The Edward Podvoll Legacy Project: Document Library
The Compassionate Practice of Psychotherapy
Edward M. Podvoll, M.D.
- Foundations of Clinical Recovery
- A Design for Treatment: Mind and Environment
- Intensive Psychotherapy: Intimacy and Exchange
- The Nature of Courage in Psychotherapy
This is a transcript of an intensive training seminar given by Edward M. Podvoll, M.D. at the Karme Choling meditation center on contemplative psychotherapy and the Windhorse Project, October 1-4, 1982.
Lightly edited by Jeffrey Fortuna, 2008, Boulder, Colorado.
Talk No. 2: October 1, 1982
1. Foundations of Clinical Recovery
Welcome to this training session in contemplative psychotherapy. What we would like to do this weekend is talk about working with people from a point of view that is somewhat different then the way many of us have been trained. That is always a bit of a shock. It certainly was to me, to begin working with people from the point of view of first working with one's own body, speech and mind. Many people here are professional psychotherapists, but professional or not, everybody is working with people. Those who have constituted themselves as "professionals" in this area of working with people have a particular burden and at the same time a particular responsibility. As professionals, we gather upon ourselves a social accreditation, a socio-political privilege. That it has always been so from time immemorial, that people were granted that kind of status in their culture which stated that they had acquired a certain degree of training and capability, a degree of maturity that allowed them to fully, thoroughly enter the lives of others and be useful.
Psychotherapy, although it is quite a new term in our culture, (82 years old), has acquired a similar responsibility to work with people and that is a statement that psychotherapists exemplify the possibilities of health and of recovery. Healers have always taken on themselves. At the same time, when we look around and see what the world of professional psychotherapy is, we find a three-ring circus. We go to any convention of the American whatever and we find a circus of possibilities and techniques. We find all kinds of statements and hopes about what people are doing and what is possible to do with one’s life; what health is to begin with. And certainly we have seen that among the wide variety, there is very little that we ourselves would partake in. If we were in extreme states of mind, if we were in a lot of trouble, what would we do.
It is an interesting event to look at: how we ourselves would go about looking for, evaluating, another person whom we would trust, to put our life on the line with, so to speak. Where is it that someone goes to these days? A quick perusal of Time Magazine and other periodicals demonstrates a complete disaffection with "therapy" and with those who claim to be the psychotherapists at all. And so we have become very suspicious of psychotherapy in general. We have gotten very suspicious of people who have presented themselves as those who might be useful to us, especially those who are professionals and are making quite good livings out of doing such things. What do they know about health and what do they know about recovery and what do they know that we do not know or that we cannot get from books and so on? We look at these people. We might go from one to another. We might actually interview them. They think they are interviewing us but we know we are interviewing them. We are looking at them.
Whenever we go to a therapist we are wondering, "What kind of person is this? What do they have? What do they know and who are they? How are they living their lives?” These are generally the same questions that patients, otherwise known as people in pain, are asking when they enter an interview or consulting office. They are saying, “Who are these people?” And they do not quite have the courage to ask that question but they are looking, making up their minds in any case.
The variety of credentials about who such a person might be, does not hold much water. Patients look and see how we behave, how we interact with them, and they continually wonder about what our lives are like. And if they ask such a pointed question we think they are being intrusive. In any case that is the usual, the most conventional of conventional attitudes toward a patient's wondering about who we are and who they are putting themselves in the hands of - an intrusion.
The various therapeutic schools have speculated about what it means when a patient wonders about us as therapists, about how we are living, and how trustworthy we are. Some schools have elaborate theories about the notion of trust, as if another human being should be able to trust us on the spot. As if trust were not an earned phenomena, a situation which gathers and develops. This is not necessarily meant to be a critique of psychotherapy such as we know it, or have experienced, or as it has appeared in theories about interpersonal interaction but it is just the common experience- when we go to another for help we wonder who they are. That moment of inquisitiveness about other might be a spark of health itself.
We wonder what kind of training that therapist has had and when this appears- as it must at some point in therapy- the therapist begins to wonder, “What exactly am I doing, what kind of training have I had to enter so intimately into another person's life?” We present ourselves as the possibility, the link, of a relationship that might be useful to another. We as professional psychotherapists have taken on this credential of helping people. They question us. We question ourselves.
For the most part, that question is the ground of what we call "contemplative psychotherapy", that there is a possibility of training ourselves in such a way as to have some confidence about the experience of just what recovery is. There is no way to talk to another person from an attitude of being useful to her without having experienced some degree of recovery in our own lives, without having actually worked toward recovery in our own state of being. There is a continual kind of oscillation that takes place in a psychotherapeutic encounter: every word we say is met with the response, more or less, "Does he really know what he are talking about?” And the more intimate we get with people, the more sharp that response becomes. So we have to know what recovery is, what health is at all, if we are going to accept this burden and appeal from another person to help him recover. Our own experience of this phenomena, of recovery, is crucial, and it is crucial to whether he trusts us or not, which means whether we earn another person's trust or not.
We might wonder what this thing called “recovery” is. It has a variety of characteristics for different people. I am sure that everyone has had an illness of some kind, such as a prolonged influenza. What is it like to begin to come out of that, sometimes after a week or two, after feeling ill, losing appetite, losing any kind of joyfulness, or energy, not wanting to work, feeling ugly, bloated, not even wanting to look into the mirror.
Then there is a moment when you are coming down the stairs of your house. There is a moment where things are suddenly all right and you know you are coming out of it. There is an instant of connection with the way things used to be, except they are completely different. It is like the first spark of spring in Vermont. You know it is going to come eventually but it is there and it is different then you have ever seen it before at the same time. The moment you try to hang onto that, and say, "Well now everything is fine", there is a kind of relapse and it is not so good. Recovery seems to be a strangely joyful, almost inspiring, phenomena and extremely evanescent at the same time. It could be someone like Beethoven who wrote the 9th Symphony, (the last movement which he called "Joy to the World”), which he wrote right during his recovery from catastrophic pneumonia. The basic characteristic of recovery being inspiration, appreciation, curiosity, and desire for contact, what we generally call “outgoingness”.
That outgoingness and appreciation of sense perceptions and contact with people, of having "come back", recovered, is a moment of health. This is a moment of health that all of us long for. It is essentially a recovery from the continuous preoccupation with illness. That is the metaphor of what we are talking about. The metaphor is that we recover from self-preoccupation with illness and pain. But that kind of recovery is only the exaggeration, the highlight, of what we had been trying to do all along. Illness is the closet, the closed room, the stuffiness that we are trying to burst out of. Illness is an intensification of everything that we have been trying to get away from. So that when we fall ill, in the vast varieties of possibilities of psychological illness, those are just the intensification of what we knew had to be dealt with throughout our lives. When someone becomes psychologically ill, we could say that fundamentally, she is exaggerating a situation of self-preoccupation. The illness is a distorted attempt to leave that, to go beyond a constricted sense of personality, to bring things to a head. We desire to go beyond ourselves, to have these moments of recovery, to recognize a Springtime of possibilities. When we come to a professional psychotherapist we wonder how much that person can recognize what we long for, and how much that person has recognized and accomplished that kind of recovery in her own life.
There is a problem that comes up at that point in terms of psychotherapy. We might, in some way or another, desire another person's health. This has, from the very beginning of the history of psychotherapy, been an issue: of whether it constitutes an unholy desire or not. Throughout the literature, and throughout the supervision experience of people who have trained in Freudian, Jungian, Gestalt work, or whatever, the issue comes up: whether or not our desiring another person's health is an ego enhancement on our part. If there is anything that ties together the varieties of schools of psychotherapy, it is this issue. Whoever your supervisor is, whatever their training might be, they are suspicious of your desire for another person's health. That suspiciousness has an interesting source. It has to do with whether we are using another person in his attempt at recovery for our own purposes. At the same time, it seems odd that in the ordinary course of things we should not desire, wish for another person's well-being, for his experience of recovery.
It is something of a dilemma that psychotherapy is facing. On the one hand, there is some kind of purity of intention or motive, that one could approach another person, work with another person, without desire for their well-being because it might be an interference. Yet how could one do such work, which is sometimes quite intensive and grueling, without that desire to begin with? It is a kind of catch 22. It seems to boil down to just what the self-gratification of the therapist might be. The notion of the therapist's ego is at stake. It comes down to this: if such a therapist could work with a patient and hope for the patient's recovery without ego being involved, that is fine. And everything else is suspicious. So, how could we actually hope for another person's recovery without ego being involved? Which means, how we could work with our own ego-aspiration as professionals.
