Paul Fulton Ed.D. is Director of Mental Health Programs for Tufts Health Plan, an Instructor of Psychology in the Dept, of Psychiatry at Harvard Medical School, and is the president of the Boston-based Institute for Meditation and Psychotherapy.
These comments are excerpted from a talk given at the bi-annual meditation retreat for psychologists and psychotherapists at BCBS in July 2003.
When we look closely at some of the empirical studies conducted on the effectiveness of psychotherapy, it begins to appear as though most of what accounts for effective treatment has very little to do with the technique or the philosophy of the therapist. In fact, what seem most to account for outcomes are factors that have next to nothing to do with the treatment at all. It has far more to do with certain qualities that the patient brings, and for other changes in their lives.
For example, if a person is depressed over having lost their job, the single most powerful treatment is to get a new job. That’s going to exceed anything that the therapist is going to do. There are also expectation effects and placebo effects which have been empirically demonstrated. It has been shown, for example, that somebody who has one visit to a therapist seems often to have done as well as the person who is in continuous treatment over three months.
The truth is we don’t really know what’s going on in treatment. But from our training in graduate school, we acquire a tremendous body of explanations that we offer ourselves. These tend to justify the time and expense of our training, and the fees that we receive. But in fact, what is happening seems to not be precisely what we think is happening.
The area where we do have the most to contribute to what’s happening in treatment is, of course, in the nature of the relationship itself. And most importantly, it’s not the therapist’s assessment of the quality of the relationship. It is the client’s assessment of the nature of the relationship that’s going to be most predictive of having a positive outcome. That being the case, I have come to believe that the greatest value of meditation practice for the psychotherapist is in the way it helps us to cultivate certain qualities of mind—in fact, it helps us cultivate precisely those qualities which are most conducive to the successful treatment relationship.
This is the theme I would like to explore with you this morning. Let’s look at some of the specific ways that meditation practice is of benefit for the therapist.
Making Contact
In meditation practice we are simply learning how to make contact again and again and again with what’s actually before us. We make contact not through our concept formation and through our thinking, but through returning to what’s most adamantly true in the moment, without recourse to our usual avenues of avoidance. When we find ourselves vanishing into fantasy, or into desire, or into memory, we come back again to things as they are—not because they are more pleasant (in fact, usually our fantasies tend to be more pleasant), but because they are true.
We do this knowing that we need not actually get rid of anything. When people come into treatment, or when they begin a meditation practice, it’s usually with the expectation that the only problem is the need to be someone else. Woody Allen said his only regret in life is that he wasn’t born someone else. When people come to treatment, it’s usually because they have something they need to get rid of—some quality or habit or pattern. Or there’s something they feel they lack, that they need to get more of, that they’re going to “get” through the psychotherapy or through the meditation. We all have these fantasies of what enlightenment is going to get us. It’s very interesting to look at what our ideas are about that.
When we practice meditation, in fact we’re not trying to get rid of anything, and we’re not trying to hold onto anything. We’re simply practicing attending to what actually is. There may be the subtle intent to change the world through our practice, but that’s a distortion. The practice is always and only taking refuge in this moment, just as it offers itself to us.
In the process, then, meditation practice teaches us how to open to and accept intense affect. In the process of learning to tolerate more of our own discomfort and pain, it simultaneously and automatically grants us the ability to tolerate the affect of our clients as well. The more we can be truly accepting of our own experience, the more we can be accepting of our clients’ experience. This, of course, is simply the practice of equanimity.
It’s not equanimity in the sense of being remote and distant. It’s being absolutely present with what is, and allowing it to come, and allowing it to go, because we know that it will. This is also learning to be non-judging; as we learn to let go of judging, others around us, including our clients, feel this and can begin to trust.
Holding the Form
What enables us to do this hard work in meditation is of course a bit different than what happens in psychotherapy, though each offer “containers” to support us. The thing that allows us to tolerate what is difficult in psychotherapy is the structure. Certainly, the integrity of the therapist, is paramount, evinced by respect for the boundaries of the relationship, and the absolute promise of confidentiality. But also you’ve got elements of structure like the scheduled hour—the predictability, perhaps, of the same time each week, knowing that you’re going to start on time and end on time. The frame of the professional relationship is actually very powerful. Even the very fact of an exchange of fees gets the client off the hook of having any other obligation to the therapist but to show up and be honest. That right there is a huge support, a container, and a protection.
