WillSpirit!

Readers might suspect me of forgetting my pledge to discuss Acceptance and Commitment Therapy. But although the last essay never mentioned it, the topic of how we respond to grief is highly relevant to ACT. The connection was implicit in the last paragraph: All the questions and recriminations with which we torment ourselves after the death of a loved one are products of language.

ACT emphasizes how verbal thoughts can interact with feelings to obstruct our pursuit of values. Let’s take my mother’s death as an example and see how this works.

As mentioned last time, my mother died in a psychiatric hospital after battling depression for years. That much is factual. But my mind has never been satisfied with the documented information.

A big question for me has always been: Did she commit suicide? Factually, I cannot know for sure. She died several days after admission to the hospital. I’ve long suspected she overdosed on her many medications, and tricyclic antidepressant toxicity can sometimes cause death after a long delay. So it is possible that she took too many pills and died of the effects. On the other hand, no family members who were adults at the time have ever concluded my mother took her own life.

Even if my mother died of natural causes, she wanted her life to end. At home, she prayed out loud in petition for death. She spent her time alone in a darkened bedroom, displaying little interest in her children. So regardless of the facts, her death felt like a suicide to me.

And I was left without a mother whether or not she deliberately ended her life. In a very real sense, the ‘truth’ doesn’t matter.

Even so, the truth or falsity of suicide has obsessed me for most of my life. An answer would have made no difference in any material aspect of my life. It wouldn’t have changed how my stepmother mistreated me. It wouldn’t have made my father into a better parent. It wouldn’t have prevented my sister’s death from alcoholism. Only in my mind could the answer have exerted any influence.

And that’s exactly the point. The idea that my mother killed herself altered my world view and worked against my happiness. The (unproven) belief that my mother committed suicide fueled deep-seated fears that she didn’t value me as a son. I felt unlovable, which drove me to sabotage friendships and spurn viable romances. A toxic belief augmented by distressing emotions led to avoidant behaviors that limited me for decades.

This would be one interpretation under ACT; other psychological models might view the situation differently. But without doubt, thinking that my mother’s death proved me unworthy undermined my behavior in relationships.

Although it’s useful to inspect and challenge my beliefs, what’s needed even more is practice in relating effectively with others.

Admitting that my mother might have died of natural causes won’t suddenly make me feel worthy. My mom’s actions toward the end of her life transmitted the message that I had become unimportant. The implications became deeply ingrained. My obsession with knowing “the truth” has perhaps been a quest for validation of the insecurity bequeathed by the waning interest in motherhood that preceded her death. (Note how thoughts and feelings are in constant interplay; it isn’t simply a case of one leading to the other.)

One tenet of learning theory is that we build on what came before; we never truly forget anything that carries psychological weight. The feelings of unworthiness stirred by my mother’s death will always remain a (hopefully diminishing) part of me, even as I gain a mature understanding of my importance to others. And yes, that sense of consequence can be fostered, but only if I take the necessary risks and create friendships.

The critical question becomes: How do I act in the face of negative expectations and painful feelings? Can I still reach out to others even if my love was insufficient to sustain my mother’s life? Can I take the risk of rejection despite how much it hurt to lose my mom? Can I remain in friendships even if they sometimes dredge up feelings of abandonment? Can I resist the urge to flee when the awful fear of loss arises?

Only by reaching out despite my dread of rejection will I reclaim my worthiness and begin to feel better around others. Only by taking chances will I find community. Only by sticking with relationships even when they hurt will I discover love. Only by acting effectively despite my obstructing thoughts and challenging feelings will I build a meaningful life.

How we perceive a situation, and how we feel about it, aren’t as vital as how we act. We can move toward what we value no matter how bleak our thoughts or how painful our emotions. This is the message of ACT that has so decisively improved my life.

To be alive is to be vulnerable, but to be human is to be sensitive in ways undreamt of by other creatures. All life forms are prey to death, loss, illness, and injury. But people also fear disappointment, ill-repute, and injustice. As was touched on last time, our values make us susceptible to considerable pain.

The most obvious and universal value is love, and it inevitably brings grief. No one we love will be with us forever, and except for those rare cases of simultaneous death, one lover always passes from this life before the other. The result is grief. No one who lives beyond youth escapes it, and many children suffer it too.

When I was five years old my grandfather died, and a beloved dog was stolen, never to return. I learned two flavors of bereavement that year. In the first case, I felt remorse. My father’s father seemed to me a frightening and humorless man. He often yelled at me and my cousin and never played with us. We made fun of him behind his back. When he died after a bad car crash, I couldn’t forgive myself for my disrespect. If only I could have gone back and behaved better, learned to love him more and tried to understand him.

The loss of the dog was tragedy tainted with guilt. My mother had received threatening notes about our pet, saying we would lose Inky if he continued barking and escaping into the neighborhood. After he disappeared, I never saw him again despite multiple trips to the police station and dog pound. I felt miserable, inconsolable. I also felt at fault; I might have forgotten to latch the gate. I should have been more careful.

These early losses were preludes to the major bereavement the following year. My mother had been suffering with severe depression after a painful divorce, cycling in and out of psychiatric hospitals, and openly wishing for death. Then one day she failed to return from her confinement for shock treatments. Her parents told everyone she died of natural causes, but suicide seemed a more likely cause of death given her oft-stated desire to die and her otherwise good health at age thirty-seven. It seemed obvious that she had taken her own life, a fact I understood even at age six.

