Confidentiality and the unique nature of the psychotherapeutic relationship

Psychotherapists are treating more or less like any kind of health professional when it comes to confidentiality. Just like your doctor is not supposed to go talking to her friends about your health problems, a psychotherapist is not supposed to go talking about your mental health. What this means practically is something that you (hopefully) already know:

psychotherapy is confidential, meaning nearly everything that is said in my office is kept secret.

There are a few exceptions:

  • If someone tells me that he/she is going to kill himself or another person, I have to take action to stop it. Usually this means calling the police or local psych emergency services.
  • If someone tells me about a case of child (or elder) abuse, I also have to report that to the state department of child protection and/or the police.
  • If I'm subpoenaed by a court or being investigated by an oversight agency, this might result in some confidential information being shared (depending on the nature of the investigation/case)
  • If you give me written permission to talk to specific people or organizations.

This last case is the cause for the vast majority of my disclosures of information as a therapist. For instance, I need to give certain information (billing codes, sometimes summaries of treatment or my notes) to insurance companies in order for them to pay for therapy on your behalf. If you come to see me and use insurance to pay for therapy, you sign a form that gives me permission to give this information.

When it's to your benefit, I may also get your written permission collaborate with your other health care providers. The idea that it's for your benefit is important: even if you give someone permission to share your protected health information, the idea is that it's not gossip or for their amusement. Sometimes the ethics of information sharing for the client's benefit is straightforward--say I call a psychiatrist because some medicine she put our mutual client on doesn't seem to help. Pretty straightforward. But it's not always so clear. While your primary care doctor and your cardiologist might have no qualms about sharing information, therapists often do have qualms, especially with providers who aren't mental health professionals.

The question is like this: how much does your cardiologist really need to know about your mental health, even if it's impacting your heart? Another way of looking at it is like this: Client-therapist relationships are typically highly privileged, meaning there's stuff you'd tell a therapist you wouldn't tell your PCP or your podiatrist. If your therapist turns around and tells them, it could feel quite violating. So even though professionals are given a lot of leeway about talking to other healthcare professionals, and even though you probably signed a piece of paperwork at your first doctor's visit that gives them permission to talk to anybody they need to in order to facilitate your care, a typical therapist will get formal and explicit written permission to talk to another of your health care providers. This protects the exceptional nature of the therapeutic relationship, makes sure you know about and are okay with any disclosures of information, and protects the psychotherapist legally.

Likewise, if you give written permission--typically if you complete and sign a form usually entitled "permission to release protected health information," a therapist  can talk to someone else--maybe a family member or a friend--about what's happening.  Usually I make sure I know exactly what information is okay to give and not give. Again: client-therapist relationships are usually unique and should be protected.

Another important note or two: If the client is under 18, parents also can get information about treatment of their child. I don't usually see clients under 16 or so, but if I'm working with an adolescent I make sure to talk to the parents specifically about what information they will want so that the rules are clear. Just like anyone, a 17 year old is not going to feel very comfortable talking about certain things (for instance, her mother) if she knows that her mother is going to get the scoop from the therapist.

These rules have some other broad implications:

Even the identity of my clients is protected. So if someone calls me and wants to know if her brother has been seeing me for therapy, I have to say that I'm not allowed to tell the caller.

Likewise, if two of my clients know one another, I can't tell either of them that I'm seeing the other. That said: I can and will ethically refuse to see a new client if I'm seeing someone close to him/her and it would get weird, but I have to give a vague reason (like "I can't see you for ethical reasons" or "I can't give more information, but I think we know people in common and it would get weird.")
After the recent election, someone asked me if Mitch McConnell is one of my clients. Why he asked this, I have no idea, especially since Senator McConnell is from Kentucky and works in Washington DC, while I live and work in Massachusetts but--as you might guess, I had to ethically respond, "I can neither confirm nor deny the identities of any of my clients."

