On Bare Attention: Notes on Ascetical Practice in Psychotherapy

I'm trying to teach my students this semester what it is required of clinicians if you are to open yourself to a patient in psychotherapy and listen to them at depth and in a way nobody else does. Such listening has, of course, gone under a number of phrases, starting with Freud's "evenly hovering attention." He posits this as the equally demanding practice expected of the analyst to correspond with the "fundamental rule" of free association. Both are deceptively simple on paper, but fiendishly difficult to practice regularly. 

I've never forgotten the first time that phrase came back to mind as a life-preserver as it were. It was during my internship and I was listening to my first-ever patient to report childhood sexual abuse in the Catholic church. It was a horrifying tale of systematic gang rape in essence lasting many years. As detail after detail poured forth, I found myself fixating on each fresh revelation, trying to sustain an equal level of horror and compassion for every new item. But after about 15 minutes of this, I felt my mind (in what I now regard as a protective-defensive manoeuver to protect me from this demonic horror) starting to disbelieve the patient and think she must be joking. Horrified at this, I realized I had to pull back, as it were, and allow my attention evenly to hover over the entire story rather than immersing myself in the bloody and dark gore of each detail. This allowed me to listen with less inner perturbance and with a greater distance on the scene, which, of course, is what the patient needed for she already knew how horrifying it was, and my constatnly saying so added nothing useful. 

I felt twinges of guilt as I pulled back, as though not being constantly horrified at each detail was somewhow to fail at being compassionate. But I've learned over the years that you cannot be over-identified with your patients. That does not, in the end, help them. They need you to be more objective, to have greater distance, and to offer a perspective that differs from all others in their life. 

How do I know this? They tell me, very explicitly! People will note how their friends will rush to offer them heaps of support and unquestioned sympathy, but they themselves know they need more and other than that, which is why they present for therapy in the first place. 

From this one can derive a technical rule: Don't try to outdo their friends, thinking this is what "empathy" is! As my first supervisor pounded into my head, "The fact you get paid means you will never be friends with your patients!" Thus, I tell my students, you need to listen in ways that go well beyond what friends and family do. Listen for the gaps, the pauses, the inconsistencies, the contradictions; listen for the darker emotions their friends and family did not hear and could not handle. 

From this a second technical rule can be derived: do not collude, especially unconsciously, in hating the people your patient hates. You need to be free to see what might be good in the person (typically parents or spouses) they claim to hate, and how that hate is invariably closely bound up with more tender emotions, including those of love. Your colluding in hate will preemptively destroy any space for ambivalence to emerge and breathe. 

How can you do such things, avoiding such entanglements as over-identifying and hating? At this point I introduce to my students the concept of "bare attention," which is a Buddhist-inflected concept found in the works of Nina Coltart. What does that mean?

Fittingly, Coltart offers only a very minimal definition, saying that to practice bare attention requires that we "teach ourselves so continuously to observe, and watch, and listen, and feel, in silence that this kind of attention becomes--in the end--second nature to us." But what does that look like? She does offer two highly complex paragraphs (quoted here) trying to explain this, which I have my students "meditate" upon as it were. But for the time being I want to advance the thesis that "bare attention" and "evenly hovering attention" are both practices I can only describe using explicitly theological language: they are ascetical practices.

Now "ascetical," for those who remember their Greek, is not in fact theological in origin, but simply pertains to that form of "training" or, as the OED has it, "ἀσκεῖν to exercise." Thus listening with "bare attention" requires the same sort of exercise, training, or practice as you would expect Olympiads to put in to train for a marathon or comparable exercise. 

The sheer physicality of this training should not escape us. It means--as I have learned by trying to ignore some of these things--that you have to take seriously the following as inescapable components of your training:

Food: don't skip meals or hydration in order to see more patients. Your practice of "bare attention" will be severely weakened as you pay more attention to your growling stomach or fantasies of how large a steak you will grill for dinner. (I've learned to keep "good" snacks in my desk--fruit and nuts usually, but also dark chocolate, along with a large pot of tea.)

Exercise: Coltart learned to her great cost that years of sitting without exercise can bring on severe back pain. Do not stint on getting up and walking around between sessions, and working in as much physical movement as you can outside of your clinical schedule. (For me running 15 miles a week is the bare minimum I need to sustain my attention as well as clear my head of the "vicariously traumatic" details of my patients' lives.) 

Timing and Scheduling: Figure out what works for you. If late afternoon or early evening appointments mean you are very tired, but are wide awake for an 8am appointment, then adjust your schedule if you can. There's no attention--bare or otherwise--paid to your patients if you are nodding off! 

Furniture in your consulting room: Again, Coltart was a cautionary tale for me: crappy chairs for you to sit in (including a lack of the fabled ottoman!) will induce discomfort that make your practice of "bare attention" much more difficult. Don't stint here! 

Sleep: You can't pay attention to anything or anyone if you are exhausted all the time. Get good sleep and don't stint on this to work in a few extra appointments.  

Your own Psychotherapy: I think for me likely the single-biggest factor on this list is my own first full psychoanalysis and then ongoing analytic psychotherapy which has allowed me to feel sufficient "ego strength" as it were that I can open myself up to my patient in a self-denying way without feeling threatened or deprived. To put it in "oral" terms, their slaking their needs through me does not leave me starving and resentful. 

These practices require a commitment to training or physical exercise, a form of discipline, a type of "rule of life" known to monastics of antiquity. Observing these things requires a form of self-discipline, indeed of self-denial and self-emptying. 

Such language may make some uncomfortable. Perhaps they will be reassured by learning that no less a figure than Thomas Ogden, in his book Reclaiming Unlived Life, on which I reflected a bit here, calls for such self-denial: 

the analyst must engage in an act of self-renunciation. By self-renunciation I mean the act of allowing oneself to become less definitively oneself in order to create a psychological space in which analyst and patient may enter into a shared state of intuiting and being-at-one-with a disturbing psychic reality that the patient, on his own, is unable to bear.

Ogden does not make the point explicit, but I have to think he would be adamant here that none of this self-renunciation is to be done masochistically.

Here I think Ogden would gladly join hands with Karen Maroda who, echoing Emmanuel Ghent, has rightly called for  "distinguishing between emotional surrender and masochistic submission" (p.39) in the therapeutic dyad. If you are masochistically foregoing food or sleep or other basic needs in order to spend more time with your patients, perhaps you need to ask whether this is really helping you practice the "bare attention" they need and want from you? 

In the end, then, the paradox of self-renunciation is that it helps not just the patient but you as the psychotherapist. After all, which of us does not want to be well-fed, well-rested, decently mobile and fit, and reasonably comfortable in our consulting rooms? Perhaps in the end "self-renunciation" is a disguised synonym for that sometimes infelicitous phrase "self-care"?