EP. 82: ZEN AND THE ART OF PSYCHOTHERAPY

WITH MARK EPSTEIN

Oct 3

WITH MARK EPSTEIN, MD

A psychotherapist, practicing Buddhist, and writer shares how he harnesses Buddhist mindfulness and meditation techniques to help patients overcome suffering by reframing their relationships with their personal stories.

Listen Now

Episode Summary

What is the intersection between psychotherapy and Buddhism? For decades, Mark Epstein, MD, a practicing Buddhist and psychiatrist, has deeply explored how Buddhist philosophy can be integrated into therapy to help patients heal from trauma. His key insight is that Buddhism grants us the wisdom to reshape our relationships with our personal stories, through which we conceptualize and contextualize our emotions and identities. Dr. Epstein is the author of Thoughts Without a Thinker, The Trauma of Everyday Life, Advice Not Given, The Zen of Therapy: Uncovering a Hidden Kindness in Life, and other books. Over the course of our conversation, Dr. Epstein shares how he discovered Buddhist meditative and mindfulness practices during his formative years, how he helps patients reframe their understanding of suffering, and what it's like to be allowed into the most vulnerable, intricate, and even spiritual spaces in the minds and hearts of other people.

Mark Epstein, M.D. is a psychiatrist in private practice in New York City and the author of a number of books about the interface of Buddhism and psychotherapy, including Thoughts without a Thinker, Going to Pieces without Falling Apart, Going on Being, Open to Desire Psychotherapy without the Self, The Trauma of Everyday Life, and The Zen of Therapy. He received his undergraduate and medical degrees from Harvard University.
In this episode, you will hear about:
• 2:12 - Dr. Epstein’s reluctant path to medicine after growing up as the child of a doctor
• 10:08 - The lessons Buddhism has taught Dr. Esptein about himself and his relationships with others and the world
• 17:12 - Differences between “medical materialists” and “medical humanists”
• 19:33 - How Dr. Epstein’s humanistic views of medicine have affected his approach to treating patients
• 23:45 - An overview of psychotherapy and psychoanalysis
• 28:12 - How Dr. Epstein’s approach to working with patients differs from other psychiatrists due to Buddhist influences
• 36:54 - The extent to which Dr. Epstein’s patients are aware of the source of his approach and techniques
• 39:42 - How Dr. Epstein grapples with the high stakes involved when treating the mental suffering of his patients
• 46:12 - Dr. Epstein’s advice for medical students and clinicians on managing the mental distress of patients
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] What is the intersection between psychotherapy and Buddhism? For decades, Dr. Mark Epstein, a practicing Buddhist and psychiatrist, has deeply explored how Buddhist philosophy can be integrated into therapy to help patients heal from trauma. His key insight is that Buddhism grants us the wisdom to reshape our relationships with our personal stories through which we conceptualize and contextualize our emotions and identities. Dr. Epstein is the author of multiple books, including Thoughts Without a Thinker, The Trauma of Everyday Life, Advice Not Given, and most recently, The Zen of Therapy: Uncovering a Hidden Kindness in Life. Over the course of our conversation, Dr. Epstein shares how he discovered Buddhist meditative and mindfulness practices during his formative years, how a strong desire to become a therapist led him to a career in medicine, how he helps patients reframe their understanding of suffering, and what it's like to be allowed into the most vulnerable, intricate, and even spiritual spaces in the minds and hearts of other people. Mark, thank you so much for joining us and welcome to the show.
Mark Epstein: [00:02:10] Thank you. Nice to be here.
Henry Bair: [00:02:12] To start us off, can you share with us your path to medicine and how Buddhism played a part in it?
Mark Epstein: [00:02:18] Well, initially, I tried to avoid it as vehemently as I could. I was like, I am not going to medical school. Leave me alone. My father was a fairly well known professor of medicine, first at Yale and then at Harvard. You know, he wanted it for me, let's put it that way.
Tyler Johnson: [00:02:36] I was going to say, you make it sound like you had people chasing you around with medical degrees trying to, you know, bestow them on you wherever you went.
Mark Epstein: [00:02:44] That's what it felt like, or at least push me in that direction. So I didn't take any pre-med courses or anything in college, but I was lucky enough to come upon Buddhism and meditation and, you know, Buddhist philosophy, Buddhist psychology. And after I graduated from college, I majored in psychology, but they called it social relations, where I went to school. So I majored in social relations. And then after I graduated, I was like, oh, no, what am I going to do with my life? I'd better go to medical school.
Tyler Johnson: [00:03:21] As one does.
Mark Epstein: [00:03:23] Well, because I had found what mattered to me, I felt like I'd really discovered what, you know, something that was going to be mine. And then I was like, Oh, well, what am I going to do with this? And I had the vague notion that I could be a therapist.
Henry Bair: [00:03:37] What was that one thing that mattered to you?