That is the whole idea, and where the whole training in contemplative psychotherapy comes in. From the beginning, illness is a distorted, perverted attempt to get out of a claustrophobic, stifling sense of having been conditioned in a way that one is beginning to reject. In any case, wanting to be someone different, wanting to be perhaps the promise of what one felt one could be. Then one meets, in the therapeutic situation, the dilemma that the person you are in a relationship with cannot hope for the same thing. Perhaps this is getting a little muddy -- a muddy exchange -- at this point. What I am trying to address is the dilemma of psychotherapists who are working with people and who are being presented with the same problem: that they, the therapists, have faced and are facing continuously in their own life, and that is the problem of their own attempt to be someone more compassionate than who they are. The therapist's continual concern, most deep-rooted issue, is whether they are compassionate or not, of whether their ability to be deeply compassionate people has been cultivated enough, or whether they are just faking it. That is the issue that the patient approaches us with and it is the issue that always comes up in our own lives and in our work: of whether we really have the stuff to deliver what our credentials and our social status give us the permission to deliver.
Therapists have nightmares about that. No matter what school of thought, no matter what the training is, there are nightmares of whether they can so completely take on that responsibility and whether the challenge of intimacy with another person is something which they are capable of accepting. That is the central issue of a therapist's life: doubt about the depth of their humanness. That has happened across all of the schools.
What we have done this weekend, is create a situation where there is possibility of looking at this in a slightly different way: to look at who we are, to look at the nature of our own state of being, as therapists, as people who are making this presumption, and to see what we can learn from that. That involves a few things: it involves listening to some of these ideas and discussing them. It involves the practice of meditation: of joining looking at ourselves and looking at our relationships together at the same time; of looking at how our mind works about relationships and looking at how our speech works about relationships together. So that perhaps we do not have to go through that nightmare of doubt completely alone. We could at least share some of the depth of our own concern about working with people and perhaps we could come up with something that could be useful. Basically, what we want to do is be useful to people in pain and who have no path whatsoever. We are there in our agency, mental health office, whatever, and we are just sitting there anyway. We can be there and actually cultivate a discipline of relating with our own experiences of recovery while we talk to people who are yearning for just that.
Audience Question (Q.): Sir, you were saying that illness was a distortion, a way of breaking out of the conditioned existence that one did not like having imposed on one, to reconnect with the promise of what one could be, an effort to reconnect to that. And then you said the therapist cannot hope for the same thing and I was not sure what you were referring to.
Edward Podvoll (EP): I mean the therapist has not much choice in the situation except to wish well for another person. But now in our training…what is your training?
Q: Art therapist…painting...
EP: It might depend on the school of art therapy. But, for the most part, the caring concern for a patient's recovery could be obstacle to their recovery. That is basically one of the fundamental tenets of supervision that I think cuts through every conceivable school in psychotherapy now. Our desire and concern might be an impediment to another person's recovery. But, we know they have experiences of recovery, using the metaphor of the flu and obviously more than that. We know that we have experiences of recovery and we know that other people long for that: vividness, appreciation, happiness to be alive again, and free, at least momentarily, from pain and complaint. So we know that is going on. We know that people devise incredibly complicated means of trying to achieve those very simple moments. They experience moments of goodness about their lives and they have every right to long for them. So we have to know a lot about that. We have to know a lot about how those moments occur, what the texture of them are like, and how they disappear. We have to know something about the grotesque ways that some people try in order to manufacture them.
Q: I have some problems with seeing recovery in the way you put it. I guess because my own experience of recovery, of recovering myself, is more a process of unlayering, more in process terms then suddenly feeling that I am. Although I can see that point of seeing moments of health and waking up, and maybe more in retrospect, knowing that I have come through a layer. Do you know what I mean?
EP: The layer being what?
Q: Maybe the raising of a veil or something that was keeping me imprisoned but not the sense of…
EP: Could you describe a moment like that?
Q: I can see what you mean…having some sense of clarity. But I wonder with people in therapy, and I am looking at my own process too, and I wonder if it isn't more of a process that takes place over time, and that sometimes we don't even know we are coming out of something. In retrospect we feel it is not there any more.
EP: Well, what we are trying to do is not necessarily talk about the actual structure of recovery at this point, the process of recovery, but rather to earmark the experience, the delightfulness of that experience, because it is a moment. It is moment of every experience that we have of recovery. And we have to know more about. That if we are selling the process of recovery, we should know what the product is. And then, we might be able to make a better product. We are trying to get above, lift our head above, the notion of a bandaid mentality. We are trying to get beyond the concept of putting things back to the way they were. We are trying to get out of the concept of health as a car and a television set and making it. As if there was no more to do. We are trying to get beyond the concept of the quick turnover model of treatment which is, we found out, asking for trouble. We are trying to get out of the notion of just getting the pain over with. Because we know that at the bottom of that people want more and they will reconstitute their pain and their variety of attempts to achieve states of recovery. So, it is a matter of trying to learn more and more about this thing we call recovery. We are not talking about remission. We are not talking about maintenance care. We are talking about what people want to begin with and in their failing to get it, how they fall ill. People's illnesses are so often an attempt to manufacture, however fleetingly, these states of recovery or states of experiences of vividness and intensity and appreciation beyond themselves—springtime. It seems to be on the surface of things and we should be experts at that.
Q: Is it probably a question of maintaining? For instance, maybe there is no state of enlightenment to be sought, maybe there is a constant seeking, or constant process, or maintaining of some effort that produces recovery in the case of illness.
EP: That is getting close to the notion of recovery itself. If someone felt that he was actually, genuinely working toward that, then the experience of recovery is already taking place. We are not talking about the big, final "live-at-ease-ever-after" notion but we are talking about actually working with states of mind, our life, and our relationships in such a way that we feel that recovery is constantly possible. It does not mean that if one is in a state of chronic depression, recovery means only that it is gone and one has to feel happy. But rather, that one is learning a lot, for example, from depression and there are moments when depression is vital and there is richness to it and then there is contact out of that with the tenderness of other people. One could work with severely depressed people in terms of these profound possibilities of their understanding tenderness and sadness in other people, and because of that there is a moment beyond depression and self-pain. So the illness itself is rich and provides them with a lot of knowledge and insight about how other people work and where one might actually be useful to other people. We are not talking about getting rid of illness. We are talking about actually using it. And that is a long process, a continuous process.
Q: What you said just now about not getting rid of illness, then you mentioned before about manufacturing recovery and those springtime moments…can you give some examples of what that would be?
EP: Tomorrow we will give a long example. We are going to present a case tomorrow about someone who tries to manufacture springtime, moments of well-being, which are actually experienced as bliss. But I suppose the easiest example would be someone in a state of mania, excited mania. At the beginning we see a lot of energy coming. A little after that we see that she is feeling very joyful and we might even notice our sense of envy of her joyfulness. Then the next moment we see there is something forced about the whole thing. Not only is she trying to convince us, she is trying to convince herself that everything is fantastic. There is a drama…a forcing it forward. At every moment where there is a flagging of that energy, she has to push it further. Then, we notice she is playing a character. So there is a suspicion that she is manufacturing something. She has gotten our attention, and maybe a flash of our envy, and she is going further. It is becoming buffoonery, that she has to keep going, forcing the issue.
Q: So, if it is not forcing the issue, manufacturing, forcing it…I would like you to say more what this health is, or what you are talking about that is not forced.
EP: I am saying that it is an intrinsic possibility arising out of self-preoccupation. The exaggerated caricature of recovering from illness is what people are longing for. That is always going on. But in the cases of people that we work for as professionals, they are trying to manufacture moments of recovery, and they are not doing it well, and it is making them sicker. It is leading them very much into side roads and distorted attempts to achieve some kind of experience, an enjoyment of their world beyond themselves, the “springtime”. They have no idea of how to do things differently.
Q: There seems to be somewhat of a paradox about your speaking of illness as a preoccupation with self. I am thinking about both myself and people, particularly one person I am working with at the moment, who is so much more preoccupied with the others that she can't think of herself as having any power or ability to do anything for herself, and so without that she cannot be sufficiently occupied with herself to have any strength to see herself as overcoming the enemy which is destroying herself. So a certain amount of preoccupation with self is healthy.
EP: Well, that is because we are talking about preoccupation with one's own pain, the pain of one's self as being a powerless person: "I am a powerless person" at the mercy of family or whatever. That is already a definition of self.
Q: You're talking about preoccupation with pain rather than preoccupation with one's own self and doing?
