Psychotherapy: What’s Metaphysical Got to Do With It?

| December 29, 2009 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD
Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base.

Psychiatry (Edgemont) 2009;6(12):26–31

Financial Disclosures

The authors have no conflicts of interest relevant to the content of this article.


The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Key words

Spirituality, metaphysical, meditation, mindfulness, psychotherapy


Clinicians have a number of treatment options for dealing with the emotional ills of patients, including psychoeducation, psychotherapy, and pharmacotherapy. However, after years of experience in the clinical field, we have recognized that these treatment options may not be sufficient to adequately address the problems of some patients. We have found that adding a metaphysical/spiritual component may be helpful, particularly for those patients with histories of childhood trauma. In this edition of The Interface, we discuss four metaphysical techniques for facilitating patient healing—1) refocusing on the present, 2) reframing adversity, 3) practicing surrender, and 4) meditation. These approaches can be mutually integrated and compliment a psychological treatment in either the psychiatric or primary care setting, regardless of whether or not the patient has formal religious beliefs.


In working with patients for more than 25 years, we have relied on the cornerstones of our psychiatric/family-medicine training for the treatment of psychiatric disorders—psychoeducation, psychotherapy, and psychopharmacology. We candidly acknowledge that these three therapeutic approaches have been invaluable in treating many patients with emotional difficulties. However, despite this cache of clinical interventions, a number of patients continue to emotionally struggle. Something in the overall treatment strategy appears to be missing. We have long noted that these struggling patients oftentimes have histories of childhood adversity. In our earnest endeavors to address this enigmatic deficit and to enhance patient care, we began to explore additional therapeutic options and found some possible answers in the metaphysical/spiritual literature. Collectively, these metaphysical techniques seem to offer a spiritual component to the treatment of emotionally complex patients.

While novel for some healthcare professionals, the addition of a spiritual component to the preceding three conventional therapeutic components was described long ago by Native Americans. These pioneers developed the medicine wheel and its four key areas-of-life emphasis: the intellectual (i.e., psychoeducation), the emotional (i.e., psychotherapy), the physical (i.e., pharmacotherapy), and the spiritual (i.e., the metaphysical). In this edition of The Interface, we discuss this fourth component—the metaphysical/spiritual—and describe four techniques from this literature that may offer additional therapeutic support to patients.

The Importance of the “Now”

A number of contemporary metaphysical authors stress the importance of “living in the present.”[1–7] They pragmatically emphasize that the present is the only experiential space in which we realistically can live. This perspective essentially requires one to relinquish, to some degree, compulsive preoccupations with the past and the future. Neither past nor future allows one to experience the only reality that an individual can ever actually experience, which is the present.

Without reasonable anchorage in the present, one is left with the vicissitudes of the past and future, which at times may be entrapping through compulsive preoccupation. Indeed, Eckhart Tolle describes these mental past/future machinations as being “trapped in time [with] the compulsion to live almost exclusively through memory and anticipation.”[8] This metaphysical emphasis on the present does not exclude the necessity of healthy reflection and realistic future planning in one’s life, but rather confronts the ongoing churning of distressing past/future mental movies.

Living in the past. For many of our patients, it is reflexive to emotionally anchor in the past, especially for those with traumatic life histories. Childhood adversities, particularly sexual, emotional, and physical abuses as well as physical neglect and observing repetitive violence, tend to be powerful and influential psychological material upon which to obsess. At its extreme, in some tragic cases, repeated victimization in childhood (i.e., genuine victim status) morphs into an artificial “victim” identity in adulthood, replete with its chronic self-defeating behaviors and continual re-enactments of self-destructive relationships. Such extreme mind identification with the past effectively defeats the genuine unfolding of the individual’s true identity in the present, leaving him or her trapped in a monotonous and robotic life script. In the aftermath, ongoing preoccupation with the losses and abuses of the past, which distracts from the experience of the present, may unintentionally precipitate intensely negative feelings, which may lead to clinical depression in susceptible individuals.

Living in the future. Like the past, the future is also fertile ground for mind play in a variety of forms. One common example is excessive and/or neurotic planning to avert some imaginary disaster, which behaviorally reaches a crest in the phobic patient. Another common example is the excessive mental activity focused upon “getting somewhere”—i.e., achieving a highly desirable endpoint (e.g., completing an education, closing a business deal, achieving the prescribed retirement nest egg). Granted, it is necessary to do a reasonable degree of planning for the future, but compulsive rumination about the future may set the stage for impatiently waiting for an imaginary future life to unfold—all at the expense of being able to experience the reality of the present.