Mark Epstein: [00:03:40] It was something in Buddhist thought that allowed me to see my mind as something pliable, you know, as not just a repository of my anxieties, but potentially nourishing a place for me to explore. And I got that off of Buddhism, and I went as deep into that as I could. I met a bunch of Buddhist teachers, mostly American Buddhist teachers, and I sat a few retreats. So I had a real personal experience of it that gave me the courage or the impetus to think beyond the moment. So I decided to, you know, I thought, Oh, being a therapist is going to be the way to go. So then what's the best way to become a therapist? You know, and I talked to a bunch of people in the field and they were all, well, if you go to medical school, you'll have the most freedom to do what you want to do. Because I already knew what I wanted to do was to try to integrate Buddhist thought and and Western thought. So I could go to social work school, or I could get a PhD or I could go to medical school. So I was like, okay, I guess my father was right. So I took all the pre-med courses in an extra year after college, and then I went to India for a year and applied to medical school during that year and then came back and went to medical school with the express purpose of becoming a psychiatrist. So there were only about two people in the class of 100 or so that had that agenda.
Tyler Johnson: [00:05:13] So I hope we'll get back to the therapy piece in a moment. But before we get there, one thing you may or may not know about the show is that I think we are unusually open to the exploration of the spiritual paths of our guests. And in fact, Henry and I have remarked to each other many times that one of the things actually that has surprised us the most on the podcast is that our intent was not to explore that with the podcast. The intent of the podcast was to say to lots of different people from lots of different walks of life, health care practitioners, and not what makes medicine meaningful and how can we help people who are listening return a sense of meaning to the practice of medicine. But in spite of that fact, this question of spirituality or the metaphysical dimension of medicine or whatever you want to call it, comes up again and again and again. And so with that openness towards exploring your spiritual path, I'm wondering because when I hear your story, as you just relate it, even though we were asking you about how did you end up in medicine, what I hear is a person who, as you were just describing, it, was sort of beset with anxiety and your own preoccupations and kind of caught up in your own head.
Tyler Johnson: [00:06:25] And then had I'm putting this word out there, not you, but it sounds like had a sort of an epiphany where Buddhism introduced to your life something that had not been there before, something that really allowed you to see the world. In a new way. And I also I just as preface to this question, I will say that I feel like Buddhism is one of those things that has become just present enough in sort of mainstream Western thought that we all sort of assume that we have this vague understanding what it is and what it says about the world and what it means when in fact 99.9% of us probably have no idea what it is or what it says or what it means. And the only thing worse than no information is bad information, right? So all of that is just to say, can you just take a minute and explain to us what were the great truths that Buddhism taught you that led to such an important awakening for you, that it allowed you to sort of reframe how you were looking at your life?
Mark Epstein: [00:07:27] Well, let me just say first, I wouldn't say I had an epiphany the way you're describing it, but maybe a very, very, very slow rolling, unfolding epiphany. It wasn't so much that it let me see the world in a different way, but it let me see myself in a different way.
Tyler Johnson: [00:07:42] Yeah, tell us about that.
Mark Epstein: [00:07:44] Well, I hardly knew myself. I was 20, 21 years old. I had gone to a therapist at the health services at Harvard where they made a little therapy available for free. And I had talked my heart out in a couple of sessions, but the therapist said, Oh, it's not that serious. Sounds mostly like something some kind of Oedipal complex. And and I didn't really know what he meant.
Tyler Johnson: [00:08:12] Well, that cleared that right up. Thanks a lot.
Mark Epstein: [00:08:15] Gratified.
Tyler Johnson: [00:08:16] I'll just go pick up my Oedipal pills at the pharmacy and it'll all be fine.
Mark Epstein: [00:08:19] I wish I was. I had to get those on the side. But then I then I was lucky enough to meet some of my first Buddhist teachers. Jack Kornfield, Joseph Goldstein, Ram Dass people, people of that ilk. And they rather than naming anything that was the matter with me, they were like, Oh, why don't you actually experience yourself a little more fully right now in this moment? You know, that was the beginning of an introduction to to meditation that let me kind of peek behind my anxieties to see that there was something else that was possible in my experience. You know, in my mind, it just gave me a sense of the sort of hope and mystery. I had already worked for a fellow named Herbert Benson, who was a cardiologist at Harvard who did the first physiological research on Transcendental Meditation, showed that it slowed the heart rate and lowered the blood pressure and so on. But I wasn't really looking for the relaxation. That seemed sort of like a false idol to me. I was more interested in how can I handle myself? How can I feel more true, I guess, or more real in myself? I got that first from meditation. I've had lots of psychotherapy since then. Which. Which has also helped. I don't mean to put down psychotherapy or anything, but Buddhism I think gave me hope in a certain way and that that hope that I felt for myself is something that sometimes as a therapist, I've been able to kind of hold out or communicate to my patients. So that's, that's been very valuable in my my career.