In the normal course of things, it also means that if I bump into a client at the grocery store or in downtown Northampton (or any public setting), I can't reveal in any way that I see him or her for therapy unless given some kind of permission to do so. Usually this means (for simplicity) that I don't acknowledge the person at all unless the person acknowledges me first. In short, I follow their lead: if a client waves and says hi, I assume that it's okay if I do the same. If someone introduces me to her friend, I assume it's okay for me to acknowledge whatever she's said.

Again, this is about the nature of the client-therapist relationship. A lot of stuff can happen in my office. It's comforting for most people to know that, even though I'm a person who leaves my office and buys groceries or parks in the lot behind Thornes Market, what they talk about (and even that they were in my office in the first place) doesn't get shared unless they're okay with it.
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Sometimes when I explain this to new clients, they'll say, "well, it's fine with me if you come up to me in public." This may be true, but it's hard to tell: I explain that they might feel different if they were around specific people--a new romantic interest or people from work. Or, after we get into the midst of therapy, they might feel differently no matter who they're around. I always point out that if they want to acknowledge me and talk to me in the moment, they can also do that, but I'm not going to make any assumptions.

I should also note: clients can do whatever they want in terms of confidentiality. The rules and guidelines govern me, not them. I will, as noted above, follow their lead. I have certainly had clients who happily come up to me in public and want to talk, or even tell the people they're with (or the people that I'm with) that I'm their therapist and how great I am. And, my own modesty aside, that's also fine.

Other therapists will have other rules and different ways of handling situations, but we all follow generally these same guidelines.  Actually, (nearly) every healthcare provider follows these guidelines. But psychotherapists, by in large, take these guidelines very seriously because of the nature of our work. Sometimes this is criticized, especially as managed care moves psychotherapists into doing more cognitive and short term work. This presumes that because healthcare is becoming faster paced and less thorough, that therapy should too. Even if therapy as a whole moves in this direction, it presumes that the unique nature of the client-therapist relationship can be cast aside. Granted, everything in this world needs to be able to change and adapt, including the institutions of psychotherapy. But psychotherapists aren't primary care doctors. It is a different science and art. And I think people will always think of us as such, and relate to us differently. So I think its uniqueness should be respected, and do my best to do so.

 

Yoga nidra as a home practice

Imagine a scenario with me:

Imagine you go to see a psychotherapist and decide to work with him to help you with some issues you've been facing in your emotional life and relationships for a while. You feel stuck and everything you try doesn't seem to help. After explaining all this and talking about a lot of different things during the first session, the therapist brings up the idea of homework.

After imagining worksheets or something boring, you're pleasantly surprised when he brings up doing a daily meditation practice designed for just the kind of issues you're having. He says takes about half an hour to do every day. You haven't meditated before and aren't sure you can do it and say so. He reassures you, "This is a very easy practice. Just listen to this recording once a day and follow along with the instructions. I think you'll enjoy it actually." He also explains that this isn't the sort of meditation that requires sitting on the floor or doing anything particularly special. In fact, traditionally it's done lying down, like at the end of a yoga class. He adds that it's optional; you can try it and not continue if doesn't work for you.

In the end, you're impressed at his conviction that both the meditation and the psychotherapy will help your problem from different directions--that they'll work synergistically to help you resolve your problems more quickly and easily. He also indicates that the meditation will help with your sleep (which has been a problem off and on) and help you to unwind from stress.

After you get home, you decide to try it. The therapist has emailed you an mp3 which you conveniently cue up that evening. You do find it relaxing. In fact, you fall asleep. But over the next week, you find you enjoy making the meditation part of your routine, and find you only fall asleep when you're utterly exhausted from the day.

The next time you see the therapist, he explains that falling asleep is the biggest "side effect" of the meditation and not to worry. Even when you're asleep, he says, the meditation does some good. And probably you needed the sleep. You have a good session with him and are beginning to feel a bit better, even though it's only been a little over a week.

As time passes, doing the meditation feels quite natural. You discover you can be deeply relaxed when you do the meditation and still be aware of what's happening, and you actually fall asleep rarely. You find this relaxation and sense of awareness slowly carries over into your daily life:

Things that normally catch you  or bother you up seem more matter-of-fact. You  feel as if you're making different choices about how to respond to your life. This leads you to change some significantly things in your life--things you've thought maybe you should change for a while but now have the perspective and will to do something about. A quirky physical issue you didn't know was related to your level of stress starts to improve. You find working with the therapist insightful and gives you another way of looking at your relationships and the patterns of your life up to this point.

