The Role of Meditation Practice In Psychotherapy

In recent years I have begun implementing meditation practice during the first ten minutes of a session with some of my patients. The choice whether to meditate or not is always at the discretion of the patient. The purpose of such practice is to help bring awareness to one’s internal world in the present moment. This encompasses improving one’s attunement to emotions and physical sensations that can be detected in the body. I have found that many people are initially uncomfortable being with themselves in the here-and-now, and thus they flee being in the present and resort to living in the past or future, allowing their thoughts to distract them from what is right before them.

Most people do not need my help accessing their thoughts; they can fairly readily identify what they are thinking. It can be a different matter when they are trying to identify what they are feeling. When an emotion is intensely felt, it is likelier that the individual will notice it and be able to describe it. One is more apt to recognize that she is enraged than to recognize that she is mildly annoyed. But if we believe that all people have thoughts, feelings, and physical sensations at every moment, whether we are aware of it or not, then we can begin to see how difficult it can be for many people to access feelings when felt to a lesser degree. This concept that people have thoughts, feelings, and physical sensations at every moment is similar to breathing. Once an individual is encouraged to focus on his breathing, he usually can do so easily. We are all breathing at every moment but often we are not paying attention to our breathing. The same applies for thoughts, feelings, and physical sensations. Some people may find identifying and accessing physical sensations challenging. Still more may struggle to identify and stay with their feelings. Trauma survivors in particular may struggle in this way, given that one of the ways they learned to cope with the trauma they experienced was to numb themselves and dissociate from their internal world. This serves a protective function. As adults many of these individuals have difficulty knowing what they are experiencing when it comes to emotions and physical sensations.

Meditation seems to assist people in building their awareness of what is happening internally. Furthermore, it can help people learn to stay in the present moment and tolerate inhabiting their own internal world without feeling threatened by unpleasant emotions. I’ve witnessed people who initially had trouble sitting still because they were so anxious learn to relax into a ten minute meditation practice and open themselves up to the present. With most patients we start and end the meditation practice with four deep breathing inhalations and exhalations. This seems to help people relax and prepare themselves for the meditation. During the meditation itself, patients are instructed to focus on something simple, such as their breath, that they can keep returning to when their minds start to wander. They simply can notice and be curious about the thought that distracted them and then return to their breathing. With some patients, it is preferred to scan the body from head to toe during the meditation as a way to tune into what is happening internally. By conducting a body scan, one might become aware of tension and other physical sensations that are being held in various body parts. Another option is to draw one’s awareness to the sounds around them, both near and far. I invite my patients to focus on their breathing or to do a body scan, however, because these are ways to increase awareness of one’s internal space, whereas sound brings the individual to something that exists outside of them. Over time, most patients tell me that they have found that the meditation helps them be more aware of what is going on inside them, both with emotions and with physical sensations, and these skills can transfer to the their lives apart from the meditation. For the purpose of developing these skills during psychotherapy, I find that the term “awareness building” rather than “meditation” may be a better fit. People can get confused by what is meant by meditation practice. When we agree that we are working on improving their awareness of their feelings and body sensations, they can best understand how such practice can be of value to them. After the ten minutes, I find it useful to briefly discuss how the patient experienced the exercise and what she became aware of during the time. I also attend to whether starting with this practice has a positive shift for the remainder of the session and can help the patient feel more present and connected to me while engaged in the therapeutic endeavor.

The Role of Attachment Theory in Psychotherapy

Although attachment theory has its origins in the research of infant development and is not a model for how to conduct psychotherapy, I have found it increasingly useful as a therapist to consider attachment style when sitting with a patient. In a healthy development children develop a secure attachment with their primary caretaker, usually the mother. More often than not an insecure attachment develops. John Bowlby outlines three types of insecure attachments. An avoidant attachment style is one in which the child adopts the attitude that he/she is fine without the caretaker and maintains this “I don’t need you” stance throughout life. An individual with an ambivalent attachment style responds to an unpredictable parent by either becoming angry or exhibiting helplessness. And an individual with a disorganized attachment style can present as scattered and disoriented, especially when the attachment figure is unavailable.

