You gotta Have Heart
by Christopher Germer
Psychotherapy Networker, January/February 2006
Mindfulness has become one of the hottest growth areas in the field of psychotherapy in the past few years. It's a surprising hit even among cognitive-behavior therapists, whom nobody would ever accuse of being frothy-brained New Agers. Our scientific colleagues, such as Steven Hayes, regard "mindfulness and acceptance-based therapies" as the "third wave" of empirically based treatments, after behavior therapy and cognitive therapy.
The distinctive focus of the mindfulness-based approach is the intractability of emotions, and the recognition that pushing around difficult feelings often only makes them worse. In contrast, in the spirit of the mantra of the mindfulness approaches—"Change follows acceptance"—they prescribe a combination of awareness and acceptance as the primary intervention.
Several therapy approaches incorporating acceptance have proven to be effective with such difficult-to-treat conditions as the suicidality connected with borderline personality disorder (Dialectical-Behavior Therapy), recurrent depression (Mindfulness-Based Cognitive Therapy), psychotic delusions and hallucinations (Acceptance and Commitment Therapy), and a host of chronic, mind-body disorders, such fibromyalgia, psoriasis, and chronic pain (Mindfulness-Based Stress Reduction). Although the techniques used may differ, these programs share common psychological processes, such as disentangling from thinking ("thoughts are just thoughts") and learning to stay with unpleasant experience.
Nevertheless, in their enthusiasm for these new approaches, therapists run the risk of ignoring another psychological process essential to mindfulness practice—lovingkindness. Throughout the 2,500 years that mindfulness has been a part of the Buddhist contemplative tradition, it never was intended to be strictly an awareness or attention-regulation exercise. Take away lovingkindness and mindfulness is like being forced to watch a frightening scene, close up, under a bright light. That isn't an experience that most of the emotionally distressed patients we see need to have.
What we're trying to do with mindfulness is evoke a complete state of mind, much as a hologram can project an image into the center of a room, or a poem can illuminate a perception in the heart of the listener. Within the cognitive-behavioral tradition, the word acceptance, or radical acceptance (to use Marsha Linehan's expression), is used typically to convey the nature of mindfulness. I've found, however, from personal and clinical experience, that other words are necessary to evoke the heart quality of mindfulness. They include tenderness, care, self-compassion, lovingkindness, and simply love.
Thinking with the Heart
My path to understanding the importance of lovingkindness in mindfulness-based psychotherapy wasn't always smooth. Madeline was one of my first client-teachers.
She was an 82-year-old woman who, even though in good health and of sound mind, despaired that she'd have to leave her beloved home of 45 years, because she lived on a portion of a suburban street where neighborhood children congregated to play . . . and scream. The noise kept her from sleeping, and she was experiencing chronic stomach and neck tension. She'd tried what she could to reduce the noise level—talking to the children's parents, playing soothing music to shut out the sounds. In spite of such steps, however, she lived in fearful anticipation of the next child's shriek. Madeline felt sad about her noise sensitivity because she wanted to enjoy the ebullience of her neighborhood kids, just as she'd enjoyed her own children's energy earlier in her life.
Initially I thought Madeline might benefit from listening in a more spacious way to the sounds around her—not focusing all the time on the children's screaming. I made Madeline an audiotape, "Mindfulness of Sound," that taught her to passively notice all the sounds in her environment. It didn't work. She said she just found the noise of the children too disturbing.
Next I thought she might benefit from internal exposure. If she could mindfully explore her physical and emotional reactions to the noise, perhaps she'd be able to relax. And if her body felt better, I hoped, maybe she'd obsess less about the noise. Ever cooperative, Madeline explored her sensations, thoughts, and emotions whenever she noticed she was anxious: "Where does it hurt?" "What does it feel like?" "Does the pain come and go?" "What thoughts and feelings come along with the stress of those noisy kids?" I instructed her to simply notice what she was feeling in her body and how her body reacted to the external sounds. This exercise didn't help either, not the least little bit. All it did was focus Madeline on just how bad she felt, and made her even more upset with herself and her situation.
The closer Madeline got to her distress, the more overwhelmed she became. We might call this exposure without desensitization, or mind less exposure. The trick with mindfulness techniques is to maintain attentional stability and a certain nonattachment as uncomfortable experience is allowed into awareness, but not become emotionally overwhelmed. In some cases, medication may be required as an adjunct to mindfulness-based treatment. I suggested to Madeline that she discuss taking Klonopin or Paxil with her physician. But she demurred—she rarely took medicine, on principle, and wanted to continue exploring behavioral techniques.