That grief was unspeakable, shameful and untouchable. I felt crushed and utterly without hope. When our family moved to another town, I pretended my stepmother was my real mother until the woman’s cruelty toward me in front of my friends forced me to admit my mom had died. But even then I never named a cause of death. It was an awful, lonely secret. And as I hid the facts, it seemed as if I were betraying the only person who ever truly loved me.

There’ve been many losses since, of course. Three more grandparents (two of whom were almost like parents to me), a father, a beloved uncle, a remarkable cousin, a stepmother (whom I both loved and hated), two of my best friends (one to suicide), a number of other relatives, and then (just last year) my sister and only sibling. Each time there has been pain, regret, guilt, questioning, lost dreams, and hopelessness in varying combinations.

Grief is universal, as is the fallout from it.

Each loss feels different. If it comes with advance warning the death seems easier to bear than if sudden. If the person led a joyous life one feels less regret than if they were unhappy. If the relationship was harmonious there is less guilt than if otherwise. If nothing could have saved the loved one, there are fewer questions than if things could have gone better. If the person died elderly and frail, near the end of life with little opportunity for joyful experience, there is less sense of tragedy. And if the person was someone we spoke with rarely, someone with whom we only occasionally shared hopes and dreams, there is less sense loneliness and isolation.

Each grief is different because each relationship is unique, with its own special meanings. To lose a mother to suicide at age six is different from losing a sister to alcoholism at age fifty-three. Both losses are painful, but they are not the same. Death baffles a young child, and to be motherless is to be cut adrift in an unfriendly world. But one feels torment watching a loved one choose to continue a deadly habit despite constant warnings from her own body and protestations of love from those nearby.

To lose a child, they say, is the worst bereavement of all. Myriad hopes and dreams get crushed. The wish that one could have protected the son or daughter must forever haunt. I don’t know the experience of losing offspring, but just watching my pomeranian get killed by a large dog on the beach gave me a taste for how wrenching it can be to see a being you’ve nurtured from birth die while you are powerless to protect. I can’t imagine the far greater pain of losing a human child.

My father died suddenly, robbing me of the chance to offer the many apologies and praises he was owed. I would have loved to forgive him, too. So much regret. Hardly a day goes by that I don’t wish he were here for one last conversation. How many of us share such remorse?

And on and on.

My aunt lost her husband of six decades about two years ago. Talk about an unspeakable loss. I’ve been with my wife but twenty years and already feel so bonded that life without her is inconceivable. To overcome such a separation must be one of the greatest challenges of human existence.

But people move on after even the most painful losses. How do we overcome grief? By filling in some of the holes in our lives and making peace with those that remain. By forgiving ourselves and others. By recognizing the universality of suffering and bereavement. By finding faith in something greater than daily life with its bills, chores, and frustrations. By learning who we are without the beloved by our side.

I can offer very little here. Through the losses I’ve endured I’ve learned only one certain thing: grief lessens with time. It never ceases, but its horrible early sting dulls a bit, and one is left with a gnawing ache rather than a gaping wound. People regularly go forward after even terrible bereavement. What choice do we have?

Values bring vulnerability, and love brings the greatest vulnerability of all. Animals have been known to grieve; elephants in particular are recognized for behavior that looks like mourning. But it is unlikely that elephants imagine what life might have been like had the beloved survived. I doubt they feel regret for past acts or wish they had acted more protectively. I doubt they wonder if life is worth pursuing anymore.

All the questions and recriminations with which we torment ourselves after the death of a loved one are products of language. They are human constructs without counterpart in nature. Perhaps we would be happier if we experienced life and death like the animals who, while capable of genuine love, live mostly in the moment without vivid and unstoppable imagination of past, future, and better outcomes.

We all hope to pursue certain directions in life. We may not always admit how much our values affect us, but they greatly influence our thoughts, emotions, and actions.

The person who makes a mistake and loses a cherished job feels shame. The mental obsessions that surround the shame may center on what went wrong, on the boss who couldn’t tolerate errors, or on the spouse who will be disappointed. Despite these different thoughts, the shamed response is driven by the conviction that doing a good job is important. Mistakes matter because the work matters (consider a surgeon who made a dreadful error—he or she is concerned about the patient’s outcome, not just personal consequences). Performance matters because work well done brings social approval, which is painfully lost when the boss fires a failing worker. Employment matters because material support keeps family fed, clothed, and sheltered. But most of all, work matters because it is a central value in the lives of most people.

If the job is lost because of addiction, then the addict feels shame about his or her dependence on substance use. But the shame remains driven by the underlying value: useful work.

If the job is lost because of agoraphobia, the anxious person feels shame about the emotional vulnerability that makes leaving home difficult. But again, the shame is driven by the value.

This description is an oversimplification. Making mistakes, suffering addiction, and feeling controlled by fears lead to many negative self-appraisals, some of which seem independent of external consequences. The self-criticism may echo punishments from childhood or internalized societal judgments. But the primary reason we feel badly about such problems is that they undermine what we consider meaningful and valuable.