Over time, it feels like your life has gone from riding white knuckled in a canoe down rapids to gliding along on a beautiful mountain lake. It's not clear exactly why things have changed, but they definitely have.

---

As you might guess from the title of this blog entry, the meditation in this scenario is a practice called Yoga Nidra. Despite its Sanskrit name, this practice is very accessible and is designed for modern times. In the 1940s and 1950s, a Swami named Satyananda Saraswati created this meditation style, adapting it from much more complex and esoteric Hindu practices that were available at the time. It has continued to evolve and be modified by other meditation teachers since then. There are actually many varieties of yoga nidra now, including those taught by the Bihar yoga school (which Satyananda founded), a form adopted for working with trauma and anxiety called iRest, and types adapted by other schools of yoga, and various yoga teachers all over the world. In its current form(s), yoga nidra has pieces that are similar to mindfulness meditation (especially the body scan and mindfulness of breath--two of the most common mindfulness practices), and also has elements that are like hypnosis or guided imagery. There are other elements that are similar to Hindu or Buddhist tantra, and there are elements that are unique.

The best general description I can give is that it's a guided deep relaxation practice that's made up of smaller practices that all work together, like a well-formulated multi-vitamin or a Chinese patent medicine. The practice is non-dogmatic, requiring no spiritual experience or beliefs, and is very straightforward to do.

As a psychotherapist, I have been attracted to yoga nidra because it is so compact and easy: A lot can happen in the 30-45 minutes it takes to do yoga nidra. It's not a big time commitment for someone with a busy life, is easy to do, and the effects are good.

It is also infinitely adaptable. Meditations can be tailored for specific goals or to solve specific problems, and with specific people in mind: I have been working, for instance, on yoga nidra recordings that are suited to help with common problems that bring people into therapy. You can get one of these practices here if you join my e-mail list (which, at the time of this writing, will send you notifications of when I write more blog articles).

Based on my study of yoga nidra, hypnosis, traditional medicines, mindfulness, and related psychological models, I've also started designing yoga nidra practices especially for certain people or groups of people. This really is akin to formulating a Chinese or Tibetan herbal formula that treats a specific condition in a specific person with few (if any) side effects. If you know anything about Chinese herbal medicine, you know this can be quite a spectacular thing.

This personalization is also relatively rare: Although Swami Satyananada would do this, most yoga nidra is taught in yoga studios and/or is based on general scripts. If you attend an open yoga nidra class, you'll get a very general experience. Although these general experiences can themselves be therapeutic--deeply relaxing, meditative, spiritually relevant, mindful experiences--they're only a part of what is possible.

That said, this practice is not magical. I hope nobody reads my scenario and sees anything supernatural or unrealistic: therapy (and beneficial change in general) is still work. And I would still recommend having a therapist to work with in concert with using a home practice like yoga nidra if using it as part of a treatment. Yoga nidra is also not a replacement for other meditation practices. I continue to recommend loving kindness or mindfulness practices instead if those are what are what would be of most benefit. My intention is simply to convey that this is a great tool.

Are you interested in trying it? Contact me or feel free to download an mp3.

 

How to make your therapy go further...

Dear readers,

My apologies for blog radio silence for a few months. I've been having a period of reading rather than writing, learning rather than teaching--of taking in rather than putting stuff out there.

I've been researching primarily based on a question that has become a major area of interest for me: what kinds of activities or practices best augment psychotherapy? One very straightforward way of expressing the question I've been asking is:
Someone comes to therapy and spends money on it. What can a person do in between these 1-hour-a-week sessions to get the most benefit from that hour?
Or even more straightforward:
What can I tell my clients to do to make therapy work better?
Or really bluntly:
How can I make sure clients are getting the most for their money?