Those things allow the client, then, to begin to move closer to what is difficult than is possible when those supports are missing. This is the reason why people don’t do as well speaking, for instance, to friends. With a friend there is a more reciprocal relationship, with all the obligations that implies. This message came home to me in my very first therapy, which was analytic therapy on the couch several times a week. I was concerned that I was boring my therapist at the time. Though I wasn’t sure at first, I came to feel that his comment was terrific. He said, “It’s okay. You’re paying me enough.” He didn’t tell me I wasn’t being dull, only that it didn’t matter. I was off the hook of having to be entertaining. The fee I was paying him gave me permission.
In meditation, of course, there are a number of different supports for standing ever closer to the heat of difficult experiences. We can run through a quick list:
Sitting in a group is a great support in itself. You may feel like running screaming from the room, but you don’t because of the social pressure. The truth is that taking refuge in the sangha [community] is a way of using social pressure to support something which would be more difficult if done alone.
Another support is found in the teachings. Just knowing that there is a map, a body of understanding and instruction, which can help us understand and guide our practice is very helpful. We’re not just out there flapping about. Even though the instruction is so simple—to stay with this moment—in fact it is supported by an enormous body of understanding.
There is also the fact that this path has been traveled by many, many people before us. There are teachers, for instance—people who have walked this path and can provide support to help us tolerate things that we might not otherwise put up with. It gives a great sense of confidence.
The more we can be truly accepting of our own experience, the more we can be accepting of our clients’ experience.
Still another support that makes it possible to tolerate the affect is holding to your posture. This is really a matter of being willing to abandon other methods of avoidance. Typically, if some discomfort comes up, we’re immediately scratching the itch or shifting our posture. When we renounce, for the moment, the easy escape—wiggling or itching or moving—we actually empower ourselves to redirect our attention to look at our relationship to this thing we would normally habitually avoid. In other words, to decide not to move, even for a brief period of time, becomes very empowering because it redirects our attention.
In the process, we also cultivate greater concentration. When the mind remains unmoving—when you choose just one object and come back to it again and again—concentration becomes stronger. Concentration brings certain qualities of mind, such as stability, imperturbability, and calmness, which make it possible to endure being thrown about by the emotions. It’s not enough just to be mindful of changing mental states; concentration is the fortification that allows us to stay with these experiences in a steady way.
The Contingency of Experience
Our meditation practice teaches us is that no emotion is ever final. What’s interesting is that in the throes of many emotions, we don’t know this. While depression is not precisely an emotion, it’s a wonderful example of what I’m saying. When a person is depressed, there’s no life, no future, outside of this experience. There is no hope. Hopelessness is in fact a primary symptom of depression. Never mind that as recently as weeks ago, an individual may not have felt depressed. But the memory of that is not sustaining, because the notion of the future has been contaminated by the symptoms of the depression. Against all reasoning, against all logic, we may come to believe that what we’re experiencing in this moment is forever.
We can tolerate what for the moment our clients can’t, because we hold an understanding of impermanence.
One of the things that we learn from our meditation practice is, “It isn’t so.” Nothing remains. No emotion, no experience, can be counted on to remain. It may get much worse! But it will not stay the same. As therapists, it’s useful to know this, to really know this in our own experience. It tells us that we can tolerate what for the moment our clients can’t, because we hold this understanding of impermanence. Indeed, we can hold the memory of a time that the client felt better. We may even do something as simple as remind the individual that this was not always so, and that we know that it will not always be so. Their job right now is not to rid themselves of this feeling, but to take care of themselves until such time as it leaves them.
