the consequent normality, even near inevitability, of their desire gap.Â As I spoke, Eddie and Joyce became quiet and attentive. Neither of them had had the slightest idea that testosterone--or the relative lack of it--was such a major player in female desire. I concluded with my core message: "What all of this means is that it's entirely possible to love someone a lot, but still not be very sexually turned on by him or her." Joyce and Eddie remained silent for a moment. Finally, Joyce spoke up. "So what you're saying," she said slowly, "is that I'm not just trying to punish my husband."
She glanced quickly at Eddie, who seemed lost in thought. "Well," he finally said, "I guess the good news is that maybe I don't have to feel like such a jerk when I get turned down." I sat quietly with them for a few minutes, letting the deeper message of my mini-primer soak in. I wasn't expecting any big epiphanies or tearful embraces, nor did they materialize. All I wanted was to give this couple sufficient relief from their mutual sense of sexual failure to commit to the work ahead. I wanted time. Eddie gave me my opening. "I like the idea that the trouble we're having maybe isn't all personal," he began. "But, not to be rude, so what? If I'm some kind of hormone factory and she's not, what the hell are we supposed to do now?" I responded that even if their hormonal makeup contributed to a natural difference in libido, it was entirely possible, with sufficient time and effort on their part, to develop a satisfying sexual connection. When, in the last few minutes of the session, they agreed to try, I felt a small jolt of elation.
Having now worked with scores of couples who suffer a substantial desire gap, I understand more about the private hell that couples like Joyce and Eddie inhabit. In our sex-saturated culture, the woman or man who is "low-T" is already, by definition, defective. But if you are that person, imagine then the experience of living with a "high-T" partner, who comes to you for sex again and again and again, when you truly feel you have little to give. The screws of inadequacy get turned still tighter as you experience your many varieties of unworthiness--unworthiness for not matching the "normal" sex drive of your partner, unworthiness for failing to live up to a fundamental expectation of a committed relationship, unworthiness for repeatedly turning your back on your partner's helpless, fervent desire for you.
And the inescapable truth is that your partner is hurting. How could it be otherwise, when he or she inhabits a reality of constantly slamming doors? Because of the raw exposure of self that attends sexual intimacy, this more ardent partner may experience chronic sexual rejection as an existential wound. Again and again, I have heard the more sexually desirous partner say to the other: "I've shown you myself--the real me. And you don't want it."
As I worked with Joyce and Eddie in the succeeding months, my goal was never to transform them into the hot couple of the month; nor was it theirs. Using other strands of "desire ed" that I wove into our therapy sessions, they understood that they had long since spent their allowance of PEA-spiked passion; from now on, whatever sexual intimacy they might experience would have to be consciously created.
To begin this process, I asked each partner to share with each other what kind of sexual-emotional activity would feel most loving and satisfying to them. For Eddie, it was what this couple jokingly came to call a "marital"--a periodic, 15-minute session of sex that gave him both a measure of physical release and, more important, the feeling that Joyce cared for him. For Joyce, it was receivingÂ regular, leisurely massages from her husband, which might or might not culminate in intercourse, depending on her wishes. Haltingly at first, each tried to respond to the other's requests for behavior that seemed, initially, alien to his or her own impulses. But as they gradually deepened their understanding that their partner's experience of passion was both different from their own and entirely valid, they became more generous in their capacity to stretch to respond to it. The result wasn't blood-boiling sexual fireworks, but rather a budding sense of mutual intimacy and trust that began to energize both their erotic and emotional connection. Slowly but perseveringly, they began to feel their way toward a state of marital grace that I call mature love.
I am not arguing here for any particular therapeutic approach to sexual desire problems. My observation is that a number of useful ones already exist, from the skill-building orientation of traditional sex therapy to the more emotion-centered approaches of numerous schools of couples therapy. Many therapists, no doubt, pick and choose from several models. My point is that whatever overall approach you favor will almost certainly be rendered more potent and effective by integrating some basic education on the biology of passion. By the same token, if you omit desire education, you risk giving your clients a hazardously incomplete understanding of their situation.
For example, if Eddie and Joyce had taken their dilemma to a mainstream sex therapy clinic, their problem would likely have been diagnosed as "hypoactive sexual desire" on Joyce's part, with a program of sensate focus exercises prescribed. There is much to be said for sensate focus, in which partners are taught to hold and stroke each other while attending to the sensations that emerge, to help each discover what kind of touch is pleasurable. The limitation of traditional sex therapy antidotes is that they are typically taught in the absence of context: They rarely give unhappy couples a way to feel less flawed and freakish about the sexual afflictions they have laid bare. In fact, a couple's shame may even be deepened by sex therapy's habitual use of such pathology-laden labels as "hypoactive sexual desire" or "retarded ejaculation." Desire education, by contrast, avoidsÂ the medicalization of sex in favor of a gentle, humanizing context. It conveys the idea that nobody here is inherently damaged or inherently unlovable. Desire differences are natural and normal. Relax.
Desire education also has a key role to play in couples therapies that focus explicitly on the emotional aspects of sexual desire dilemmas. The hazard of purely relationship-centered sex therapies is that by focusing solely on the interpersonal factors that fuel passion problems, a therapist may convey the message that once partners resolve these emotional conflicts, they will become, once again, the effortlessly synchronized sexual match of their courting days. But by judicious melding of information on the psychology and the biology of desire--especially about the experience of red-hot sex as a short-lived, PEA phenomenon--a therapist can convey reasonable optimism about a couple's sexual future without raising erotic expectations to untenable levels. For the reality is that when a substantial, hormonally mediated desire gap exists between partners, their ultimate erotic satisfaction will depend on a steady, vigilant effort to sustain their sexual connection. Even when two people love each other deeply, postinfatuation passion is rarely a free ride.