These attachment styles originate in infancy and persist through adolescence and adulthood. We find that these are transmuted generationally, with children often mirroring the attachment style of their caretaker. It is imperative for a clinician to be aware of one’s own attachment style as well as to attend to one’s patient’s unique attachment style, as these will emerge in the treatment as the relationship between the therapist and patient evolves. It may well inform the clinician and patient about what is being enacted in the therapy, and if a clinician is not paying close enough attention, the danger is that things get acted out in the therapeutic relationship without being addressed.

Attachment styles are not set in stone. Through the work of therapy, someone who previously had an insecure attachment style can learn to develop healthy attachments in their closest relationships. It may not replicate the experience of one who was born with secure attachments, but it is still possible for the individual to establish and maintain close, meaningful interpersonal relationships. As a therapist who works relationally, I view the therapeutic relationship as the primary agent of change. By focusing directly on attending to what occurs in the relationship between therapist and patient, we can afford the patient the opportunity to experience a healthy attachment, possibly for the first time. The real relationship between therapist and patient offers the patient the chance to learn and practice developing true closeness with a nonjudgmental parental figure with whom one can reveal their authentic self without repercussion of rejection, abandonment, or wrath. Over time, the hope is that by modeling a healthy relationship between therapist and patient, this experience will transfer to other close relationships outside of this dyadic relationship. In this way, the bulk of therapy happens in the room by addressing the ever-changing landscape of the real relationship between therapist and patient. The therapeutic relationship thus presents a unique opportunity for emotional intimacy that may endure as one of the closest and healthiest relationships the patient has known.

The Plight of the Performing Artist

The gratification of a standing ovation, uproarious laughter when you land your joke just right, the sense of mastery you can experience at reaping the rewards of your hard work and preparation…these are just some of the allures of being a performing artist. Inherently, nothing is wrong with basking in the limelight for a job well done. But when the measure of one’s sense of self-worth is determined by external validation as opposed to internal validation, it may drive that individual into a nonending chase after that all too temporal adoration.

Children develop self-worth by the age of five. In a healthy development, the child learns an intrinsic sense of self-worth and is internally validated. Such a child comes to believe that he is a valuable individual merely because of his existence on this planet, as opposed to because of how good his grades are, how popular he is, how attractive he is, or any other of the numerous false markers of “worthiness” that may be prescribed at a young age. Often when one is seeking elusive validation of their self-worth, that individual may feel incredibly insecure and “less than” on the inside. If that person then pursues a career which is so closely intertwined with the response of an audience, as would be the case of a performing artist, then often the need for external validation becomes the thing that drives the artist’s performance above all else. When one’s primary motivation for one’s art hinges on the accolades of an audience, it is likely that this individual at his core has a depreciated sense of self.

In addition to seeking constant adulation, performing artists may attempt to compensate for a lack that is at their core. Numerous behaviors may be employed to this end: substance abuse, eating disorders, anger outbursts, depression, anxiety, self-harm, and sexual acting out, to name a few. Such behaviors often are attempts to manage underlying feelings of low self-worth.

Psychotherapy can help a performing artist uncover the previously hidden unconscious motivations that have been operating, thereby assisting her in increasing her awareness of underlying relational patterns that get repeated if not addressed. By becoming aware of how one has exhausted herself with this constant drive for validation, one may be better positioned to shift things so that one can learn to derive satisfaction from one’s intrinsic sense of self-worth. Such a person will still have ups and downs, losses and successes, like any individual, but one’s identity can remain solid and intact even during times of hardship because one’s sense of self-worth is no longer dictated by some outside validation over which we have no power.

The Collective PTSD of a Nation

Since the Presidential election of 2016 - even prior to it - there has been a spike in the number of patients who are reporting experiences of anxiety, powerlessness, restlessness, fear, difficulty sleeping, and being more scattered and disoriented than they previously have known themselves to be. This is particularly jarring when their sense of self is shattered and they are exhibiting symptoms that have not materialized before in their adulthood. Still more concerning is when, given the changes in health insurance in recent years, patients can no longer afford their deductibles and therefore opt to discontinue treatment at a time when they might most need to be coming in.