Henry Bair: [00:10:08] So that's kind of interesting because Buddhism is it's one of the world's great religions. So it purports to teach truths about the nature of the world, of our place in it and how we relate to the world and those around us. When you described Buddhism as it applies to you, you were invoking a lot of the techniques that you learned along the way mindfulness and meditation very practical. In fact, I'm wondering if there was that other element of it for you, right? Like the great truth about the world, like that aspect of it. What does Buddhism teach you about what your purpose is in the world and how you relate to other people?
Mark Epstein: [00:10:45] Well, it doesn't teach you much about what your purpose is other than to be real with yourself, you know? But I always think of Buddhism as the most spiritual of the world's psychologies and the most psychological of the world's religions. The first real teachings that the Buddha gave, he gave in the form of a of a medical diagnosis of his day. You know, he said, here's the illness. The word he used is dukkha, which is generally translated as suffering. So the conventional view of what he was saying is that here's the first great truth that there's suffering in the world. We're all destined, even if we live for 80 years with no illness, we're destined to die. Those we love were destined to have to separate from life always gives us situations where we're forced to be in contact with people we don't like, etcetera. But a better translation of that word is that he's not saying there's no pleasure in life. That's how Buddhism is usually misunderstood, he's saying. Saying that there are plenty of pleasures, but they don't last, so that there's always a little it's tinged with unsatisfactoriness. So Unsatisfactoriness is maybe a little bit better translation than suffering. But just articulating this idea that happiness should be automatically available to us and that if we're suffering somehow we're at fault, that the Buddha managed to turn that on its head and normalize suffering as something that we all have to deal with.
Mark Epstein: [00:12:14] But and as I was saying, he presented it like a medical thing. So the first truth is the illness. The second truth is the cause, you know, so not a germ. And again, the conventional translation is the cause is desire. But once you start digging deeper into Buddhism, he didn't really say that desire is wrong or bad. He said that really the cause is that we we misperceive reality. We see our lives from a self-centered self-preoccupied point of view that obscures the way things really are, and that if we can get rid of that self preoccupation, then the things become more open. So and then the third truth is that there's hope, that there's the possibility of enlightenment or awakening or nirvana, whatever you want to call it. And the fourth truth, which is the prescription he called the eightfold path, which is basically like you have to live your life in a in an ethical, mindful, truthful way. So all of that just made sense to me right from the beginning. And I was like, okay, I've got a structure now.
Tyler Johnson: [00:13:23] Okay. So now that you have explained a little bit of both the personal impact that this philosophy or religious system had on you and also the truth that you came to understand about the world by by studying and and internalizing those teachings. Now, I want to circle back a little bit to something you said a minute ago, which is that you said, you know, you were dead set against going into medicine. You were you know, this has been your sort of the script that was laid out to you, it sounds like, from when you were a little kid and you were just not going to go there. And then you learn about both these interpersonal truths and these also, you know, sort of truths for the greater world. And then that catalyzes a change where you say, okay, now I'm going to take this new knowledge that I have, this new approach that I have, and now I am going to go into medicine, unpack that for us a little bit, like what did you intend to do with the truths that you had gained? Like what was it about gaining those truths that made you do an about face and say, okay, now that actually where before specifically that is the one place I was not going. Now that is where I'm going.
Mark Epstein: [00:14:34] Yeah, well, I felt like I had to make it mine. I didn't want to be imitating the meditation teachers, the mindfulness teachers, you know, I didn't want to become a monk. I wanted to have a life. And I kind of understood from the beginning that the challenge was to integrate all of this stuff and actualize it. And I did have that notion that, Oh, therapy. Therapy sounds like something that I might be able to do. It didn't seem like real work to me, which was part of the attraction. You know, I knew that I liked people and I knew that I could listen to people and that I could sit and talk with people. And so I went for it. And, you know, I think because of my dad, because I grew up in an academic medical environment, I wasn't intimidated by medicine or by medical school or by organic chemistry or any of any of that stuff. You know, I knew I could. I thought that I could do it.
Tyler Johnson: [00:15:34] I'm like picturing your dad drawing electron pushing diagrams at the dinner table or something.
Mark Epstein: [00:15:39] Just he drew diagrams of the kidney. He was a nephrologist, but.
Tyler Johnson: [00:15:43] Oh, no. All respect to your dad. But I can only imagine in that case, what dinner table conversation was like.
Mark Epstein: [00:15:50] It's interesting, it turns out, but I had a mental block against it. But when I finally got to the first year of medical school and I realized what I had gotten myself into and that everyone else in the class, you know, had knew all this stuff already, I actually, you know, kind of freaked out at first, and I wasn't sure that I that I'd be able to do it. And I tried to drop out and go to social work school. But everyone I talked to told me I was crazy to drop out of Harvard Medical School, to go to Simmons Social work school. So I stayed with it. I discovered that they they had all the exams for the courses, all the old exams in the medical school library, and that you could go to the medical school library and get the old exams. And by studying the old exams, you could see what the questions were going to what you had to figure out in order to. Survive. So I learned how to study, you know, the science. And from then on, it got easier. And I did love the psychiatry. And I found a few teachers in clinical medicine who I felt were were humanists and not just scientific materialists, you know, and encouraged the more humanistic side of the of the doctor patient relationship. So there was a stream of that even at at Harvard Medical School.