EP: One's self becomes pain. One's self becomes defined by inadequacies here, incapacities there, and becomes a whole boundary of pain. But we find that when people recover they become more concerned with other people's pain than their own. These are the most important moments of recovery. Even in the midst of a chronic psychiatric ward, patients may come out of their catatonia to attend to someone else. They feel very good about that. They feel relief. And then fear.
Q: How does a therapist help someone to do that? How to be less preoccupied with her own pain in the way that you think and work as a therapist?
EP: First to know what this fascination with oneself is, the fascination and intoxication with one's own pain. How one could be so captured by that. I think one has to know a lot about that. I think that is a lot of what sitting practice of meditation gives us hints about: the mechanics, the actual mechanics of how we get hooked on self-preoccupation.
Q: I suppose it can keep one from thinking about one's feeling…being preoccupied with the pain.
EP: Well, the pain is just one of one's feelings and how to get out of that pain is another. It could be endless feelings. That kind of intoxication is what could lead one to be trapped in a self-definition of pain. We have to know a lot about that, as much as we have to know about moments of recovery, and I think we will talk more about that through this weekend.
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Talk #2: October 2, 1982
2. A Design for Treatment: Mind and Environment
Our discussion of recovery continues with how we know it, how we can apply it, and how other people can recover along with us. We want to talk about the actual application of what we understand about recovery and what we experience about it.
One of the applications is a treatment program, a possible model, that we have been working with in Boulder, Colorado designed to work with highly disturbed people using some of the principles about the nature and experience of recovery. We have said that recovery begins with mind. How we relate to mind becomes the possibility of recovery from illness. One could awake from the interminable self-preoccupation of illness.
Of course, we are talking about the seeds of illness, incipient illness; the continuous potentiality of illness, which begins with self-preoccupation. ,Just like severe alcoholism begins with taking a drink, the desire for a drink, a social drink with the desire to be more social. In the same way, we mean that illness born from self-preoccupation, becomes a fascination and then intoxicates one. Recovery is possible, in terms of waking up out of that intoxication, with the experience of a moment of vividness. Recovery has its own natural history. It arises and decays, just like everything else. But nevertheless it can be recognized, and the recognition of the space of awakening during moments of recovery takes place through relationship.
Relationships have a power to acknowledge and possibly enrich such moments of recovery. That puts psychotherapy in a unique position. A relationship could be the bridge for recovery to become a process that is continuously related to. That seems to be our little specialty in this culture: people who look carefully at the nature of human intimacy and who are able to apply what they know about recovery in the service of other people. That is all we are saying at this point that a psychotherapist is.
Beyond that we find that we can relate to the enormity and intensity of another person's illness and see where the connection can be made within the complexity of illness to experiences of awakening and recovery. With that principle in mind, we would like to discuss an actual person and the possibility of that person's recovery. That person is in a treatment situation, which specifies an environment and relationships, which we believe can bring about and foster recovery.
I am sure everyone knows, that presenting a case in a short time and in public, might involve us in endless possibilities and complexities of detail, especially when it is about such an interesting person. So we will have to do just a quick sketch and not linger too much on history and origin, but just who this person is. We could make it brief because who he is, is already the total manifestation of where he came from and how he got to be that way. We will call him “Mr. California”, for reasons that will become clear.
He is a twenty nine year old young man and he is trapped in a delusion. The delusion has endless intricacies, and if we looked at the delusion in more and more depth we would see how the delusion reveals and exposes the step-wise function of his falling ill. So it is necessary to give a summary of the delusion which has made him nonfunctional and needing others to survive. He would be offended by my using the term "delusion", because that makes him sound insane. But I have no other choice for the purpose of communication. If I presented his dilemma as something other than a delusion, I would sound insane. It is a principle of this kind of work that one can be deluded and sane at the same time.
It is a case of possession. This man is possessed by a woman who manifests to him through the "astral plane”. She has been with him for almost three years, never leaving him, always watching him. She controls his body, his thought processes, his energy level, his communication, and the way he thinks about the world. He defines himself in terms of this delusion. Everything that takes place in his body or in his relationship to his mind, he says is “not me”. He is almost saying, "I am not-me. I am under control. I am possessed by her. I have no will-power. I cannot exert my own will”. And interestingly enough, this person under whose control he is continuously in, he calls "Willow".
He grew up in California and is a product of a particularly exaggerated form of new-age spirituality, which we sometimes associate with the supermarket variety of spirituality. He has been involved in every conceivable spiritual adventure that could take place on the west coast. For the past 10 years or more he has been completely immersed in a variety of practices of almost every religious movement or offshoot. But it is Willow that he sees as his final religious movement. The delusion being that her possession of him is for the sole purpose of his bending his will towards her, surrendering towards the demands she makes on him in the form of voices, and visual and somatic manifestations. They demand surrender, submission. One demand on him is to strip himself naked in the middle of the street. Sometimes the command might come in terms of his hurting himself physically and perhaps even killing himself in her service. “Eat, don't eat”. They are often contradictory. The purpose of all that is for his liberation, his freedom from the bondage of his own ego-ridden will. If he comes through, performs the acts of surrender and submission that are required of him, he will clean the slate of his wrongdoings and the sense of guilt that he has carried with him for eons. When he accomplishes such a thing by the proper performance of self-surrender, and actually cleanses himself in such a way, he will achieve a sense of purity and liberation which will be a model and somehow useful to all human beings. He feels this to be something of a personal burden that he carries. In this lifetime he can be of enormous service to the species. He cannot fathom why he was the one chosen for this presumptuous task but nevertheless, he is the one who has been given the opportunity and the privilege to perform these actions. If he fails, a precious event in human history will be lost for all of us.
His big problem in life is that he "procrastinates". On the edge of self-surrender he holds back, he hesitates and is unable to follow through with the actions required of him. And then he sinks into depression and self-loathing for not having used this opportunity. The guilt of ingratitude is added to his problems.
He is a very loveable person. He is extremely gentle, almost exaggeratedly so. Not in the sense of being a non-entity, but in his firm belief that he is gentle, beyond aggression, and cannot do anything to hurt another being. But it is actually more than that. Ever since he was a little boy, people noticed how gentle he was and even as a 3-year-old child he was careful not to step on insects. That principle of not harming things has suffused his personality but at the same time it has become a hindrance to his path of self-surrender because true submission requires him to perform violent acts. Not to submit is also violent. It has become his catch 22, how to perform this type of submission and not be violent at the same time.
We began working with him about seven months ago using a basic recipe. It is a simple recipe and the essence of the whole treatment approach has been one of simplicity. It involves about a dozen people working with him. Now that sounds like a lot … a dozen people working with one person. It sounds almost un-American, so many working with so few, rather than the other way around. But nevertheless, it is not so time-consuming as it sounds. We are talking of roughly 7 or 8 hours a week of anyone's time. And because of that the same team can work with several people at once.
We began him in this treatment program which consists of, first establishing him in an ordinary household situation: a simple one but quite decent and dignified without being too brilliant and thus frighten him. It was essentially a student situation, an apartment with two bedrooms. He lives with a roommate who is a member of the treatment team also. We think of the roommate in terms of being a "foster-friend", a companion, helper, and at times, a basic administrator of the needs of the patient.
A schedule is established for the patient, with the patient, that involves giving a structure of time, a sense of orderliness to the day. That involves everything from sleeping, waking, food, and exercise, to the structure of relationships. It is not very rigid but it is very clear. And the boundaries of activity are quite clear. The principle behind that is that the boundaries, the demarcations of action during the day, become models of how to discriminate the boundaries between delusion and non-delusion, between being awake and being asleep, between being in a daydream and relating to reality. What demarcate that schedule most vividly are the relationships: the patient is involved with several people throughout a single day. The group that works with him spend blocks of time (three hours each) with him, and he might see people a minimum of 2 or 3 blocks of time each day. Other times, he is with his roommate or spends some time alone. But it amounts to a great deal of time with other people. On top of that is his involvement in intensive psychotherapy with me, which is 4 times a week. So it is quite active interpersonally.
The quality of these relationships is something that we want to talk more about later; that is, what it means to do the kinds of things we do with this patient which seem to be somewhat different from what one ordinarily finds and yet it is not so obvious on the surface. On the surface what we do are household activities: we go shopping with the patient, we take hikes with the patient, we sit and talk over a lot of coffee with the patient, go to movies, concerts, be with him, take occasional classes (he is a musician), and so on. These are quite ordinary, practical things. But what takes place in those relationships is something very intimate and very sane. The function, for the most part, of these relationships is a sense of introduction, a connection from the world of delusion into the vivid real world. There is a sense of mediation between those two worlds, the world of fascination and intoxication with the world of vividness and also of sadness, at the same time. How one provides that sense of introduction and bridge we will describe later, but we call it the nature of being a "therapist-friend", and the action is one "basic attendance".
