When I was at Kelly Wilson’s workshop at a mindfulness and acceptance conference about a week ago, we abandoned our problem-solving mode for a bit and practiced simply being present with each other while discussing early experiences of things we did not like about ourselves. Part of what happened in those moments was the cultivation of understanding and compassion that was incompatible with anger. Compassion for ourselves, and compassion for others.

Yesterday I attended an all-day seminar by psychoanalyst Martha Stark, which came at all of this from yet another perspective, and was really intriguing. Stark talked about “relentless hope: the refusal to grieve,” and “relentless outrage.” She described patterns in which we are faced with disappointment from others, and instead of adapting to it, we often maladaptively and persistently keep trying to get what we want. This is a defense mechanism, in that it is a reaction to stress that we are not ready to cope with.

When the parent leaves the infant alone briefly, the infant loudly protests. Over time, and repeatedly experiencing the reliable return of the parent, the infant begins to learn to self-soothe during the absences. When the unmet needs are too traumatic, however, the ability to self-soothe is overwhelmed, and defense mechanisms kick in. This may manifest in relentless pursuit of the object or relentless anger and hopelessness. There is a defensive need, it is traumatically frustrated and thus strengthened, but then eventually hopefully transformed into adaptive capacity. We become stronger at the broken places.

The therapist helps the client by both being supportive when needed and challenging when possible. The challenges involve interpretations that help the client to gain insight into the behavior, re-experience the feelings involved, and re-enact the earlier unresolved issues. This happens naturally, because therapist is inevitably less than perfect, as the parent was. The client reacts to this with characteristic defenses.

Stark formulated several models of therapeutic work. In Model I, the mode of therapeutic action is enhanced knowledge. The therapist and client work through resistance to gain insight. Resistance is the defensive reaction. Over time, with more insight and knowledge, a more thoughtful and reflective response develops, and the client becomes more aware of the dysfunctional dynamics.

In Model II, which we shift in and out of, we listen empathically. We adopt the client’s affect. We share the experience. In Model I we are opaque, not bringing ourselves into the interaction. In Model II we bring the best of ourselves into the room. The client as child needs to grieve deprivation. Ideally this results in structure, internalization, an adaptive ability to handle grief within. If it is too overwhelming, defenses can include narcissism or a stereotyped posture of shame or disappointment such as, “I knew no one would like me.” Model II is about acceptance of the object as “separate, limited, immutable.” It cannot be controlled even though we want to control it and may relentlessly pursue trying to make over the object into what we want.

The same dynamics get co-created again and again to allow this re-enactment. Stark quoted Warren Zevon: “If you won’t leave me, I’ll find somebody who will.” In Model III, the therapist is engaged in an authentic relationship with the client (whereas model II is for the client). As therapists we strive for “benevolent containment” of the “toxic mud balls” that the clients give us. The internal yearning that has been traumatically frustrated is displaced onto the therapist. The client has found a new bad object. “The therapist brings to bear her own ability to adapt: benevolent containment of toxicity.” The therapist has the capacity to relent. Together with the client we repair the disruption in the relationship. The bad becomes good. What were knee-jerk re-enactments become structural change.

We repeatedly have to come back and join with the client. In those instances it is not about what we think, it is instead expressions such as, “it just hurts so bad.” We are listening with every molecule of our being, and the clients go ever deeper, as Stark puts it. They lead the dance and we follow. In Model III we “stay centered in self and take in their stuff.” It is a “co-created story.” The story is “about there and then and also about here and now–the therapeutic relationship.” Part of all of this is accountability. That is, we have to look at what we have contributed to the transference and hold ourselves accountable in an honest way. This is echoed by Yalom and others.

We “challenge when possible and support when necessary, so they can re-organize at a higher level.” Our interpretations are anxiety-provoking, and have to be done in the right amount with adequate support. Like sands in the hourglass, minor avalanches of stress contribute to the reconstitution of the pile. This optimal stress helps the patient to go back and forth between reality and the experiences she finds herself having. We provide “conflict interventions,” such as “You do know that he’s gone, but you find yourself still hoping.”