Tyler Johnson: [00:17:12] So we actually just finished a really interesting conversation a few weeks ago that involved a pretty deep discussion of materialism. And maybe I'm just attuned to it because we just aired that episode, but I mentioned it only to say that I it's interesting to me to hear you say that when you went to medical school, most of your professors in the medical school were what you termed materialists, but there were a few of them who were what you termed humanists. Talk us through a little bit. What is the difference, in your view, between a medical materialist and a medical humanist?
Mark Epstein: [00:17:44] Well, I'm getting into territory with this that I'm not really qualified to to explain.
Tyler Johnson: [00:17:51] I'm just asking your view not, you know, Aristotle's or Plato's or something.
Mark Epstein: [00:17:56] The way that most of us in our Western scientifically based culture are raised. And I'm not totally critiquing it. It's not it's not all wrong is, you know, this idea that we are sort of thinking computers, you know, that our brains, our brains are like the hardware. The the neurotransmitters are like the software that if we're any disease that we're suffering is because there's a problem with the mechanics in the system, you know, and all the advances in cell biology and in neurobiology and neurochemistry and immunology and so on about tinkering with the machine. You know, it's easy just to see the the human being as some kind of materialistically based individual, you know. But we're also people who used to think of ourselves as having souls, you know, And the the idea of soul has gone out of fashion. And even in Buddhism, Buddhism is attractive to many Westerners because it explicitly counters the notions that many people have of of an existence soul. But a humanistic approach, to my mind suggests that the ingredients that make us up are not the whole explanation of who we are and that we can come from the top. You know, we can come from the whole person as well as from all the fragments that science has let us take apart.
Henry Bair: [00:19:33] So I think in medical school, we absolutely lean heavily, in fact, probably exclusively into the mechanistic aspect of illness, right? Like we learn that certain neurotransmitters are out of balance and therefore we give this medication. I think in some ways thinking about the human body as a machine is fairly comforting in the sense that, okay, we can pinpoint exactly what the problem is and then try to fix exactly that. So when you introduce this dimension of something else -the mechanistic parts don't explain everything- when you introduce that aspect of it. I would imagine that for a lot of physicians it would be anxiety inducing because how are you supposed to address something that we have no explanation for, Right? Since you sounds like very early on recognized that this was -whatever you want to call it, the metaphysical, the human soul or something else- How did this influence your approach to medicine, to treating and healing people?
Mark Epstein: [00:20:28] What you say is true in a way. The first paper that I ever wrote, I wrote with with Dr. Benson on the placebo effect because we were both interested in, you know, like what's behind the placebo effect that many people -30% of the time, 40% of the time- their conditions improve when you give them an inert substance. So what's what's going on and what's going on in psychotherapy? If we're not giving an antidepressant, which, by the way, we don't really understand, we talk about neurotransmitters, but we don't really know what most of those antidepressants are actually doing to make people feel better. But, you know, when you train as a psychiatrist, when you train as a therapist coming up through the medical model, nobody really teaches you how to be a therapist because they're teaching you like surgery. You know, like watch one and then do one kind of thing. So in medical school, when you do a psychiatry rotation, I don't know if you guys ever, ever bother, but when you do a psychiatry rotation, usually there's a couple of introductory lectures or seminars and then they give you a patient and this is your patient, you know, and you have to go do the intake with the patient. Or write up the patient, you know, and they evaluate you mostly on how you wrote up the patient. But the real learning is, you know, you take that patient into the room and close the door and it's just you and them and what are you supposed to do? You know, so when that happened to me, the I only had two things to go on.
Mark Epstein: [00:22:02] One was my experience in meditation where I had already learned how to look at my own mind in a non-judgmental way. And the other was my experience in psychotherapy. I had by then found a good psychotherapist so I could imitate how my therapist talked to me and talking to the patient, you know, and the way he was with me was not that different from how I tried to be with my own mind and meditation. So. I tried to make my own version of that with that first patient and listen to her attend to her in an open, non-judgmental, mindful manner. And she liked me and she wanted to talk to me. And I met with her a couple of times. And I think it made an impact. You know, that was a big teaching for me. Then some sometime later, I started to go through Freud's recommendations to physicians practicing psychoanalysis, where he comes closest to describing how a psychoanalyst should attend to the patient. And if you take his language and if you don't know it's Freud, he sounds like a Zen master describing how to meditate. You know, he says, suspend judgment and give impartial attention to everything there is to observe and turn your unconscious to the unconscious of the patient, like the newly discovered telephone receiver, you know, is turned to the sound waves, you know. So I found that very affirming that even Freud, in his own way, was was listening in a meditative manner.
