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Therapy As Craft - Page 2

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Wired for Overconfidence

Recent work in decision-making psychology has shed new light on skills and how we develop them. In his book Thinking, Fast and Slow, Daniel Kahneman, the only psychologist to win a Nobel Prize (in economics), proposes that skills are learned with two human operating systems: System 1 (intuitive, automatic, fast) and System 2 (more deliberate, more logical, slower). New skills are difficult and tiresome to learn because they take so much System 2 work at the beginning. Read a puppy therapist's mind during a session and you're likely to hear this: "What should I ask next? Am I talking too much? How am I going to get the husband into the conversation? Should I try something cognitive here, or maybe something behavioral? Now what was she just saying?" Being in flow this is not.

Once this taxing period is past, the therapist's skills and intuitions come to reside in System 1. A seasoned therapist senses what's needed in the moment and confidently executes a smooth, readily available skill. No need to calculate each step! I experience this process as having the confidence that I can listen deeply to my clients without knowing where I'll take the conversation later--what interventions I may make. I trust that the insights and words will be available to me at the right time, and they usually are.

This is the beautiful side of having skills: the feeling of being on your game, of doing something you love, and getting paid for it, to boot. But there's a dark side to this confidence. Kahneman's work is mostly about the unreliability of System 1 and the inadequacy of System 2 in correcting us when we go astray. Once our skills reside in a zone of confident intuitions, our reflective, self-corrective abilities come into play only when System 1 generates a warning signal that it's becoming unreliable. The problem is that System 1 doesn't easily admit being off base. When a skill isn't adequate, System 1 generally substitutes another response that comes to mind, often approximately correct, but sometimes quite wrong. System 2 usually endorses and rationalizes these ideas and feelings, because it can't easily distinguish a genuine skill from a substituted, biased response delivered up with confidence. System 2 is a sucker for confidence, it seems, and as Kahneman says in his sardonic style, System 2 is lazy when asked to work.

We can easily see this happening in other professions. When a patient with diabetes is getting worse, a physician in training assumes that he or she may not be offering the right treatment, and seeks consultation. A seasoned physician using standard treatment protocols is likelier to conclude that the patient isn't being compliant with the correct treatment regimen (losing weight, watching diet, taking medications as prescribed). This explanation for repeated treatment failures is System 1 talking and System 2 agreeing. For an experienced physician to entertain the possibility that he or she may lack skills for engaging and motivating patients and their families to incorporate a difficult treatment regimen into their lives would take a big shift out of a professional System 1 comfort zone. It would require learning challenging new skills and becoming a clumsy beginner at new ways to communicate with patients and their families--something that System 2 wouldn't welcome unless there were a pressing need. And if the physician's community of medical providers embraces the traditional approach to his/her healing craft--make a good diagnosis, inform patients about how to handle their illness, and the rest is up to them--then there's little likelihood that a particular doctor will say, "Hold on. I lack a skill set with these patients, and I'd better learn it." In this case, change has to start from the outside, as is happening in outcome-oriented healthcare that has financial repercussions when a clinic's pool of diabetic patients is below expected levels of metabolic control. Now more providers are signing up for courses in motivational interviewing.

Therapists aren't immune to this overconfidence about our intuitions and skills. We share a tendency to rationalize our failures and rely on our current skills instead of upgrading them. When my client blew up at my interruption, my immediate System 1 intuition was that this was a vulnerable, explosive client (true), and that I'd made no mistakes in the session (wrong). If I'd stayed with these intuitions, my System 2 processing would probably have endorsed them--rationalizing, as did his former therapist, that there was something seriously wrong with him--and my work with this man and his wife would have suffered. But over the years, I've trained myself to respond to disturbing and surprising developments in therapy with an immediate assumption that I missed something. In this case, I had enough data from the telephone intake and from the client's wife's reports about the prior therapy blow-up to anticipate his explosive anger if he felt disconfirmed. Even so, I decided to interrupt him early in our session, rather than let him settle in and feel heard before I moved him in a different direction. Fortunately, my System 2 received enough self-corrective data from System 1 to get to work on a plan to readjust my approach to him.