By now, I seriously doubted that I could help Madeline. Then I recollected that she'd volunteered for many years at a nursing home, brought Vietnamese children to the United States after the war, and was active in her church. I started to wonder whether she could bring the same quality of compassion that she had for others to herself. Would lovingkindness help her better tolerate her distress?
Together, we came up with a new meditation: "Soften, allow, and love." Madeline was enthusiastic about this one from the start, so I made another 20-minute audiotape for her to practice with.
The meditation begins with simple awareness of whatever sensations may be occurring in the body. Can you feel the pressure of your body on the couch? Can you notice the movement of your breath? After a minute, attention is shifted to an unpleasant physical sensation. For Madeline, this was either her tense stomach or her neck. The first component of the meditation, "softening," refers to relaxing that uncomfortable part of the body. However, to avoid frustration if relaxation doesn't occur, softening is an invitation to relax.
When you feel discomfort, can you soften that part of your body? You don't have to relax; just allow that spot on your body to soften—if it's ready to.
The next component is "allowing." This refers to allowing the physical sensations of the body to be just what they are—unpleasant, neutral, or pleasant. It's an ancient Buddhist meditation technique.
Can you allow yourself to feel the discomfort as long as it lingers? Can you just let it be, as long as it's there, even if it hurts? You don't have to change it—it'll pass at its own time. Can you let it come and go as it wants to?
Finally, in the "love" component, you try to recollect a feeling of love that can be redirected at your own body. This is a variation on the lovingkindness practice. Instead of reciting phrases, we capture a feeling—a brain state, if you will—and associate it with a new object of awareness. In this case, the new object is a difficult body sensation.
Now, imagine what it was like when one of your children had a tummyache, just like you. Can you sense in your heart what you might have felt, or feel, as you sympathize with his or her struggle? Can you hold that feeling in your heart?
Now, can you give your own stomach the same love that you'd feel for your child if he or she were suffering in the same way? Can you bring some love to the very place where it hurts?
This meditation then led Madeline to fill her whole body with the same love she'd identified, and let that feeling of love gradually radiate out into the room and into her community.
After Madeline learned this meditation, she innocently inquired, "Where does the love come from?" "Where can I draw it from, if it doesn't come up on its own?" We decided that love just seems to be a quality that comes naturally to everyone. Sometimes we feel it most for a child or a pet. It seems to be inherent in all of us, just like awareness. The skill is to recollect what love feels like and to direct it where it's needed most.
Eventually we expanded Madeline's loving awareness beyond her physical pain to encompass the emotional discomfort she felt when her home became too noisy.
Two weeks after learning this exercise, Madeline reflected aloud, "I think I have to learn to love myself more!" Four weeks later, she was feeling some enthusiasm for "working" with her noise sensitivity, and she said she felt 50 percent better. She surprised herself that she was actually beginning to feel affection for the noisy kids. She bought a lovely hat for one neighbor girl—one just like hers—when the child admired it.
Six months after Madeline learned this practice, I called her to inquire how she was feeling. She was still practicing self-compassion on a daily basis. She said, "When I hear a scream and I'm up and about, I kind of welcome it, because it's a part of my world. It gives me a chance to practice, too. I'm not saying I'm 100 percent cured, because there are times when I get annoyed, like when I'm reading the Bible and am with God. Then the noise is intrusive. But I'm generally much happier. I didn't know I could give love to myself!
I asked her if the practice changed anything else in her life. She replied, "I have a sense of my own worth. I don't have to please people. More on top of things, you know? I don't feel victimized. I'm more accepting. If people say something wrong, I let it go. I don't have to be right. I can let it go."
I still wanted to know specifically how she was practicing lovingkindness. She said she intentionally recalled the great compassion she'd felt for her youngest son, about 44 years ago, when he'd awoken with his eyes sealed shut from discharge. Her little boy was terrified, and she was filled with love for him at that moment. "Now I direct that love at myself," she said. "Where exactly do you direct it?" I asked. "I direct it at my upper body. I don't quite know how to describe it; my heart, yeah, it's a heart thing," Madeline replied.
Lovingkindness and compassion are heart qualities. They bring heartfulness to mindfulness. It's curious to me that heart qualities are marginalized in our profession. Perhaps they're not masculine or scientific enough. Lovingkindness isn't a secondary component of mindfulness; when we have to deal with difficult emotions, lovingkindness is primary and indispensable.
