The Compassionate Practice of Psychotherapy Part III: Intensive Psychotherapy: Intimacy and Exchange

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 the Recording of Part III

Transcript of Part III

Dr. Podvoll: 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 straightforward and commonsensical but 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 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 characteristics 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 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 a 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. “The darkening of the light injures him in the left thigh. He gives aid with the strength of a horse. Good Fortune.” 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 a 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 a variety of agencies, to go further into other people’s pain. They are already on the verge of what conventionally is called “burnout,” 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 burnout. 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 burnout there is. Burnout 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 burnout 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 to him in unlocking cul-de-sacs he has taken on his own.

Student: It would help me if you would explain what Mr. California’s mistake is, as you understand it, or as you see it?

Edward Podvoll: 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.”

S: Well, they are not exactly the same are they? I have my own idea of what his mistake is: 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.

S: Have you met her?

EP: Sometimes I feel I have. 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 I felt that because his bodily experiences were so powerful, so sensible a delusion, 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, 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.

S: Well, she is real. Right?

EP: Yes. You’re getting it too? [Laughter]

S: 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 lived 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. 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. We have to remind him of those.

S: 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 life saver. When someone is drowning, the idea is not to drown with the drowning person and there are ways that the life-saver 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 life-saving?

S: 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 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 guidelines 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. How you conduct yourself in a frightening situation is another kind of discipline.

S: 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 we were 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 led 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.

S: You felt his grief when he was laying on the couch?

EP: I felt my grief.

S: 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.

S: 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 to be attached to those intuitions.

S: 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.