Henry Bair: [00:23:45] I think here it might be actually very valuable because keeping in mind that a lot of our listeners, yes, there are a lot of clinicians, but there are also a lot of medical trainees and pre-medical students and people who are not affiliated with the health care profession at all listening in. So I think it would be very valuable here if we took just a little bit of time to actually explore what psychotherapy and psychoanalysis are, or at least the way that you practice them. Right. Because I suspect there might be some misunderstanding or lack of understanding of what they are and how they differ or why are they unique from just psychiatry in general?
Mark Epstein: [00:24:18] Well, psychiatry in general has become very focused on psychopharmacology. So most psychiatrists who are trained in a residency and so on are very knowledgeable about what psychotropic drugs are helpful for what conditions. And there are at least three drugs that are helpful for certain things, you know, and then many variations on the three drugs, anti-anxiety drugs, antidepressants and antipsychotics and mood stabilizers, maybe we would say, too, for people with bipolar disorder. So psychiatrists are trained now to be the go-to person when someone is having a hard time, you know, emotionally and maybe they need like a pill or, God forbid, electroshock or now they, you know, the psychedelics are coming back into fashion. So now there's a, you know, sort of side element that's possible. But psychotherapy and psychoanalysis from which psychotherapy derives, psychoanalysis is rooted 100 years ago in in Freud's time when Freud discovered that simply sitting with a patient and asking them to say whatever was on their mind, you know, moment to moment, whatever they were experiencing, even if it made no sense or they were ashamed to divulge what they were really thinking or feeling, but that if they could, he called it free association, if they could be as honest as possible about what their actual emotional experience was with the therapist, and if the therapist could listen in an analogous way, not trying to zero in too quickly on what the problem is, but allowing the therapist's own associations to come, that there was the possibility of actually a very intimate and very deep conversation that could help somebody understand themselves more, understand themselves better, understand where, from my point of view as a therapist coming a little bit from this Buddhist side that has so influenced me, if I can help people understand how they're getting in their own way, how they're perpetuating their own problems, how their own, I might say, clinging, how their own distortions, how their own defenses are, keeping them locked up in their own anxiety and their own suffering, then maybe I can really help them. That kind of conversation requires a big trust between people so that first that someone will be willing to tell me the embarrassing stuff, the secret stuff, the private stuff. And second, that they might be willing to hear what I have to say about it, you know, and not and not just get defensive. When that happens it's a lovely thing.
Tyler Johnson: [00:27:26] So I think you're the first person we've had. We have spoken with other people who are involved, certainly in psychology or psych. But I think you're the person who is the most arguably the the most focused on therapy per se, as a therapeutic technique. You know, as you told the story, that was I mean, that was actually the thing that brought you to medicine, right? It wasn't, okay, I'm going to be a doctor now. What kind of doctor should I be? It was I want to do this thing as influenced by Buddhism, and doctoring is a way to get there. So with such a central focus for you on therapy, I want to read from the introduction to your latest book. You tell this story about the Buddha, where basically he faces this time of great trial and suffering in his own life and goes out into the wilderness and determines that he's going to subject himself to self abnegation and that getting rid of all of his desires is kind of the way to, I don't know, transcendence or to get away from his problems. And then when he's out in the wilderness, then he meets this woman named Sujata, who eventually brings him a bowl of rice pudding. And then he goes inside of himself and comes to the recognition that what he does not need is self-abnegation, but instead needs the nourishment that comes from this rice bowl. And then sort of this whole experience becomes this transcendent, transformative thing for him. And then you write, I'm going to read this.
Tyler Johnson: [00:28:52] "I think of this chance encounter between Sujata and the Buddha as a metaphor for psychotherapy. The symbolism is overwhelming. The Buddha, like most people who come to therapy, had a sense that he was doing something wrong, that he was somehow getting in his own way. The coping strategy he had developed to deal with his own trauma was not really working. It was, in a sense only perpetuating the very feelings of deprivation he was struggling to eliminate. Having left his own wife and child with the mistaken thought that renunciation of worldly entanglement was essential for his spiritual progress, he could not proceed without reestablishing the connections he had divorced himself from. Those connections were both inner and outer. He needed to remember his childhood joy, and he needed to feed, so to speak, at Sujata's breast. Two critical events that in my way of thinking, were redolent of the trauma of his own mother's death seven days after he was born. Without the recovery of his relational nature, the Buddha could never have awakened. He would have worn himself out in a heroic quest of self denial. Sujata, as the Buddha's spiritual friend, gave of herself new mother that she was without ever knowing how meaningful her contribution would be, and the Buddha, propelled by his recovered memory and nourished by her grateful offering, finally set himself right. At my best I see psychotherapy in the same light."