Getting Off Plateaus

If therapy is a craft at which we become more confident over time, we should get better over time, right? The evidence says otherwise! When it comes to therapy outcomes--how well our clients do--there's no difference between early-career therapists and later-career therapists. These are averages, of course; some therapists no doubt do get better. But most of us think we're better because we feel more confident. Scott Miller has demonstrated a related illusion: we nearly all think we're above average therapists in comparison with our peers. We're all from Lake Wobegon, it seems.

So why don't most of us improve over time? I think it's because we plateau at a certain point and become too confident and comfortable with our skills. So we keep treating clients in the same basic way. In medicine, they call this "clinical inertia," the tendency to stick with what we know and keep doing it. We help the same percentage of clients as the years go by, and have the same success and failure rates with different problems. Like physicians treating diabetics, we become good at rationalizing our failures as successes in disguise (that couple was doomed to divorce anyway, and we just helped them get there with less hostility), as the fault of the client (not motivated to change, had an Axis 2 diagnosis), or as a problem with the healthcare system (not enough sessions).

My own tendency toward clinical inertia is no different from that of other therapists. After learning my craft, I've only seriously shifted my approach when I've been propelled by challenging circumstances to upgrade my game. The first time was when I took a job in a family medicine training program and came across people whose medical illness wasn't just a metaphor for psychological and familial dynamics. I realized that I had no language to talk about bodily pain, blood levels, medication side effects, diabetic reactions, and invasive medical tests that lead to no diagnosis. Like many therapists, I was tongue-tied when clients talked about their medical problems unless I could connect them directly to the psychological or family issues we were working on. I was contributing to the mind-body split in people's lives: they can talk about their minds with their therapist and their bodies with their doctor.

I was forced to become bilingual by hanging out with medical colleagues and fellow therapists who were making the same discoveries about the limitations of our language. I had no coach, but I had good teammates who shared their successes and failures working on a new therapeutic language. Most of all, I learned by listening to my clients with both ears, not just my psychological ear. Lydia, a client who had multiple sclerosis along with a troubled adolescent daughter, was one of my best teachers. I recall the outset of a session when she immediately teared up. I offered one of my regular System 1 empathic responses: "Sounds like this is a hard time for you." She calmly replied, "Oh, don't worry about my tears. That's my M.S. talking, not me. I've actually had a good week, and I'm feeling good today." I went on to learn how M.S. can make people emotionally labile, and that I shouldn't assume I knew what was behind a sad look. Through experiences like this and conversations with colleagues, I expanded my craft to be good at conversations that include the biological aspects of the human condition. Nowadays, many therapists are going through the same process in learning the new, multisyllabic language of neuroscience.

Later, I went through a similar shift regarding ways to bring a moral dimension into therapeutic conversation. Like many therapists in the 1970s, I was trained to ignore or challenge any moral language a client was unfortunate enough to use in my presence. Fritz Perls became a kind of therapist folk hero in the midst of the cultural ferment of the 1960s, not only by rejecting psychoanalytic orthodoxy, but by challenging guilt-ridden clients to stop "shoulding" themselves. Obligations must be translated into needs and wants, or they're inauthentic, he taught. When a client on the verge of divorce would say, "I'm worried that I'm trading my kids' happiness for my own--making them miserable so I can have what I want," I was trained to keep the conversation focused on the needs of the client's self: "I think it's important for you to focus on what's best for you right now; kids are resilient." I had no vocabulary to engage in moral discourse that avoided the twin mistakes of trivializing moral intuitions or stoking unproductive guilt and shame.

Although I'd read critiques of "value-free" therapy (feminism nailed that illusion), I didn't have the craft yet. The breakthrough moment for me was with Bruce, who came for a final session to say good-bye after his wife had kicked him out. After a few minutes, he calmly announced that he was leaving town--and his kids--to start a new life. He'd already abandoned two children after his last divorce. In Kahneman's terms, nothing in my System 1 skills gave me the language I needed at that moment, but fortunately, my System 2 had taken in enough information about the significance of moral values that I realized I had to try to reflect that knowledge in the therapy somehow. I knew that it wasn't going to be enough to just encourage him to slow down or to emphasize how much he'd miss his kids. Time was short, and he was about to leave another set of children grief-stricken and confused.