As a corollary, many people seem to over-value the outcome of an experience and the foreshadowed rewards or relief that it may bring, rather than “experiencing the experience.” In this regard, American culture including the media tends to play an active role in nurturing these mental preoccupations with the future. We are constantly bombarded with futuristic formulas for success. Children have to get into the right private schools. Particular clothes, make-ups, fragrances, bodies, neighborhoods, and cars will ultimately garner social success and happiness—once one has accumulated the extensive financial resources to afford them. Happiness awaits when one moves into the big house. The folly of these cultural myths may seem self-evident, but for young patients and those with poor or absent mentoring (i.e., patients with deficient parental mentoring, whom we so commonly encounter in those with histories of childhood adversity), this cultural dogma may function as the only life guidance for scripting “success.” On an emotional level, this excessive preoccupation with the future may unintentionally reinforce worry and tension, which may lead to clinical anxiety states in susceptible individuals.

Case example 1. Regina described the situation exactly as she had experienced it. “I just sat there…thinking to myself over and over that the flight was going to be cancelled. After sitting for an hour on the tarmac, they started pulling off the luggage because of weight requirements. Then, after another hour of sitting on the plane, they started pulling people off. I just knew that I would never make my connecting flight in Atlanta. I just knew it! I would have to stay in a hotel overnight in Atlanta and get into town the next day. I hate unnecessary overnights! Then, I would never make my business appointments. I wondered if I should call work and cancel my appointments.”

Therapist: “What happened?”

Regina replied, “The plane took off two and half hours late, but I made my connection.”

Case example 2. Ben was working very hard as a first-year resident in the internal medicine program. “I’m working 80 hours a week, studying all the time, and I don’t get to spend much time with my family, but it will all pay off when I finish. I’m going to have a great salary, nice house, club membership…you know…that’s all I think about…I’m really going to have made it!”

Living in the present. Granted, the metaphysical principle of staying present appears to be a very easy concept—stay in the present and avoid an excessive focus on the past (depressogenic) or the future (anxiogenic). However, putting this principle into actual spiritual practice can be a frank challenge.

At this juncture, we wish to emphasize that the importance of living in the present is hardly a new concept. Indeed, “being present” appears to have its early roots in Buddhism and is described in the Third Noble Truth. Likewise, living in the present is not a novel concept in psychiatry. Cognitive behavioral therapy attempts to curb futuristic thinking (e.g., the endless “what ifs”) as well as the self-imposed constraints that have consolidated through past experience (e.g., “yes, but…”) by confronting unhealthy cognitive patterns. However, the importance of routinely sensing and being aware of what time frame one mentally experiences appears to be relatively novel to the field of psychiatry.

How can the clinician approach the patient who demonstrates compulsive preoccupation with either the past or the future? The initial intervention would seem to be psychoeducation. We believe that patients need to understand and accept (intellectually and emotionally) that their automatic and unattended mental activities are contributing to their overall life dissatisfaction. After explaining the benefits of present-minded thinking to the patient, we suggest several techniques that seem to promote better anchoring in the present.

One initial technique is simply beginning to recognize and be aware of past/future compulsive thinking. “Watch your thinking, observe it, witness it.” This alone may begin to result in the disruption of compulsive patterns of thought. This exercise needs to be undertaken in a nonjudgmental manner (i.e., neutral self-observation) and continually practiced.

A second technique is the immediate cueing on the environment. This technique entails using the five senses to instantaneously experience the immediate environment. “I want you to see, touch, smell, and hear your world…in the moment.” This practice relates to the principle of “mindfulness” or simply being aware. This form of mindfulness practice may be particularly helpful in a number of clinical situations. For example, in an individual with binge eating disorder, the clinician may augment the patient’s experiential tasting through mindfulness practice. “I want you to really experience, savor, and fully taste your meal. Focus solely on the food…it’s texture, color, and taste. This means no distractions, eating slowly, and fully concentrating on your eating.”

Another time-honored technique is focused attention on one’s breathing. Breathing is obviously a physiological experience that is very much “in the moment.” “I want you to concentrate on your breathing, as you breathe in and out. Observe and experience each breath.” This can be undertaken in conjunction with meditation practice.