Even as I write this, I am confronting this challenge in my own life. I am still a classic "low-T" woman who, just three months ago, married an unmistakably "high-T" man. Fortunately, this time I knew--and so did he--that the exquisite tango of brand-new love would downshift, inevitably, into the reality of differing sexual setpoints. We know, now, that our work together for the long term will encompass much stretching beyond our respective sexual comfort zones--stretching to understand, to empathize with and to accommodate the other's unique experience of passion. Neither of us expects this process to be easy; at times, it may well be excruciating. Our hope is that during the toughest moments, when even our best efforts cannot bridge our differences, we can hold fast to the conviction that our desire dissonances are rooted in nature, not in an insufficiency of love.
For clinicians, perhaps the most invigorating potential of the emerging science of passion is the challenge it poses to radically reenvision our concept of human sexual relationships. Up to now, therapists have been offered two divergent, even diametrically opposed, ways of looking at clients' sexual problems: Either they are a direct reflection of the troubled state of the relationship, requiring deep emotional work, or they are a set of physiological problems, requiring primarily technical intervention--usually through referral to a sex therapist. The biology of desire offers a more encompassing vision: Our sexual selves are mind-body creations in the deepest, most inclusive sense. To consider the influence of our neural and hormonal processes is neither to diminish the power of emotional factors nor to deny the usefulness of sexual skill-building; instead, therapists can use the lens of human biochemistry to enlarge clients' understanding of the entire spectrum of influences on human erotic connection.
All of us need to become active, knowledgeable sex educators in this new, more inclusive sense. While we may think of this realm as belonging to clinicians who somehow "specialize" in sexual difficulties, the reality is that virtually all therapists work with people who are struggling with problems of passion--the woman who wonders whether she should leave her boring husband for the new, more enthralling man she has met at the office; the love-struck, single man who is rushing to the altar far too precipitously; the couple on the verge of splitting up because she wants it and he doesn't. These are deeply emotional concerns, but they are also matters of raw, palpitating bodily desire, and our clients can ill afford to have us uninformed about them. The emerging science of passion, which has relevance for nearly every sexual-emotional event that transpires between two individuals, can help us explicate these dilemmas for clients with a new level of depth and authority.
Still, it can be tricky, demanding work. As we teach clients more about the biology of desire, the age-old, inexorably human tug-of-war between biological imperative and moral responsibility is likely to emerge with renewed force in the consulting room. If desire is tied to biological processes, how responsible are clients for their sexually motivated behavior? Under the influence of PEA, can a long-married man "help" having an affair with his sexy new law partner? Or, if a woman now comfortably accepts herself as a "low-T" person, is that a legitimate reason to abandon all efforts to revitalize a sexually stagnant, otherwise committed relationship?
These are the moments when therapy becomes a high-wire act, as we try to maintain a fragile balance between a generous acceptance of biological reality and a fierce, nonnegotiable allegiance to consciousness, the quality that makes us human and saves us from being utterly at the mercy of our molecules. If we are serious about trying to stem the tide of marital and family misery in this culture, our clients' most torturous questions about their intimate relationships--Do I stay? Do I bail? DoÂ I officially stay but just go through the motions?--will require arduous discussions about choice and responsibility, as well as about the proclivities of neurons and hormones. Our body chemistry counts--much more than we ever imagined. But in the end, biology is only backdrop.
Pat Love, Ed.D., a family life educator, trainer and lecturer, is the coauthor of Â Hot Monogamy. Â Address: 6705 Highway 290 West, Suite 502-291, Austin, TX 78735; e-mail address: Pat@patlove.com
Rx for Passion
Antidepressants needn't depress the libido
by Valerie Davis-Raskin
As a psychiatrist and couples therapist, some days it seems as if I never talk about anything but sex. And increasingly, I find myself educating my patients about the impact of the new selective serotonin reuptake inhibitors (SSRIs) on sexual interest and pleasure. Sure, I've had patients blush or change the topic, but most welcome the invitation to discuss problems in their sex lives, some related to medication, others not.
I didn't used to talk so much about sex and the sexual side effects of antidepressant medications. When I started practicing psychiatry a dozen years ago, we weren't yet in the better-sex-through-modern-chemistry era. Then the landscape changed. We began to live and practice in a culture that has come to consider pharmacology an acceptable (if not ideal) means of reducing depression. But until we had some ideas about how to counteract the sexual side effects of antidepressants, it still didn't much matter whether we talked about them or not.
Things are different now. We know that sexual side effects are among the most common and most troublesome difficulties experienced by antidepressant consumers. And more important, I know that I usually can help my patients recover from debilitating depression or anxiety without paying a sexual price.
When Prozac first came on the market, the medical profession didn't have a clue about how vital serotonin was to sexual pleasure and responsiveness. We didn't realize that Prozac and its two bestselling counterparts, Paxil and Zoloft, can and often do greatly reduce human suffering, but they also frequently kill sex drive, cause delayed ejaculation or completely eradicate orgasms. To this day, the Physician's Desk Reference (PDR) grossly underestimates the rate of sexual dysfunction caused by SSRIs. The PDR lists an incidence rate of medication-induced sexual dysfunction in the range of two percent or less. Would that this were true! In reality, between one third and one half of all individuals taking the most commonly prescribed antidepressants experience sexual side effects. And these three drugs--Prozac, Paxil and Zoloft--are among the top 10 most common prescriptions written in the United States for any condition--affecting, literally, millions of Americans.