What we are doing is working with the possibilities of body and mind being tuned together. We recognize that the basis of his illness is the continuous attempt to unhinge, or desynchronize, his body and mind and live within the space and possibilities of that disconnection. It is there that he elaborates his delusional world. The more that we bring body and mind together, the more clearly he sees things, his environment, relationships, and qualities of his mind. The more clearly he sees things, the more he begins to recognize some things. He recognizes that the voices that talk to him are remarkably unreliable. They never come through with their promises. When he sees that clearly, doubt arises. The doubt is basically whether he is dreaming or awake. Then a doubt about everything he has lived through. It is an instant of awakening, of recognition, and curiosity, and it has a great deal of pain in it at the same time. He has devoted himself body and soul to his peculiar spiritual path and every moment of doubt is a moment not only of clarity but of intense pain and excruciating humiliation. Because of that, his progress – or might be better called his “journey” – in his relationships with us is one of continuous oscillation. This fact also seems to tell us something about the nature of recovery. That is, recovery is happening in bits and pieces. There is awakening and there is pain and there is desire to fall asleep and dream again. It is an unending cycle and progression. Recovery is not a linear phenomenon.
What we have seen in the past 7 months are particular phases that we think are "phases of recovery". We can say that because the patient does seem to be moving, which for us means the shifting of allegiance from a world of intense imagination and death, to an allegiance and yearning for the intensity of human contact; actual passionate relationships with the people that he works with. That shift is having consequences on the nature of his delusion and how he is living his life. We can identify some phases of how that seems to be happening. We have some confidence that it is part of the process of recovery from severe delusion because we have seen exactly the same thing happen with others before who have been in the treatment situation I have been describing.
The recipe continues. First, an ordinary household situation with a roommate, then a schedule, and intimacy and intensity of relationships are established. Beyond that, the group itself has met in group supervision to talk about the patient and our reactions to him, and to discuss where the obstacles are to the patient's recovery such as we understand the principles of recovery. At a certain point, the patient is invited into this group and becomes a part of the group itself. That usually happens from 2 to 4 months into our work with people. At that point, the team becomes less of a thing imposed on a patient and has a lot of the characteristics of an extended family. We begin to have picnics together. We begin to actually host the parents when they visit. And when the parents do visit and have meetings with the team, they meet with the team that includes the patient. It has a peculiar effect on the family situation, which at this point is not easy to describe. Essentially the effect is this: when the family members enter the team environment, they seem to begin to appreciate each other more than they had for a long time. It becomes a meeting place for a family to gather as if in a family reunion. Although on the surface the meeting is around the focal point of the patient’s illness, it actually takes place on the basis of a sense of enjoyment of the patient’s recovery. Even peripheral members of the family seem to partake and enjoy each other, which might not have happened since childhood.
We see phases developing out of this kind of situation, within this kind of environment. We think of it as a “sane environment”. Sane in the sense that the patient is surrounded by sane people, people who are working on their own intelligence and their own process of recovery through meditation practices. Being in the midst of such people there is not much choice: either one goes deeper into madness to escape such things or changes one’s allegiance. It is an old story but to us in this culture it seems new. The old story is that when you put an insane person together with other insane people he gets less healthy. When you put an insane person together with healthy people he becomes healthier. It is a simple formula, which our hospital system has not quite seemed to discover yet.
(1) The first phase seems to be a kind of infectiousness of sanity. That means that mind and environment etch each other, because of the simplicity of schedule, and of action, and of doing things, and the boundary between activities. Then mind quiets down. The psychotic confusion and speed seems to be almost immediately effected by an atmosphere of simplicity and some kind of soft discipline at the same time. First, some quietness appears within the delusion itself. What seems to happen, when the relationships begin, is a kind of drawing of fire from the patient. Passion begins to develop. The patient, even in spite of himself, begins to like these people and is attracted to their health. As this happens, he begins to recognize moments of interest and curiosity and beyond that, moments of concern draw him out, almost drag him out of himself.
(2) When this appears, the next phase seems to be a cleavage of the delusion. Cleavage in the sense that as the relationships develop with team members, they seem to have a life of their own, independent of the delusion. The patient begins to discover that he is living a double life and he has to maintain a lot of energy to live, as if in two worlds at the same time. What happens so often in other kinds of treatment environments, is that the outer world gets covered by the delusion: “My doctor is so and so” in the delusion, and the nurse and whomever become engulfed in the delusion. But that does not seem to be the case with the people we have worked with. What seems to happen is that a double life gets imposed on the patient.
(3) The effect of that is that the delusion does not seem to propagate itself. The delusion stops at a certain boundary and it does not invade the relationship.
Beyond that, the delusion itself does not grow much further, even though it seems to have a subterranean life of its own. It is like the delusion does not have much oxygen.
(4) Then, from within this split life, the islands of healthy relationships that develop with a wide variety of people, also have an independent life. They are relatively free from delusion and begin to make the patient very curious about how these people live, how they work with their own lives, how they have relationships to people in their lives. And the patient is not shielded from any of this. The patient sees as much as he wants to see.
(5) There occurs a kind of occasional flicker, a shift of allegiance into wanting to live that way. Each desire in that direction leads to the problem I mentioned earlier. First, there is an awakening, being drawn to live like another, and then fear, guilt and self-aggression. It is a crucial part of the work itself, to recognize the whole natural history of these moments of recovery and the deterioration of recovery. It is necessary to include all of that: to be able to accommodate the whole cycle of events in our relationship with the patient. Our desire for the patient's health is recognized to include the same cycle of events. Because of our accommodation the patient can accommodate the awakening of his curiosity and also his fear of humiliation.
What we mean by a healing environment then, is not only the structure, but the potentiality of including all of the events of the patient’s psychology: the moments of recovery and the moments of illness, as well as the possibilities of further illness. In the same way, we include our own process of not clinging to the patient’s moments of recovery, not being drawn into any reward system, and not becoming discouraged as we see the unfolding natural history of those moments, which could lead to pain and depression. All of that is part of this environment, and it is used and related to precisely. We believe that this patient is in the process of recovery, which has this oscillating and vulnerable character.
Q: I wonder if your commitment to this man is to stay with him as long as his allegiance flickers back and forth, eventually going more and more going recovery. Will you work with him around his choice to go back into the delusion, and to stay with that and make that more complete in a way. What I need to know is if your commitment is to stay with him as long as he is oscillating until he makes the choice clear?
EP: It is more of a sense of the gathering and accumulation of the flickerings. One image we might use is of islands of sanity that coagulate so that he spends longer times in it and less time in delusion. But much more than that, is how he might learn to come out of the delusion. That is a further sense of journey, beyond his relationship to us. The sense of commitment is seeing him through his oscillations knowing all the time that his oscillations are our oscillations, and our commitment is to relate to our oscillations of "Oh, he's getting better. Oh, he's getting worse". It is going on all the time…hope and disappointment. How do we relate to his oscillations? That seems to be a large part of our work, both individually when we are with him, and collectively as a group. Our commitment is to work with ourselves and to work with him. We begin to learn more about the details of the process of how we might come out of the delusion or at least stop it. That means his learning more about what this issue is of his "procrastination and hesitation".
Q: Is there a sense then of his becoming sane in the delusion?
EP: Exactly. It is in the phenomenon of procrastination that we find the intricacies of little practices. There is nothing to call them but “little practices”, because they are very heavy, intense disciplines of giving in, surrender, not exerting his will. There has developed a tremendous precision over the years in accurately seeing when and where he could not do them, when and where he procrastinates, and when he does not. He is down to micro-moments of mind's existence, which has become a very accurate field of observation. The pinpoint of accuracy of his whole existence is sharpened in his delusion and so we have to work with where he is most accurate in his life. This seems to be the only place where he is truly accurate. It would be nice to just sweep away the delusion but we cannot. Nor can he. Because that is where his intelligence is actually manifesting as his greatest precision and his pride.
Q: I'm thinking about the treatment model and the old issue that we used to call "secondary gains" and I wonder if an ideal world is not being created for him that will be lost if he regains sanity. And I wonder if he manifests concerns about that?
EP: The ideal world being the treatment environment itself?
Q: Of course. It is wonderful. It is lovely. And I wonder if that is being built into his delusion in the sense of feeding the procrastination.