There are some great classic answers to these questions... Here are a few:

Contemplation and Creative Expression

For a long time, it's been clear to therapists like me that pursuits like art, writing, talking about personal stuff with warm friends and other forms of introspection, self-reflexion and self-expression help. What works best depends on the person. Some people draw or paint. Others write. Journaling is great. I often even just encourage people to have a white board they write things they're thinking, their goals, dreams, ideas. In a busy world, this helps a person focus on what's really important.

Exercise

Likewise, research suggests that for mild to moderate depression and anxiety, different forms of physical exercise may actually be the most effective intervention. Oriental medicine chimes in that moderation is key.

Medication

Likewise, In some cases, taking a good medication is an indispensable adjunct to therapy: if someone is in such rough shape that they can't focus during therapy sessions or can't look at what's happening easily, therapy won't go far. It's like trying to have an important conversation with loud music on: first thing to do is turn down the music. Of course--in my view anyway, the long term idea is to eliminate (or at least significantly reduce) medication. 

Bibliotherapy

Sometimes I will recommend a book. This can work in a number of different ways. The most straightforward way is that I might recommend a book that talks about some of the issues we're talking about in therapy, or which connects to a technique we're using. I recommend some books on my website. Feel free to check them out.
Sometimes, I'll also recommend a book that's less straightforward. For instance, I might recommend a fiction book or a book of essays. When I do this, I'm usually thinking about a client's need for a certain kind of psychological nourishment. If this sounds woo-woo, you should take it literally instead of figuratively: just like our bodies need good food, so do our minds. A good story provides nourishment. Put another way, reading a story can make someone feel less alone, or it can give someone strength, or even provide a map for how things could work out. This is necessary sometimes. Just like a person needs good food to heal from a physical injury or in order to gain muscle, a person needs good psychological food to recover from a psychological injury or to grow strong psychologically. Actually: good (physical) food helps a lot too.

Continuing the session...

There are also some more subtle things: one of my favorite therapists and I would often talk about the process of internalizing one's therapist. Or as I sometimes frame it to my clients: "even though you have to leave my office, you should take me home and continue therapy by yourself. Think about what we've talked about. Continuing talking.  Imagine me responding. Then, when you come back, tell me about our conversations."

What this really speaks to, of course, is something we all do: we rehearse and imagine conversations with people. If you have a skilled therapist that you like, no matter what kind of therapy you're doing, you'll probably find yourself doing this.

Rather than proof of some kind of psychotic process, this is a good thing (as long as you're aware your therapist isn't actually in your head). What you're really doing is continuing the session. When you come back and talk about your conversations (as I suggest) you're honing your internal imagine.

Effectively you're crafting your own internal therapist--one not limited to a regimented hourly schedule. And isn't what anyone who felt alone with a world of hurt has always wanted?--someone with wisdom and caring closer than their own nose?

More soon...

One of my major interests, of course, is meditation and other mental practices as an adjunct to therapy. I've studied mindfulness based approaches in great depth over the years. Likewise, of course, loving kindness (metta) practice, after which this blog is named. There are (of course) other practices.  I will write more about some soon. 

about depression...

After my last post about the autumn, a lot of questions about depression have been coming up. Naturally, people are curious what they can do about seasonal depression, and likewise about their mood in general. 

It's late winter now--we're past the new year and most people's enthusiasm for cold and dark seems to wane sometime around this point. A colleague of mine recently thoughtfully noted to me though that we're actually past the worst part: the solstice--Dec 22nd--is the longest night. We're on our way out now. If you're dealing with seasonal depression, keep this in mind. It will be coming to an end soon. 

Different people experience seasonal depression differently: for some the worst part is the fall. For others, it's the mid-winter darkness. For yet others, it's the sheer longevity of winter or the contrast between the urge to nest and the demands of work and life. Whatever your experience, remember to be kind to yourself. Vitamin D supplements, light therapy, and being around warm people all will help. But something easily overlooked is curiosity about your experience: it's very easy to jump into a mode of fixing things. When it comes to the mind, fixing things doesn't always work. 

More about depression in general...