The target of antidepressants are the neurotransmitters, our brains' chemical messengers. But neurotransmitters like serotonin are also found outside the brain wherever there are small blood vessels, a fact that accounts for many of the common side effects of SSRIs, such as nausea or jitteriness. Because serotonin is a sexually inhibitory neurotransmitter, increased serotonin in the brain may curtail the urge to have sex. Outside of the brain, serotonin may reduce genital sensation, somewhat like a mild anesthetic: what used to feel great feels good, what used to feel good feels okay, and what used to feel okay doesn't even register now. This means that arousal, both the psychological interest and physiological blood vessel reaction (blood flow to the clitoris, while less obvious, is as important for pleasure for females as blood flow to the penis is for males), may be suppressed by antidepressants that increase serotonin. Clinically, this translates into any combination of possibilities: lack of interest in sex, difficulty reaching an orgasm or outright absence of orgasm, inability to maintain an erection or prolonged erection. Some individuals experience a variety of side effects, while others experience only one, in an unpredictable fashion. And of course, it's just common sense that if you can't have an orgasm, eventually the libido falters as a consequence.
The chart below summarizes the degree of sexual side effects likely to be caused by the most frequently prescribed antidepressants.
Prevalence of Sexual Side Effects Caused by Antidepressants
Monoamine oxidase inhibitors (Nardil, Parnate)
One common intervention for any SSRI-induced sexual side effect is simply to lower the dose, as long as effective treatment for the psychiatric condition can be maintained. Since arousal, erection and orgasm changes are all dose-related phenomena, a substantial number of people will continue to benefit emotionally from smaller amounts of the offending SSRI. However, lowering the dose always carries the risk of a symptomatic relapse, and should symptoms exacerbate following dose reduction, other strategies are necessary.
Some people will benefit from a so-called "drug holiday" (an intervention that does not work for Prozac, due to the much longer time that Prozac remains in the bloodstream, compared with the shorter-acting SSRIs). A physician might recommend a regular drug holiday, in which the medication is taken on Thursday morning, skipped on Friday and Saturday, and resumed on Sunday morning. Ideally, a couple would opt to make love first thing Sunday morning, but many couples would find that a Saturday-night schedule is preferred.
Should these more conservative measures fail (or be clinically inappropriate in the prescribing physician's or patient's view) there are other options. Three of the new antidepressants--Wellbutrin, Serzone and Remeron--have no sexual side effects at all. Wellbutrin is generally well tolerated, but may cause insomnia, headache, tremor or increased anxiety. Its major drawback is that it is only effective for depression and may exacerbate conditions such as panic disorder. Wellbutrin is pharmacologically distinct from the SSRIs in that it enhances the neurotransmitter dopamine rather than serotonin. As a result, while it has comparable efficacy for depressive disorders in general, any particular individual may respond preferentially to an SSRI (or vice versa).
Both Serzone and Remeron are very sedating, although this effect often wears off over time, especially for Remeron, which is taken at bedtime. However, Serzone must be taken in the morning as well, and sedation is a troublesome side effect for many. Remeron's major drawback is the high incidence of weight gain, a side effect far less tolerable in many cases than low libido.
The tricyclic antidepressants, such as Elavil, Norpramin, Pamelor and Tofranil, may cause sexual side effects, including erectile or arousal problems and anorgasmia. Nevertheless, the incidence is far lower than with the SSRIs. The major drawback to tricyclic antidepressants is their potentially negative cardiac effect, elevating the risk of suicide and overdose. Higher doses may cause sedation, constipation, dry mouth and weight gain. Tricyclics have a particular utility for panic disorder, since lower doses than those needed for depression may be effective, allowing a mid-range dose that causes neither sexual dysfunction nor other significant side effects. Antianxiety medications, such as Klonopin and Xanax, do not affect serotonin and do not have sexual side effects as a rule.
Finally, some physicians may recommend St. John's wort, which is not believed to cause sexual side effects, although this has not been systemically studied. Unfortunately, because St. John's wort is not regulated as a pharmaceutical substance, efficacy may vary widely among preparations, and even from one bottle of the same brand to the next. This, along with the fact that it has not been rigorously tested in head-to-head comparisons with traditional antidepressants (for efficacy and also for side effects), limits its use to mild cases of depression or anxiety. St. John's wort should be taken three times per day and many people have a problem remembering the midday dose.
If switching to an alternative medication is not clinically appropriate or effective, a physician might recommend adding another medication on a daily or as-needed basis. Taking a second medication may be problematic on several counts. Women often feel awkward about actively seeking sexual pleasure. Many people also are extremely hesitant to take anything for depression, let alone two drugs. For others, a second medication offers a wonderful antidote to the side effects of an otherwise helpful medication.
Most commonly, psychiatrists prefer a single low dose of Wellbutrin for patients complaining of sexual side effects from other antidepressants. It is prescribed initially only as needed, but daily if required. This comedication strategy employs lower doses of Wellbutrin than would be necessary to treat depression. Pharmacologically, Wellbutrin enhances dopamine, which has the opposite effect on libido and orgasm of serotonin. Small doses may restore the serotonin-dopamine balance, alleviating sexual side effects.
The list of agents used to comedicate for sexual side effects include stimulants such as Ritalin (methylphenidate), Urecholine (bethanechol), Yocan (yohimbine), Symmetrel (amantadine) and Periactin (cyproheptadine). Anecdotal evidence suggests that the botanical preparation ginkgo biloba may reverse libido, arousal and/or orgasm problems. Anecdotal reports also suggest that Viagra (sildenafil) is effective for SSRI-induced absence of orgasm--even in women--but its use may be limited by cost ($9 per pill).
At times, it's easy to distinguish whether sexual problems are a relationship issue or are caused by side effects. SSRI-induced sexual dysfunction follows a typical pattern: it begins within days or weeks of starting the new medication. For example, soon after she began takingÂ Prozac for obsessive-compulsive disorder, Maria found she could no longer reach climax with her husband, Steve. She did not volunteer this information, which is one reason I routinely ask women about inability to orgasm. My male patients can tell me that "things aren't working right sexually," without having to look me in the eye and complain that sex is no longer pleasurable. Many women, however, experience an ambivalence about whether nice girls are allowed to like sex or should just go along with it. And some women are terribly embarrassed to talk about orgasms. "He could stand on his head and nothing happens" is Maria's euphemistic description of her sexual difficulty. "It's like a switch turned off down there." Maria hasn't talked about this with Steve, and I suggest that she let him know that medication is the problem, since he may be wondering if it's his "fault." Maria looks horrified at the thought, so I give her some written information to hand him.