EP: Sure. This is one of the reasons why he is procrastinating. He does not want to leave us. He knows that if he harms himself in any serious way he endangers our being together. He occasionally he burns himself with cigarettes, or shaves his head in an attempt to surrender, but these things are not quite working like they are supposed to. He is hesitating at the edge of more drastic acts, like taking his clothes off in the middle of Main Street, because first the police pick him up. They take him to jail, then the hospital, and at best he gets out in six months at worst 2 years. He knows the actual facts of his spiritual path. He knows all of that. But he does not want to leave us. He likes his little life. But it has a lot of irritations at the same time. We make him clean up the house (we do it with him) and change his clothes. There is a constant interruption with his love of television. He likes the people and he does not want to do anything to hurt us. So that is promoting the procrastination. We are a monkey wrench.
Now the next question would obviously be: since we throw a monkey wrench into his fully entering the world of delusions, we may also be a monkey wrench to his entering a more complex world that does not involve so many friends all the time. We have actually lived through that with another patient, the woman we talked about last January. She was very concerned about losing her friends as she became healthy but that turned out to be quite a good thing to worry about, a healthy thing to worry about. When any of us become healthier and more independent, there is a concern about losing people. Or that their only attraction to us has been because of our need for them. There is a lot to learn from that. We did not know what was going to happen, how it was going to turn out. As it turned out, she has not lost us. We see her socially without any real dependence taking place and losing the team has not been a dramatic event. At some point it was her desire to say, "Stop, I want to see what happens". What she wanted to do was not only live more independently and feel like a person who could actually live and work without the constant companionship which she had for almost a year, but she wanted to know how she would relate to these people when they were no longer in her service. We also wanted to see. We did not know. Would we just drop her and say she's gone? No. Instead there has been a continuing contact that has been very friendly. And we see that it might never end. It might go on for a long time...the continuing social contact no matter where she lives. That seems fine.
Q: How did this man get in treatment with you, find out about you and come into the program?
EP: That seems to have been an accident with both patients we worked with.
Q: Did the patient bring himself in?
EP: That seems to be so in any case, no matter who first discovers Maitri Psychological Services [the Windhorse service in Boulder, CO, 1981-1987], whether it be a family member or the patient himself, the final common denominator is that the patient has to say “Yes, that is the way I want to do it…not in a hospital, or a half-way house, or with lots of drugs.” The patient has to say, “That sounds right.”
Q: I'd like to know at what point you discontinue the round the clock program. Do you gradually phase out?
EP: From everything we are saying, it is gradually phasing out so that even a patient that we stopped working with last March is still in some kind of contact with us and that is going through certain phases. It means that if we are talking about a sane healing relationship, it may never end.
Q: But do you make a conscious effort to eliminate blocks of time that person spends with therapists?
EP: To make it more efficient?
Q: No, just to phase out the contact he has with the therapist?
EP: What are the signs? I'm not sure. A lot of it comes from the patients of where they want to have more free time, more time to do things on their own. I think the edge of it is that they want to test the reality of this friendship, whether it is paid for or not. I think this becomes an intriguing point of where they want to cut down. "This person who says she is my friend, and acts like my friend, and does everything a friend is supposed to do, and makes me feel that way towards them: if there is no money involved, what is that going to be like?" I think they are intrigued with the possibility of testing that out. And then they want to have some room and see what is going to happen.
Q: Could you say something more about how the staff works with their own oscillations of hope and disappointment. How does that relate to the patient doing the same thing. I wonder if it involves, if not common discipline, at least parallel disciplines. I can see how the staff would be working with experience in meditation and knowledge of the nature of mind oscillations in general. How would the patient find a way of working with his own oscillations and what the connections would be?
EP: Meditation practice alone is not quite enough to work with the clinging to the hopes and disappointments of another person's health, about another person's recovery. It seems that meditation experience has to be turned on by relationships, has to be further enriched or catalyzed by the intensity of relationship. That is one of the reasons we bring the patient into the group, into the extended family situation, so that we can talk exactly about this: that we are working with our own disappointments and our own tendency to reward health in an attempt to stabilize it and solidify it. We openly discuss that: how to not get caught up in each other's moods, how our health and our functioning is not dependent on our moods. The patient actually watches us processing this and perhaps is internalizing that, but nobody knows what that means. At least, there is a model of how it could be done in an interpersonal context that he actually witnesses. It is in front of his eyes, of how we relate to him and relate to other team members and how we relate to our children. He sees us in wide variety of life circumstances. He goes to dinner with team members. He baby-sits. He sees us in not just a professional, properly disciplined role in an office. He sees us on the line, on the spot, all the time. So, hopefully the saner we are the better the model is.
Q: It sounds like a mutual commitment for working with others. You described this seminar in the brochure as working with Mahayana vision and it seems the patient could become infected in a sense with this way of going beyond the continual momentary obstacles that seem to come up, towards dedication to someone else and longing to not undermine that.
EP: It goes both ways. Even in the crudest sense of our working with people as professionals -- which takes a lot of unlearning, a lot of recovery to do that -- we are depending on him. He is the cutting edge for us to be able to practice. Our recovery and our development as healers are totally locked into our relationship with him. So it is interdependent recovery.
Q: I'm wondering about your intensive psychotherapy with him and how it fits in. Moments of recovery are fleeting and it seems that part of what any recovery process would involve would be lessening the contrast or the distance with what he identifies as his experience and the moments of recovery he wishes for. Do you try and decrease that kind of contrast and whether that happens? That is traditionally what happens in a transference relationship with an analyst like your self.
EP: I'll attempt to discuss some of that later in a talk about the more intimate qualities of relationship. But as you said, his idea of recovery is "liberation" and "enlightenment", which means his concept of that. Our idea of recovery is that he might begin to reevaluate what liberation is and what his life might be like. It is true. We are at odds about that. We have gone through some quite intense episodes about that. We don't understand him and certainly we can't understand him, not having his unique and spectacular bodily and perceptual experiences. Nevertheless, we seem to come to some kind of reconciliation, that he has his path and we have our path and they are both quite valid. He knows all about our meditation practice. Occasionally his roommate does a retreat and comes back. He knows all about
that. And he has met teachers of the Kagyu lineage...he has been quite fortunate to have done that actually. But we have lived through a mutual respect for the essence of the spirituality that seems to be involved. That is, to transcend ego.
One might say, “How can you respect such a weirdo system as his?” Well, what we are respecting is his desire to free himself from the bondage of ego, which is excruciatingly painful to him. In some ways it is more painful to him than to a lot of us more ordinary folk. He has a recognition of constriction, of the painfulness of ego, and he is doing battle with it even unto death. William James talked about such people and said that basically the reason why they go so headlong, maniacally involved with such spiritual paths, is that they felt the pain of ego more than most of us do. We could say that about him. We've seen things like that about him and we respect that. We know that from time immemorial people have tried to deal with their lives and attempted to transcend the limitations of conditioned personality by throwing themselves into a do-or-die spiritual path. It must bring them to the edge of insanity. It is an old story. We have talked about that with him. He is one of those people who might cross into total lunacy or he might have some kind of spiritual development. But if he does it totally on his
own without guidance or companionship, then most likely he will go crazy and he seems to understand that. So, it is a kind of mutual respect. That is what allowed us to put an end to the warfare of whose way was better, or who was doing the right thing, and who was doing the wrong thing, or who understood and who did not.
Q. Could you say more about his family? I was struck by the fact that of the positive processes that came about through the most dysfunctional family member in his contact with people so different as compared to what usually happens.
EP: Family work…people have talked for a long time about the family involvement, especially in psychosis, and the sense of "sacrifice". That is, patients present themselves as a ritual sacrifice to a family that seems absolutely crippled to the patient. It is said that in this way the patient's distorted and sometimes grotesque ways are attempts to heal the family. I think you could say there is a touch of that here but for the most part it is not a very disturbed family. They have always loved this boy and his gentleness, in spite of the fact that they could not understand it. His father is diametrically opposed to him, or to put it the other way around, he is diametrically opposed to his father in terms of temperament. For example, this boy, who would not step on an ant at the age of three, has a father who is a mountain of a man and a champion arm-wrestler. It is an interesting juxtaposition. They are actually quite friendly. The father loves this boy dearly even though he always wanted him to be more aggressive, and the boy recognizes the very soft quality of his father at the same time. But occasionally there are struggles about who is right. It is hard to fit it into any neat category. The family continues to visit more and they enjoy being around the team members.
Our general attitude to the family can be described by the example of our relationship to his sister, whom we have never met. The patient's younger sister is disturbed by what happened to her brother. They had been very close until the time he went further and further into esoteric spirituality, when she lost contact with him. When he entered a world of delusion she felt angry at him and was frightened by contact with him. So we have invited her to visit. Our attitude is that we advise the parents that she should come here and make friends with him. He is not so difficult to be with and we can help her do this. For her benefit, he could actually be quite sane for a period of time. It would be very important for her to experience that and important for him to be able to do that for her. So fundamentally, our attitude to a family is the same as in any other healing environment: to provide opportunities for compassionate action to take place.