Our values make us vulnerable. If a certain valued domain has not been pursued effectively, we may resist even acknowledging its importance. For instance, after my surgical career collapsed due to neck problems, it wasn’t long before even thinking about my old work felt terribly painful. Accusations arose whenever I considered what had been lost: Why didn’t I wait longer before quitting? Could I have found ways to deal with the pain and keep operating? Why did I choose a surgical specialty in the first place, when my neck was hurting already? Although motivated by regret, these thoughts steered me away from looking squarely at how much I’d lost. Rationalization served the same end: “There were many things I didn’t like about that job;” “I didn’t have a surgical temperament;” “I should never have chosen to train in that field.”

This inner dialogue, with its accusations and justifications, kept me from simply experiencing a terrible loss. It kept me from feeling grief. My frantic mental striving to avoid the sorrow shows how much the career truly meant to me.

If feeling useful in an occupation hadn’t been so important to me, early retirement would not have stimulated such distress. If it hadn’t been for the value, there’d have been no vulnerability.

When life serves up too many setbacks, cynicism becomes a tempting response. It certainly protects us from facing our values and feeling the pain they cause. If I give up on ever succeeding at anything ever again, I don’t have to fight the fears, uncertainty, and inertia that stand in the way of my trying. If I say work no longer matters to me, I don’t have to feel badly about not working? Isn’t that right?

No, in fact such cynicism just substitutes unconvincing rationalizations and anxious avoidance for the more empowering choice of looking squarely at a value and figuring out how to pursuit it under current circumstances. Maybe I can’t work as a surgeon anymore, but I can blog. Does a blogger enjoy the same status, money, and accomplishment as an oculoplastic surgeon? Not even close. To compare the two activities on any of those dimensions would be laughable. But does blogging help me feel like I’m making a contribution? Yes. And so it furthers my value of working to help others. Taking small steps in a valued direction is better than taking no steps at all.

Blogging has helped me feel effective again. As a result, I was able to try my hand at acupuncture. Writing a book begins to seem plausible. If I had chosen cynicism and stasis, my ‘work is important’ value would have languished and I’d have made little forward progress.

While writing about the Acceptance and Commitment Therapy (ACT) stance on values in the last post, I imagined the discussion might distress some readers. One person might see himself mirrored by my example of staying in bed rather than socializing. Another might feel anguish about the way her workaholism degrades relationships. Others would recognize destructive consequences of addictions. And in looking at the effects of problematic behaviors, they would feel pain.

This pain is exactly what we feel when we value a life dimension highly, but our behaviors sidetrack us from its pursuit. It is the vulnerability that comes with caring. Just as they say, “grief is the price of love,” vulnerability is the price of every value.

The natural response can be to turn away and not look at how we’ve abandoned some of our values. But there is more vitality in sitting with the pain of our choices and acknowledging that regret highlights our priorities. We can then start working toward valued directions in whatever small ways we can.

Engagement, not avoidance, is the answer.

When a post gets lots of comments, a blogger feels gratified. There’s a sense of reaching people, of making a contribution, of being part of the global conversation. It’s tempting to leave the post with the high comment count in the top position for a long time, so new visitors will get a sense of vibrancy from the site. Sometimes, one even contemplates quitting while ahead.

But none of that explains why it’s been a few days since I’ve posted. Mostly, I’m recuperating from my recent hospitalization and all that followed. I’ve spent time emailing, answering comments, and working on some other projects, but I’ve also been resting. After writing posts almost daily as an inpatient, a break felt necessary.

Even though I’ve been writing less, the decision I’ve made to expound upon Acceptance and Commitment Therapy (ACT) has been on my mind. Writing about ACT feels like the most valuable blogging direction I’ve headed in a long time, mainly because the method has helped me live more effectively than ever before. As I’ve worked on my emotions and moods over nearly forty years, I’ve tried many therapies, spiritualities, and activities, but only with ACT have I seen robust improvement. Part of ACT’s effectiveness in my case may be due to the groundwork laid by earlier practices, but there’s much more to it than that. I therefore feel called to help popularize the approach.

The last essay talked about how hardship can become enriching when we find meaning within it, which is a central theme of ACT. I also pointed out that some people have trouble bearing up under life’s burdens, by which I specifically meant they die due to poorly chosen coping strategies. Suicide, and death caused by substance abuse, seem like clear signs of failure to manage life effectively.

But does addiction, by itself, mean a person is living poorly? Does chronic depression? Workaholism? High anxiety? Extreme sensitivity? Low self-esteem?

In evaluating these questions, we come to ACT’s emphasis on values as one of the six dimensions of psychological flexibility, and hence wellness.

Which brings us to perhaps the most important question we face: what makes living valuable? It’s worth putting some effort into this one, and in fact we each work with it daily. Every time we choose one action over another we create consequences. These effects can either be in line with our highest values, neutral toward them, or in opposition.

If we feel depressed and stay in bed rather than going out with friends, we are choosing a mattress over companionship. Since most of us value social connections, this is an act that opposes a widely held value.

If we drink ourselves into a foggy, detached haze we are choosing the haze over true, present connection with those around us. There may be a boozy sense of conviviality, but our interpersonal communication is shallow compared to what we’re capable of when sober. If we consider intimacy important, drinking opposes our value.