The "Soften, allow, and love" exercise was subjectively different from Madeline's (and my) earlier attempts at mindfulness, because it allowed her to expend less effort to change her experience. The loving attitude allowed her to "let go" and abide in the midst of her suffering with greater equanimity.
Our patients come to therapy to get better—to be cured. They want to become something other than they are, in an effort to avoid pain and maximize pleasure. Therapists shouldn't buy into this agenda though. Even Sigmund Freud noted, "A man should not strive to eliminate his complexes, but should get into accord with them." Lovingkindness allows our patients to just "be." No wasted effort.
Sharon Salzburg, a meditation teacher at the Insight Meditation Society in Barre, Massachusetts, and the author of Lovingkindness: The Revolutionary Art of Happiness, may be credited with bringing lovingkindness practice to the West. The four phrases Sharon suggests as a starting point for this practice are:
May I be free from danger.
May I have mental happiness.
May I have physical happiness.
May I have ease of well-being.
Repeating these phrases inclines the heart toward our suffering, rather than falling prey to the instinctive tendency to run away. We are not trying to eliminate what's happening at the moment. We're simply practicing love while in pain. It's the practice of care, not cure. But, paradoxically, with emotional suffering, cure often follows care.
For most people, self-compassion in the moment of suffering is a radical act. We're quite good at loving others, but rarely think of directing love toward ourselves in our moments of suffering. Perhaps we don't know how. Maybe we think we don't deserve it. Often we just can't find ourselves in the crowd—we're too busy toughing it out even to know when we're suffering. Practicing mindfulness with self-compassion allows us to know when we're in pain, and it calls forth a new response.
Simply reading about lovingkindness practice is no substitute for the therapist's own personal experience. The reader is invited to write down the four lovingkindness phrases and simply to recite them over and over for a few minutes the next time you feel upset. The more distressed you feel, the more likely you are to experience the deep, internal softening that accompanies the practice. When the mind throws up arguments against the practice, simply take notice and return to repeating the phrases. If the mind didn't protest, there'd be little need to practice.
My client Rachel panicked whenever she blushed, fearing it would signify that she wasn't a competent, intelligent colleague. Anticipatory anxiety led her to avoid social settings. She avoided the coffee room for fear of personal conversations; she was afraid to use a public restroom when others were around; and she avoided public speaking, at considerable cost to her career. She took antianxiety and antidepressant medications for her condition.
Poetically inclined, Rachel rewrote the lovingkindness phrases as follows to help her accept her anxious temperament and blushing, to anchor her awareness in the present moment, and to encourage her to continue to participate in life, even though she usually felt quite vulnerable.
May I have a peaceful spirit-mind and be free from sickness and harm.
May I paddle my currents and laugh with my quirks.
May I see the pulse of waves, feel the gusts of falling snow, hear the cry of the loon, sense the awe of the wilderness.
And may I hold my exposed heart in the embrace of my soul.
A mere three weeks after beginning to practice, she reported that she was taking less Prozac, had stopped Klonopin altogether, and was more energetic in meetings with colleagues. She related another effect of lovingkindness practice that I've often heard from patients: she'd begun talking more encouragingly to herself. Her inner dialogue included supportive comments like: "You'd like yourself if you met you!" "You're who you are, so say what you want to say!" and "Go ahead, quirk out!"
Rachel's increased capacity for self-compassion had another surprising effect. She found she no longer had to turn off the TV when tragic stories, like starvation and disease in Sierra Leone, came on the screen. She had the emotional capacity to handle them. She said, "I'm less afraid of what might come in—yes, the world has terrible beauty."
Bringing Love to Therapy
At the present time, there's only one clinical study I'm aware of that examines the use of lovingkindness exclusively to treat a clinical condition—in that case, back pain. However, a warm attitude can be discovered implicitly in all the empirically validated protocols mentioned earlier. Zindel Segal's Mindfulness-Based Cognitive Therapy (MBCT) and Jon Kabat-Zinn's Mindfulness-Based Stress Reduction program use poetry to help inculcate the gentle quality of mindful awareness. One such poem is "Wild Geese," by Mary Oliver. It begins:
You do not have to be good.
You do not have to walk on your knees for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body love what it loves.
The healing qualities of allowing, acceptance, and letting go permeate Oliver's lines. Through this poem, the word love has even found its way into the MBCT treatment protocol. That's a milestone for empirically-based treatment.