The most important take home message about depression: 

If you're dealing with depression, you're not alone. Depression is very common. A BBC News article came out last November about the global impact of depression. Depression, is, perhaps surprisingly, a global issue. 
I say "perhaps surprisingly" because a common feature of depression is a feeling of aloneness, alienation, or lack of support or understanding from others. It can be hard to believe others feel exactly the same. Other common symptoms are hopelessness, self-blame, feelings things will just continue like this forever (remember what I said? winter is going to come to an end), lethargy, poor (or over-active) sleep, changes in appetite, certain kinds of obsession, and (in some cases) suicidal thoughts.  Culturally we also tend to sweep depression under the rug, which can add feelings of shame and the need to hide. In truth, these feelings are symptoms, you might say, of something all-too-common. 

It didn't always used to be so common. We don't know why, but depression has increased significantly over the last century. Nobody (as far as I know?) clearly understands why. Perhaps it's something to do with modern lifestyles? Or with lack of community? Other changes in social structures? The industrial revolution?... There are many theories.

In contrast, I talk to many people who understand depression (and most mood problems) as the result of a chemical imbalance. Usually people are referring to the theory that mood is tied to serotonin levels in certain parts of the brain. SSRIs (Serotonin Synaptic Re-uptake Inhibitors) work based on this theory... Though, truthfully, at this point, nobody is sure how exactly neurotransmitters, especially in relationship to one another and to experience.

One very important thing to remember is that brain chemistry (in whatever form) is not a one way street. Often, when someone tells me he or she has a "chemical imbalance" it's a way of saying, "It's not my fault I feel this way--it's biological!" On the one hand, I agree with the sentiment of blamelessness: it's not going to help to say it's your fault you're depressed. Remember self-blame is a symptom of depression (I listed it above)--getting mired in self-blame usually worsens the depression. On the other hand, when someone says his or her depression is biological, it's usually a way of saying nothing can be done about it except a pill.

In a perfect world where antidepressants worked like antibiotics or athletes feet creme, that would be fine: you could say, "it's a biological problem!," take a pill, and be better. But depression isn't like that. Antidepressant medications, when they work, may address a chemical imbalance, but they re-balance it only temporarily. Don't get me wrong--antidepressants can be great tools on the path of recovery, but the real work of depression is to change brain chemistry by changing how one thinks. 

This isn't as hard as you might imagine. We've actually been changing our brains for thousands of years. It seems that that's what our brains are actually built for. We used to think that people would learn stuff and their brains would change until they hit their mid-thirties and then their brains would start dying and it was all downhill from there. We know now that this is very far from the truth. In fact, neuroscientists have been noticing how much what we do with our minds changes our brains. A great layperson's book about this is The Brain That Changes Itself by Norman Doidge. In both classical Buddhist thought and in Cognitive Behavioral Therapy, the idea that thought creates mood (and even one's experience of reality) is well established, and both traditions contain powerful techniques for changing how one thinks. Happily, psychotherapists (at least ones like me) are learning from both of these lineages.

If you're looking for a practical take-away, remember how I started: first to remind yourself that you're not alone. Get yourself whatever kind of help you need: see a therapist, a psychiatrist, or your doctor and talk to warm friends. If you're noticing suicidal thoughts, utilize lifeline or contact emergency services for your area (link is for Western MA). Like my colleague pointed out, the darkness will come to an end.

 

Fall, depression, grief, and abundance

Fall can be a rough time for people. There are lots of interesting studies and anecdotal evidence about winter being a time when people deal with Season Affective Disorder (a term used as a fancy name for seasonal depression, usually). I think Fall sometimes gets under-considered compared to winter in New England. Of course, what season can compete with winter in New England? But I've been talking to a lot of people struggling with their mood this fall, so I wanted to discuss it.

It's late fall now.

In the hills where I live, it's frosted a few times, the time change has happened, and the leaves are all gone. I think of Fall as having two distinct phases: early fall, when the leaves are changing and it's windy and crisp--there's the sense of things coming--things happening.

And then late fall, when it's certain that winter is on it's way, the leaves are gone (or at least thoroughly brown) and the air, though still crisp with the sense of coming winter, isn't charged in quite the same way. One can, I think, feel that the energy of life is retreating, moving away from the exposed natural world deeper into the ground, into our bodies, and into our houses.