Q: Do you think the staff will feel successful if the patient does choose to be insane?
EP: Probably not. Our work with him could be described as making him more conscious or aware and precise about what that choice is; to go further into his imagination or come out of it, to make him more responsible for that choice. But that means that not making a choice is actually part of the process. The more he is aware of the minute details of the psychological phenomena of making such a choice, the less likely he is to make it. He becomes stuck of the edge of doubt.
I've wondered what it would be like if one of our patients committed suicide. We are working with disturbed people and sometimes they wake up, look around, and see what they have done with their lives. It is a poignant time. It could lead to wild despair. Will the group completely collapse or will it keep on going?
Q: Actually your answer reveals an assumption in being therapeutic: that helping this patient to be more aware of his own situation is the forecast that he will make the choice to be sane.
EP: That is the assumption. The assumption is that the joyfulness of ordinary life will be more attractive to him than the torment, bliss, and hell of his imagination. Do you think that is a good assumption?
Q: I think so?
EP: Well, sometimes we wonder, because psychotic ecstasy and sense of power is never forgotten. There is no way it is ever just put aside. Even those who recover most vigorously never forget, are haunted by the possibility of that kind of bliss. It is a constant magnetic draw and the choice has to be made over and over and over again. It is the issue of continuing effort beyond hesitation.
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Talk # 3: October 3, 1982
3. Intensive Psychotherapy: Intimacy and Exchange
It has always been obvious to us that some kind of training is required to actually put this treatment program into effect and work within it. Because without that, the supposed simplicity becomes enormously complicated. One time when we were describing this situation to other health professionals they said, “We could do that. It sounds like the right way to do things.” But they could not make the-first step in that direction.
At some point, we might begin to sound just like the patient that we have been discussing. He said one time, “I don't understand why I can't just do this thing and get it over with. Why I'm hesitating?” He said, “I know exactly what I have to do and it makes perfect common sense to me. I should just do it and get it over with and start living my life.”
There are some things that are so straightforward and commonsensical that are arduous to do. In fact, simplicity is given birth to from a great deal of training. That is what we want to talk about now. The patient is confronted with a mirror image of himself. Everything we have described as his "pathology", or his distortion of his world, and his attempt to make some sense of it, are actually the same kind of issues that we as a team are involved in and it is sometimes quite humorous. What he is involved with are acts of self-surrender and attempts to transcend a constricted personal sense of self, which is just what everyone working with him is trying to do in their own lives as well. It is a peculiar paradox. And although this particular case puts this paradox in exaggerated form, I think we need to ask if this is not always going on to some degree or another with everyone whom we work with.
What we have observed so far in working with people from this point of view of practice -- our personal practice and our attempt to mine the intelligence of other people's practices -- is that the primary aspect of the other's development is the same as our own. That is the awakening, unfreezing, or unlocking of compassionate impulses. It has been difficult at times to talk about working with disturbed people in terms of their compassionate impulses. Sometimes people say, “I have never seen such a thing. I've never seen a psychotic person be involved with anything but his own miserable self.” But when we work intimately with highly disturbed people, we see them dwelling on the edge of the blockages and hopes to be more compassionate. In fact, everywhere we look among the psychopathologies of either psychosis or neurosis, we find the origin of disturbance to be the varieties of inhibition of impulses to be compassionate and useful to other people.
If and when we recognize the origin of illness to be such a state of affairs, it means that we have to become somewhat expert and accurate in discriminating those impulses in others – what the obstacles are and how we might help them overcome such obstacles. But before that can happen, we have to know all the characteristic and landmarks of incipient compassionate impulses in ourselves. It is the same formula that we have used throughout, that we cannot recognize anything in another person until we have experienced that and know it thoroughly in terms of its origin, its maintenance, and its natural history in our own life.
This kind of simplistic work that we have been describing requires more than mindfulness disciplines in order to make the recognition that the recovery of health is an ongoing, continuous, fleeting moment that is possible for us to be aware of and acknowledge in our body and mind. We have to go further than that. It is the issue of surrender. Here we might begin to sound exactly like Mr. California, in saying that the complete therapeutic environment requires personal discipline of self-surrender. If we described this to Mr. California he might understand to some degree but think we were off the track. He might think we were mistaken in spite of the fact he does not see anything wrong with his own personal discipline of submission, self-surrender and devotion to a woman who lives on the astral plane. He might think we are deluded in training ourselves to surrender to another person's pain. Not his autocratic whim, but his pain. For us, it is the further development in contemplative psychotherapy, the next step beyond a meditation discipline, its fullest development. It has been said to be the completion of the meditation discipline. Well, we are not necessarily going for broke like Mr. California is because we find that doing the process itself is already quite useful. Actually attempting the process has consequences that are valuable and helpful to other people. We are somewhat less ambitious than the patient but we are basically going in the same direction. He says the path to enlightenment is total submission and we are saying something similar to that. We are saying that other people are more important than ourselves. He is saying that she, Willow, the queen of the galaxy, the mover of stars, and the controller of all human beings is the one to be submitted to and prostrated to. His prostrations to her cause us endless anxiety when we go for a walk and he suddenly starts prostrating. But at the same time, there is a slight appreciation for what he is involved in, a perverted attempt at recovery, of going beyond his sense of self which has gotten to be so hateful. We are saying that in order to work with him and people like him, and perhaps everyone, that something of this appreciation has to happen. We as professional psychotherapists have to be in some kind of process of surrender. When we work with people's pain, their pain is our major connection. They are in pain and they somehow wind up in front of us, in the same room with us. Because of their pain, we have an opportunity to work with them, an opportunity at the same time, to work with our own lives.
We might feel uneasy about the notion of psychotherapeutic work being inseparable from developing ourselves but it has always been said in the Buddhist tradition that working with people in extreme states of mind is quick path. It means risking our sanity. Putting ourselves on that kind of edge is also the possibility of sharpening the edge of our own meditation practice. It is the edge of being shock absorbers for other people's pain. That is considered to be quite an elaborate and intense form of meditation practice in every Buddhist discipline. It is exactly that kind of practice that is required of us in order to put into effect the very simple formula and recipe that we described – the surrender of personal territory.
Whenever we talk about this model or design for treatment, what strikes people about it is the sense of generosity. The people on the treatment team are opening up themselves to such a degree: their home lives, how they live, dissolving the barriers of professionalism. It takes courage to do that. It seems simple but is actually quite hard to do. It is hard to do, not only because of the mechanics of the whole thing, but we risk being called names for doing that, like “fostering dependence” or “breaking down the boundaries” of who you are and who they are. So, the generosity that we talking about is also the courage to work with people and expose ourselves, our lives, our practice, and how we relate to people not just in the confines of an interview room. That is the part of this practice of "exchanging ourselves for others". That is the technical name, which many of you have heard. But then there are all kinds of ways of practicing that. There is actually a formal rehearsal to do such a thing. Certainly. I am not going to try to give the formal
instruction of that practice tonight, except by coming in the side door, the side door being psychotherapy.
In any case we are already doing such a thing. To the extent that we do not acknowledge that we are doing it, we are in trouble. To the extent that we don't acknowledge that when a highly disturbed person (or anyone for that matter) walks into our environment we are not at that moment as highly disturbed as they, we are in trouble. And when we are in trouble, we produce trouble. All the work that I have been describing with Mr. California is the possibility of acknowledging exchange, which becomes the ground-base of relationship. In fact we live primordially at the level of exchange with other people and with our environment in general. We do not recognize that most of the time, and the practice of exchange is to know more about that and to go further towards it without procrastination and hesitation.
A crude example of the basic exchange is when you go to a movie on auto racing and the film is viewed from the point of view of the driver's seat and the picture is speeding around curves. When you stay with the driver and experience his life that way you notice that everyone else in the movie theatre is also going back and forth with each curve. Well, we are doing it all the time, especially when we are in intimate contact with another person who is in pain and in more or less silent appeal to us. The possibilities of exchange within the psychotherapy environment are extremely intense. To deny or ignore that, to try to preserve oneself in the face of that, is dangerous. Mostly it is dangerous to oneself. Because if one does that long enough the other person just disappears and says, “I didn't get along with her. Didn't work. Didn't click…couldn't talk to her, so I'll find another therapist.” Or it might lead to what is called a "negative therapeutic reaction" where the patient struggles to make himself felt, to break through the therapist's protective armor, and he will do so in his characteristic way. But it hurts us. It hurts our development not to acknowledge that the basis of human intimacy is this exchange. The possibilities of further acknowledging it and actually using it have to do with this formal practice of absorbing another person's wretchedness and recoiling from that with some kind of gentleness.