Moreover, we learn that our happiness is not dependent upon external conditions. In fact conditions can be wonderful and conducive to happiness, and we can still be miserable and stewing all the time. Or conditions can be enormously difficult, and we can be joyous in the midst of it. Somehow we have this idea that we need to control our lives and make everything “just so” as a qualification to happiness. Yet we can begin to see this as just the effort of our minds to try to control things. In fact, happiness is so often entirely independent of our material conditions.
It is possible, even in the midst of tremendous pain, to enjoy our lives. We can feel joy, not because everything is fine, but in spite of the fact that it’s not. If we are capable of recognizing this ourselves, it also means that we can begin to be a model for our clients of how to be happy. I suspect that happy therapists are more effective than desperate, despairing therapists.
Cultivation of Empathy
Other benefits for the therapist include the cultivation of empathy and compassion. We know that empathy is the cornerstone of a good treatment relationship. Yet graduate schools have yet to find a way to teach students to be empathic. However, when we become compassionate and empathic with ourselves, simultaneously the heart can open, and we can allow ourselves to be empathic and compassionate with our clients as well. Meditation is the only method I can think of to truly teach this. Simply suffering through your life may not be enough. Think about people who have endured tremendous hardship and sorrow. In many instances it can lead to tremendous compassion. But it can also lead to hardening and withdrawal. It’s not enough just to suffer. There needs to be a practice of generating kindness and compassion toward ourselves for that to become an opening experience.
To be attuned, attentive, not absorbed in your own thoughts, internally quiet and still yet responsive—these are the qualities cultivated in meditation practice. When we learn to listen to our clients with the same degree of wholeheartedness and undistractedness, wonderful things are likely to happen.
Gaining Equanimity
Empathy for the suffering of a client will also be tempered by the broader view of equanimity. Meditation practice helps us to cultivate an absolute respect for the integrity of another person’s experience. We can develop all manner of compassion and empathy toward our clients, and at the same time recognize that all of that is not going to make a difference in the quality of their lives per se. Ultimately they themselves are the owners of their own experience. We recognize that we give everything that we have to offer, within the framework of the treatment relationship, and we also recognize the absolute and genuine limits of our ability to change anybody. When we are not covertly insisting our clients change, they are granted an environment in which they are free to choose.
Learning Humility
Such equanimity leads to the cultivation of a quality of humility as well. Our clients may attribute to us all manner of powers, and it is so easy, I think, for therapists to begin to buy their own press. These attributions can sometimes be very useful; a positive transference doesn’t really need to be analyzed until and unless it becomes a transference resistance. On the other hand, to begin to believe that we’re as powerful as our clients secretly believe is very, very dangerous. Meditation, I think, helps us to remain mindful of the limits of our own capacities. It teaches us humility.
Seeing Hidden Possibilities
The meditation practice teaches us of possibilities that are yet unseen by the patient. We can see that there are ways to not be trapped that the client doesn’t yet see. I don’t think we need our meditation practice for this, truly. The greatest asset I always felt I had with my own clients is that I wasn’t them! Whatever my traps were, they happened to be somewhat different than those of the person sitting before me. Therefore I had some capacity to see the traps that they were setting for themselves and stepping in. I could demonstrate how maybe the world needn’t be defined by the particular dilemma that they posed. I could show them there was another way out that comes from reframing, letting go of the problem as the client has defined it. Meditation is excellent training for this dimension because it always calls on us to see how we construct the world, our conflicts, our struggles; it invites us to step back, and back, and back. Perhaps it is more a constant process of “deframing” than “reframing.”
Revealing One’s Own Narcissism
The meditation practice also helps us to identify where our own narcissistic needs are entering into the treatment, and to know it without judgment, without needing to be a saint. The greatest danger is to imagine that we are not narcissistic when we are. It is in the denial or the negation of these things that lurks the greatest harm.
This is one of the great contributions not just of meditation, but of having a good analysis as well. You really begin to learn about transference and countertransference, and indeed, this is why a course of treatment is good training as well. You begin to see those things that were formerly invisible, and the places where your own sense of identity gets activated in certain ways. We can begin to see how our own needs can interfere with the treatment. Our need for the clients to rid themselves of their pain, for instance, because we can’t tolerate it. Or the need to be a good therapist, or to be admired by our clients. I’m not suggesting that we’re going to rid ourselves of these things. I am suggesting that the most important piece is simply to see them as clearly as possible for what they are.