I invite Maria to bring her husband to a session so that we can talk this over together. In our joint session, I explain that she is on a high dose of an SSRI for Obsessive-Compulsive Disorder, an illness that only responds to serotonin enhancing antidepressants. Because an SSRI is the only reasonable medication, switching to something like Wellbutrin isn't an option. Further, I explain to her that since effective doses of SSRIs are typically higher for OCD than for depression or panic disorder, lowering the dose isn't a good idea. Likewise, the drug-holiday approach isn't appropriate for Maria. This leaves co-medication, an idea that Steve likes a lot more than does Maria.
Steve reveals that he feels so selfish since Maria stopped having orgasms, and he would like things to be the way they were before. He feels that he is imposing on Maria, because these days, he's the only one reaching a climax when they make love. Somewhat reluctantly, Maria agrees to try comedication and I review the alternatives. Does trying something just when needed prior to intercourse seem best, or would a regular daily comedication be better? I explain that the only-when-needed medication is like a diaphragm--you lose spontaneity, but you don't have to ingest it all the time. When I mention that the only "natural" remedy I know of that may alleviate inability to orgasm requires daily use, however, Maria jumps at this, stating that she'd rather take something natural even if it means taking it every day. I tell her about ginkgo bilboa, which she purchases at her health food store. Six weeks later, she reports that "it's not like fireworks or anything, but it's lots better. Steve says thank you."
Maria remains reluctant to "own" sexual pleasure, continuing to describe her medication-induced sexual side effects-- and return of orgasms--as Steve's issue. Until Prozac came into her bedroom, Maria's unexamined belief was that Steve mostly cared about his own pleasure, and that she was just there fulfilling her wifely duties. Now she's heard from Steve loud and clear that her sexual pleasure is an integral part of his pleasure. A seed has been planted. For the first time, she and her husband have discussed their sexual relationship openly, and she has an opportunity to reframe her sexual self-image.
Valerie Davis-Raskin, M.D., is the director of academic psychiatry at MacNeal Hospital in Berwyn, Illinois, and a clinical associate professor of psychiatry at the University of Chicago. She is the author of When Words Are Not Enough: The Women's Prescription for Depression and Anxiety Â and coauthor with Karen Kleiman, M.S.W., of Â This Isn't What I Expected: Overcoming Postpartum Depression.
by Lynne Stevens
A fee policy can clarify the therapeutic relationship
Money is an underdiscussed topic in graduate programs, supervision and peer groups, yet every therapist I know has felt the awkwardness of seeming mercenary when insisting to a client who has fallen behind that he or she needs to pay. Unfortunately, most therapists were never coached about how to reconcile the closeness of the therapeutic encounter with the fact that therapy is also a business. When I first started out, I made the mistake of letting my caretaker impulse overcome me and charging a certain client who was in crisis a lower fee for several sessions. When she didn't pay even that fee and later let it drop that she had gone on an extravagant vacation, I felt like a fool. It has taken me years to understand that therapy is not separate from the exchange of money. I am in this profession because I care and have skills and knowledge that can help, and I also need to make a living.
These days, I run into the problem of clients who don't pay far less frequently than I used to. I attribute this to two changes I've made. The first was convening a peer group to discuss money issues. We examined our family values and messages about both the importance of money and the secrecy that often surrounds money matters, while also looking at the impact of social messages about gender and earning potential. When I heard everyone's war stories about clients who owed hundreds of dollars or terminated therapy without paying, I realized that my discomfort with money wasn't a character flaw, but a deficit in my training. More than anything, doing this personal exploration is what prepared me to explore the topic with my clients. The second change I made was developing a few practical steps to make it more likely that my clients will pay on time: prevention, intervention and having a bottom line. Prevention involves setting clear boundaries up front about my expectations regarding payment. I give written guidelines to clients during the first session that explain how I run my business: I prefer to be paid weekly, but will accept payment monthly; I charge for missed sessions unless clients give me 24 hours' notice. My guidelines also extend to questions about sliding fee scales and how much notice I give before I raise my fee. I ask my clients to read and sign die guidelines while they are in my office. The next week, I follow up and ask them if they have any questions or thoughts about them. Even though it's not legally binding, the document signals a commitment to take the business side of therapy seriously. Later, if money issues come up, I show them the signed copy I keep on file.
Of course, having a signed piece of paper doesn't eliminate conflicts over money. When the client's checks keep bouncing or are never sent, I have to intervene. One client, Sherry, was four weeks behind in her payments, for which she offered a series of reasonable excuses. The next week, Sherry's session focused on a very intense description of an episode of childhood abuse. But when she got up to leave at the end of the session without paying me, I cleared my throat and said, "So, today is the day you need to settle up for the last few sessions, as we agreed." She was upset that I could care about money after she had just revealed her deepest pain. At that moment, thinking about money as a boundary made it easier to stick to my guns. Sherry's not paying was not only a violation of our contract, but a replication of old family patterns in which uncomfortable issues were not discussed and boundaries were regularly violated. My kind but insistent tone let Sherry know that I was not her mother or her best friend, and that money was a fact in our relationship as surely as the clock that told us when it was time to end the session. Although she was angry, she wrote me a check before she left.
At the beginning of the next session, Sherry talked about feeling humiliated that she had to pay someone to care about her. It gave us an excellent opportunity to talk about the therapeutic relationship, what she could expect from me and how I was different from a friend or parent. I saw this conversation as a deepening of the bond of trust between us. She admitted that my treating her like an adult by expecting her to pay had given her a positive sense of herself as being capable and mature even while she was exploring her childhood wounds.