To work through resistance clients first come to understand how they create the situations and how they gain from them. They know that they need to let go, but they so desire what they want that they engage in masochistic hope, or they lash out in sadistic outrage. As therapists, our response to their outrage toward us should be, “How did I fail you?” They often think we are being critical, and set us up to be so; that’s what they know. Yet being too loving is perceived as controlling. We must allow ourselves to be turned into the bad object (projective identification), and even take responsibility for our part in all of it: We relent. However, we also challenge: “How did you imagine that I might respond?” Or, “You are really angry, but you know that if you’re ever going to get better, someday you’re going to have to slow down and give someone a second chance” (!).

At the end of the day, Stark shared a touching story in which she described a re-connection with her mother, who had disappointed Stark in her childhood, by never being that into parenting. This re-connection was essentially facilitated by compassion for her older, frailer mother, and appreciation for the good qualities that her mother did have–forgiveness by Stark involving empathy, acceptance, and adaptability.

Bill McKibben lecures at Pomona College

Notes and quotes from Bill McKibben’s lecture Thursday night (10/27/11): He named his recent book Eaarth because the planet needed a new name. It is a different planet than that seen in the 1968 Apollo 8 photo of Earth rising. The ocean is 30% more acid and there is 40% less ice in the summer in the Arctic.

Since Eaarth was published 18 months ago, we’ve seen the warmest year on record. In July, 2010, Pakistan hit 129 degrees Fahrenheit. Warm air holds hold more vapor, and so the planet is 4% wetter than it was 40 years ago. The hydrological cycles that had been steady through the Holocene now involve more drought and evaporation. Russia, the third largest grain exporter, stopped all grain shipments after 8 days of 100 degree weather, fire and drought, causing a 70% spike in grain prices, which is a disaster if you are poor and buy cornmeal for your food source. Drought in the Horn of Africa is the worst. Texas and Oklahoma are dryer than it was in the dust bowl years. Austin is fighting fires in conditions of lower humidity and higher temperatures than ever before.

Water vapor stays in the atmosphere 6-7 days, and then it comes down. Incredible downpours in Pakistan dumped 12 feet of rain in a week. The Indus flooded 20% of the country and made 20% of the people homeless. Record rains also overfilled U.S. rivers. Hurricane Irene went up the East coast encountering New York and New Jersey seawater warmer than ever and soaked it up, dumping it on Vermont and taking 150- and 200-year-old covered bridges downstream. Flood records were broken by 30%. There were record rains in El Salvador, Guatamala, Manilla, Ghanna, Bangkok. Bangkok has experienced rising water like they’ve never seen.

All of this is from a temperature increase of one degree. Another degree rise is in the pipeline. If we don’t get our act together, there will be a five- to six-degree temperature rise before the end of the century. With every degree of temperature increase, Stanford agronomists say there will be a 10% reduction in grain yields. Peace, stability, and development are not possible with 10-30% fewer calories; we cannot allow that to happen.

How do we do something about all of this? So far we’ve basically done nothing as a country and a world. There have been 20 years of bipartisan doing nothing in Washington. McKibben wrote The End of Nature at the ages of 26 and 27, and he thought people would read it and change, and they did read it. He thought that our best scientists would explain all of this to our leaders, who would put a price on carbon and do other such things. This was a valid expectation, but it is not how things turned out, because it did not factor in the fact that the fossil fuel industry would be bellowing threats and promises that would keep the politicians from acting. We need a movement.

He especially realized this when he went to Bangladesh, where the rivers pour into the Bay of Bengal and the land is incredibly fertile. They face trouble with sea water backing up into the fresh water, but there was an acute problem there as well. The warm wet planet is ideal for mosquitoes, including those that spread deadly Dengue fever, which he caught but survived. For Bangladesh to have problems from climate change is incredibly unfair because they have no carbon footprint. They drive rickshaws. The 4% of us that are in the U.S. are responsible for 40% of the bad gases that have been added to the atmosphere.

He called his writer friends in Vermont and said, “Let’s go to Burlington and get arrested on the steps of the Federal building.” His friends thought that was a great idea, but when one of them called the police there to ask what would happen if they had a protest on the steps of the Federal building, the police said, “Absolutely nothing.” So instead, they had a protest walk to Burlington, 1,000 of them, camping in fields on the way. And they got their politicians to sign a large piece of cardboard with a document that only scientists had thus far signed, and all of their representatives signed it, including a woman who didn’t believe in global warming. And in ’06, that was sadly the largest demonstration on climate change in the U.S. to date.