Tyler Johnson: [00:30:24] So I guess in one sense, this gets to the dichotomy that we were talking about earlier in the sense that if I were to go ask, let's say an interventional cardiologist, right, you know, who are doctors that I work with every day, and if I were to say, what is your job? And they might say, well, most of the time I'm unclogging heart arteries. Maybe they'd use slightly fancier language, right? Or probably more jargon. But in effect, that's what they would say, right? Or if I were to ask a gastroenterologist who does procedures a lot, like what do you do? They would say, Oh, I try to identify precancerous colon lesions or whatever, right? Even as an oncologist. Right. I recognize that what I do is largely give medicines to try to get rid of cancer cells. Right. Which is just to say that most doctors have a very whatever you want to call it, mechanistic, materialistic, reductionistic, whatever -istic way of viewing their view in a patient's life and viewed by those lights or by comparison to those ways of thinking about what a doctor does, your paragraph, that paragraph that I just read is I want to use a word like stunning, right? Because you're not talking about heart arteries or colon polyps or even cancer cells. You're talking about becoming the catalyst to this -I think you even use the word spiritual- to a reawakening, to a transformation, to epiphanies. Right. You are the bearer of the rice porridge that transformed the Buddha and set him on the right path. That's just so, um, it's so different from the way that I think most doctors conceptualize their role in the therapeutic relationship. And so I wanted to start by just sort of asking to talk a little bit about having such a different view of your role in a world where virtually all doctors don't think about it that way, even as you say, most psychiatrists, I think, would say, well, I'm managing brain chemicals or whatever. It's just so different. So I was wondering if you could talk about that tension.
Mark Epstein: [00:32:39] Yeah, sure. I'll tell you two stories that I think relate. When I finished my medical internship, which I did in Boston and moved to New York to do my psychiatry residency, which which I did at New York Hospital, the person who ran the psychiatric residency was a very well known psychoanalyst named Otto Kernberg, who had a very fierce reputation. People were scared of him. Super smart, brilliant guy. But a friend of mine in Boston took me aside before I left, and he was actually a Sufi psychiatrist, this friend of mine. And he said, When you go to work with Kernberg, you should not talk about your spiritual leanings. You know, don't let him know. Because if he finds out what you're into, he's going to eat you alive. So so I very dutifully listened to him and I did my whole residency there, and I kept it very private. And I had kernberg as a supervisor myself for a whole year. I met with him every week and talked about a patient and we and I loved him. He really helped me. And then they offered me a job after I finished the residency and because the unit chief on the unit I'd worked on was pregnant and they asked me to step in and be the acting unit chief, which I did. And I decided, okay, now that they've offered me a job, I'm going to start to talk about what I'm really interested in.
Mark Epstein: [00:33:59] I don't care if they eat me alive, let them try. And then it turned out, like all the psychiatrists, including Kernberg, were totally interested in where I was coming from, and one of them was already leading a group therapy at the Yonkers Zen Center. You know, they were all it was already infiltrating. The Buddhist thing was already infiltrating. So I had kept myself all perhaps unnecessarily. So that was a big teaching. Like, it's okay, you know? And that's when I started writing. But the other story is one of the one of my main mentor figures who really helped me in my early years was the psychedelic pioneer who started out being Richard Alpert and became Baba Ramdas. And I knew him when I was young, when I was 20, 21, and I stayed in touch with him. He he, he was a big influence on me once. I, you know, did my residency, became a psychiatrist, got married, had children. He moved to California. I didn't see him for a long time. And then he had a bad stroke that partially paralyzed him and gave him an aphasia. And he was living out in in Marin County in Tiburon. And I went out to visit him and I'd maybe been in private practice for 15 years or so. When I went to see him, I visited him at his home. He was sitting out on his porch. He greeted me warmly. He always. Kind of teased me.
Mark Epstein: [00:35:24] And I know for him I was always know 20 years old, even though by now I was probably in my 40s. But I remember he said to me, Oh, Mark, you know, so are you. You're the Buddhist psychiatrist now. I think I had written my first my first book or two, and I sort of sheepishly nodded my head and said yes, very slowly because of the aphasia. He said, Do you see them? Meaning my patients? Do you see them as already free? Do you see them as already free? And it took me a minute because he said it so slowly to really take in what he was asking me, but I realized he was hitting on the on. Like, that's one thing that was really different for me. You know, I think because of the background in Buddhism and I think that's going to your question about the Sujata and the spiritual, whatever that spiritual connection is doing, you know, yes, I have the sense with my patients that even though they may be confused and upset and worried and bad things have happened, that within all of that, you could say or behind all of that, they're already free. And so my job as the therapist is somehow to maneuver them to where they can have a sense of that also. And that's such a challenging but wonderful thing to be trying to do, especially if I really believe it's true. You know.
Henry Bair: [00:36:54] I'm just I'm really curious because it's clear that you bring such a totally Buddhist influence worldview to your practice of psychiatry psychotherapy. Does this come up in the conversations? Are your patients aware that this is where a lot of your techniques and your where you're coming from?