Having a bottom line about our fees is hard for all of us in the helping professions. It doesn't mean cutting off anyone who doesn't pay like clockwork, but it does mean not being a doormat. I try to catch potentially disruptive money issues by dealing with clients' accrued balances in a timely way. I also address clients' resentment at being charged for a missed session that they forgot to cancel and explore their expectations of how "understanding" I will be when they tell me about financial hard times. With some clients, there has come a point at which I have had to recommend that they take a break for a few months until they can catch up on payments, or I've discussed options such as coming in less often to make therapy more affordable. There are very few cases in which I have had to say to clients, "No more therapy until you pay me for the sessions you owe." Sometimes, hearing that I am going to be that firm about payment jolts clients into action and a check appears in my mailbox. Other times, the client hears it as a rejection and leaves in anger. I try to leave the door open as much as I can, while at the same time holding to my bottom line. I am always on the lookout for creative options. One colleague who had past experience of clients who ; ended therapy without paying their balances now asks clients ending therapy to write postdated checks that she can ! cash throughout the year. It has cut I down on the amount of collections she ; has to do, and makes it easy for clients, who don't have to remember to send money every month.
The only way I can make sure that money issues don't harm the therapeutic relationship is to be self-aware enough about my own issues around money, and then be willing to raise the | subject with my clients when it comes | up between us. There is an old truism : that therapists are more comfortable discussing clients' most intimate sexual details than talking about money. This is no longer true in my practice. I now welcome the opportunity to examine the meaning of money with my clients. Our clients are not going to lead the way. When money issues come up in therapy, it's up to the therapist to blaze a trail of openness, honesty and healthy limit setting.
Lynne Stevens, C.S.W., B.C.D., has been a psychotherapist in private practice in New York for 20 years. Address: 159 West 95th Street, Apt. B, New York, NY 10025.
by Richard Simon
IT'S BEEN ALMOST 20 YEARS SINCE I FIRST SAW SALVADOR MINUCHIN in action. Back then, I was a young Ph.D., just a few months into my first clinical job. In graduate school I had of course read Minuchin's books Families of the Slums and Families and Family Therapy, which were, as far as I was concerned, practically sacred texts, but I had never actually seen him do therapy in person. The family field was at the peak of its messianic, we-shall-change-the-world phase and Minuchin, in his staunch opposition to psychiatric orthodoxy, was both its leading visionary and presiding clinical wizard, part Moses, part Merlin with a little dash of Rush Limbaugh thrown in on the side.
So my trip to the Philadelphia Child Guidance Clinic for an introductory workshop Minuchin was giving on structural family therapy was more than a quest for a few C.E.Us. It was a pilgrimage to the place that Minuchin had turned into the Mecca of family therapy itself, an initiation into the mysteries of how to put the airy abstractions of systems theory to work transforming lives. Standing in front of the audience of 200 therapists, Minuchin, a compact, dapper man with a Latin accent as thick as his black mustache, exuded an air of brusque command at odds with the traditionally pacifist culture of psychotherapy. Heaven protect anyone who stumbled through a lame question or tried to say a kind word about psychoanalysis. He seemed to me the most confident person I had ever met, as if he had been to the mountaintop, seen the Truth and discovered he was It. Of course, he was exactly the kind of hero I was looking for. And when he began to explain a clinical strategy by quoting from a 16th-century book called The Way of the Samurai, any last reservations I may have had completely disappeared.
The centerpiece of the workshop was a live family therapy session broadcast to the audience via closed circuit TV Once the interview started, Minuchin's intimidating aura dissolved and he became a kind of therapeutic sleuth patient, respectful, infinitely curious, frequently playful, surprisingly gentle, but, above all, utterly focused on figuring out the puzzle of what was maintaining the problem the family was trying to resolve. Sometimes Minuchin leaned back in his chair and took long drags on his cigarette as he questioned the family a poor, black, single mother and her three young children about their presenting problem, the 8-year-old boy's disobedience and school difficulties. Hyperalert to the family's every gesture, every pause, every shift of mood, he seemed to drink in information through all his pores as he pursued his inquiry.
Toward the end of the session, Minuchin asked the defiant 8-year-old to stand up, explaining, "I am still trying to figure out what makes you so powerful." The boy smiled slyly as he rose to his feet, clearly delighted to take part in whatever game this curious man was devising. After speaking with the boy for a while and complimenting him on how strong and healthy he looked, Minuchin asked the mother to stand up. As she did, towering over her small child, Minuchin asked, "Where has he got the idea that he is so powerful? He is a healthy boy, but look, he is just a little kid who somehow has convinced you that he is much older than he really is." It was, I learned later, one of Minuchin's favorite gambits, but as I watched it unfold, I was stunned by both the power and the sweetness of the moment. Both mother and son were smiling, basking in the attention they were receiving, coming more fully to life as if renewed by the prospect of order being restored in the family. And later, as the mother, with Minuchin's gentle, persistent coaching, was finally able to lay down some simple rules in the session with a newfound authority in her voice, there was no doubt that she and her family had recorded a small victory in that room.
I am equally sure that over the next weeks and months, the therapists in that audience went on to direct hundreds of children and their parents through a similar routine, the image of Minuchin's mastery still alive in their memories. The fact is that once you saw Salvador Minuchin at work, a little part of him lived on indelibly inside you. Through family therapy's formative years, he became the standard against which therapists measured their best work, and when they failed miserably with a family, they asked themselves what Minuchin might have done. From his early work with delinquents and their families at New York's Wiltwyck School in the 1960s through his long stewardship at the Philadelphia Child Guidance Clinic, he was probably the most renowned and most imitated family therapist in the world.