A very powerful contribution of meditation practice is simply this: You don’t know what the next moment will bring.
Learning to Not Know
A very powerful contribution of meditation practice is simply this: You don’t know what the next moment will bring. So too as a therapist, it’s often the ability to not know that helps the most. We have to truly let go of our expectations of our clients, those we might have because we think we know them, or the expectations based upon adhering to some model or theory of treatment. It’s in letting go of that—which can be frightening—that the ground of creative possibility and of real growth arises. We help people not by knowing where they need to go, but by creating a space in which they feel safe amid the uncertainty. When a person begins to feel that safety, understanding can emerge from the not-knowing-ness.
The meditation helps us to recognize the limits of our own theoretical model-building.
We are all so well trained. But I believe there is an imprinting period in professional development. Whatever it is you learned as a graduate student seems to stick with you, no matter how much subsequent training you get. And you don’t even see it, it’s so subtle and pervasive.
But with meditation, we begin to unearth many of our assumptions about what people are made of and how they operate. We learn to let go of our models, and even our confidence in diagnostic labels. I don’t think I know of a single experienced senior therapist who hasn’t abandoned to some degree a lot of their adherence to theory.
Learning to See Your Mind
Something else of great value has to do with the moment of clear comprehension. This is the thing: you learn to see your mind. As one sees one’s own mind, so arises the capacity to see another’s mind. When you see them getting identified with and lost in the story, you can remain centered and see how they may be replicating all of their neurotic conflicts in the treatment itself. This is a genuine contribution of having done meditation work for a period of time.
Therapists do a great disservice if they make a person feel responsible for certain forms of suffering that are truly innate to living.
Another important thing we learn to see about the mind is that it is constantly regenerating itself. The immense value of this momentariness of life is that there is a genuine opportunity to begin again in every moment. We not only offer ourselves this opportunity—regardless of a history of failures—but we offer this to our clients as well. We’re not going to hold them to their history. When they’re ready to abandon it themselves, we’re there with them. And it is never too late
Gaining a Wider Wisdom
Meditation is useful for cultivating, for lack of a better term, wisdom, or the ability to clearly discriminate. It helps us to not mistake what I call existential suffering for neurotic suffering. People come to therapists because they don’t know where else to go with some personal sorrow or suffering. They come as though they believe all suffering is a neurotic problem to be solved. It reflects the assumption that if one is mentally healthy, one would not have to endure the suffering. Because we assume we are supposed to be happy, the fact of unhappiness must be taken as evidence of illness, or arrest, or neurotic conflict. So people come to therapists.
Therapists have never met a problem they didn’t feel they could solve. So we take the bait, and believe that we’re actually equipped to help someone cope with concerns that may not be neurotic at all, but may be absolutely endemic to having been born into a human form. Because of its home in a branch of medicine, psychotherapy uses the metaphor of health and illness, often appropriately, and often to some harm.
One of the great contributions of meditation practice is to recognize that elements of human suffering are not neurotic and are therefore not susceptible to psychotherapy treatment. Rather, they are part and parcel of being born as a human being. Therefore, they need not be personalized or needlessly pathologized. A therapist does a great disservice to his client if he neuroticizes a problem, making a person feel responsible for forms of suffering that are innate to living. Even in such instances talking with a therapist may have benefits, but only if we keep in mind the universality of suffering and don’t promise what psychotherapy can’t deliver.
In fact, if we are not clear about this ourselves, we can make things much worse. This alone would be reason enough to wish to go to a therapist who has a meditation practice, so that they can begin to make some of these discriminations. The metaphor that comes to my mind for this is that very often people are in a pit. They come to the therapist, who hands them a shovel, when what they really needed was a ladder. For many clients, a reasonable outcome of therapy may be to “go the next step,” reach for the ladder and begin their own meditation practice.
