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Psychotherapy's Greatest Debates - Page 5

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SIEGEL: I think much of what Michael is talking about is very useful. Basically, he seems to be saying we need to be mindful of what we’re applying when teaching mindfulness clinically. Of course, he’s right: we’re doing many different things. We’re involved in a therapeutic relationship, we’re prompting our clients to want to please us in all sorts of different ways, and we’re providing all sorts of suggestions. So when somebody is leading somebody through a mindfulness practice and says, “And the body will begin to settle,” that’s obviously a suggestion. So I think being conscious of that and all of the subtleties involved, as Michael is calling for, is vital.

That said, let me bring up a point about which he and I might debate. Is mindfulness just another interesting cognitive-behavioral technique—just something that therapists might add to their toolkit—or is it something more than that? As part of a broader conception of psychopathology, the alleviation of suffering, and, frankly, the purpose of living a life on this planet, I think both approaches to mindfulness can be of use.

One could make a pretty good argument that our purpose as psychotherapists is to alleviate suffering, and one approach to that is in the realm that some might call spiritual. Of course, spirituality has so many different meanings to different people. To most people, it implies a belief in a deity of some sort—a belief in the supernatural, a world outside of that which can be seen, tasted, touched, and felt. But there are other understandings of spirituality. In the Buddhist tradition, spirituality refers to a way of experiencing the interconnectedness of things. It involves understanding how the conceptual mind takes what biologists would call an ecological system and divides it up into this and that, me and you, the dog and the cat, rather than seeing all the interconnectedness, all the interdependencies. So, for some therapists, mindfulness is more than a set of methods: it’s a whole spiritual framework that offers its own insights.

YAPKO: I don’t have any difficulty with helping people develop an understanding of the interrelatedness of things. But I want to make sure that, as therapists, we’re clear about what exactly we do to create a context in which clients can discover their capacity to have these transformative experiences that seem magical and develop this ecological understanding.

That’s the starting point for any effective therapy, whether it’s CBT or psychodynamic therapy or any other approach: how do you set up a context for change? First of all, you start by establishing an expectation that you’re offering something that can help the client. I want people to have positive expectations for treatment and to be cognitively flexible enough and behaviorally flexible enough to be able to shift perspectives readily. I want this person to be willing to experiment, regardless of which therapeutic modality I’m operating in. So, rather than getting lost in the content of the teachings of Buddhism or any other approach or the spirituality of it, I’m interested in what the common denominators are that create hope and positive expectations for change, and prime people’s unconscious participation in a way that they can have nonvolitional, transformative experiences, whether they’re labeled “spiritual” or not.

SIEGEL: I think you’re calling on therapists to be more conscious of what we’re doing when we’re doing it. To be conscious of that, we have to be educated in a lot of different ways of noticing how people evoke responses and influence one another’s unconscious processes. That seems to me utterly essential and important. But I want to emphasize an important point here. Sometimes people ask me, “Where do I get trained to do mindfulness-based psychotherapy?” I say, “Don’t. Get trained to be a good psychotherapist. Get supervision from somebody who knows something about transference and countertransference, knows something about the effects of the therapy relationship, and knows something about a broad variety of psychopathology. And be sure to do your own meditation practice, so you become more aware of your present experience. Develop greater affect tolerance, loosen up in your attachment to your particular conceptual frame, so you can take things flexibly and lightly, and then let the two blend with each other later on.”

With most of the folks who come into my office for treatment, I don’t treat them with meditation. I never mention the B word—Buddhism. I say this because I want to disabuse listeners of the notion that if you’re incorporating mindfulness into psychotherapy, this means you’re teaching people to become a Buddhist or you’re trying to get people to go on a spiritual quest. Rather, mindfulness is primarily a means of guiding our own therapeutic understanding of what we see as human potential—where people might evolve.

Much has to do with the timing of this; the skill that we use in deciding for whom, what, when—the same kinds of decisions that I think a good hypnotherapist, or a good therapist from any tradition, is making all the time.

Q: Michael, what are the specific elements of hypnosis training that you think people interested in mindfulness should learn more about?