He and seven students at Middlebury College started 350.org, named after the 350 ppm cut-off for acceptable CO2 levels pinpointed by outspoken award-winning NASA scientist James Hansen. (We’re at 390 ppm now and rising.) On 10/24/09 there were 5,100 demonstrations around the world, including 15,000 people in the street in Addis Ababa, and a 3-part artwork with the three numbers 3, 5, and 0 in Jordan, Palestine, and Israel, respectively. Supporters from around the world sent in photos in solidarity. There were pictures of Bungee jumping from a coal-fired power plant in Africa to council meetings in the water in the Maldives to bring attention to the fact that they will be underwater in 50 years. Most of the protestors did not look like environmentalists. They included many poor people of color. (And the world’s largest solar array is in Abu Dhabi!) One hundred and seventeen nations signed on to the 350 target, but they were the wrong nations. Rich addicts like us didn’t sign. Six months later the Senate couldn’t even bring modest measures to a vote. The 60 Democrats were scared of the fossil fuel industry.

The current focus is the Alberta-Texas pipeline. If this second-largest carbon pool in the world were burned overnight it would take the atmosphere from 350 to 540–essentially “game over” for the climate. We’ve got to stop it. The President will either grant it a Certificate of National Interest or not. Over two weeks 1,253 people have been arrested. A few days ago 1,000 people in San Francisco chanted, “Yes we can…stop the pipeline,” when President Obama was there. A guy was dragged out of one of his speeches. A State Department review, farmed out to Entrix (that has Trans-Canada Pipeline as a major client), said it would have negligible impact. Thursday (10/26/11), Vermont Senator Bernie Sanders joined Senator Wyden from Oregon and Senator Whitehouse from Rhode Island to seek an investigation of the scandal. Senator Kerry just responded to constituent demands to do the same. Today, there is going to be an effort to circle the Whitehouse with signs containing quotes from President Obama in 2008: “End the Tyranny of Oil,” “Oceans Will Begin to Heal,” “Transparent Administration.” It is President Obama’s chance for a shot from the top of the key. The fossil fuel industry has more money than God. Exxon-Mobil made 10.1 billion this quarter. How can we keep them from stopping the progress to fix the planet?

Those of us who have burned fossil fuels all our lives should bear some of the burden of this movement. The students have been the real leaders of the pipeline protests and the global warming fight. Political scientists say the odds are too high to overcome. Scientists say we’ve gone too far to recover. But we can’t make those bets. Morally responsible people must get up every morning and work to change the odds. There are those in so many places where they have done nothing to cause the problem but are willing to work with those of us who have. There are people who will fight this problem and it is great to be with those who are willing to fight, and he will fight shoulder to shoulder with you as long as he can.

Maldives supporters

Xian, China, supporters

Cape Town supporters

Miller stressed that we have to have some way of measuring how we are doing (know our baseline); we need to get formal and routine ongoing feedback and compare it to norms; and we need to engage in deliberate practice. We have to overcome automaticity, and work hard to develop the highly contextualized and deep domain-specific knowledge that allows us to see things that others can’t: Like the NICU nurses who can see infection before the bloodwork comes back, or the baseball players that adjust their fielding positions before the ball is in the air.

The tears came in the afternoon, as Kelly Wilson talked about how things will go horribly, terribly wrong, such as in the deaths of his brothers, the plight of the people of the Mississippi Delta, and in all of our lives. He was especially able to engage the audience when he asked us to imagine what we liked least about ourselves, and how long that that thing had been an issue. As we sat with eyes closed, we were asked to visualize and empathize with our young selves, and to communicate something helpful to them. In doing this activity, Wilson had collected lots of responses over the years, on index cards (from both lay and professional audiences). For some folks it had been bothering them as long as they could remember, and most people said it had been an issue since at least adolescence. Many had kept it to themselves all those years. He wasn’t sure what to do with all the cards, but his daughter had an idea. She made a video of them with her iPhone: A card or a few of them together were each shown for several seconds, set to music. As he showed the video, card after handwritten card said, “I am not enough,” or something very similar. What, he asked, if we all have a dark secret that we carry around, and it turns out it is the same secret?