So I broke a taboo by using moral language about the consequences of his actions for others. "Bruce," I said, "how do you think your leaving will affect your children?" His response: "They'll be hurt for a while, but they'll get over it soon." I replied, "I don't think so. I'm really concerned that in dealing with your pain right now--which I understand feels overwhelming--you're about to do something that'll harm your kids permanently." Bruce paused. He knew I cared about him, and he was absorbing this challenge to his moral integrity. After some back and forth, in which I offered to help him deal with his sense of rejection and hopelessness, I added: "Your children aren't responsible for this divorce, and I don't think it's fair for them to be its casualties." Bruce eventually decided not to leave town, recommitted to these children, and later reconnected to the set of children he'd left behind after the previous breakup. This experience was a turning point in my career, teaching me that I had to learn the craft of what I later called "moral consultation," because moral issues are part of the human condition that people bring to therapy, just as medical issues are.

But eventually, I plateaued again in my therapeutic craft, becoming more a teacher of what I knew than an excited learner. Recently, I started on another period of craft development: learning a new way to work with "mixed-agenda" couples, in which one is leaning out of the relationship and the other wants to save it. A couple of decades ago, I learned a basic craft tool from master therapist Betty Carter, which I used in my practice, but never fully explored--like learning a new riff on a guitar without realizing that it could be the basis for a new style. After working with a family-court judge and a group of collaborative divorce lawyers who were looking for places to refer mixed-agenda couples, I felt pushed to develop the tool I'd gotten from Carter into a full-blown protocol for working with a kind of couple that drives therapists crazy. I named the new approach Discernment Counseling. The essence of the protocol was to tell two spouses who were at odds that I'd help each of them accomplish their own goal: one to save the marriage, and the other to figure out whether to divorce or work on the marriage. I'd never imagined couples could tolerate my working two seemingly contradictory agendas at once. The key was to do this mostly in separate conversations with each spouse, along with carefully calibrated summaries at the end of sessions.

Then, with the idea of craft in my consciousness, I decided I needed to seek out enough practice experiences before I began to teach Discernment Counseling to colleagues. In sports terms, I realized I needed enough reps (repetitions) to hone my craft in light of the wide range of mixed-agenda couples who seek therapy. So I asked my lawyer colleagues to send me cases, and I stopped doing regular couples therapy to focus on this new craft. I asked fellow therapists to observe my sessions so that we could process them. I listened to their sessions. I obsessed about things like what words to use to open sessions after the first one, since this is an exploratory, decision-making process, not a traditional couples-therapy process.

My current opener is: "I'd like each of you to say something about your frame of mind as we begin our second Discernment Counseling session." Here I'm avoiding asking for stories of what happened during their week or even their goals for the session (we'll already have agreed on the goals of Discernment Counseling in the first session). Instead, I'm inquiring about what attitude they're bringing to the session today. By mentioning what session it is (two out of five), I'm reminding them that there's an urgency to get to work. For couples who've had traditional couples therapy, this opening signals that we're doing something different from what they tried before. How I open these sessions will no doubt evolve over time in a community of Discernment Counselors, but I'm committed to paying attention to this level of detail.

If therapy is all about pacing the conversation, I'm learning when to be emotionally present but low-key in Discernment Counseling (when the couple is in the room together), and when to be more intensely supportive and challenging (when talking to each partner separately), and how to set up the likelihood of a positive but realistic end to the session (when the couple is again back in the room together). It feels like learning the craft of an orchestra conductor: how to open, how and when to contain or unleash intensity, how to close--all complicated by the fact that the spouses don't play well together, or they wouldn't be in my office! It takes lots of reps--doing it over and over while looking for mistakes or better ways to do what's merely OK now. It's all about paying attention to details and practicing your skills. I push the therapists I train to work on specific aspects of their craft, such as how to make a smooth transition from supporting a complaining spouse's feelings to challenging that person's own contributions to the problem.