For the past 15 years, although he has continued to write about family therapy, conduct workshops and direct a small training center in New York, Minuchin has seemed to be in search of fresh worlds to conquer. He spent some years traveling and pursuing his interest in play writing, seeing if he could transfer his flair for the drama of the consultation room to the theatrical stage. For more than a decade, he jousted with the New York City child welfare bureaucracy, trying to apply his ideas about family systems to reforming the foster care system.
Today, at 75, he speaks with some bemusement about his reputation for consultation-room charisma, as if fondly recalling a brash younger brother who had yet to learn some of life's later lessons. Fifty years of experience with families has smoothed the keen edge of absolute certainty that once gave his work its sense of urgency. These days, he sees himself less as an advocate for a particular clinical method or theory than as a philosophical meta-observer of a profession he, as much as anyone, helped to create and to which he continues to feel responsible. He has just completed his ninth book, Mastering Family Therapy: Journeys of Growth and Transformation, cowritten with nine of his supervisees, which offers his current take on the state of family therapy training. The interview that follows was conducted in the Back Bay town-house in Boston where Minuchin lives with his wife, Pat, a clinical psychologist who has been his collaborator in his efforts to revolutionize foster care, to whom he has been married for 45 years. Here, Minuchin reflects on some of the latest developments in family therapy, discusses his own evolution as a clinician and offers his perspective on nearly 50 years of the field's history.
FTN : How would you contrast your work with the approaches that are popular among younger therapists today?
MINUCHIN : I think I am much more interested in the exploration of conflict than many therapists today. My therapy grew out of the "try, try again" active therapy of the 1960s, with all its optimism and energy, experimentalism, creativity and naivete. I bring the family drama into the therapy room. I encourage members to interact directly with one another in the belief that the family is the arena in which people can most fully express themselves in all their complexity. So family interaction with all its potential for both destruction and healing continues to occupy center stage in my practice.
But today therapists are wary of my brand of therapeutic interventionism. They seem to believe it is impossible for a therapist to produce specific, targeted changes in a family. They want to be noninterventionist and turn therapy into a simple conversation among people. The therapist asks questions that provide people the opportunity to reconsider meanings and values that up until then they have considered as "given" or normative. The solution-focused and the narrative therapists say, "Let's not deal with problems. Let's deal with solutions." But in the process, it seems to me, the therapist is restricted to operating only in a collaborative, symmetrical posture. Gone is the latitude to play, to give opinions, to be the complex, multi-faceted person in the therapy room that you are outside of it. All that remains is to be a distant, respectful questioner.
FTN : Janet Malcolm once wrote in The New Yorker, "Watching a Minuchin session, or a tape of it, is like being at a tightly constructed, well-directed, magnificently acted play." You seemed to relish dealing with explosive situations in therapy. What do you like about dealing with those situations?
MINUCHIN : I think what drew me to family therapy was the excitement. Every family represented an exciting puzzle. When I worked with delinquents and their families at the Wiltwyck school back in the '60s, the particular challenge was to help them find concrete ways to calibrate relationships. We were concerned with helping disorganized families to give more order to their relationships. So we would interrupt a fight in the family to say, "When your mother talks, you cannot talk. Okay, now you can answer." The emphasis was on guidance. At that time Virginia Satir had developed a very popular therapy that emphasized nurturance and the mid-wifing of feeling. But we felt that in the families we saw, people already knew how to nurture. The problem was that the parents were ineffective in taking control of their kids. What they did not have was the constancy that allowed them to give the children a sense of self-efficacy.
FTN : A lot of your reputation as a master therapist had to do with your getting seemingly resistant families to do what you asked them to do. How did you manage to accomplish that?
MINUCHIN : At the time I wrote Families of the Slums, I was full of political passion in defense of the underdog. I had an enormous amount of zeal and people responded to that. All of us back then were tremendously hopeful about teaching poor people to become competent in this social laboratory that was the family. We relied on techniques of moving in and out of the conflict, of being both an observer and a participant in the session. So we would say, "Mom, talk with Jimmy and find a way to make sure he really listens." The goal was to get the parents to exert competence in an area in which they could succeed. The more competent people felt, the more they would listen. Our naivete at that time was that we could not yet look beyond the boundaries of the family and recognize the impact of the larger culture. That came later.
FTN : When I think of the teaching tapes you made at the Philadelphia Child Guidance Clinic, what stands out for me is the art of the small victory going through some hellish struggle to get somebody in a family to do something they have never done before. Of all the cases that you treated, is there one that stands out for you?
MINUCHIN : There is a famous tape of an anorexic girl eating a hot dog. That was a family situation that was horrendous. There was this girl named Carol who was so underweight that she was in danger. So I said to the parents, "Unless she eats, she will die. You are the parents. Don't let her die. Do something." So I tried to help the family discover a new pattern of interaction by creating a crisis in which the parents had to do something that was novel for them. Now these parents were faced with an impossible situation. The mother starts by saying, "Carol, I want you to eat," but soon she and father are beginning to fight, so I say, "Look what's happening now. Carol is still not eating." And the parents now attack the girl, "You will eat!" And food is no longer the issue, and questions of power, autonomy and control become the central issue in this transaction. At that point, it is possible to enter by supporting the girl's autonomy not around eating, but around what her parents are doing.
FTN : But how did you get out of being stuck in the power struggle?
MINUCHIN : A therapist must walk both sides of the street. At the same time you are getting the parents to take control, you also talk about the girl's autonomy. You explain that good parenting is not just control, it is also about giving space. And while you encourage the girl's autonomy, you talk to her about the parents' need to be respected. Bringing the conflict into the therapy room is just the first step in challenging the old pattern and moving parents outside of the world of the girl. Maybe I'm thinking of this particular family because Carol just called me a few months ago to tell me that her father, whom I had not seen in 25 years, was dying and wanted to speak with me one last time. After all these years, he still felt connected to me and what had happened in the therapy. Somehow talking with me at the end of his life was his way of closing a circle. I am frequently surprised how long the memory of a therapist can last in the life of a family.