Not long ago I attended a seminar in which the speaker addressed how in ways not previously seen to this extent or magnitude, people seem to be responding to a collective trauma brought on by our current political climate. Clinicians, in addition to our patients, are struggling to manage their own levels of anxiety and powerlessness. Many of the people in our country show a complete dismissal or disinterest in facts, choosing instead the ease of not having to think for themselves and diminishing their personal fears by taking comfort in entrusting those in authority who are disseminating lies and "fake news." On a national (if not global) level, this is incredibly terrifying. Many of us are reeling from the continual onslaught of political egregiousness. This constant bombardment of one horrific incident after another is a form of trauma and the very thing that can disrupt us to such an extent that we are left in the position of having to always be in a reactionary stance, having to brace ourselves for further trauma.

For people who have a history of trauma in their childhood and adolescence, the current political landscape is all the more fraught. It is like walking through a landmine that presents us with ongoing triggers which reawaken those early traumas which may be deeply entrenched. One might react internally in much the way they did when they were young, defenseless children. 

I encourage patients to limit their exposure to the news if it is interfering with their ability to function. Given that it may be crucial to have a safe relationship such as the one that can develop in a therapeutic relationship, I think it is important to work together to figure out how people can continue coming in if their insurance is the barrier that is preventing them from seeking the help they require. Having a support system and appropriate self-care is of the utmost importance for both patients and clinicians during this highly chaotic time. 

Suicide Survivors Part Two: The Parallel Process

In my last blog post, I addressed the topic of suicide survivors, i.e. people who are impacted by the loss of an individual who has taken his or her life. In light of the recent news of the suicides of celebrities who are in the public spotlight, I wish to follow up on my last post by focusing on the issue of "parallel process."

One of the common themes that most survivors will speak about is how powerless they feel in the wake of such a tragic event. Often they feel guilty that they were not able to do more to prevent the suicide. In the presence of the survivor's grief, others can feel powerless as well, not knowing how to best provide support or comfort to the survivor. They may feel compelled to help but are not sure how. I believe that in this particular circumstance, this response differs from other types of losses. We frequently can find ourselves in situations where friends, family members, and colleagues are impacted by the death of someone close to them. Many people have experienced these types of losses themselves and/or have witnessed others who are in mourning.  Yet this may not be as frequent when it comes to suicide. Especially if the person has never experienced a suicide or known a suicide survivor, they can feel ill-equipped to know how to respond.

In psychological terms, we can refer to this experience of helplessness or powerlessness as a "parallel process." It is often the case that the people left behind can experience in themselves a parallel experience to the person who took his or her life, namely that of feeling powerless. We can imagine that the person who saw no alternative to suicide must have felt incredibly helpless, powerless to do anything to improve their situation and feeling utterly hopeless that things can get better. Many of these people have tried multiple things to alleviate their symptoms, such as therapy, medication, meditation, yoga, body work, nutrition and exercise. At the end of the day, none of these things have alleviated the depression, shame, negative sense of self, and other feelings underlying their suicidal ideation and intent.

When others are caught in a parallel process, feeling powerless ourselves, our instinct is often to try to "fix it," to find solutions for the people who are grieving. This stems from the discomfort they have tolerating their own profound sense of powerlessness. I encourage people to sit with this discomfort. Sometimes the most we can do is to simply offer support, communicate that we are thinking about the person who is grief-stricken, and let them know that we care about them. Depending on the specific situation, we may spend time with the survivor, bring them food, and check in with them. It's different for each person. To ask the survivor what would help them can even feel like too much for them; it puts the burden on them to have to respond or even know what they need. Our intentions are coming from a place of a sincere wish to help. It's good to remind ourselves that sometimes just the simple things are a form of help. 