Beyond Our Natural Gifts

When it comes to deep conversation about what's most important in life, therapists are naturals. Unlike many people listening to intense emotional suffering, our instinct isn't to run or to fix. We know how to stay with pain until our client feels heard and is ready to move. If we were musicians, I'd say that most of us start out with natural good pitch, rhythm, and timbre. If we were athletes, I'd say that we can run, throw, and kick balls better than the other kids. But these natural advantages are only the thin edge of competence and far from genuine mastery. As the old saw goes, "How do you get to Carnegie Hall? Practice, practice, practice." The equivalent might be said for athletes, surgeons, potters, carpenters, architects, chefs, healers, or anybody else whose occupation requires a high degree of practical skill, along with a body of theoretical knowledge.

These experts--including therapists--don't learn how to do their craft once and for all: it's a process that continues throughout life and is never finished. Not only that, but keeping fit and staying on game means we can't continue practicing blindly, by rote, what we already know how to do. We have to stretch ourselves, make ourselves uncomfortable by practicing what we don't know how to do very well. We need to learn and repeat over and over exactly those skills that don't come naturally, that make us feel like awkward beginners. In fact, a continual willingness to begin all over again may, paradoxically, be characteristic of the acknowledged masters of any skilled practice.

But practicing by ourselves won't cut it. We can't remain fully competent in our craft, much less grow and become better at it, without the support and challenge of our colleagues. No decent athletes, much less world-class champions, practice in isolation. They have coaches, whose job is to give them honest feedback, point out their weaknesses, and keep after them to work on the weak links in what, to us mortals, might seem to be total perfection. The same is true of musicians. If they don't have individual coaches with them every day of their lives, they hear and feel the "coaching" of their conductor, their colleagues, the critics, and ultimately the audience--which will let them know soon enough that they aren't performing up to par. Psychotherapy is virtually unique in not having built-in coaching/feedback opportunities, and yet, arguably, we need it more than most craftspeople. In the intimate world of the therapy encounter, we truly are unseen, unjudged, unchallenged by any except the client--whose dissatisfaction is only too easy for us to dismiss.

Regular feedback helps us practice and learn more effectively, and it keeps us honest. We can't easily fool ourselves into thinking that it's all the client's fault when five or six others in our consulting group are telling us--nicely, we hope--just how badly we screwed up. In fact, it's just this kind of sounding board that enables us to become aware of what we aren't doing right, what we don't really know (and often don't know that we don't know). Feedback not only makes new learning possible, but contributes to one of the most important traits in a therapist, or maybe in any highly skilled craftsperson: a sense of humility and the certain knowledge that we don't have all the answers.

For those of us who've been in this business for a long time, the idea of therapy as a set of hard-won skills doesn't fit the glamorous vision of being a therapist we derived from watching the buccaneers of family therapy: Salvador Minuchin, Virginia Satir, Murray Bowen, Carl Whitaker, Alex Haley. It's hard now to imagine those icons of clinical starpower and shimmering self-confidence (not to mention, the even grander, more august company of the psychoanalytic masterminds of yesteryear) simply as hardworking craftspeople. Yet, there's something good and solid in the thought that no matter how much prestige any of us acquires, no matter how many clients we see, how big the workshop audiences we attract, how many books and articles we write, we still have a lot to learn. Maybe, since the glory days of the psychotherapy magic shows, we've grown up a little as a profession and as individual therapists, and gained some salutary humility about our powers in the process. Maybe by thinking of ourselves more as craftspeople on a noble but futile quest for perfection, we're becoming better therapists, even as we demystify the glamorous idols of therapy.

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3 comments

  • Comment Link Monday, 01 October 2012 12:42 posted by Kemila

    One of the most interesting reads for long. Thank you.

  • Comment Link Saturday, 15 September 2012 08:00 posted by jeffrey von glahn

    Kahneman and Klein (2009. Conditions for intuitive expertise: A failure to disagree. American Psychologist, 64(6), 515-526) write about "skilled intuition." This ability can only develop in a setting that has stable relationships between input and response. The authors cite firefighting and medicine as examples. Psychotherapy is certainly one. Long-range forecasting of the value of a stock or of an election are not examples.