Graduating Psychotherapy

“I’ve graduated!” Most mental health professionals would not expect a patient to utter this proclamation at the end of therapy. Yet I have heard it more than once. The first time I was a bit taken aback as even I was lacking appropriate context for this framing. At the time I remember inquiring, “What about your accomplishment feels like graduating?” Their answer was so simple. “I have learned so much and radically changed because I have embraced this knowledge and use the skills in my daily life. I am still me, and yet, I am a me I could not have imagined being before I started this work. Therapy was not school but it feels like I have earned a degree!”

Though I don’t agree, psychoeducation is often considered separate from the therapy itself. I have always been a big fan of educating patients as part of the therapeutic process. Getting them excited about knowledge I have worked so hard to gain. Wisdom from biology, neuroscience, social science, psychology, and contemplative science is often as much of an ‘ah-ha!’ moment producer as directly perceiving mind, or landing firmly in embodied presence, or experiencing how goodness, kindness, openheartedness melt away anxiety, depression, loneliness and meaninglessness. It is all part of delivering an integrated package of resources for symptom alleviation and awakening.

Completing therapy fully equipped to meet life’s challenges with intelligence, humility, flexibility and inner strength is the aim. If accomplishment of that goal that feels like graduation I am all for it!

Last week

Last week…
Over and over session after session;
Patients truth-telling.
Aliveness transforms.

Habit narratives are so damn limited.
Drop them.

I watch the beauty of learning to turn toward experience
And dive in fearlessly.

Inspired, I encourage.
“Fear not. You will not be swallowed up and chewed into bits.”
Experience opens its arms; welcomes them in.
Scoops them up and lifts them high.

Dance  sway  rest  feel
Open in wonderment!

This is real.
The alive one you have always been.

Tranquility and Breath

Tranquility is a necessary component for contentment. Tranquility is also the proximate cause of insight. This is generally why teaching concentration practices precede insight or vipassana practice. Only a calm mind can realize its true nature: radiant and pure.

Humans are blessed with breath; an ever-present biological function that acts as a conditioner for the body-mind system. Quality of breath directly influences quality of mind and body. When we are stressed or fearful, breath is fast, short, and shallow. Conversely, slow, long, gentle, deep breathing leads to cognitive-affective-somatic contentment and restfulness. You may have noticed when you feel agitated, if you put your attention on how breath is and gently slow in-breath and out-breath, anxiety and agitation subside.

Adding awareness or what is called “relaxed attention” on breath in a focused way calms the body-mind system. When we stay with breath long enough, calm leads to interest in the mind, and joyfulness in the heart and body. Eventually, the excitement gives way to a contentment, which arises from the direct experience of the mind knowing its own radiance and clarity. This is what the Buddha famously taught in the Ānāpānasati Sutta (find more information in my textbook on Buddhist psychology for clinicians.)

If radiance and clarity is the true nature of mind, why do we not experience these qualities of mind all the time? Primarily this is due to the presence of habitual thought-generated mental hindrances, such as craving, aversion, laziness/inertia, restlessness, and doubt, which grip conceptual mind and prevent it from realizing its own empty, luminous essence.

In concentration meditation we learn to stop feeding the hindrances by starving them. We train the mind to stay present with an object like breath, which naturally leads to calm, clear, and contented states of mind. Continually choosing over and over again, to turn away from distressful states of mind and turn toward the experience of breath eventually gives us the confidence, to turn the mind toward the hindrances, and stay present with these distressful states of mind to engage in the inquiry of vipassana meditation practice. You can learn more about this on the Groundless Ground Podcast Episode with Buddhist teacher Shaila Catherine.

Intersubjectivity and Interdependence

Recently, a colleague shared the following, “I am more and more tuned into the reality of separateness, gradations, distinctions. I think we are being hoodwinked by this idea of universal oneness. This feels particularly true when working with patients, where I find most significant change occurs from investigating distinctions and details.”

While I agree that in-depth exploration is critical for insight, contrasting that process with notions of universal oneness rings hollow for me. And that common mistake may simply be due to widespread misinterpretations of ‘oneness’; most especially the Buddhist concept of emptiness or interdependent co-arising. Although emptiness is a concept, therapeutic dynamics provide a real-time example of how interdependent co-arising actually manifests in human experience.

The Intersubjective School of Psychoanalysis hypothesized an intersubjective field continually mediating bidirectional knowing between psychotherapist and patient. Intersubjectivity enables a psychotherapist to empathically use their entire psychophysical system to receive and mirror a patient’s cognitive-affective-somatic material. That form of empathy or therapeutic attunement, is the primary process through which a patient feels known. So, although a psychotherapist may deliberately direct patient inquiry, intersubjectivity tells us that both parties are equal participants and influencers in the therapeutic container’s ebb and flow.

Acknowledging that apparent interdependence does not discount or negate the appearance of two separate participants. Each exists from their own side in a relationship of mutual influence. Nagarjuna, the progenitor of the Middle Way School of Indian Buddhism argued that emptiness rests on two principles: (1) things/selves in the world appear nominally, and (2) because of their impermanence, interdependence and insubstantiality, these entities lack any essential (svabhāva) nature.

For example, take the device you are reading this blog on. If it was self-existing, it could not be broken down into its parts—cover, screen, content, matter, particles, quantum information and so on. It is no more than a so-called object, interdependently linked to nominal parts similarly lacking any essential nature. Though the device does have conventional or relative existence, it also cannot be found to ultimately exist separately from its myriad parts.