FTN : Your ability to handle conflict seems to come out of your skill at convincing both sides that you are with them. What keeps families from just seeing you as a manipulator?
MINUCHIN : For people to accept my interventions, they must know that I really see them. They must say to themselves, "Yeah, that's me. Yes, he has my number." I think that what it comes down to is that I really care. Once I work with a family, I am absolutely concerned for them. I suffer with them. I cry with them. Even though I am like Jiminy Cricket I am their conscience I also care for them. When Jay Haley wrote about Milton Erickson, he emphasized his inventive interventions and his command of hypnosis and metaphor. But when you look at tapes of Erickson with patients, what you see above all else is a man who is absolutely benign.
FTN : Since the early days of structural family therapy, you've been considered a champion of a here-and-now approach to change. So I was surprised to hear you say in your new book, "We have tended to overlook family history."
MINUCHIN : I believe that to understand the present one must always make incursions into the past, in order to become free of it. The analysts also believed this, but for them, the investigation of the past was open-ended and took a lot of time "First, tell me about your father. Now tell me about your mother." And one would go on exploring and exploring, weaving together all these strands to make an interpretation of the present. My idea of how to explore the past was different. I saw it not as an intellectual exploration, but as a search for new responses. You start by seeing the narrowness of people's responses in the present and ask, "How did you learn this narrowness?" You then explore the past, looking for something very specific and focused. The exploration is in search of a solution that will make the client more complex in the present.
F TN : So what exactly are you looking for in that exploration?
MINUCHIN : You explain to people that families make people into specialists. The specialty may be "I need to defend myself from criticism," or "I am accepted when I help others," or "I am acknowledged only when I am a winner." Each one of the these labels for the self comes with a view of the complementary roles others take and with certain preferred strategies for dealing with life. So people develop a set style of transacting with significant others, and while they may have other alternatives, they are specialists in this one. As a therapist, you look at the past in order to see how the past created constraints that are not useful now. And you say to the client, "Let's use that understanding to free you from the constraints that don't serve you anymore."
FTN : Does that understanding in itself free people?
MINUCHIN : It's basically Harry Stack Sullivan's concept of parataxic distortion, the idea that you are not really responding to the present, but seeing it through blinders that you have forgotten you are wearing. And the therapist says, in effect, "Let's take those blinders off."
FTN : What do you think of the statement by Jay Haley in his most recent book that "Rather than assume that insight into the past causes change, it's better to think of change causing insight into the past."
MINUCHIN : I think he is wrong and he is right. I am an old man, but I still have memories of my childhood that cannot be erased. Some of them are uncomfortable and I would like to erase them, but they don't go away even though I have changed and am experientially much richer. I know the way in which these early experiences still organize my thinking today. But to a certain extent, I am able to marginalize them so that they are not significant in the way in which I function. Still they are part of me, and I really do believe in the importance of understanding the past in order to give people the freedom to take their blinders off and see how the past organizes the present. From this perspective, I would disagree with Jay. But I also think he is right. There is something else that happens when you deal with memory. Not only do you change how people look at the present, you also rearrange the past.
FTN : What do you mean?
MINUCHIN : I think that we are always rearranging our past. Some therapists, like Milton Erickson, would sometimes deliberately introduce through hypnosis old memories that never actually took place. But even outside therapy that happens automatically all the time. I'll give you an example. Years ago I paid a visit to my high school in Argentina, where I met a woman about my age who asked me what I was doing there. And I replied, metaphorically, "I am lassoing ghosts," which is a very Argentinean thing to say. As we talked, we discovered that we both had been in that high school at the same time. But even though she had told me her name, I could not remember who she was. So later I went to the office in the high school and asked for a roster of former students. As soon as I saw her name on the roster, the memory of her as an adolescent came full-blown into focus. Clearly her presence as an adult interfered with my memory. Suddenly all kinds of memories that had not come to mind for 50 years came back to me, not in the competitive and timid way in which I originally saw them, but from the perspective of being older and looking back. My memory created something very different in that moment from earlier memories of the same period.
FTN: So you think we're always "recovering" memories?
MINUCHIN : I think so.
FTN : So what do you think about the criticisms of "recovered memory therapy?"
MINUCHIN : The mistake some therapists make is to believe in the immutability of memories. I think that we always create memories that's a very normal, natural process. What I don't agree with is that once these memories appear in therapy, they represent truth or reality. Therapists must be very careful not to see memories as immutable truth.
FTN: Since the last interview we had 12 years ago, what have you discovered about being a good therapist?
MINUCHIN : During these 12 years, the certainty that I had when I was younger has disappeared. I no longer believe that I own the truth and I have become more accepting of other points of view. I know myself better and realize that when something new happens in the field, my first response is to oppose it and only later do I begin to incorporate it. My first response to the feminist group was to respond negatively to what I saw as its stridency, especially since I was the target of much of its criticism of the field. But I learned to incorporate many of the feminists' ideas. And even though I still have problems with the constructivists, as I was saying earlier, the same was true of the work of Michael White and Steve de Shazer. I begin with polemical opposition and move toward assimilating what I find useful.
FTN : So, for example, what do you find useful in solution-focused therapy?
MINUCHIN : I like looking beyond problems to solutions, saying to clients, "What if one day you get up in the morning and your problem disappears? What would that look like?" I use those questions sometimes, just as I have incorporated pretty much everything that has been written on family therapy, particularly the ideas of Jay Haley and certainly all the thinking of Carl Whitaker. Today, technically, I am much more complex than I was as a younger therapist. A lot of that, of course, is a result of age. As you get older, all certainties become question marks. You also begin to ask yourself fundamental questions like, "Would the world be different if I did not exist?" So you become less attached to your particular contribution.
