The Compassionate Practice of Psychotherapy Part I: Foundations of Clinical Recovery

This is a transcript of an intensive training seminar given by Edward M. Podvoll, M.D. at the Karme Chöling meditation center in Vermont on October 1–4, 1982. It has been lightly edited by Jeffrey Fortuna and Skye Levy.

Part I: Foundations of Clinical Recovery

Part II: A Design for Treatment: Mind and Environment

Part III: Intensive Psychotherapy: Intimacy and Exchange

Part IV: The Nature of Courage in Psychotherapy

Listen to Part I

Transcript of Part I

Dr. Podvoll: 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—eighty-two years old—has acquired a similar responsibility in working with people and that is that psychotherapists exemplify the possibilities of health and of recovery. Healers have always taken that 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 kind of care would we actually want for ourselves?”

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. Who 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 psychotherapists at all. 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 is 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, 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 a patient 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 “Ode to Joy”), 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, they are 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: whether this 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 could we 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, in the therapeutic situation, one meets 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, 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: 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 the 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 who are 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.

Student: 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.: 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?

S: 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 an 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 in 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 their texture is like, and how they disappear. We have to know something about the grotesque ways that some people try to manufacture them.

S: 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 un-layering, 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?

S: 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?

S: 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, 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 anymore.

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 a 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 Band-Aid 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.

S: 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, 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.

S: 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.

S: 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.

S: 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 preoccupied with 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.

S: 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.

S: How does a therapist help someone to do that? 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.

S: 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.