YAPKO: Much of what drives mindfulness is exactly what drives hypnosis—understanding how dissociation works. It’s vital to be able to detach yourself from experience in order to transform it. So that as soon as you say, “Watch your thoughts go by as if they’re clouds in the sky,” you’re making a strong, direct suggestion of dissociation. If you say to somebody, “Focus on your feelings” or “Focus on your breathing,” you’re suggesting that this person detach awareness from everything else in order to focus on breathing.

So now it opens up a whole slew of new questions. How, as a therapist, do you determine who is capable of that detachment, and how do you learn to work with people with varying capacities to do that? When we look at the difference between people who respond dramatically to mindfulness practice and those who respond minimally, it comes down to hypnotic responsiveness—something that’s been studied for the last half-century. There are a lot of different hypnotizability tests, through which we’ve gathered normative data, validity, and reliability on, literally, hundreds of thousands of people, assessing their capacity to respond to experiential processes, like mindfulness and hypnosis. Just telling people you need to practice more isn’t enough. We have to then ask the bigger questions. Is hypnotizability modifiable? Can anybody learn to have these kinds of experiences? If not, why not? And if so, why?

SIEGEL: You’re raising interesting questions—particularly, what’s the relationship of various states that happen during mindfulness practice and dissociation? I believe that mindfulness practices lead to a view of awareness as a steady unfolding of moment-to-moment shifting objects of attention. Further, that the felt coherence that we have—the sense of “I am me,” which is our conventional sense of self that most of us are embodying most of the time—is seen as something of a delusional overlay to the moment-to-moment experience within these processes.

YAPKO: When you say to somebody, “Focus on breathing,” you’re bringing into this person’s awareness the breath. You’re associating the person with their breathing. So as you associate them to their breathing, what are you dissociating them from?

SIEGEL: From identifying with the thought stream, such that they can begin to notice that it’s just a thought stream, rather than seeing that narrative as reality with a capital R.

YAPKO: Exactly. There’s what I’m talking about when I use the term dissociation. You’re saying to this person, in essence, “You’re more than your thoughts,” and that’s such a powerful message. To say to somebody with a history of trauma, “You’re more than your history.” To say to somebody who’s wrapped up in their feelings, “You’re more than your feelings.” But then we’re using suggestion as a vehicle for encouraging that separation, in order to say to the person, in essence, at a process level, “focus on this” or “defocus from that.”

SIEGEL: Most of us tend to think of dissociation as avoiding something. But within the mindfulness tradition, stepping out of the thought stream in order to be with the pain of sadness or the tension of anger is a felt experience that’s quite different from what’s conventionally thought of as dissociation. That’s usually viewed as a sense of detachment, rather than a sense of full participation in an experience without identification with it. I know this is a little bit of a subtle matter, but when one cries mindfully, it feels fully connected, alive, poignant, but there isn’t a lot of “me” there.

Q: I think the language of hypnosis, as opposed to mindfulness, is largely focused on the methods the hypnotist uses to transform the experience of the subject. But, Michael, you seem to be making the point that hypnosis brings about shifts in consciousness that are every bit as valuable as mindfulness traditions. What’s so important about those shifts?

YAPKO: First of all, the experience of acceptance is the vital cornerstone. Earlier, Ron cited Carl Rogers’s statement about acceptance from the ’60s. Erickson wrote a piece in the 1940s about how vitally important acceptance is as a precursor to utilization, and his work came to be known as “The Utilization Approach.” How do you acknowledge, accept, and utilize each part of the person in the most benevolent way possible?

The other thing that stands out for me is empowerment. If experiential avoidance is the antithesis of awareness, the question is why does somebody avoid? Somebody avoids when they feel helpless, hopeless, that there’s nothing they can do about their life. I want my clients to be able to know, at any given moment, what they need to respond to, and how to best respond to it to produce the best possible outcome. So, for me, it’s less a global sort of thing, and much more moment to moment. How do I make a wise choice now that’s going to serve me now, serve me later, help me, help the people around me? I think what’s positive about the growing attention to mindfulness is that it focuses on helping people develop an internal locus of control, which is central to empowerment. It teaches people that they can find resources inside themselves they didn’t know they had and change their self-definition as a result. You’re nobody’s victim when you start thinking in terms of your own internal resources.

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