FTN : How have you assimilated pieces of feminism in your work?
MINUCHIN : The feminists made me realize that I had put women in certain narrow categories and that my labels for women had gender biases: for me a mother's concern could too easily be dismissed as "overprotectiveness." I focused on men providing guidance and women nurturance, and my work emphasized the importance of guidance and took nurturance for granted. I don't think I do that anymore. I'm more aware of the messages of the labels and I pay attention to what I privilege. But I still work systematically, seeing how couples trigger each other in their interactions. I've always thought that working with the man is an important way to bring him closer to the family, make him more of a participant and ease the burdens of the woman, but I pay more attention now to making sure that her voice is heard, her pain expressed and her need for respect understood.
FTN : And what about the narrative approach?
MINUCHIN: Do you remember Nathan Epstein?
FTN : Of course.
MINUCHIN : Nathan Epstein had an extraordinary quality of inspiring family members and transforming them very, very fast into talmudim.
FTN : Into what?
MINUCHIN : Talmudim literally, it means, students, but I think of it as students of the rabbi. Epstein would say to his patients, "I want you to study your family," and somehow he managed to generate such a lively atmosphere of intellectual inquiry that everyone would get very involved. Externalization has the same ability to reduce emotionality and put people into a position of inquiry about the effects of the world upon them, while highlighting the intellectual possibilities of something new. It gives families the idea that the enemy is outside them and that family members are all okay, banded together against outside forces. I think that's very clever and very good.
FTN : So you've assimilated these various influences, but do you think your therapy has really changed very much?
MINUCHIN : Theoretically, I do what I have always done. I still look at the way in which the current transactions in a family support conflict. I am always saying to people, in one way or another, "There are more possibilities in you than you think. Let us find a way to help you become less narrow." But the ways that I say that today are less dramatic than they used to be. I ask more questions and give fewer prescriptions.
FTN: As you look at the way family therapists practice today, what most disturbs you about the direction the field is taking?
MINUCHIN : Let me give you a little roundabout answer to that question. I think that what therapists do is to make people respond to the tools they use. So if my favorite tool is the question, "Imagine that one day the problem has disappeared," then I will need to create an articulate patient that responds to this tool. The same is true of externalizing questions. I remember seeing Michael White do a very masterful session of narrative therapy, but it was like watching a sheep dog at work. He kept pushing people through a series of constructed questions into the groove of seeing their stories in the more positive way that he wanted for them. The therapist changes the old story and convinces the client that the new story is more true than the old. We all offer our patients a language, and we say, "Let's begin to see your life in this language, and I will give you solutions in this language." I do it. Everybody does it. What disturbs me now is that, as a field, we have gotten so interested in these therapeutic techniques and our particular language that we are paying little attention to the family therapist as a system and the therapist as an instrument of change.
FTN: Why do you think we have gone in this direction of what you call the "noninterventionist, restrained" therapist?
MINUCHIN: Some talk about doing a more "respectful" therapy that does not impose the therapist's biases. But I don't think it has anything to do with being more respectful of clients. I think it has to do with changes in social outlook. As citizens of this pessimistic society, therapists have lost their optimism and just have fewer expectations of effecting changes.
FTN : Does that include you?
MINUCHIN : No.
FTN : How did you manage to escape?
MINUCHIN : I grew up as the child of immigrants in a world that was expanding, where people felt that, through hard work, you could realize your dreams and control your destiny. To many people today, those beliefs seem naive. Maybe I am still a part of the 19th century. But I think it is also important that I stopped thinking of myself as a family therapist years ago and became interested in how the skills of systems therapists can be applied in the larger world. I went from thinking about the small unit of the family to thinking about the possibilities of affecting larger institutions. So by working in a field in which there are new possibilities, I still am optimistic. I am exploring with the Department of Mental Health in Massachusetts some ways of making home-based therapy more effective, which is the kind of challenge that I love. Probably if I were working only as a therapist, then I would need to respond to the constraints of the market just like everybody else. I would be tinkering with alternative therapy approaches that are easier to use or simple methods in which you can train people more cheaply.
FTN : We've been talking about trends in the therapy world today. I see a lot of therapists growing more interested in the connection between spirituality and psychotherapy. Is that a connection that interests you?
MINUCHIN : Not especially. My whole life I have been interested in logic and order. I have always been a very politically involved person. Maybe it comes from being Jewish, but being concerned about the underdog has always been important to me. I suppose my version of spirituality is connected to the dream of social justice. The kind of spiritual thing that you seem to be talking about has not been a big part of my life. Maybe that's part of my limitations.
FTN: How do you see your relationship today to the field?
MINUCHIN : I used to influence the field from the center. Now I do it from the periphery. I am now an elder. I support other people who are doing interesting work. I think it is part of being an elder to be a critic. I also think an elder is the carrier of the oral history of the field, so I feel bad when young therapists don't acknowledge the influence of people like Murray Bowen, Virginia Satir, Jay Haley, Carl Whitaker and Lyman Wynne.
FTN : Do you feel satisfied with life at age 75?
MINUCHIN : I thought that at 75 I was going to retire and become a full-time grandfather. But retirement is not a comfortable niche for me. Other people at 75 find that this is a time to paint, to play the piano. But that is not enough for me at this point. Pat and I have moved to Boston to be near our children and our granddaughter. My relationship with my granddaughter is very, very special. So there is renewal in that. But I am a person who likes to help other people. 1 don't find it useful to look too much at the past or way ahead to the future. I relate to the immediacy of the present. Even though financially we are okay, I need to work in order to maintain myself intellectually and because I love it. After all these years, if a family calls and wants to come to therapy with me, I still love it.
Richard Simon, Ph.D., is the editor of The Family Therapy Networker.