Our brains evolved to do evaluation and comparison between bears and blueberry bushes, and it was safer to miss lunch than to be lunch. As we developed language we turned this evaluation and comparison device toward ourselves. But as therapists and humans we often must abandon our problem-solving mode of thinking, and simply behold the person in front of us, listening intently, trying to know and understand.

During a break, I talked with Kelly about my preoccupation, experiential acceptance self-efficacy, and he thought that I am on the wrong track (and being error-centric, I found this pretty riveting). He cited recent data that suggest that changes in self-efficacy (and cognitive content in general) are more an effect of than a cause of improvement in client functioning. Fascinating stuff.

“The more rigorous definition is that transference is a state of mind of a client toward the therapist, and it is produced by displacement onto the therapist of feelings and ideas that derive from previous figures in the client’s life.”—p. 203, The Theory and Practice of Group Psychotherapy (5th ed.), by Irvin Yalom.

“A major task of every therapist, psychoanalysis asserts…is to help patients see how and why they experience the therapists the way they do. Why does one patient argue with the therapist almost every time the latter says something? Why does another patient act like a compliant child and accept almost everything the therapist says?”—p. 110, Strean.

Strean goes on to point out that the transference may not necessarily relate directly to earlier experiences of the patient, but may be a fantasy of the patient’s regarding someone the patient needs, such as the way a parent should have been.

Irvin Yalom (an analytically trained but mostly existential psychiatrist), in his classic group therapy text, echoes what Strean said about the importance of clarifying aspects of transference for patients, to help them to stop distorting the way they see and interact with others. Certain things can increase transference, such as when the therapist is sort of a mystery or blank screen to the patient, and other things can decrease it, such as when the therapist discloses her own reactions more in therapy. Yalom is very interested in the benefits of being more transparent to clients, in helping them to reduce the distortions they have, and has written a lot about it. He views group therapy as being all about this, and his definition of transference includes the distortions between group members:

“Transference distortions between group members can be worked with as effectively, and perhaps even more effectively, than transference reactions to the therapist.” –p. 205, Yalom.

However, Yalom is careful to point out that sometimes people’s reactions to each other and to the therapist are based in reality. If your client is angry with you or in love with you, it may be at least in part because of real things that you are doing (and so that is worth carefully scrutinizing and is also a reason why therapists better damn well know themselves and how they may tend to act out their own issues).

These are the kinds of nuances to conducting psychotherapy that make it an engaging and sustaining endeavor.

Even with research-tested approaches, difficulties can arise for a variety of reasons. The issue of client motivation has been a particular concern, and led to approaches such as motivational interviewing (helping clients resolve ambivalence and set goals[1]) and similar approaches (e.g., “paradoxical agenda setting” or “paradoxical inquiry”[2]), as well as harm reduction strategies (e.g., intersperse water and food with alcohol intake) that do not assume adherence to an ideal regimen. Additionally, special interventions have been developed for clients with very severe emotional symptomatology[3].

When treatment approaches do work, it may be due to factors unrelated to the theoretically effective components. Interesting findings have emerged in several treatment areas that suggest that benefits of treatment apparently may be tied in large part to the ability of the treatment to enhance the clients’ perceived control over problems, even when this does not involve actual control. For example, the use of biofeedback to reduce headache was shown to be effective even when false feedback was used. More broadly, so-called “placebo” effects are widely recognized, which enhance adaptive beliefs and in turn yield a variety of downstream benefits.

Closely tied to perceived control is the concept of acceptance. In stress management approaches, for example, problem-focused coping is augmented by emotion-focused coping. Whereas problem-focused coping involves attempted control over external stressors, emotion-focused coping enhances the ability to cope with negative affect. And although emotion-focused coping (emotional regulation) can involve increasing control over one’s emotions, it can also involve acceptance of undesirable situations and negative internal states. For example, some of the research on panic disorder that suggests that the difference between people with panic disorder and people without panic disorder is that although both groups experience unexpected and uncomfortable physiological arousal from time to time, the people with panic disorder become worried about it, and start taking steps to try to prevent another “panic attack”[4]. People with panic report difficulty accepting being upset, and a tendency to avoid unpleasant emotional experiences.