Work may be so consuming that we seldom spend time outdoors, or in museums, or having fun. We might let our dogs frolic beside us as we walk through an open landscape every day, but we ignore both canine joy and natural wonder because we never stop thinking about our projects. In this case, we are choosing work over beauty. Productivity may be valuable to us, but in our excessive pursuit of it we neglect other values, such as play and aesthetic appreciation.

We may feel so anxious, sensitive, and insecure that we turn down opportunities because we’re afraid of the pain that comes when we expose ourselves in front of others. If so, we choose stasis over effective action. Since most of us want to feel useful, the overly self-protective stance undermines our value.

Do you see how this works? It isn’t a question of judgment about who succeeds and who fails. It’s a personal, moment-by-moment process of choosing whether to further our values or abandon them.

Of course, we can be confused about what we truly value in life. My father enjoyed drinking so much it looked like one of his most important priorities. But I think what he truly valued was feeling free-spirited and playful. With just a few drinks his mood lightened, he became jovial and funny, and a mischievous smile erased his chronic worry lines. The initial two or three glasses served his value of seeking relaxed, happy companionship.

Unfortunately, he never stopped with those first drinks; he kept imbibing. Inevitably his mood became pugnacious, his humor sarcastic, and his grin morphed into a contentious grimace. I often imagined filming his behavior and showing it to him the next morning, when he seemed to have no memory of having undermined and insulted all who came near.

I don’t believe he valued the end consequences of his drinking, but he only recognized the early benefits. He remained oblivious to his alcoholism’s true effect on his family and friends.

Values, according to ACT, are freely chosen. Remaining in bed while depressed is not freely selected; it feels forced. Substance abuse, as anyone in addiction recovery can attest, loses the quality of choice and becomes compulsion. The workaholic doesn’t strive out of spontaneous, joyful pleasure in producing; he or she feels driven.

Deep down, we each know when we are right on track and when we are flying of the rails. We neither need nor want others to make this judgment for us.

Looking at the consequences of behavior is helpful to anyone who wants life to feel meaningful. Every action creates effects (as embodied in the Hindu/Buddhist concept of karma); if we allow moods, addictions, compulsions, or fears to drive our choices we reap consequences that often feel lifeless or destructive. But if we choose our values carefully, and do our best to act in service of them, we build lives of vitality and contribution.

God never gives us more than we can handle.

IMHO, this famous saying speaks nonsense! Consider that between preschool and first grade I watched my mother slowly wither away and then die from depression after a painful divorce. Consider that my sister recently succumbed to alcoholic liver disease after drinking against her pain for decades. Consider that I’ve watched friends destroy themselves in various direct and indirect ways, or that countless patients of mine suffered from self-inflicted wounds and diseases that finally killed them. If you weigh all that evidence (plus any of your own you’d care to add to the mix), you’ll recognize that life overwhelms many people; they cannot endure the hardship and pass from this world in misery. Where is the evidence to suggest that the universe serves up only ordeals we can handle?

On the other hand, there is no trauma or loss so severe it cannot be transmuted into something valuable. The fact that many people never effect such alchemy does not negate the truth that many others do. Transcendence of suffering is always within our reach, though we often don’t know how to grasp it.

Once I viewed a YouTube clip that showed psychiatrist Viktor Frankl talking with a young man afflicted with quadriplegia. This youth described in convincing terms how he gained meaning and insight through his devastating injury. Perhaps only a few paralyzed patients embrace their fate with this level of acceptance, but at least one did, so it must be possible.

Acceptance and Commitment Therapy (ACT) practitioners feel great fondness for Viktor Frankl, by the way. His most famous book, Man’s Search for Meaning, describes the inhuman conditions he endured during his interment in a Nazi concentration camp. The prisoners suffered cruelty and privation that far exceeded the trials most of us complain about in developed nations today. And yet, when Frankl saw an opportunity for escape, he deliberately chose to remain so he could look after his patients in the rudimentary medical ward. With that act, he ceased to be a prisoner and became a voluntary servant of humankind. Are we not told that Jesus elected to suffer and die for the benefit of humanity? Frankl adopted a Christlike stance and sacrificed his own safety and welfare in service of others. A miserable predicament became a source of Grace.

During an early session, my ACT therapist told me about Frankl’s discovery of meaning in what most would consider an unbearable situation. The story affected me very little at first. For years I’d looked at myself as irreparably damaged by the despair, bereavement, chaos, and cruelty of my formative years. Frankl’s tale sounded like a rare exception to how people ordinarily respond, and I assumed his upbringing must have been exceptionally supportive. In short, I imagined him as almost a different species: the kind of human produced by a perfect family. Note that I dreamt up this myth without any evidence one way or the other about the man’s childhood.

After a year or two I finally broke down and read Man’s Search for Meaning, and I finally got the point. By that time I was starting to release my grip on the inflexible belief that my personality had been ruined at an early age. An inner transformation of cruel circumstances into tender and meaningful experiences was manifesting in my own life. Since my childhood surely counts as traumatic, I had to abandon the conviction that early mistreatment dooms a person to a lifetime of pointless suffering.