Often therapists find themselves working for years on end with the same patients, giving love and compassion, and hoping that it'll rub off in some way. We hope that the kindness we extend to our patients will eventually be brought by the patient to his or her own suffering. Often that doesn't happen. It's as if there's a hole in the bottom of the pot. Sometimes, within minutes of leaving our office, a patient may be hit by despair, just like smacking into a stone wall. These patients are usually the ones with few friends or family to support them. How can we help such vulnerable people nourish themselves?
I'd been treating a 35-year-old man, George, for approximately four years before I taught him lovingkindess practice. He'd been so severely neglected as a child that he could barely walk when he went to kindergarten—he just flopped around. No one cared. He'd also been physically abused on a daily basis by his single, alcoholic mother. He ran away at age 15, and never returned home.
When I asked him how he'd managed to stay alive, and even finish high school, he said he remembered some kind moments with his grandfather. His mantras for overcoming adversity came from muscular role models in World Wrestling Entertainment, such as Ric Flair: "Win if you can. Lose if you must. And you can always cheat!"
He's one of those patients that make you wonder if people can ever recover from a horrible childhood. He was underemployed, but employed. He didn't have any friends, because he didn't think he was worth their time. He was quite overweight, suffered from depression and insomnia, and had been taking antidepressants for years.
Therapy with George was always a delicate dance. I didn't want him to open up his wounds too much, lest he become overwhelmed and unprotected outside the session. This is often a dilemma with trauma victims—they don't have the self-compassion skills to manage reawakened memories, so they may decompensate and regress in therapy. Loving attention by the therapist, which opens up the heart like a flower and exposes old wounds, may cause difficulties outside the session, when clients remain open and vulnerable, but defenseless. Hence, I had to go slowly with George. Fortunately, he'd managed to marry a nice woman, who came to sessions occasionally when he resorted to such primitive self-regulation strategies as cutting himself and punching walls.
I taught George lovingkindness a few months ago, and the impact was almost immediate. As I repeated the phrases to him, his eyes became red and moist. He slowly lowered his head and said softly, "I can do this."
George announced the following week, right off, "I'm coming into my own!" He'd applied for a better job, even though it meant risking rejection. He said he was tired of being ashamed of his childhood, which meant not trying to get ahead. When I inquired what led to this change of mind, he said he was doing lovingkindness in bed, morning and night. He'd taped the phrases to his office computer, and he repeated them to himself whenever he felt "overwhelmed with self-doubt."
It was as though he'd woken up overnight and could see life from a broader perspective. He said he realized his elderly father-in-law said cruel things to him, not because George was actually "stupid" or "useless," but because the feeble, old man was demented. He added, "I'm not personalizing bad news so much."
Over the following weeks, this remarkable trend continued. George said he was volunteering for projects at work, he'd signed up for an art class, and had taken his wife on a "road trip." Where? They visited his old housing project for the first time since he'd left 20 years earlier. He said he was flooded with traumatic memories, but then started enjoying pointing out the sights, like the corner where he often found the dead bodies of junkies on his way to school in the morning. "Now I'm not ashamed. I have a lot of people who love me. Like the Tin Man in the Wizard of Oz. I think, 'I can do this,' 'I deserve this.'" Tears filled his eyes as he told me that he deserves friendship and love.
"I've spent a lot of time motivating others," he added, "at work and at home. Now I am motivating myself!" Months later, his general level of happiness and sense of humor continue to improve.
In George's case, self-compassion practice led to a radically different sense of himself in the world. He developed the nonattachment and happiness of someone who feels truly loved. As Tara Brach wrote in her beautiful book, Radical Acceptance, many people suffer from a "trance of unworthiness." When people feel bad about themselves—self-loathing, shame, self-doubt—they need an antidote at the same gut level of feeling. They need love.
Most of our clients come to therapy already exhausted by heroic but futile efforts to change themselves. We shouldn't further disappoint them by buying into the change agenda. It's ironic that clinicians themselves, when looking for their own therapists, don't usually choose experts in behavioral change. They seek therapists who are known to be warm and kind. Why would we want to offer anything less to our clients? The compassionate attitude has to come first. Kindness is the change agent.
As mindfulness is codified and manualized within our profession, we need to be especially careful not to overlook the primary healing process of lovingkindness. With self-compassion, our patients can bear seemingly unendurable emotional pain. Without it, awareness is barren and lifeless, and can even be harmful.
Christopher Germer, Ph.D., has been integrating meditation into psychotherapy since 1978. He specializes in mindfulness-oriented treatment of anxiety and in couples therapy. He's a clinical instructor in psychology at Harvard Medical School, and is on the teaching faculty of the Institute for Meditation and Psychotherapy. He's also a coeditor of Mindfulness and Psychotherapy.