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Clinical Illustrations of Inquiring Deeply

The frame for the psychotherapeutic dialogue in inquiring deeply is provided by the patient’s relationalship or emotional problems. As with any psychoanalytic approach, special emphasis is also placed on what is occurring in the therapeutic here and now. In this section, two clinical vignettes are presented in some detail to show the overlapping of close process attention and mindfulness of connection.

Clinical Illustration 6.8: Allen, Part 1

Allen was a 35-year-old mortgage broker who was having trouble controlling his anger. He reported problematic outbursts of temper both in the workplace and with his wife. He was referred to psychotherapy for further help after completing an MBSR-based anger management program.

Allen was socially pleasant and mild-mannered, but seemed tense and rather depressed and had what struck me as a sullen edge.

In the session excerpted here, Allen has just shared a nightmare in which some violent and awful things happened. He found the dream quite disturbing and wanted my help sorting out its meaning. His surface associations were to a movie he had recently seen that was quite upsetting. Based on material discussed in our recent clinical hours, I suggested that perhaps the dream also expressed Allen’s fears of what could happen if he allowed himself to deeply feel his own anger.

M.S. I noticed that just now when I was sharing my thoughts about your dream that you looked sort of uncomfortable. Were you aware of feeling uncomfortable?

A. No, not really. I thought your interpretation was probably correct. I am afraid of what might happen if I really let my anger out. Umm, well now that you mention it, it did cross my mind that maybe you thought only a very angry person would have a dream like that.

M.S. You were concerned about my judgments of you ... that perhaps I might think you as some sort of monster, like the criminal in your dream .

A. Yes.

M.S. You might consider the possibility that there is a part of you that makes those kind of judgments about yourself.

A. Yes, I think you are right about that. I don’t like it that I have such violent dreams. It must mean that deep down I am a violent person.

In this first part of the session, I touched on some implications of the psychological content of the dream Allen had presented. Taking note offeelings expressed on his face, I brought his attention to what he was feeling. I also interpreted what I presumed might be beneath the surface: concerns about my judgments about him. This is the essence of “close process attention.”

At this clinical juncture, I might have taken up Allen’s narrative of himself as a violent person, but I chose instead to focus further on the psychotherapeutic connection in the here and now:

M.S. I wonder if there was anything you perceived or sensed in me, or between us, that made you feel that I might be judging you ...

A. Not that I’m aware of... that’s a familiar feeling though. I often worry about how others are perceiving me .

[Allen looks down, apparently uncomfortable]

M.S. Yes. I’m reminded of what we’ve talked about regarding your older brother; your concern with how he views you ...

Do you consciously worry about how I perceive you?

A. [pause, re-engages with intense eye contact] Sometimes ...

M.S. [pause] How about in this moment?

A. No, I don’t think so. Just for a minute there when we were talking about my dream .

M.S. Okay. I’m still wondering, though, about what is coming up for you with me right now.

A. I don’t know exactly. I’m not sure I understand what you’re asking .

M.S. Nothing specific. I’m just asking about how you are experiencing our relationship in this moment . whatever you’re aware of . maybe a feeling . maybe just the underlying attitude in your mind right now.

A. [closes eyes and looks inward] I am aware of feeling tense, my teeth are kind of clenched and my jaw feels tight... [long silent pause]

M.S. Maybe check out what it feels like with your eyes open ...

A. I feel very exposed.

M.S. What are you concerned that I might see?

A. I don’t know. I just don’t like the feeling of being looked at.

As we had this exchange, I became aware, not only of Allen’s initial discomfort, but also of the fact that my probing seemed to exacerbate the feeling. Shifts in his gaze alerted me to the fact that our exchange was highly charged for him. When I went on to ask him directly how he was experiencing our connection, my sense was that he avoided the interpersonal moment by “performing mindfulness ” (perhaps in a manner he learned in MBSR) rather than engaging in a more connected and authentic way. In hindsight, I thought that I had perhaps been too direct and confronting. In any event, I made an effort at this clinical juncture to steer the conversation in a more comfortable direction. I spoke empathically about his feeling exposed, framing it as a kind of self-consciousness or shame reaction, and suggested that it might be useful for Allen to pay closer attention to these kinds of feelings when they came up in daily life, to see what he/we could learn from them (therapeutic suggestion for strategic inquiry).

In ensuing weeks, this turned out to be a very generative area of investigation.

Allen discovered that there were several people at work with whom he felt quite self-conscious and exposed. Mostly these were people in positions of authority over him, and mostly they were people he disliked. This led to some important discoveries about the way reactive anger and dislike covered over and protected against feelings of vulnerability.

In the work with Allen described above, for instance, I called attention to something which I had just observed in the therapeutic here and now. Using close process attention, I interpreted the feelings I read on Allen’s face and speculated aloud about what his inner experience might be. But I also tried to focus clinical attention on Allen’s experience of the therapeutic connection. I had hoped this would open up into deeper mindfulness of connection, but things didn’t happen that way (perhaps because I had triggered a defensive response).

In some subsequent work I will now describe, I sought to help Allen open further to the therapeutic relationship by using a meditative/hypnotic induction for deepening mindfulness of connection:

Clinical Illustration 6.9: Allen, Part 2

M.S. I have an idea ... would you like to try a little experiment?

[He nods agreement]

M.S. Just relax your gaze ... no need to look directly at me, just let your eyes go softly out of focus ... just putting yourself in a receptive frame of mind .