Although my upbringing exposed me to more loss and danger than most, I grant its advantages were not insignificant. My father’s intelligence was passed on to me genetically, and his love of learning came to me as he informally taught me about science, history, and politics over his morning coffee. Although my dad’s household was otherwise dismal, every summer I spent time in other settings where there was more love and freedom. And I understand that in my first year or two of life, before the divorce and my mother’s depression, my mom treated me with boundless tender affection.

But is it not the case that every person is exposed to both positive and negative influences during childhood? I’ve met many people over the years who came from horribly damaged households, and every one of them had unique strengths. And each had enjoyed at least some positive childhood experiences. Every person’s task in life is to build on assets and transform deficits, and we each will find both in our ledger.

So no, God does not protect us from being crushed by fate. But everyone has the potential to bear up under life’s pressure. We need guidance, support, and perseverance, but transcendence can be achieved. In my own case I see this especially clearly in the aftermath of my recent painful and life-threatening illness, with its continued discomfort and limitation. Despite a situation that might once have reduced me to quivering defeat, I stayed fairly upbeat throughout by maintaining a perspective of open-hearted curiosity. I can honestly say that the experience feels positive, on balance, despite the hours of painful vomiting, the indignity of prolonged medical procedures, the uncertainty about my future, and the possible demise of my acupuncture practice. If this wounded soul can rise above the mire of suffering, I believe anyone can, with practice and proper instruction.

Ever since the Enlightenment, Western humanity has been operating blindly. As Christian theology retreated before material science, people were left with few wise resources to help them cope with hardship. Only during the past fifty years did the West begin to awaken to Eastern meditative traditions, which have consistently offered effective recipes for transforming suffering. These practices do not depend critically on metaphysical claims that contradict conventional scientific theory, and so have helped fill the gap opened by a weakened Christianity. (It may not be coincidental that these practices first originated in India, where the populace has a long history of privation.) But until recently in the West, instead of wisdom we’ve been served up a hodgepodge of unproven psychological treatments and potent but ineffective drugs. Eastern philosophies don’t appeal to everyone, and choosing among the numerous strains can be confusing.

Fortunately, the scene is improving. To my eye ACT is one of the most promising and well-developed therapeutic approaches currently available, though there are many hopeful emerging paths. With these techniques, which combine the best of Western and Eastern knowledge, more and more of us will begin to find hardship enriching rather than merely punishing.

After years of advocating Acceptance and Commitment Therapy in passing, I’ve decided to devote some essays to talking about it more directly. Although I believe readers will find the discussion helpful, my decision isn’t entirely altruistic. By writing about the basic features of ACT, I’ll come to better understand them myself. And since I’ve started reading ACT literature directed at therapists rather than just the books meant for laypeople, this extra effort is needed as I sort through the dense technicalities that get glossed over in self-help tomes.

But it’s also becoming clear to me that of all the paths I’ve explored in service of achieving mental peace, ACT presents the most coherent, modern, and well-substantiated approach.

The Eastern spiritual traditions offer much of value, and ACT draws from them. But if one takes up Buddhist meditation, for instance, one is confronted with a vast body of scripture and commentary that varies in both philosophy and practice. As just one example, consider the confusion about mindfulness versus concentration meditation. Some writers go to great lengths to separate mindfulness (which they define as undirected awareness open to consciousness as it evolves) from concentration (the practice of focusing attention on one aspect of experience, such as breathing). Other authors use the word mindfulness loosely, so that it can mean either unguided consciousness or focused attention. This isn’t a criticism of Buddhism; such inconsistencies always arise in ancient traditions that have evolved in a multitude of times and places. But they can slow the process of finding peace of mind.

A less elaborated, more coherent practice like ACT has the advantage of allowing one to jump on board and immediately begin to recover from emotional distress. You don’t need to choose among various sects of ACT or worry about loyalties to tradition.

Plus, although ACT could be dovetailed with a variety of spiritual practices, it operates from an unwavering agnostic stance. No verbal statements about the ultimate nature of reality will be found in the ACT literature. In fact, most ACT practitioners would consider any language-based metaphysical hypothesis as rather hazardous, since excessive fusion with symbolic thought is itself a big part of our problem. This isn’t an atheistic take on reality, it’s a nonverbal one. I find it refreshing to escape the debate about ultimate Truth, and I believe ACT to be both compassionate and inclusive in its refusal to take sides. This is modernity at its best: open-minded, non-judgmental, and welcoming.

Finally, although the buzz-phrase Evidence Based Medicine has been abused, there is value in documenting the effectiveness of recommended practices. ACT has been developed with a constant eye toward substantiating its claims with appropriate research. This makes it easy to get behind its techniques: they’ve been demonstrated to work in a variety of conditions, settings, and populations.

Let me end by apologizing for the expositive tone of this introductory essay. As this series goes forward and explores ACT further it will downplay dry, theoretical language. My plan, instead, is to show how ACT concepts work in my day-to-day life. When I look back at the WillSpirit posts that generated the most meaningful commentary, they were the ones that dealt with difficult emotional issues from a personal and heartfelt stance. People seem to appreciate when my writing describes my actual experience rather than mere thoughts. I hope to bring this intimate quality to my discussion of ACT in subsequent posts.

Ever since my first hospitalization I’d had trouble reading until just yesterday. Maybe the medications interfered, or the stress, or the exhaustion. Finally, however, my ability to track and absorb text has started to return.