Acceptance of negative internal states has become an important tenet in newer cognitive-behavioral approaches[5]^,[6] such as Acceptance and Commitment Therapy and “mindfulness,” sometimes collectively called the “Third Wave of  Behavior Therapy.” These approaches are considered more compatible with the acceptance aspects of 12-step programs and spiritual approaches than are traditional behavior therapies[7]. Acceptance is a key part of 12-step self-help groups (i.e., “to accept the things I cannot change,” in the Serenity Prayer). Wisdom traditions such as Buddhism advocate acceptance in order to cultivate a peaceful state of being. Some protestant Christian groups have traditionally encouraged members to accept current difficulties with an eye toward the hereafter. Acceptance of negative affective states is typically a more adaptive approach than many alternatives, such as addictive behaviors or self-harm, and more effective than other methods of emotional regulation, such as thought suppression.

However, some meta-analyses have found that although therapies using acceptance are better than placebo or waiting list control groups, they are not better than established therapies at treating depression and anxiety[5]. This is not an unusual finding in psychotherapy research (the so-called dodo bird effect, attributed to nonspecific factors). However, in this case it may reflect that measures of acceptance have not been appropriately specific[8]. The most important (negative) factor may be unwillingness to experience negative internal states[9]. This is a fascinating area of study, with lots of promise, and lots of exciting findings already. The experiential avoidance-experiential acceptance continuum is proving to be a very valuable dimension in psychotherapy research.

Although I view individual differences as being more important than past experiences, overall, when it comes to handling negative affect, early negative events may well set the stage for pessimism and depression over the long run. Neuro-anatomy is affected by sustained high levels of stress (e.g., increased sensitivity of limbic neurons and the norephinephrine system as suggested by Goddard’s work). If early stressors were psychologically unmanageable, an inability to handle future stressors may develop. Thus, people who have had substantial negative events in the past become biologically and cognitively different from those who have not. Thus there are individual differences in the ability to tolerate negative affect that correspond to personal history.

James Pennebaker and Susan Lutgendorf’s separate work on journal writing indicates that the key to therapeutic effects in writing about upsetting events is focusing on meaning. That fact bridges the gap between erroneous “boiler-pressure” psychodynamic models and the observed benefits of processing events in psychotherapy: It is not catharsis per se that is helpful; it is coming to understand the events in one’s life in a different way. As in forgiveness work, and cognitive therapy in general, it involves rewriting the narratives of our lives. We have been damaged by our past, and we must reinvent that past to begin to heal.

These ideas–the need for fascination with the material and the suggestion of starting study at the point of greatest interest–are exceptionally good advice. Learning does not have to follow someone else’s starting and stopping points. Once you have absorbed the stickiest knowledge, you have a framework with gaps to fill in, and filling in gaps is interesting because it resolves questions.

Intelligence involves curiosity and persistence, which are practically synonymous with fascination. This alone may be good reason to pursue what most interests you, and find the aspects of the material that fascinate you.

Amy Walker used another pedagogical strategy without mentioning it, by the way, and that was repetition. By the time you listen to the accents clip, you are not likely to forget her name.

The movie was strong on several levels: It portrayed alcohol dependence well. It dealt with fatherhood and psychological maturity. It had a theme of fulfilling one’s promise, or not, based on being able to cope and function adaptively.

When I was young, I thought there was honor in being a misfit. The idea of being a brooding, troubled rebel seemed romantic. With the counterculture as a backdrop, and an insistence on doing things my way, I saw little but hypocrisy in becoming part of what was called “the establishment.” Although I no longer idealize being troubled, I still find it a challenge to follow advice, make wise choices, have patience, and be disciplined. Crazy Heart made me think about these issues again.

1. Sharing genuine love and affection with your significant other.

2. Babbling back and forth with a child who likes nothing better than to be with you.

3. Reaching your family on the phone when you want to and getting to talk with them a long time.

4. Being in the yard watering plants in the yellow glow of the very late afternoon sun.

5. Coffee, oatmeal, and a blank page, with early morning sun filtering in the windows.

6. A good book and a bunch of pillows in bed.

7. The moment that a song comes on that you absolutely have to get up and dance to, and you do.

8. Feeling very connected with the small group of friends you are with.

9. Sitting in the hottub at night.

10. Browsing in a bookstore on a Sunday afternoon with a cappuccino.

11. Finding a great sushi chef with a fellow sushi fanatic.

12. Being at a beach in any weather on any day at any time.