Traditionally in Chinese Medicine, fall is associated with grief. I think grief is an interesting idea to contemplate. One way of thinking about grief is in terms of what's happened over the course of the year: Summer is the time for play, opportunity, and possibility.

When fall really gets into swing, and the energy of life starts moving inward, this can trigger a sense of grief for what's being lost, and also for what's been missed: the opportunities not taken, the possibilities not explored.

A basic rule of psychology is association:

One feeling of grief or regret can remind you of another--griefs and regrets forgotten can resurface again because of the grief of the season.  The very blowing of the wind through the brown leaves can trigger this feeling. But it can also be more subtle. Even if you're not watching the turn of the season, there's something about the quality of the air that can bring up all sorts of grief and regret. An acupuncturist friend of mine says he can see fall in how people hunch their shoulders. Even if they aren't aware of it, he says, he can see the inward movement in their postures.

In my office, I see fall as trouble sleeping, thinking about things from the past, people evaluating their lives, and people experiencing strong grief or regret about the paths they've taken and not taken. Sometimes this arises in small ways: the vacations they took or not or the summer. Sometimes in large ways: how they've lived their lives or the choices they make 15 or 30 years ago that still affect them now. This is the energy of fall.

If you have many regrets, or are simply sensitive to the nature of things, this can take a lot out of you.

Many people I talk to have trouble keeping up the fast pace of their lives with this sort of inward movement of retreat and grief going on. Usually, I suggest people give themselves a break if they can: the fast pace of our lives these days is not so great for us in any case. So if you can slow down a little (not stop entirely, mind you, but slow down) and feel the pangs of the loss of the warmth in the world, or the loss of some aspect of your life you never lived, do so.

Like all feelings and seasons, the grief will pass. Actually, depression this time of year is the result of trying to clamp things down--trying not to feel the grief and regret, or trying to avoid it at all costs. Chinese medicine would say that this does much harm to our systems--tensing your systems when they should be naturally preparing for what comes next, winter.

Other specific recommendations from my experience and from Chinese medicine are as follows:

  • Move your sleep cycle earlier
    Use the fall time change (fall back!) as an opportunity to go to bed earlier and then get up a bit earlier. The autumn mind is often clearer in the morning, and fall morning air is supposed to be good this time of year to prepare the immune system. Likewise, if you have any tendency toward being a "morning person", you'll be able to use the little extra time in the morning to slow down a bit and prepare--pull out your scarves and hats from the closet--or to at least treat yourself kindly by eating a good breakfast and thinking about your day.
  • Consider not just the regrets and grief but also the joys
    Our minds have a fascinating tendency to look at what's gone wrong. That's alright. But while you're thinking about regrets, consider also what has gone well. If you can't think of anything, look a little deeper. There's no story without at least moments of spring.
  • Welcome the “return of the dead” (a real Halloween)
    Sometimes I think that Halloween was a wonderful idea crafted by smart people who wanted to give people a way to acknowledge the way the past resurges as late fall arrives. Metaphorically, the dead return. Same idea I've been talking about, right? Our modern Halloween is not so contemplative and usually involves dressing up and gorging on sweets (or beer) instead.
    If you can, take a few moments (whether at the end of October or some other time this fall) and acknowledge the dead, so to speak. I often will use the kitsch of Halloween to remind me: I'll look at the costumes and the lawn decor and I'll say to myself something like, "Fall is really here" and let the what comes up come up.
  • Celebrate abundance, the other aspect of fall
    Just like Halloween seems like it could have been invented by brilliant people, Thanksgiving seems like it could be a great opportunity to make the transition into early winter: you've reconciled with regrets and now you're looking at the abundance of what the season has left you: food, friends, family. If you can sort through your feelings and you have the outward circumstances to have such a meaningful thanksgiving, great! More often than not, in my experience, this is not a typical thanksgiving experience. Instead, thanksgiving can highlight the opposite: what's gone wrong, crazy families, regrets, lack. Typically we deal with some performance of family and then retreat into the consumerism and glitz of the holiday season. Sometimes, when I know someone is about to embark on terrible holiday season, I encourage them to make predictions and lists of everything that will come up and go wrong: all the family antics, all the problems and petty arguments or dynamics that will come up. You can try this too: write down everything bad you expect to happen. After doing this, people sometimes also notice the good things (or at least find the humor in the bad things). If you have friends in the same boat, you can also make a game out of it by seeing how accurate the list is: as the holidays happen, check things off. You can see who got the most "points." Then you can have a real thanksgiving (or Christmas or whatever) in which you celebrate your friendship.