Last night I read the early chapters of Mindfulness for Two, by Kelly C. Wilson. This book for clinicians describes key elements of Acceptance and Commitment Therapy (ACT—pronounced as one word), which I’ve mentioned many times on this site. It’s helpful for me to learn the more technical aspects of ACT now that I regularly apply the basics to my mental life. And acquiring this information while recovering from a major illness makes sense, since I’m working through a lot in the aftermath of falling sick. ACT concepts offer guidance as I sort out some major decisions and changes.

Wilson begins with a nice meditation on the universality of suffering. This might sound Buddhist and no doubt derives influences from that source, but the focus is on concrete clinical situations rather than the global human dilemma. Plus, as one reads further one sees how the ACT recipe for alleviating distress differs from the Buddhist approach. In my opinion, ACT redefines suffering so that much of what we normally consider undesirable gets embraced. Thus, intense feelings of fear, loathing, grief, and longing are not viewed as afflictions to be banished, but as transient mental states to be experienced with open heart.

The causes of these inner fluctuations are considered less important (from a clinical standpoint) than their effects. Do intense states interfere with pursuit of valued activities? Do they prevent intimacy or block creativity? ACT emphasizes such pragmatic questions over the theoretical musings we often associate with psychotherapy. (Does fear of intimacy arise from ambivalent attachment style? Is creative work resisted in order to avoid success and exposure?)

Compared with Buddhism, ACT devotes less attention to problems of attachment in the worldly sphere. Whereas Buddhist teachings train us to recognize material impermanence and so relax our grip on circumstances, ACT highlights the continual fluctuation of mental states and allows us to experience inner distress with less sense of alarm. We may feel just as much grief as ever, but we feel less traumatized by the experience because we understand it better. Whereas a Buddhist teacher might suggest we let go of our mistaken expectation that beloved persons will endure forever, an ACT therapist would encourage us to openly face the sting of loss but remain committed to bonding passionately with others.

There is a great deal of overlap between Buddhist and ACT approaches, and neither method is superior to the other. I’ve heard Buddhist teachers endorse openness to emotional flow in terms that would fit nicely in Wilson’s book, but in general Buddhist teachers guide aspirants more in the direction of affective detachment rather than unresisted emotional engagement.

The best approach is to develop sufficient flexibility and repertoire to mix and match strategies depending on circumstances. In the case of affection and grief, it makes sense to recognize that everyone we love is mortal and all relationships must end, but healing is promoted when we also honor the heart’s fearsome spasms of sorrow after death intrudes.

For those of us who’ve spent years battling intense emotions, it’s a relief to learn that we can drop our ineffective defenses and allow feelings to flow more freely. They are not incompatible with successful, meaningful life.In fact, emotional currents enhance most every aspect of human experience, provided we can ride the turbulence while continuing to channel our lives in valued directions.

Perhaps I will continue to muse on the key points in Mindfulness for Two during coming posts. Although ACT is best learned experientially, it also helps to understand the philosophy that underpins it. And exploring the interplay between ACT and other traditions enriches my own understanding of a therapeutic approach that has proven decisive on my road to stability and acceptance.

Long ago I suffered what is sometimes called Medical Student Syndrome. When aspiring doctors begin to learn about the human body and the many ways it can fail, they often become hypochondriacs. At one point during medical school I self-diagnosed a small cyst as testicular cancer. Several times I felt short of breath and feared various respiratory diseases. And for a long time AIDS seemed a near certainty despite my very low risk for the disease.

The AIDS paranoia wasn’t surprising, since I started medical training in San Francisco in 1983, when the disease was widespread, completely unstoppable, and largely mysterious. I diagnosed it many times in guys exactly my age, and I felt awful watching terror dawn in the eyes of these unfortunate men. Scores of my patients died of AIDS over the years.

The worry about my lungs arose from my previous history as a heavy marijuana smoker. I gave up that pernicious habit prior to starting med school, but I feared lung cancer and breathing disorders for years afterward. (And as you’ll soon read, I suffered a couple of serious respiratory problems growing up, which probably primed this anxiety.)

The testicular cancer scare may have arisen from childhood mistreatment inflicted by my stepmother. After my sister moved out when I was eleven, my parents began hosting ‘free love’ parties, so the household became highly eroticized, exhibitionist, and unsafe. At the same time, my stepmother often humiliated me with emasculating language, and she sometimes intruded on my dressing and showering. My guess is that the combination of inappropriate sexual exposure during my preteen years and constant attacks on my budding masculinity caused heightened castration anxiety; Freud would likely agree.

This morning I’m looking at my current and all-too-real illness from the perspective of my earlier imaginary afflictions. As you can see from the above, hypochondria doesn’t occur randomly, but focuses on those body parts most loaded with personal meaning.

Could actual diseases come with symbolic baggage just like imagined ones do?

Most of my current pathology centers around my pancreas, which may be the organ ancient Chinese physicians had in mind when they spoke of the spleen. In Chinese terms the spleen (pancreas?) is considered an organ of digestion. It suffers breakdown under conditions of intense study and excessive worry (which are looked at as forms of mental digestion). During the past two or three years I worked hard to learn acupuncture, and I fretted almost non-stop about the difficulties of building a clinical practice. It wouldn’t be surprising, from a Chinese perspective, that something went wrong with my spleen/pancreas.