A final technique is having the patient examine the world through the eyes of a newborn baby. “I want you to see the world in its wholeness and not focus on its parts. See the forest, not the trees. See the world as if it were the very first time you had ever seen it. Like a baby might see it.”

Again, we wish to emphasize that the shift from past/future to present-minded thinking is far easier said than done. It seems to require a consistent and authentic desire to retool one’s thinking processes and ongoing frames of experience. Like any skill, present-mindedness requires continual practice, so we frame this technique to patients as a lifestyle change. At the same time, just as any skill, it becomes easier with practice and more automatic with time.

The Adversity Paradigm

Adversity—it sounds onerous—hardship, misfortune, difficulties. No one is immune to life’s obstacles. Yet, a number of metaphysical authors emphasize that all things happen for a reason.[2,6,9] For some individuals, this proposition may require the proverbial “leap of faith.” How could all things happen for a reason? Certainly, bad things don’t purposefully occur. Whether the position that all-things-happen-for-a-reason is causally valid or not, believing so may improve mental health functioning by facilitating the patient’s adaptation to adverse circumstances.

How does reframing adversity promote patient adaptation? First, we must illustrate the differences between perceiving adversity as a random event versus perceiving adversity as an event by design. If the patient perceives adversity as a random event, then a series of well-honed cognitions are likely to follow—such as “I got screwed,” “I’m a loser,” and “Why me?” These distressing cognitions naturally result in negative feelings, such as helplessness, demoralization, and a sense of victimization, and may culminate in the troubling behaviors of either acting out or internalizing. However, by accepting that all things happen for a reason, the patient is actively challenged around determining what is to be learned from this adverse experience. There is a shift from random victim to psychological explorer. As an example, perhaps an impulsive son (the adversity) is there to remind an impulsive father to keep on his spiritual path of growth and not get side-tracked in his own impulsive behaviors. Perhaps an emotionally vacant mother (the adversity) is there to reinforce to the daughter the importance of being a good mother to her children.

Usually it is possible to construct a positive interpretation of most adverse events. Of course, this approach does not exclude the validation of the patient’s pain and sense of loss with such events. However, helping the patient to refocus in this way seems to redirect them from “stuckness” toward more productive problem-solving and self-awareness. This approach consistently promotes the development of responding rather than reacting to adverse situations. But, again, this reframing requires a spiritual leap of faith—that all things are in ongoing order and that nothing is left to random design.


Surrender is an emotionally charged concept in our culture. Yet, surrender is a word that has very different meanings when viewed from Western versus Eastern perspectives. From a Western perspective, surrender is associated with giving in, admitting defeat, submitting, or capitulating. The connotation is blatantly negative and implies weakness. However, in Eastern thought, surrender entails the relinquishing of unrealistic fantasies of controlling others or events. It is the active acceptance of what is. In other words, it reflects a positive mindset.

To be clear, surrender is not the equivalent of resignation. It is not the commonplace attitude of “whatever” that we so often encounter in adolescents. Surrender is about acknowledging one’s own internal resistance to a situation and relinquishing the belief that in resistance resides one’s strength. Surrender is an action that relates to truly and genuinely accepting what is. It is about not opposing the course of life. Perhaps another way to think about surrender is that it is simply and genuinely accepting one’s path at any given time, yet understanding that choice is always a part of that path.

As an example, this metaphysical concept is particularly useful in helping patients to deal with their seemingly unending comparisons with others. We all tend to look at others and compare ourselves. People around us may seem far more gifted or more fortunate than ourselves. By assessing ourselves in this way, however, we fall into a hazardous comparison trap. Realistically, there is always someone who is more accomplished, talented, attractive, well liked—we can rarely triumph. As a result, comparison tends to generate bad feelings about one’s self. At this juncture, the metaphysical intervention would entail encouraging the patient to accept his or her unique and personal current path as highly relevant and necessary to his or her overall life course, whatever that may be (i.e., surrender), while empowering him or her around active choices. From a pragmatic perspective, comparing one’s path with the paths of others is unproductive and redirects the patient away from his or her own individualized life course.

Case example 3. Danne, a female patient with an eating disorder (ED), commented, “I can’t believe this! Here I am in this ED unit, and these girls are all thinner than me, have more money, and are prettier! Why can’t I be like them?”

Therapist: “Danne, focusing on the other patients only distracts you from the work that you have to do. Everybody has a unique path in life. You cannot have their path and they cannot have your path. Each path is uniquely valid. I encourage you to accept the idea that your path, while distasteful to you, is your path. Stay focused on the inner and be careful about being caught up in the outer.”