That is what we meant in previous talks by the expression:
The darkening of the light injures him in the left thigh.
He gives aid with the strength of a horse.
It is a matter of taking the pain and coming back out without blame or aggression. That is strength. That is the same as what we have been talking about in regard to the treatment service, which we are presenting as possible model. It must be possible for people to extract principles from, the foremost being nonaggression. It turns out that we could actually swallow aggression, eat it up, and come out with bits and pieces of something that is useful to nurture other people. It seems that in the past it has been possible to talk directly to psychotherapists about the possibility of exchange without necessarily talking about the formal practice because they are doing it all the time.
The essence of intensive psychotherapy from the viewpoint of contemplative psychotherapy is this situation of exchange. It might seem a little bit baroque, a little too much, to tell people who feel overburdened, overworked, seeing patient after patient, working with difficulty after difficulty, in variety of agencies, to go further into other people's pain. They are already on the verge of what conventionally is called "burn-out" and we know health profession people have a high rate of suicide, alcoholism, and on and on. It seems paradoxical to say, that the essence of psychotherapy is taking more pain on, swallowing further, and that is actually the way to be more useful to people and have less burn-out. Nevertheless, despite the paradoxical logic of such a situation, it seems to be true. The more we are able to do that, the more we are able to do. The more we are able to do, the less burn-out there is. Burn-out comes from the suffocation and the feeling of being bombarded, then feeling slightly paranoid, and then having to get out of that situation. What we are recommending in working with potential burn-out, is to go further into the other person's pain and to use that very sense of suffocation as the impulse to come out with qualities of wakefulness: the basic out-breath that we have been doing.
It is a weird logic, when we look at it from one point of view. If we actually said something like that to people right off the street, they might have looked at us like we might have looked at Mr. California when he told us about "her". He cannot procrastinate, hesitate in surrendering himself to her. Once again, the patient is confronted with people who are trying to do just what he is, transcend some aspect of ego, of going beyond their own limited, constricted sense of territory. He is confronted with a lot of people who understand exactly what he means and are doing it in quite a different way. Sometimes they are very disciplined about it and he is envious of that. Sometimes his envy leads him to accelerate his own practices: prostrating on the sidewalk, shaving his head, eating dirt, other things. It is an interesting edge for him to experience. His path of recovery is exactly the same as our own. The more we understand about our own possibility and journey of recovery, the more we could be useful unlocking side roads that he has taken on his own.
Q: It would help me if you would explain what Mr. California's mistake is as you understand it or as you see it?
EP: That's part of the trouble we have in talking to him. He knows what we are doing more or less and he says, “Well, what do you do that is so different than what I do? You use exactly the same words as I do.”
Q: Well, they are not exactly the same are they? I have my own idea of what his mistake is: that what he is prostrating himself toward is another ego, another invention of a single will somehow, and it is another person to him.
EP: It is a cosmic person. I mean, it is a real person who lives, we think. But she also exists in her majestic form in an astral state of being and thereby has access to all of our consciousnesses except his is more open to receive and recognize her.
Q: Have you met her?
EP: Sometimes I feel I have. [laughter] I remember distinctly one time when I felt I totally gave in to her reality. I think it had something to do with what we talked about this morning. When we went through a period of struggle. When he was trying to convince me of her reality and he justifiably felt that I was trying to convince him of her unreality and we got into a head to head struggle about that. We both gave up. Then when I felt that because his bodily experiences were so powerful, so sensible a delusion, that there was no way in the world that another human being could say that it is not true. Might as well say it is real. Then when you actually try that on a bit -- might as well -- and soon enough you are acting and you are talking as if she were real. Suddenly, communication is absolutely fluid and there is no obstruction and it feels a little crazy.
Q: Well, she is real. Right?
EP: Yes. You're getting it too? [laughter]
Q: Can you say anything about that, what his mistake is, what the difference is as far as you have gotten with it?
EP: There are a lot of ways of talking about his mistake. He feels his only mistake is his hesitation at not going with his belief, his understanding, and with his instruction. But we have already come to appreciate that he is on a unique path, a strange spiritual path. He knows that people have been off on lonely spiritual trips that have been similarly quite unique. We have agreed that doing such a thing without a teacher is extremely dangerous and that people have often followed them through to the point where they bring themselves to the verge of insanity. It is instructive to look at some of those phenomena. They include desert fathers, those who live in the desert and did ascetic practices. They include a number of Sufis for example. Or the "masts" in India, that Meher Baba worked with for many years. They include a whole almost respectable tradition of people who put themselves on the verge of lunacy in order to experience attainment. So what is the difference? One thing that has been pointed out to him is that he is lacking in any joyfulness as compared to those people who have been on unique spiritual adventures, at least the ones who made it were not like him. When they came out of it, like St. John of the Cross, they were talking flowers and stars and beautiful things. They were talking about helping people and devoting themselves to the service of other people. And he has not done that. So we remind him of the edges where he might get lost in a cul-de-sac of spirituality, which is often the function of meditation instructors. It could be ordinary: “I want to go on retreat. I must go on retreat.” The question might be, why at that point in one's life to go on retreat? That retreat could
become a cul-de-sac in one's practice or it could become a further development. So we have to have some kind of confidence that we could recognize a spiritual path, or at least the basic characteristics of it that make sense and others that don't. And we have to remind him of those.
Q: When you are talking about self-preservation in the face of another's pain, the therapist going deeper into another person's pain. I was thinking of an analogy to a lifesaver. When someone is drowning, the idea is not to drown with the drowning person and there are ways that the lifesaver makes the judgment. Could you talk about how the therapist can make the judgment of how far a therapist can go into another person's pain before she is going to get lost in it herself.
EP: Well, what is the first thing you would do in lifesaving?
Q: A quick assessment of the situation, which is largely intuitive. Then, there are releases you can use when you feel like you can't save the person because they have got you around the neck.
EP: Yes, that is the first thing. First, you realize you approach another person carefully when she is drowning because her tendency is to flail out and push you down and you may completely lose it at that point. So you approach her from the side or from the back. Yes? Then, there are ways that you hold her carefully without strangling her to death so you don't add to her misery. There are ways that you bring her in carefully, and guide her. There is a whole set of guideline that have been well worked out because people have actually approached drowning people and been killed by them. Then eventually, the methods get worked out and now there are a whole set of guidelines that seem to work when you are trained that way and you don't get in too much trouble by approaching a drowning, desperate person. In Buddhism, those are called practices of the six paramitas of how you can stay afloat and help people at the same time. Basically, the practice of exchange and of absorbing another person's pain is jumping in to the person who is screaming for help, drowning. Then, how you conduct yourself in a frightening situation is another kind of discipline.
Q: Could you say something about your own individual work with this person and maybe clarify some major differences with R.D. Laing and how he works with some very disturbed people and the approach that you are describing.
EP: I really don't understand the work he does. It is really hard to tell from writings what kind of work anyone does. No. I shouldn't even try to do that. What I am personally doing now is so mundane that I rarely even take notes anymore. It is just practical and pragmatic. I might say something about one of the last meetings I had with this fellow. He was lying on his sofa in his living room and seemed quite gone. It was a bit of a shock to me because the previous times I had seen him he was vital, alert, and present. There was very little talk about Her because he would start talking about her and say. "I don't want to talk about her". Over the past month or so, he has been playing with the possibility of renouncing talking about her. He has spent the past three years like the Ancient Mariner, talking to everybody about her, what she is doing to him. He did exactly that about Willow. But he is hearing himself doing that and says, "No, I am not going to talk about her again". The team has been working with our tendency to say "That is great". But, just letting that happen; accommodating the new possibility that he was exploring. He had been doing that until this particular hour when he was silent, morose, and obviously very involved with the mindless practices that we have come to identify with him: mindless practices being practices which desynchronize his mind and his body and facilitate hallucination. That is another long story. In any case, he was giving clear signs of doing that. Occasionally, he would stop and he would look sadly at me. I tried not to interrupt although I felt offended by the breach in the relationship that we had been having. For an instant I felt grief-stricken. Then. I said to him, "She is leaving you, isn't she?" At that point, he bolted up and said. "What made you say that?" And I said, "I just feel that she is going away. She is going to leave you. Just like you always wanted her to, and now you don't like it". That interchange has become part of the relationship now. It is in the air that she might be leaving. Their relationship might be over. It sounds very cute, intuitive, or magical, that we could tune in like that. There is no way to describe the events that lead me to say such a thing because of the months and months of accumulation of experience with him and the trust that what I experience in myself might be related to what is going on in him. But I also knew that I was
leaving in a couple of days, and I knew he was trying to ignore that. I knew that I was worried about him and that I might miss him. And he avoided the parting that was in the air and I blamed her for it, just like he blames her for everything. Otherwise, it is very mundane.