Being aware of abundance in this way is great preparation for the winter. Winter, according to Chinese medicine, can give people feelings of anxiety and lacking. Western psychology considers this to be where the real seasonal mood issues set in. You'll do best if you can come into winter with eyes open, focusing on what you've got.

 

-Nick

 

Home Practice?

I want to write today about home practices.

Home practices are "homework" I give as an adjunct to therapy to make therapy more effective.

I would say "to make therapy more efficient" but efficiency is a tricky idea especially when it comes to mental health: sometimes things change fast and sometimes slowly when it comes to mind. So efficient mental health care is elusive. But effective therapy--therapy you can look back on and say, "I got something out of that!"--that peaks my interest and is something I've been studying and thinking about for a few years now.

In a nutshell, home practices are activities, exercises or guided meditations I recommend people do when not in the office with me. One premise of this is simply that one hour a week (on average) of meeting with a therapist, though helpful, is not that much time. Anything that bolsters it is a good thing. 

I've been particularly interested in meditation practices that augment therapy.

There have been a number of studies over the last 20 years that document meditation's helpfulness when working with particular mental health issues. In certain cases, such as with Mindfulness Based Stress Reduction, an eight week course that utilizes mindfulness meditations as part of a program to manage stress and promote well being, the results have been quite dramatic.

The exploration of home practices has really just begin, though. The MBSR program, as amazing as it is, only uses a small portion of the array of mindfulness practices that exist. There are a number of others out there that are also potentially helpful.

Even the realm of mindfulness meditations is restrictive: though certainly a kind of "gold standard" for mental health promoting meditations, these meditations aren't the only type of helpful meditation out there. It's worth noting that just because one particular style or category of meditation helps one person, it doesn't mean it will help another.

The application of mindfulness to every mental health problem is like taking tylenol for every kind of physical illness. Though no one would argue that tylenol isn't helpful, it's not going to help everything. Traditionally, different practices are given to different types of people based on temperament and problems. As we learn about meditation in the West and apply it to our problems and our ways of understanding, we're learning how to do this.

Along with mindfulness practices, I've also been particularly interested in compassion practices (another heavily studied grouping of Buddhist meditations), and in what I call hypnoyogic practices--yoga nidra and forms of guided imagery--for their usefulness in augmenting therapy. All three of these groups of practices are forms of practice that are part of ancient understandings of how to work with the mind. 

What I've noticed is that people who have been willing to embark on the adventure of some of these practices are finding their therapy more effective. When I've discussed these practices with other therapists, I've gotten similar reports: those who do and stick with the proper practice do get results. 

You may notice I stuck the word "proper" in there. Really, this just goes back to the tylenol metaphor: what works for one person with a particular problem won't necessarily work for another person with another type of problem. I used to think that doing any kind of meditation practice was better than doing no practice. And (and not to contradict myself entirely), there is truth to that notion.  But there definitely cases where an expert is handy. I think anything where a clinically significant mental health issue is at play is a situation where it's best to consult an expert.

Of course, personal preference (and a host of other factors) also should be noted here.

Some people, for whatever reason, do not want me to give them home practices. This is okay. Therapy on its own is also a powerful practice for working with the mind. (If it weren't, I wouldn't be in this field.) Some people also have trouble making time in their schedules or find it difficult to take the risk on these sorts of adjunctive practices. This is also understandable.

That said, meditation isn't just about sitting on a cushion. Back to my old favorite, loving kindness (metta) practices: after you know how to do it, I think metta is just (if not more effective) to do out in the world: while driving, walking, shopping at the grocery store or waiting for a bus. Give it a try. It doesn't take any extra time--you just do it while going about your day. 