Or consider the fact that my sister died last October of liver disease. She suffered abdominal pain and her pathology was in the same general region as mine. Could there be an element of sympathy in all this?

But how could study, or worry, or sympathy cause a ligament to close off a major artery and lead to all my subsequent problems (e.g., internal bleeding and intestinal obstruction)? The underlying cause seems so simple and mechanical, it appears to lack the potential for subtle progression that could connect these putative causes with the known pathology.

Perhaps it would make more sense to look at the effects of the illness rather than its origins. For one thing, my sickness may very well terminate my holistic health practice. There’s a limit to how long I can afford the office expenses while the business sits closed, so if my incapacity goes on too long I’ll need to look for someone to assume my lease. Maybe this disease will force me to concentrate on writing and speaking rather than hands-on healing. Is this divine guidance or just bad luck?

Another instructive tack is to look at my relationship with illness in general. Back when my mother was suffering her many cycles of depression, hospitalization, and shock treatment, my childhood needs tended to get neglected. One of the few times I remember being the center of attention was when I spent weeks on a pediatric ward (under an oxygen tent) because of pneumonia. A few years later I sprained my ankle falling off a swing, and I continued to limp even after the pain had receded, simply because my mother acted concerned about me. Feigning injury seemed like a great strategy until my mom’s doctor friend called me on my ruse, and I felt ashamed.

Fast forward a few years and consider how my stepmother treated me when I fell sick. She hated to waste her time taking me to the medical clinic and always accused me of faking. For instance, when I was about twelve an attack of pleuritis made me cough vigorously with nearly every inhalation. My stepmother thought me exaggerating even as I neared frank exhaustion. Years later, in high school, I never told my family about symptoms of mononucleosis until a staph infection covered my entire tongue. I’d learned no one would believe me anyway.

Given these early illness experiences, is it a surprise that my initial reaction was one of relief when the first CT scan showed a liter of blood near my pancreas? I had awaited the result afraid the doctors would conclude I was exaggerating the discomfort of simple cramping or gas. Rather than feeling alarmed that something ominous had occurred, I was glad to be vindicated in my complaints of severe pain.

Well, this essay has gone on about as long as I like to let my pieces run, which is to say a lot further than the average effective blog post. And yet, there doesn’t seem to be any clear progression or larger point being made. But maybe I can wrap things up like this: everything we experience connects with history: our professional history; the world’s intellectual history; our childhood history. Nothing happens that can’t be interpreted in light of what’s come before.

A few posts back I emphasized how much value I find in mining experience for meaning. This doesn’t always yield lessons that are clear and unambiguous. For me, at least, the point isn’t to figure out why my life has unfolded as it has. Instead, I look at it as a sort of living poem that is open to various interpretations and can be seen from a multitude of perspectives. Like any good drama, it doesn’t offer pat answers, but it does offer food for thought.

We should always remember that our viewpoint is limited, and that others see the world differently. Of course we all know this superficially, but it remains easy to mistake personal values for eternal truths. Recently a discussion with a close friend forced me to face how enamored I’ve become of my moral system, and how it actually represents mere opinion rather than cosmic imperative.

In my writing I frequently emphasize unity as a basic feature of creation, and humility as a sign of maturity. It seems self-evident to me that all beings are so closely linked as to be essentially unitary. It also seems obvious that the wisest response to this reality is to treat other human (and animal) lives as equal in value to my own.

How easy it has been for me to avoid recognizing this as a minority opinion. Our Western culture runs on the engine of competition, which is powered by the twin assumptions that some beings are more valuable than others, and that gifted and driven (i.e., better) people deserve whatever they can grab of the earth’s resources. In the world at large, little more than lip service is given to the fact that a person who is superior at competing can be inferior in many other ways. Policy gets determined by neo-Darwinian thinking.

Over a year ago my friend and I had a conversation about humility. This man has helped me in many ways vital to my current state of mental and spiritual stability. He advised me on my moods and my meditation. He introduced me to venerable mystical traditions that I’d previously ignored. I look up to him as a mentor and a teacher. And yet I also see areas where my understanding seems to exceed his own. So when the subject of humility arose, I decided to explain what Alcoholics Anonymous and other sources have taught me about its value.

In the time since, I learned the day after leaving the hospital (the first time, back in January), this friend gave my input much consideration. He thought about it from the points of view of traditional spiritual wisdom and modern utilitarian ethics. He contemplated whether adopting a more humble stance would help him grow or change him into someone he could never respect. In the end, he completely rejected humility as a trait worth pursuing.

After he told me his conclusion, I tried to reexplain what being humble implies, so that he would understand that it doesn’t rule out self-esteem, or honest valuation of personal gifts, or taking a strong stance. It seems impossible to me that anyone could deeply comprehend this concept and still dismiss it.

But the fact is, what seems impossible, isn’t. My friend’s logic is sound if one accepts modern values. He cited Steve Jobs as a prime example of a person who was anything but humble and arguably achieved greatness as a result. He pointed out that Jesus Christ didn’t hold back from naming himself the only Son of God (if we believe the gospels’ rendering of Christ’s words). If one of the greatest spiritual leaders of all time refused to act humbly, why should anyone?