Differing Goals
Finally, a word needs to be said about some differences between the practice of mindfulness meditation on the one hand, and the therapeutic tradition on the other. It’s so natural for us to look at these as equivalent. While the common denominators between the two traditions are pretty evident—both are responses to suffering; both address profound levels of non-conscious experience; both rest on the idea of insight or of re-framing our understanding, and both rely on introspection—there are also some profound differences that need to be understood.
The most important has to do with the ultimate goals. Certainly when we do meditation we reap therapeutic benefits. Just by virtue of doing the practice there are psycho-physiological benefits. People’s blood pressure improves; trait anxiety abates; people become more accepting; they learn relaxation techniques.Psycho-physiological disorders benefit because they are less exacerbated as we manage stress.
Early on in meditation practice, Westerners often do a whole lot of therapy while sitting on the cushion. We don’t particularly care to return to something as dull as the breath when we’ve got these magnificent stories unfolding before us. In fact, people will spend hours, or years, doing therapy with themselves on the cushion. It’s not meditation, but it may not be useless either. It may actually be quite helpful for someone to do this work. However, the purpose of meditation is not to do psychotherapy. It’s not to be invested in understanding the particulars of my conditioning, but rather to begin to learn about conditioning in a more general way.
Generally speaking, the goal of any form of treatment is to begin to return people to full participation in the collective web of meanings of their society. It is to restore people from the estrangement that comes from being too idiosyncratically lost to individual troubles. In every culture there is a codified view of what it means to be healthy, whole, and to be an ideal person. This is what we call a view of the self.
Self and Non-Self
We tend to hold, in our systems of psychology, a view of the self that is separate, autonomous, individuated—these are, of course, the milestones of development. If you manage to successfully traverse the entire developmental gauntlet, you wind up with a self that is cohesive, integrated, non-fragmented. In other words, the purpose of growth and development in the West is to become a person, singular, related, capable of reciprocal relationships, but nevertheless bounded, independent and autonomous. There’s tremendous emphasis on this idea of being autonomous and self-sufficient that it drives people crazy, because it is ultimately not possible.
Why is it not fully possible? The self is not something that stands alone. The self is a process that is constantly created and informed by interaction with the rest of the world. It is something that is invented in the moment, and abates when the conditions for its arising vanish. Yet our forms of treatment are all organized around trying to help the person become more of a self, to become independent and autonomous. We use the tools and the methods of psychotherapy, appropriately, to try to help restore the self. Through mirroring, simple admiring, acceptance, we actually help a person to come to feel at home in their own self.
But these are not the goals of the meditation practice. It’s true we may sometimes use meditation practice— mistakenly—to establish some sense of identity, or to become more of what we think we ought to be. But if everything goes really well with our meditation practice, in time we begin to see how that is a mistaken motive, and that we’re actually misdirected. The very thing that we most thought we need, which is to become, is the thing that’s causing us some degree of distress. We begin to see how the sense of self, when you need to hold to it, becomes a huge vulnerability, an exhausting and endless project, and a source of suffering.
The self is a process that is constantly created by interaction with the rest of the world. It is something invented in the moment.
It becomes an unsolvable riddle: The self wants to be more of a self, to be fortified and impregnable, which is an impossible enterprise because there is no “self’ to the self—it is all fluid. So we have to run as fast as we can just to try to stay in one place.
What we are seeking to do in meditation is gradually see through all of our concepts, including the concept of “me” which we may have worked a lifetime to erect. We begin to see that all of our attachments to our fixed positions is the very thing giving rise to our unhappiness. This is a way of thinking about growth and development that is not ultimately compatible with the view of psychotherapy. Psychotherapy can take us some of the way down the road, but at the heart of our therapy practice is always the assumption of becoming more of something. This is in contrast to the idea of a radical, psychological, spiritual, emotional emancipation, a view of human potential that is not embodied in academic or clinical psychology.
It’s so easy, I think, to mistake meditation as simply another arrow in the therapeutic quiver. It is that, but there is some risk associated with reducing it to only that. But, though we have to be mindful of important differences as we begin to appropriate these techniques into therapy, there can be no doubt about the tremendous benefit of meditation practice to the therapist in cultivating qualities of mind that support a healing therapeutic relationship.
