Zen and the Art of Psychotherapy

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TALKING THERAPY

This is the delightful title of one of the best papers ever written on how psychotherapy works. The clarifying lens of Zen philosophy focuses our attention on common factors that drive change across the different forms of psychotherapy. Its author, Yutaka Ono, MD, is a master clinician most famous for bringing cognitive-behavior therapy (CBT) to Japan.

Ancient Zen precepts, which evolved in China more than 1500 years ago, provide an excellent guide to today's best practice of psychotherapy.

Cherish every encounter. All human encounters are special, irreplaceable, and to be treasured. And few encounters are as meaningful as those that occur in therapy—enriched by unusual intimacy; the sharing deep secrets; emotional catharses; uncovering unacceptable thoughts; and revealing embarrassing experiences. No session should ever be routine, and therapy should never be the slightest bit boring for either participant.

Experience the moment. Every patient contact is a once-in-a-lifetime experience with the potential to powerfully change both the patient and the therapist. This is akin to the Zen concept Ichigo Iche, where "ichigo" means "whole life" and "iche" means "one meeting." Progress in psychotherapy does not occur in small, slowly incremental steps. We never know when something we say will stimulate a great leap forward. So, we must always, in every session, be alert for the chance to create a magic moment.

Change is the only constant. “Life is a series of natural and spontaneous changes. Don’t resist them—that only creates sorrow. Let things flow naturally forward in whatever way they like.”

Lao Tzu (2500 years ago)

Everything is impermanent: your thoughts, your pains, your sufferings, your body, and so on. Whatever we see in our environment was once different and will soon be different yet again. This insight creates the happy expectation that therapy can be life-changing in a positive way. It also helps to reverse hopelessness and demoralization as well as promote acceptance and resilience when confronting life's inescapable losses.

Faulty perceptions. Things are never what they seem because our perception of them is so inherently subjective, self-serving, and fallible. Searching below the surface of our own attitudes and of the external world is necessary if one is ever to see things straight on and apprehend the real meaning of life.

Suffering. There is a radical difference between the experiential approach of the Zen master and the rational approach of ancient Stoic philosopher. But they do share a common understanding, re: how best to manage painful experiences. Both accept that: natural disasters will happen; people are often thoughtless or cruel; we age, get sick, and die; hardships and losses are a constant part of life. We cannot change bad events, but we can change how we react to them by learning acceptance; detachment; meditation; and desensitization via deliberate exposure to painful experiences.

Path to wisdom. Zen is experiential, not didactic. Enlightenment relies heavily on intuition, metaphor, and poetry. The master can point in the general direction toward wisdom, but each person must find their own personal path. One's potential strength lies only within oneself; only what is internally learned is of any importance; and only by one's own personal efforts can it be increased.

Paradox. Zen speaks in puzzling riddles. Here is a typical example: "To study Zen is to study the self. To study the self is to forget the self. To forget the self is to be awakened by all things.”

Life's quandaries often have no ready solutions—we must accept that the only certainty is uncertainty.

Implications

Both Aaron T. Beck, MD, (the founder of CBT) and Albert Ellis, PhD, (the founder of Rational Emotive Therapy) acknowledged the powerful influence of the ancient Stoic philosophers in shaping their theories and therapy techniques. Less consciously, they were simultaneously injecting Zen concepts into basic foundations of the therapy methods they created.

Zen concepts are most explicit and fundamental in Dialectic Behavior Therapy (DBT), as created by Marsha Linehan, PhD, ABPP. Linehan’s faith in Zen practice emerged from her lived experience of severe psychiatric problems during her adolescence that resisted all psychiatric treatments but responded well to Zen. DBT is a happy melding of ancient Zen practice with modern psychological techniques.

But the really great thing about the Zen concepts we have discussed is that they apply so broadly to every clinical encounter: across professions (eg, psychiatry, psychology, general medicine, social work, nursing, occupational therapy, etc); across durations of contact (eg, single meetings that last only a few minutes versus long term therapies that continue for years); and across the 50 schools of psychotherapy.

Every clinician should read Ono's paper—and also periodically reread it—to forever renew the excitement that should always inform our work.

For more on this topic, go to our third Talking Therapy podcast on the importance of magic moments in psychotherapy, which you can view here and listen to here.

Dr Frances is professor and chair emeritus in the department of psychiatry at Duke University. Find him on Twitter @AllenFrancesMD.