Q: You felt his grief when he was laying on the couch?
EP: I felt my grief.
Q: Don't you think he was in grief too?
EP: Obviously. I made that assumption that he was in grief or impending grief or struggling against grief.
Q: Do those intuitive assumptions seem to be correct for you?
EP: You know. I don't know because I do them so often that I have stopped keeping count of how many times they appear correct. Just let that go. But I think it is really important – at least with people where some kind of relationship has developed and where there is some kind of discipline within the relationship -- to be generous and offer those hints and intuitions and at the same time not be attached to those intuitions.
Q: More important to offer them then whether right or wrong?
EP: Yes, put them in the air. Like putting them out on the coffee table. I think there is a point where you could completely trust the relationship to bear that strain if you are not attached to being right or wrong. That is the crucial point.
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Talk #4: October 4.1982
The Nature of Courage in Psychotherapy
While talking about the practice of psychotherapy there has been no doubt that working with people is a practice that requires effort, personal discipline and the continuous rehearsal to do such a thing properly. Training to do this is not a matter of learning how to drive a car: learning the gears, techniques, or strategies. That kind of training is missing the point and everyone who has been involved in that kind of psychological training knows something is wrong. The real point is involved with training ourselves, and having experiences ourselves, and knowing precisely what that experience is about. If we are going to tell the truth to people and have the courage to do that it has to come from what we have experienced ourselves.
It has been obvious all along, that how we tell the truth to people is our practice and that take a bit of work, a bit of effort. Genuine psychotherapy is basically meditation in action. The first line of the brochure for Maitri Psychological Services reads, "Maitri Psychological Services is a therapeutic action group". What we mean by that, at least to ourselves, is that it is a group intensely involved with the practice of meditation in action, of how to expand our personal practices into interpersonal work. No matter what we know or don't know about strategic therapies, it is meaningless without personal work, without a direct relationship to our own mind and body and communication. When that is going on first and alongside of our interpersonal work, something different happens.
Once we had a meeting with His Holiness, the 16th Gyalwa Karmapa, and we asked him how the Naropa Institute psychology program could accommodate so many different schools of thought, so many faculty members having trained in different ways. He said: meditation discipline is like a beautiful, rich golden brocade that you set out on a table and no matter what you put on top of that brocade, it becomes more brilliant and beautiful. That is the idea. Our personal discipline can actually accommodate many trainings and skills, and they are more highlighted and made vivid by our personal practice.
It takes some work to do that and we should not shy away from it. We should not procrastinate about that. We are talking about evolving very simple and honest ways of working with people. That honesty only comes from a personal honesty with ourselves. It cannot come second. The courage we are talking about now is the courage to actually practice the honesty of meditation. It is easy to practice in this environment of Karme Choling with its blazing autumn trees as a brocade, practice becomes joyful. When we go home to practice it is more lonely. When we are practicing alone in our room we might wonder whether we are crazy or not. It is important to have some memory that the practice could be delightful and gentle, as compared to when we are alone in our agency or institution where there might not be anyone else talking this way. There is an aspect of courage in doing this and I am not talking about anything theoretical. It is the way I began to integrate meditation practice and clinical work. It was lonely to do such a thing. It is possible that people will think you are doing something weird or exotic. I recall a letter I received from an old friend after I had written a little paper relating meditation to professional work. He said, “Be careful about exposing this stuff your are doing. People are going to think you have gone crazy.” I felt very lonely reading that letter. Nevertheless, places like Karme Choling and Naropa Institute were available.
It is interesting that Mr. California is going through the same thing in his own way. For some reason I told him, “Wouldn't it be wonderful if you could convince your mother that you were not crazy all this time?” And he agreed, if there were only someway he could justify himself to his mother that would mean a lot. It seems that the thing he is most afraid of is also leaving Her behind. That is, leaving the delusion, and facing the humiliation and despair of appearing crazy to other people. He will have to say, “I made a mistake. I was wrong. It didn't work. Let's forget it.” That does not seem to be what he can do now. He would love to have his mother's acceptance that he is not insane and that everything he has been through has not been in vain, worthless, and degraded. He does not want his parents to think he is insane and that seems to also be part of what all of us are afraid of. That is part of the loneliness we are all working with.
On the other hand, this loneliness is not necessarily as bad as we think. All our patients are living with this in one form or another. To the extent that we can taste that, understand that, we might be useful. We can tell them the truth about loneliness, that it is also rich and vivid and clear at the same time. When we come here to study contemplative psychotherapy we could feel that we are doing something outrageous and risky. But that does not seem to be the case anymore. Many people are doing the practice of meditation and combining it with their therapeutic work. We are hardly alone in doing that. It is clear that people want to go further with this kind of work and want to do it now.
It is once again the same issue of not procrastinating. But in this case it is the flip side of the patient's idea of procrastinating. We feel we cannot procrastinate getting more down to earth, away from theories, and into the ordinariness of working with people. The patient is trying to leave the earth in order to become extraordinary. He is basically stuck. It will take courage on his part not to collapse in despair and nihilism, and yet not to go forward with what he is increasingly recognizing as an absurdity. It is a time for looking around to see what's true and what's not true. There are favorable signs: he is working with his mind in order to head it off from wandering into endless cosmic speculations with the reminders that he gives to himself, "keep it simple, no theories". He is becoming less passive and pseudo-gentle in his relationships and less fearful at expressing the intelligence of aggression. His body seems to be less of an alien conspiracy.
The patient’s courage to continue this way is interlocked with the courage of his friends, the team members. We also must renounce our theories about him, including what sanity is and what recovery should be like. We also can rely only on the ground experience of recovery, and of going out beyond ourselves with that. The courage of the patient and the courage of the therapist are inseparable. How on earth can we transmit the necessary attitude and skills to someone struggling with an addiction of any kind, unless we know the ingredients of courage from our own experience? That is where the courage to practice mindfulness-awareness discipline comes in: the courage to experience aloneness, renunciation, and the true nature of projections.
We don't know if Maitri Psychological Services is the most ideal treatment situation in its present form. It probably has many refinements to go. But it is going in the right direction and we just cannot wait for the most ideal situation to be there. That is another aspect of courage, not waiting for things to get better before going forward.
We can start exactly where we are. Moments of recovery are spontaneously occurring. Courage means not hesitating to relate to those moments. We do not have to go back to the infantile origins of illness and how those manifest in the therapeutic relationship. How finally the multitude of habitual patterns of transference or whatever, are eroded like water erodes rock. We and they do not have the time for that, if it works at all. The meditation discipline and personal practice of relating to our own clarity and recovery, implies all the time that we do not have to wait for the nightmare to be over. We can awaken right within it. That is what we are trying to transmit to the people we work with.
We are only doing what people have wanted to do for a long time. Journals and books are filled with concepts and theories about what is called "empathy". The issue of empathy and actual contact with people can only arise from our own experience. Meditation is the fertile ground for the development of empathy. Somehow no one has talked about that in western psychotherapy. But we are talking about actually cultivating empathy, cultivating exchange. Because of that skill arises in working with people. We need to do that. It is a big project. Psychotherapy is not like driving a car, which anyone could do. It has to be practice. The more we can practice and discuss it together, the easier and more delightful that will be.
"Recovery" emphasizes the notion of process. Perhaps we are involved with a redefinition of the notion of recovery. It is not remission. It is not normalcy. It is not just the abeyance of symptoms but it is what everyone we work with wanted from the beginning, when they engaged in a course of illness. They were looking for something beyond the falsity of constricted personality. There is a hint of brilliant sanity and they want to recover that. Recovery from illness is recovery of intrinsic health. That is the logic of the language we have been using. Recovery is possible beyond maintenance, making do, or remission.
That is not enough. If we settled for that as the end result of the therapeutic encounter, that is courting trouble. People begin a course of illness in search for something better than where they started from. They don't want to go back to where they started from. From the point of illness, there is no one to recover. That has been left behind. No one who has had a psychotic episode has ever said, “I just want to get this over with and be just like I was.” No one ever wants to be just like they were or else the whole thing would never have started.
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