Similarly, though the therapeutic dyad includes two separate beings, the therapy itself is an intersubjective, co-created process. Co-creation widens the menu of possible perspectives and makes possible successful interventions that decrease systemic reactivity and increase capacity for in-depth inquiry. Mutual influence and co-creation till the soil that yields embodied awareness and cognitive-affective-somatic openness. Such that self-fixation and its concomitant feelings of separateness fall away; and along with it the oh, so ubiquitously harmful distorted notions of self and world. Clearing those obscurations of mind is not only the optimal path to less cognitive-affective-somatic distress, but also increased tolerance and connectedness with all other beings.

The ‘somatic therapist’ nightmare

Increasingly, I am hearing disturbing stories from new patients about what is being labeled in the SF Bay Area as ‘somatic therapy’. What is clear is how many clinical and non-clinical people are calling themselves ‘somatic therapists’ and offering subpar to damaging services to individuals in need of effective mental health treatment for PTSD. 

Frankly, I have no idea what a somatic therapist is. Yet so many people are seeking somatic therapy because these days pop psychology views everything as traumatic and somatics as the cure for all trauma. This reminds me of what happened 15 years ago when mindfulness became the clinical intervention for every malady. We all know how poorly that worked out.

Integrative psychotherapy acknowledges that mental health is interdependently determined by the systemic quality of one’s mind states, emotions, and bodily responses. Human beings are organisms in constant flux; continually homeostatically reacting and responding to causes and conditions. Our thoughts are conditioned by body health as much as physical health is undermined by a chaotic mind and highly-reactive emotions.

Because traumatic experiences impact the entire human organism, resolving traumatic experiences must be a whole system endeavor. Changing thoughts is not enough. Loosening muscles and tissues will not prevent future bracing each time a challenging-enough situation occurs. And emotion regulation is a body-mind-heart mission.

Somatic Experiencing® (SE™) focuses on and accomplishes whole system trauma resolution. SE is a complex theoretical model delivered in a three-year training program. It takes time to learn how to recognize, work with, and deliver skills for effectively resolving the nervous system dysregulation commonly found in PTSD sufferers.

Other clinically helpful trauma methodologies include Sensorimotor Psychotherapy and EMDR. However, EMDR is often too activating and unhelpful for people with complex-PTSD who experienced early developmental trauma prior to adult traumatic events. SE is an excellent methodology for those individuals.

I encourage asking anyone claiming to be a ‘somatic therapist’ what training they have undergone and if they are a licensed clinical professional. Unlicensed practitioners are unregulated practitioners with no legal or ethical oversight. That is a minefield to avoid particularly for trauma sufferers.

Uncoupling excitement from danger

Though this Somatic Experiencing® intervention is not discussed widely in SE™ circles, I consider it one of the most critical steps for resolving long-standing systemic trauma response. A history of early (0-6 years of age), repeated, traumatic experiences are easily identifiable in adult autonomic nervous system (ANS) dysregulation. The primary sign is minimal capacity for sympathetic nervous system (SNS) arousal.

SNS arousal is not bad nor it is an indication of something wrong. For instance, awe-inspiring, meaningful, interesting, or joyful experiences are arousing. The body needs SNS arousal to accomplish any activity that does not fall under the category of ‘rest and digest’ homeostatic function. Many forms of overcoupling are common in early developmental trauma (EDT) response—including overcoupling of SNS arousing states of excitement and danger.

To a very young brain, most experiences are novel. Inherent in novel experience is a quality of excitement. That means interest, exploration and play are often encoded in memories of EDT events that most adults would only consider frightening, egregious, and morally corrupt. Very young children don’t feel danger until they are directly threatened, disturbed, terrified, abandoned, or physically harmed.

This intermingling of novelty, excitement and danger can be difficult for adult survivors of EDT to accept–especially when memories are laden with disgust, shame, terror and anger. A good example of excitement/danger overcoupling is in sibling sexual abuse where a tween sibling frames perpetration on a much younger sibling as ‘play’. Initially the novelty and attention can register in the young victim’s brain as an exciting experience with no negative valence. Yet, that can shift to fear, confusion and resistance at any point during a particular perpetration event or with successive events. Overcoupling of excitement and danger increases with each successive perpetration. Eventually novelty and excitement fall away and what remains is high-dorsal vagal freeze—(a parasympathetic nervous system (PNS) safety response)—because small children can rarely run from or fight off an older perpetrator. Proliferation of successive events increases excitement/danger overcoupling in SNS dysfunction.

Obviously the first intervention is helping a patient conceptually understand excitement and danger overcoupling, and then facilitating increased capacity for presencing the body-mind system’s low threshold for excitatory body sensations, thoughts and feelings. That is the ideal time to introduce SE™ pendulation skills for initiating parasympathetic deactivation, which eventually actuates healthy SNS/PNS cycling.

I feel such joy when this work results in a patient report that includes something like, “This week I actually felt excited and just let it happen without worrying something bad would occur or I’d become so overwhelmed by good feelings. It is so freeing to not be scared of my emotions… even the good ones!”

In summary, early repeated traumatic experiences impede our natural capacity to tolerate systemic aliveness. Uncoupling excitement from danger allows the ANS to move more readily, willingly and easefully between SNS activation and PNS deactivation.