As so eloquently summed up by Eckhart Tolle, “Surrender is the simple but profound wisdom of yielding rather than opposing the flow of life.”10 Indeed, opposing the flow of life is likely to precipitate profound negative emotional states.


Meditation is a structured mind/body experience that seems to transcend the thinking mind by allowing one to enter into a heightened state of relaxation and awareness. The techniques for undertaking meditation are numerous, but most, if not all, entail a relaxed sitting position in a quiet place and begin with a focus on breathing. The focus on breathing promotes relaxation as well as a sense of presentness. Following focused breathing, meditation practices may diverge into a variety of different directions. For example, some practitioners meditate to heighten relaxation. Some initiate auto-suggestion, which may be particularly effective in this relaxed state. Others seek a different level of consciousness, sometimes referred to as a fourth dimension. Yet others use meditation to broach and focus upon major life questions, hoping that the heightened sense of clarity in this unique state will facilitate a response (i.e., an intuitive “knowingness”).

Whatever the reason, meditation is a strongly espoused spiritual practice by the metaphysical community, and certainly our patients may potentially benefit from any of the preceding functions. We do not espouse a particular meditation technique, but underscore with the patient the following: 1) the potential value of meditation, 2) the importance of meditating in a calm environment in a relaxed position, 3) the initiation of this experience with paced and focused breathing, and 4) the use of simple words (a mantra) for promoting focus. After continued practice, the patient will find it easier to “calm the mind” and contain intrusive thoughts. Note that meditation may be undertaken as a practice for mindfulness and present-moment awareness.


An interconnecting theme in the preceding metaphysical approaches is the practice of mindfulness. Mindfulness is simply being aware. This means being both internally and externally attuned, without the filters of judgment, the emotions, or the culture. Note that in each of the preceding techniques, there is an element of being present—i.e., being in a mindful and aware state. For example, dealing with adversity entails being mindful of the obstacle from the perspective of “here by design.” The technique of surrender requires one to experience and accept the nowness of the path. Finally, meditation and its attendant focus on breathing is clearly an exercise in mindfulness. Mindfulness seems to be the fabric that supports the metaphysical design in the presented techniques.

What About Religion?

Religious beliefs are not, per se, a limitation to using any of the preceding metaphysical approaches. Nor is a religious orientation necessary to use them. However, religious belief may temper some interventions such that “by design” is easily interpretable as God determined. In addition, meditation may be translated as “prayer” or “spending time with God.”


The modern era has certainly provided clinicians with an invaluable array of psychotherapeutic tools to address the emotional difficulties experienced by patients. These tools include psychoeducation, psychotherapy, and psychopharmacology. Yet, for a number of patients, these approaches fall short of providing a satisfying resolution to their inner turmoil, particularly among those individuals with histories of childhood trauma. In our search to compliment these contemporary approaches to treatment, we have integrated a number of metaphysical/spiritual techniques that have the potential to offer comfort and peace to many patients. While we have only presented four specific techniques, there are others that can be gleaned from the recommended reading list in the sidebars. We are all pilgrims on this planet. We are all seeking inner harmony. Why not benefit from the centuries of wisdom that have preceded us?

table 1 and table 2 are recommended reading lists.

1. Davis J. The Diamond Approach. Boston, MA: Shambala;1999:24.
2. Tolle E. The power of the present moment. In: Tolle E. Oneness With All Life. New York, NY: Penguin Group; 2008:21–35.
3. Almaas AH. The Unfolding Now. Boston, MA: Shambala; 2008.
4. Bodian S. The practice of presence. In: Bodian S. Wake Up Now. New York, NY: McGraw Hill; 2008:79–98.
5. Batchelor S. Awareness. In: Batchelor S. Buddism Without Beliefs. New York, NY: Riverhead Books; 1997:57–66.
6. Jacobson L. Journey into Now. La Selva Beach, CA: Conscious Living Publications; 2007.
7. Brown M. The Presence Process. New York, NY: Namaste Publishing; 2005.
8. Tolle E. Practicing the Power of Now. Novato, CA: New World Library; 1999:31.
9. Richo D. The Five Things We Cannot Change. Boston, MA: Shambala; 2006:27.
10. Tolle E. Practicing the Power of Now. Novato, CA: New World Library; 1999:115.

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Category: Past Articles, Primary Care, Psychiatry, Psychology, The Interface

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