 

 

The new blog...

When I first began my private practice in Northampton, I started a blog. As things started getting busier and I started having some technical problems with blogspot, I reluctantly abandoned the project. But given the new things I've been doing and the kind of work I've been developing, it seems like the time to reinvigorate it. I named the old blog "The Metta Project" and wrote a post long ago about how that name originated. I'll share it with you now.

The Metta Project?

Metta is a state of mind that's intimately connected with mindfulness. Traditionally, it's said that mindfulness-awareness and metta are two wings of a bird. You need both to be a whole bird, and to be able to fly.

Metta the word translates roughly to something like "loving-kindness" or "loving-friendliness" in English. It's like compassion, and is related to all positive inter- and intrapersonal feelings.

In a nutshell, it's the feeling of unconditional love--or the kind of caring you'd give to your closest friend... It's the feeling you have for people you care deeply for and that you (ideally) have for yourself. Traditionally, it's also described as the feeling a "mother has for her only child"--although that might confuse the issue more than clarify it, depending on your mother. I think, though, that it's a good reference if you are a mother or father--it's that heart feeling of willingness to suffer and exert oneself for the sake of someone precious--that you often feel for your kids.

Metta is a lost art in some ways--especially when it comes to caring about oneself. Loving oneself is where it all starts: you can't love others without loving yourself. Unfortunately, most people lose track of themselves as deserving of love in the midst of all the messages we get about being better, and about acquiring the external things we're told we need, trying to acquire love and trying to change ourselves to get what we want out of life.

As a psychotherapist, I see the lack of metta and its effects pretty starkly. I'd say that the problem of 90% of the people I see in my work--and I'm not exaggerating here--is caused by an inability to love oneself for who one really is.

Wrap your mind around this. 90%. Of clients over my professional life. Addiction, depression, schizophrenia. People who can't accept and love themselves (and then can't accept others)--can't "say yes" to their own being, like in the guided meditation I posted.

The Buddha says this even better than I do... There's a scripture in which he lists a bunch of profound and righteous actions that people can do in order to develop good karma.

(Note, if you dislike about hearing about the Buddha and karma--you can pretty much substitute "a really great therapist" for the Buddha and "psychological health" for "good karma" and you'll still have the story.)

He lists a bunch of great things people can do... Stuff like feeding and clothing people--especially holy people--and supporting people who're trying to cultivate their minds. Everyone's delighting at knowing that if they give food and their possessions to holy men, they'll be happy and healthy. Seems pretty cut and dry. I can imagine people packing up to go home, pretty clear that they get the message. And then he says:

As great as all of these might be, it would be even more fruitful to develop metta even for the time it takes to squeeze the utter of a cow.  [AN 9:20]

I'm dramatizing a bit here--but I can just imagine people wrinkling their brows and looking around, confused: Weren't they supposed to give everything they owned to the Buddha? What's this about loving kindness?... It takes maybe 5 seconds to squeeze the utter of a cow. How could that be better than feeding the hungry and giving your wealth to spiritual teachers and stuff?

The Buddha goes on and says more about mindfulness.  But for our purposes, this is the punchline: Metta is a big key to psychological health. And to dig a little deeper into what he's saying, it's actually also a key to the health of the greater society. If everyone loved themselves and loved one another fully, imagine the world we'd have. You wouldn't need to feed anyone; no one would be going hungry to start with. If you have metta in your heart, you will end up helping other people, yourself--and the world--more than you know.

One day I was sitting around contemplating all this, and I thought, "If my life was a project that involved helping people find and develop their metta--even for a moment--it would be worthwhile." And so the Metta Project was born.

All the best,

Nick

A few years later, it's interesting to note that the idea I had here still stands. Though loving kindness isn't the only curative aspect in play in life today, a handful of years after I wrote the above post, I still think it's a big one. In this blog, I hope to talk about these various pieces of mental wellness from the integrative perspective that I've come to establish a name for myself by. Feel free to join me. 

Nick