[pause to allow him to absorb this instruction]

Nothing special that you need to do, just noticing how you are feeling right now .

[pause]

Bringing gentle attention to the experience of the two of us sitting here, in this room, here and now .

[pause]

Aware of the sensations of your own breathing ... and of me sitting across from you, also breathing .

And now allowing yourself to become aware of the space around us. Perhaps imagining how the molecules of breath expanding outward into the entire space of this room .

So now there is a sense of both foreground and background: each of us in the foreground, then the background space that contains us .

[pause]

See what happens with that experience offigure and ground as you sit with it. Just relax into the experience and see how it changes from moment to moment. Notice if your perception offigure and ground is steady, or if it shifts

back and forth ...

[pause]

M.S. What’s that like for you right now?

A. It’s very relaxing. I feel so much more comfortable than a few minutes

ago! So here!

M.S. You sound surprised.

A. Yes ... it really shows me what I miss out on by being so uptight all the time.

I do not often use guided meditation (or hypnotic induction, as the case may be) in psychotherapy, but this process emerged naturally in this therapeutic moment and I decided to “go with it.”15 My felt sense of our connection and of Allen’s state of mind told me intuitively that Allen was available to opening and deepening in that moment. There was no premeditation about this on my part, simply a spontaneous responsiveness to what was emerging and what suggestions would invite that deepening. The figure/ground metaphor is one I often use; it calls attention to the “space of connection” or to the flow of energy at the intersubjective intersection.

The next vignette illustrates another way that dharma practice and psychotherapy may overlap. It tells part of the clinical story of Tom, a patient who sought my help for problems feeling connected to others.

Clinical Illustration 6.10: Tom: Alive or Dead?

Feeling painfully separate was the presenting complaint of my patient Tom, a pervasively depressed man who suffered with a chronic sense of isolation and separateness from everyone and everything. He expressed feeling as though he were living life through a gauze curtain. For a period of time prior to the work described in the following vignette, we had deeply explored the relational underpinnings of his feelings of disconnection and isolation. He had experienced a very lonely early life. Although reasonably content in a long marriage, Tom had few relationships apart from his wife and grown children.

Tom experienced great relief in feeling empathically understood and formed an intense, dependent transference connection to me. But apart from this, his global sense of disconnection from life remained quite intractable.

Tom had been doing sitting practice at a Soto Zen temple for more than 20 years. Although he had no experience in the Rinzai tradition or in koan practice, he read about a koan that intrigued him and which became the subject of much discussion between us.

The koan in question tells the story of a Zen student accompanying his teacher on a condolence call.16 The student, much concerned with existential issues of life and death, bangs on the coffin and asks his teacher imperatively, “Alive or dead?” but the Master replies only, “I will not say alive or dead.” Despite repeated and escalating entreaties, the Master refuses to answer and won’t even say why he won’t answer (see Appendix 6.1).

Tom identified with the student in the story—both with his concern about ultimate truths of life and death and with his urgency. I understood from our several years of work together that Tom often felt rather dead himself. He was in urgent need of finding his own aliveness. This is what had motivated him to begin Zen practice in the first place.

As we explored his thoughts and feelings about the koan, I also speculated that perhaps Tom resonated with the frustration of having needs go unmet by a significant Othermoreover, withheld for reasons which felt both arbitrary and incomprehensible. These themes were familiar from Tom’s own childhood experience. The koan was a good fit for his life narrative, and highlighted the emotional core of his despair.

At our next session, Tom reported the following dream:

I was visiting a monastery. In order for me to practice the virtue of patience, the monks wanted me to climb into a coffin and proposed that they would lock me in. This was a terrifying prospect and I said that I would agree to get in the coffin only if they would promise not to lock it. They said okay, but once I was inside they did lock it. Somehow I broke free and I ran away in a state of great anger.

It was apparent to both Tom and me that the dream was an association to the theme in the koan, “Alive or Dead?” Overall, I found it hopeful that in his dream Tom had escaped (“lived”). Also, in our work together, we had been talking about how introverted Tom tended to be. “Withdrawal from life” is one of the basic aspects of depression—turning inward (Morgan, 2005)—and I thought this was perhaps one of the meanings of this dream visit to the monastery. Most importantly, the dream represented important relational themes, especially betrayal of trust.

As Tom continued to be engaged with the koan (and as we engaged with it together in psychotherapy), I spontaneously began probing him during sessions with the question “Alive or dead?” at various moments when I noticed changes in his affect. I often chose to ask at moments when I experienced him turning inward and away from contact with me; or, at other moments, when I experienced him shining out toward me, often with a broad smile.

Exploring mindfulness of connection in the therapeutic here and now with the probe “Alive or dead?” served to alert Tom to shifts that were occurring in his affect state. This began to have an impact on Tom’s self-experience. Whereas previously he had tended to reify the state of being “dead” or damaged (a state of imprisoned isolation behind a gauze curtain), Tom gradually began to see that “dead” was a feeling state constructed moment by moment through the psychodynamic movement of withdrawal or contraction. He felt alive when he felt relationally connected to me during the hour, or “dead” when his attention turned inward toward the experience of feeling isolated, left alone with sad thoughts and feelings. “Alive or Dead?” turned into a psychodynamic inquiry and opened up insight about the way Tom’s feelings were conditioned by the moment-to- moment experience of being in relation.

 
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