Welcome to the Past: Throughout the past one hundred years of modern day psychotherapy there have been many instances when founding fathers and mothers spoke of the need for compassion, caring, and unconditional positive regard in counseling. From Erich Fromm to Carl Rogers therapists have seen the necessity to evoke the heart qualities of presence, caring, mindfulness, using words such as tenderness, radical acceptance, compassion, lovingkindness and even simply, love.

Several contemporary, popular and empirically-validated therapies incorporate acceptance as key components of their approach, such as treating suicidal ideation and borderline personality disorders (Dialectical-Behavior-Therapy); recurrent depression (Mindfulness-based Cognitive Therapy); psychotic delusions and hallucinations (Acceptance and Commitment Therapy); and a number of chronic, mind-body problems and chronic pain issues (Mindfulness-Based Stress Reduction Treatment). What spiritual teachers have known for millennia has now become "mainstream" therapy approaches.

On the other hand, the latest development in clinical supervision is the operationalizing of  evidence-based practices (EBP) at the clinical level. Supervisors are now being trained by the Addiction Technology Transfer Centers (ATTCs) to educate staff, and to implement and evaluate EBPs at agencies. This is good, but the trend has raised considerable skepticism from clinical supervisors, seeing EBPs as "taking the heart out of counseling." Being told that agencies must either implement EBPs or risk losing their state and/or federal funding, resistance has quickly come to the surface.

However, it is not an either/or but a both/and world. We need to utilize EBPs and do so with heart, not losing sight of the healing power of the relationship in counseling. Technique without compassion becomes shallow words. Technique becomes what a therapist uses until the "real" therapist shows up. However, heart without the "head" of techniques can become "feel good" therapy, devoid of skills. Counselors and clinical supervisors need to have skills based in best practices while not losing their sense of caring and compassion for the client. Given the abundance of material written today about EBPs, this article will focus primarily on the other side of the equation, counseling from the heart, mindfulness and presence in therapy.

Thinking with the heart: how it works

Counseling from the heart incorporates a number of specific approaches. The first is a softening of one's response to pain and problems through an invitation to relax. Therapists say words such as, "When you feel discomfort, like you want to take a drink, can you soften that part of your body? Just allow that part of you to soften, if it is ready to."

Second, counselors invite the patient to allow the physical sensations of the body to be just what they are - unpleasant, neutral, or pleasant. "Can you allow yourself to feel discomfort as long as it wishes to linger? Can you just let it be, even if it hurts? You don't have to change it - it will pass at its own time. Just let it come and go as it wants to." The concept of allowing the body and mind to heal naturally are embedded in the Serenity Prayer, of accepting what one cannot change, changing what one can.

Third, the therapist invites the client to recollect a feeling of love that they can redirect to their body and mind. Clients are encouraged to recapture a feeling, a brain state, of lovingkindness. "When in your life did you feel surrounded by love? Can you let yourself now be captured by that same feeling of love? Can you bring that love to the very place where it hurts?"

Lovingkindness and compassion are heart qualities. It is odd that the heart qualities have been marginalized in our profession, seemingly pushed out by the "head" of EBP. But they need not be. Perhaps this is so because heartfulness might not seem as scientific or empirical. In the movie Contact, Jodie Foster is asked if she loved her father? She says "Yes, of course." She then is asked to prove it. She cannot prove that she loved her father, she just knows she did. Love is not a quality that can easily be put into a test tube and quantified. However, as Einstein said, "Not everything that counts can be counted, and not everything that can be counted counts."

Lovingkindness is not a secondary component in therapy but a primary healing element in counseling. Although a sense of love within a patient's life might be an end of therapy, it is also a means to achieve that end. We learn to love by being in relationship with loving people. Transformed people transform people. Thus, when patients have to deal with difficult emotions, lovingkindness is primary and indispensable. By practicing a loving attitude towards self, it allows the client to let go and abide in the midst of suffering with greater equanimity. Patients come to therapy to feel better. Many are just "sick and tired of being sick and tired." They want to become something other than they are, to avoid pain and maximize pleasure. Lovingkindness allows patients to just "be."

Sharon Salzburg, in Lovingkind-ness: The Revolutionary Art of Happiness writes that we are not trying to eliminate what's happening at the moment. We are simply practicing love while in pain. It's the practice of care, not cure, a concept very familiar to those in the addiction field and therapists treating patients with chronic illness.

Bringing love into therapy

Although there are few studies examining the use of lovingkindness to treat chronic conditions (and none so far with alcoholics or drug abusers), it is self-evident to many therapists that a warm attitude can be implicitly useful in all the empirically-validated therapy protocols, such as Lenahan's Dialectical-Behavior Therapy (stressing radical acceptance), Segal's Mindfulness-Based Cognitive Therapy or John Kabat-Zinn's Mindfulness-Based Stress Reduction Program. In my presentations, whenever I speak of lovingkindness and therapy, heads nod and people say to me afterwards, "I have always known the value of love in therapy. I know it works and is important. Hearing you say it validates all I have ever thought about therapy." And now we have solid scientific evidence that neural attractors in the limbic system of the brain contribute greatly to attitudinal and behavioral change (see A General Theory of Love, by Thomas Lewis).

When people feel bad about themselves, a central quality of most substance abusers - self-loathing, shame, guilt, self-doubt - they need an antidote at the same gut level of feeling. They need love. Quoting Jeff Georgi, "What we need to see is that the love hungry brain will, by necessity, find satisfaction either in drugs or in relationship." Substance abuse patients come to us already exhausted by heroic but futile efforts to change themselves. (It is an interesting reflection that studies have shown when therapists seek their own therapy for their personal problems, they don't usually choose counselors expert in behavioral change alone. They seek therapists who are known to be wise, warm, kind and loving). If that is the case, why would we offer anything less to our patients? An attitude of compassion from the therapist herself is the beginning. Kindness is the change agent. Remember the old maxim, people don't care how much you know until they know how much you care.

Conclusion

Clinical supervisors in the next few years will hear a lot about the need to implement EBPs in their agencies. This is good. We need to utilize scientifically-proven best practices. The challenge of supervisors will be to train staff in EBPs while retaining an attitude of caring, compassion, and lovingkindness. Clinical supervisors have a big task ahead of them to do so - but that's why supervisors get paid so much (yeah, right). 

Eventually mindfulness will be empirically studied and codified into our profession alongside of EBPs. Supervisors need to be especially careful not to overlook the primary healing process of love while teaching EBPs. It's a both/and world. However, counselors must begin with self-compassion and self-love. Then our patients can bear seemingly unendurable emotional and physical pain and craving. First, doctor, heal thyself!

This article is published in Counselor,The Magazine for Addiction Professionals, December 2006, v.7, n.6, pp.18-19.

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