Someone once told me that hearing a friend say, "I'm thinking of you" felt a lot better than if the person asks them, "How are you doing?" or "How can I be helpful to you?" A simple "I'm thinking of you" conveys that you care without requiring anything in return.  

Suicide Survivors

The term "suicide survivor" is unfamiliar to most people. They assume it refers to people who have attempted suicide themselves; in fact, it refers to people who have lost someone to suicide. Whether it is a family member, partner, friend, patient or colleague, losing someone to suicide is incredibly challenging to those who are left behind to grieve. It is a far more complicated type of death that may take a longer time to grieve and can stir up a variety of feelings such as sadness, shock, anger, and guilt. Many survivors feel very isolated, experiencing that those around them cannot understand what they are going through. Also, there is a stigma attached to suicide that often causes people to keep this information a secret. 

Working with suicide survivors is one area I specialize in, although many patients come to me for other reasons and it often isn't until much later in their treatment that I learn they've lost someone to suicide. The impact of this loss can be tremendous. We need to take into consideration the specific relationship to the patient. Losing a friend or sibling is quite different than losing a parent. Losing someone the patient had a close, loving attachment to is different than losing someone where the bond was more fraught. We also want to pay attention to the method of suicide and the patient's unique experience around the death. For instance, the trauma of a survivor who witnessed or discovered the person who committed suicide varies from that of those who were distanced from this immediate visual and auditory trauma. The experience of someone who had a loved one who had previous attempts or threatened suicide for years varies from that of the patient who was completely caught off guard by the loss of one whose death was spontaneous or unexpected. A health care provider who loses a patient to suicide may experience a particular type of guilt, as their colleagues or the institution they work for may consciously or unconsciously fault them for the death. 

As you might imagine, this is a very complex topic that has so many variables that one may have never even considered. In working with survivors, I try hard to not make any assumptions about their experiences. I allow for the space and time for them to tell their story and express their feelings about their loss. Many of my patients have described how I am the first person they talked to at length about their loss because of their shame and their experience of feeling misunderstood by others. I sometimes will encourage survivors to seek out a support group where they can hear other survivors tell their stories so that they can feel less alone with their grief. 

One good resource for more information is The American Foundation for Suicide Prevention, which has information that can be useful for suicide survivors: https://afsp.org/ 

How Women Dis/empower Themselves

I have been struck by how many of my female patients have been incredibly empowered to take action in the world and stand up for social justice issues and causes that are important to them. Yet, when it comes to their personal lives, they struggle to assert themselves with their partners, their families, and their friends. Somehow the strengths they can tap into "out there" fall away when it is much closer to home. Men may also have difficulties with asserting themselves, but in this post I want to focus on the phenomenon I am seeing with so many women. 

Many of these women will talk about how difficult it is for them to ask for what they need and to establish and maintain healthy boundaries. Often they find themselves "over-explaining," which actually is much more disempowering than being simple, direct, and firm. Or they don't even attempt to assert their needs. Some patients have expressed a fear that the response they will get will be an angry one. Or they will disappoint someone and then feel bad. Or they will be ignored and dismissed. Or the other person could leave them and they will be all alone. 

When we consider the ways boys and girls are socialized to express and manage their feelings, typically it is acceptable for boys to be angry but not sad or scared and girls aren't supposed to get angry. Of course this is ridiculous; all people feel the whole gamut of emotions and this is entirely natural and part of being human. Furthermore, when we explore with the patients their specific family and peer experiences growing up, we come to learn more about why they have developed the beliefs and behaviors they have. It is probably much riskier then to express anger toward the people they are closest to and it is safer to express anger and righteousness in situations in which things are a bit removed and there is a distance. 

In treatment with me, these women can have the experience of working with a male therapist who will offer a different alternative by not responding to their anger in the ways they expect and have experienced before. Focusing on our relationship can thus be of utmost importance to their healing process and to helping them practice assertiveness skills, emotion regulation and boundary setting. Over time, they can grow into being strong women who take themselves seriously and are taken seriously by those around them.