There are many valid arguments that challenge my friend’s position. Christ apparently believed himself the literal Son of God, so his claiming the title was mere honesty, not arrogance. Plus, the most enduring Christian teachings emphasize collective welfare over personal glory. A doctrine of self-aggrandizement may have worked in past epochs but is disastrous in the current era of shrinking resources and exploding population. I brought many such objections to bear on the debate that waged between us.

Still, a debate is nothing but an exchange of words, and words can never pin down ultimate truth. What’s more, there is no validity to my claim that humility is inherently superior to arrogance. It may offer healing to a wounded world. It may be conducive to social harmony. But it cannot be proven to be a cosmically sanctioned quality. Indeed, there may well be situations where humility undermines genuine human or even spiritual progress.

It’s even worth asking whether my own attempts at replacing my former pridefulness with genuine humility is actually an outgrowth of the low self-esteem that has plagued me forever. Does my humble ethic constitute spiritual sacrifice or self-betrayal?

Well, in my own defense, I don’t think my favoring humility is anything other than a sincere effort to be a decent human being. My gifts are not lost on me, only my former sense of exceptional importance. I know my strengths, and I see my weaknesses. I recognize my common qualities and my unique ones. In the end, I believe seeing myself as equal (neither more nor less valuable) to everyone else is both rational and humane. I believe my former arrogant attitudes were the ones driven by low self-esteem, not my current more tempered ones. But of course, that’s just an opinion.

Given all the thought it has provoked, the whole episode has been a good lesson, though a painful one. Good, because it reminds me that my beliefs must always be held provisionally. Painful, because it reveals a yawning gap between my friend’s worldview and my own. It may be that we can continue to communicate despite this difference, but I believe it will be hard for each of us now that we see how neither of us truly embraces the values of the other.

Friends don’t need to agree on everything, but it helps if they share basic standards. This isn’t the first time I’ve encountered a glaring difference between my perspective and that of a close friend, and I know that true caring can overcome such conflicts. Unfortunately, however, for a relationship to remain balanced and healthy after such a rift, the parties need to approach one another with a modicum of true humility.

“When it rains, it pours.” Isn’t that what they say when problems accumulate? Less than 24 hours after getting home from the hospital, I received a call from the disability insurance company that sends me a check every month. During my years as a surgeon I paid into this policy so that if the unthinkable occurred, and illness affected my income, financial protection would be assured.

For many years the company has paid me enough to sustain a middle class lifestyle. I don’t have the wealth that went with active surgical work, but my wife and I have been comfortable. However, for several months the company has been working to eject me from their rolls, and yesterday they announced me capable of earning enough money as a ‘physician consultant’ to no longer qualify for benefits.

Looking online, I see that most such consultant positions are filled by by board certified doctors practicing in their specialty. My board credentials lapsed a decade ago and cannot be renewed because I no longer see patients in that specialty. The insurance company claims I can make 80% of my former income (adjusted for inflation) by finding one of these unattainable jobs. According to them, they don’t have to prove that I could actually be hired for one, only that somewhere, someone has a position that pays in that range. I highly doubt anyone with my qualifications can make the requisite amount as a ‘consultant,’ but none of this seems to matter to those who hold the purse strings.

Luckily, I’ve been in contact with a very skilled attorney who works in this field, and who seems determined to help me. But I’m feeling tremendous fear around all this. As I try to recuperate from my major medical meltdown, I really don’t appreciate being hit with mounting stress and more scary problems.

The fact that I managed to wean myself off all the toxic psychiatric medications seems to work against me. Apparently one is required to ingest the ineffective neurotoxins sold by Big Pharma in order to qualify as having bona fide psychological instability and limitations.

Granted, I write here often about how the mental illness model seems wrong to me, and how I believe my mind capable of much more than the doctors used to offer me in way of expectation. But that doesn’t mean I could tolerate working full-time in a highly stressful job (rejecting insurance claims?) without suffering from depression and agitation that would sooner or later make the work impossible for me. And that’s not even taking into account how poorly my neck and back would tolerate 40 hours a week at a computer.

I’m not looking for handouts. I only want my benefits to continue, the same ones I paid into for many years to prevent just this sort of looming financial catastrophe.

Oh well. Right now there is nothing to do but wait. The insurance company can’t take action against me until I heal from the bleeding, aneurysm, and vascular abnormalities in my abdomen. There will be the option of a lawsuit if they try to cut me off. As in all legal maneuvering, one’s best weapon is patience.

In response to this new stress, I’m trying to meditate even more than usual. I bring my consciousness away from my head with all its worrisome thoughts and center it in my heart. From that vantage, the fears feel more distant. This practice also brings me closer to the disease process around my intestine and pancreas, which is where my healing energies need to be focused anyway. The financial issues will play out one way or the other. Maybe a big change in lifestyle looms, or maybe not. But for now I gravitate toward that gentle but potent cantor of love in my heart, and rest in its strong arms. From this safe, central, vantage I feel my body working to recover from its recent breakdown. And I enjoy distance from all my worries.

Now I understand better than before how to weather hardship with the right mental attitude and skillful strategies. There will be logistical battles to fight as time goes on, but when I can do nothing concrete to help my situation, I will keep meditating, keep loving, and keep learning. I will seek peace deep within, below the surface layers of storm and turmoil, where affection and grace reside.