Mark Epstein: [00:37:13] This last book that I wrote, which, you know, the Zen of therapy that you were reading from before. That's what I was trying to address in that book, because really what I'm doing is I'm just sitting and talking to people about whatever is going on in their lives. So what I wanted to do in that book is show just individual sessions over a year with random patients to show how unspiritual, you know, it looks, and yet maybe something is creeping in, You know, what's the thing that could be creeping in just in talking about the every day? So some of my patients are aware they come to me because they want a therapist who won't think that they're crazy for having a spiritual ambition or spiritual ideas. Many of my patients are not aware or it's not the fundamental thing that they're seeing me for. They're seeing me because hopefully I won't steer them wrong and hopefully they can trust me. And there's stuff going on in their lives that they need to talk to someone about. But usually one way or another, if the patients hang in there long enough, some bit of spiritual something will start to creep in. But often it's not the usual thing of, Here, I'm going to teach you this technique of relaxing you or giving giving you a state of happiness or, you know, I don't really believe in that kind of thing. It's more that you're already much closer to an evolved understanding. You're already much closer to what you're hoping to be than you know. So let's let's help you find what in a way, you already are conscious of, you know, but you're not really giving to yourself. So the wisdom that lies within, you know, it's that kind of idea.
Tyler Johnson: [00:39:02] You know, we probably a year ago or so, we spoke with a pediatric neurosurgeon, and one of the things that we talked with him about was the fact that, you know, it's one thing I don't mean to make light of this, but it's one thing if you are practicing in a branch of medicine where the stakes, relatively speaking, are lower and where, you know, missing something or getting something wrong, not that it can't cause problems, but that it's unlikely to cause really lasting or catastrophic problems. Right. But if you're a pediatric neurosurgeon, it's hard to imagine higher stakes, right? You know, a half a centimeter in the wrong direction or an artery that you accidentally clip that's, you know, small as a string of yarn or whatever. And this person who's a child could be paralyzed or they could be left without speech or they could die or they, you know, anyway, on and on and on. And we talked a lot with him about sort of grappling with that burden. One of the things that strikes me about psychotherapy is that on the one hand, as you have done a few times during this conversation, there's a way to think about psychotherapy where you kind of say to yourself, okay, this is a way of engaging in a series of meaningful conversations with a person. What I'm really doing is I'm mostly listening and I'm sort of allowing the person to kind of find their way to their own answers or something to that effect.
Tyler Johnson: [00:40:35] But at the same time, and obviously I'm not a specialist in psychotherapy, but from having spoken with a number of people who do it and in thinking about it on a principle level, the first thing is that obviously psychotherapists train psychotherapists have lots of training. Right. I mean, they have a lot of they bring a lot of expertise. And that's not to say that there aren't people who have natural gifts, just like there are people who have natural gifts for anything. But that training is for something, right? It's to equip you to do something, whatever that, you know, Henry and I have spoken to a few people in different fields of medicine over time that sometimes medicine is kind of a black box and psychotherapy seems like sort of the ultimate black box in terms of exactly what happens. But the other thing is that it strikes me that people who go to therapy are exposing themselves. It's like they're opening up sort of the deepest wiring to their motivations and hopes and fears and everything else. And even if in subtle ways sort of giving the therapist access to that space, right, to the to not just what are they going to say or do, but but actually why or how do they think about the world, right? Like you sort of referenced this obliquely in the Sujata analogy, right? It's this way of like really getting down into the deepest wiring of a person and trying to help them rewire it.
Tyler Johnson: [00:41:59] But guess that all of that is a way of saying that one of the things that seems so daunting to me about the idea of being a psychotherapist is on the one hand, how would you know that what you've done or are doing is working right? Like, how do you know that it's being successful and how do you think about or grapple with the idea that what if you make a mistake? What if they give you access to that deep wiring and yes, you help them rewire it, but the rewiring is worse than the normal wiring was in the first place, Right? Like not not to put too fine a point on it, but in some ways it feels almost more daunting than being a neurosurgeon precisely because it's so subtle and because it's such a you know, there's kind of this veneer of, well, we're not I'm not really doing anything right. This is in surgery. I'm just listening. I'm not saying you're saying that, but I'm just saying there's this kind of idea that it doesn't involve physical manipulation, but in some ways, for precisely the reasons that you point out, it feels like it's an almost weightier burden even than a surgeon. I guess I'm just asking, how do you think about or grapple with those ideas? Well, there.
Mark Epstein: [00:43:09] Are a couple of things that you're asking about in terms of the training. I realized that that maybe I've been a little bit facile in talking about the medical the importance of the medical training. For me, one of the things that I'm very grateful for, for having gone the medical route and in particular for spending a lot of time during my psychiatric training, working in inpatient units in psychiatric hospitals, is that I was able to become really familiar with what mental illness actually looks like. It's one thing to think that I would be a good therapist because I like to sit and talk with people. It's another thing to really confront. This is what a schizophrenic 18 year old is experiencing. You know, this is what a bipolar patient in a manic episode is experiencing. This is what a catatonic depression looks like. You know, this is what a panic attack feels like, you know, So really to see lots and lots and lots of all of of all of that is extremely helpful in being an everyday psychotherapist because one of the mistakes that you don't want to make as an everyday run of the mill psychotherapist is to miss a treatable mental illness, you know, where there actually are medications that help, where someone could really kill themselves if you don't get it right, where someone's whole life could be derailed if they're having panic attacks that are not correctly seen as panic attacks. And instead they the person becomes agoraphobic and afraid to go out of the house. You know, So so there's real information, real knowledge, real helpful diagnostic information that a good, good psychotherapist need to have.
Mark Epstein: [00:45:06] The second thing about what if it doesn't help? What if the therapy part doesn't work or doesn't help? Sometimes I think the the thing that links both meditation and psychotherapy is that those are two things that don't work. People come to them with all kinds of expectations that they're going to be healthy. Now, you know, they're going to learn how to relax. They're going to be happy. They're not going to be neurotic. They're never going to be anxious. They won't be depressed. They're not going to fight with their spouses or their parents or their children. That's all analogous to, like the way people wanted Prozac to cure everything that was wrong with them when Prozac first came out, you know, like we just we set up these false idols for ourselves and then we feel bad when when we can't realize them. So sometimes one of the things that psychotherapy is best for is, is to get rid of all of that. And, you know, we're just here. We don't really know if this is going to help, you know, but still, somehow being able to talk with each other in a truthful way leaves a residue of some kind of relief that somehow it's helpful. I know it's helpful for me. I feel better at the end of of it. And a lot of my people seem to too, although they then they have to come back the next week because. Because new things have happened, you know.
Henry Bair: [00:46:31] Well, we are coming to the end of our time here and typically with our conversations, we like to close with inviting the guests to share some advice you have for listeners who are somewhere in their medical training or clinicians, most of whom I would assume are not psychiatrists.
Mark Epstein: [00:46:49] I would assume that.
Henry Bair: [00:46:51] That being said, I think vast majority of all clinicians, nurses, doctors deal with suffering even when you're just on the inpatient oncology service or the pulmonology service like I was just on. You deal with patients existential crises, right? When they are confronted with terrible diagnoses and whether or not we're prepared for it, whether or not we like to deal with it, we have to deal with it because it's there. What advice do you have for clinicians who may or in this case, let's for the sake of this, this question, who are not in psychiatry, who are not trained in psychotherapy, what advice do you have for them to help patients better manage suffering and to help themselves? Like, how do we as clinicians, care providers, how do we grapple with the effect of that suffering or witnessing on ourselves?
Mark Epstein: [00:47:43] Well, you know, I wrote a book called Advice Not Given, because I realized that most of the time I was not giving spiritual advice, Buddhist advice to to my patients. Et cetera. But then I was questioning, well, should I? Maybe a little bit. One of the things that made me question was when my own father, who I mentioned at the beginning of this, got a malignant brain tumor on the non-dominant side of his brain. And so he was fully aware and conscious and so on, but knew he was going to die. I realized I had never given him any advice or even tried to talk to him about the spiritual side of things because he was such a professor of medicine. I decided I would try and I and I called him from my office and and said something like, you know, we've never talked about it, but maybe you want to know what the Buddhists say seems to happen when you die, you know, just in case they're right, in case it's helpful. And but I didn't want to use any Buddhist language. So I said something like, you know, that feeling that always the same inside of you when you're 20 years old or 40 or 60 or 80, you still sort of feel the same inside, you know? But if you try to find that feeling, if you look for it, it's kind of transparent, It's sort of invisible.
Mark Epstein: [00:48:58] And yet, you know, it's there, but you can't really put your finger on it. What the Buddhists seem to say is that if you can learn to relax your mind into that invisible space of who you've always been, that you can kind of ride that feeling out even as the body deteriorates. And he was like, okay, darling, I'll try. So what I would say that was my attempt. But what I would say for the listeners, you know, if you're asking me, what would I say to, you know, medical people who aren't psychiatrists, I would say take an extra moment with some of those patients. I know everyone's rushed and it's all you have to put everything into the computer and there's a million more things that you have to do. But but we're privileged to these, you know, liminal moments in people's lives of illness and death where if they have a soul, they're they're grappling with it, you know, So just take a take an extra moment. It could be a silent moment. Stay, you know, one beat longer with those patients just to feel the the reality of what's going on and let your presence be a warm one. And, you know, see see how you feel and see what comes from that. I would say that would be my advice.
Henry Bair: [00:50:17] Well, with that, we want to thank you so much, Mark, for taking the time to join us for opening up about your story and the wisdom you've accumulated over the years. It was it was really wonderful talking to you.
Tyler Johnson: [00:50:27] Thank you so much. We really appreciate your time.
Mark Epstein: [00:50:30] Well, thanks for inviting me. I feel very grateful to you both.
Henry Bair: [00:50:36] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:50:55] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:51:09] I'm Henry Bair.
Tyler Johnson: [00:51:10] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.