After 45 years of doing therapy, I know one thing for sure, and that’s that I don’t know much for sure.
I used to think that we therapists knew, or would soon discover, the underlying causes of psychological and relational problems. Scratch that hope: we have as many explanatory models and inconclusive studies today as ever.
I also used to think that my favorite treatment model would become the silver bullet for thorny treatment issues—or at least clear the field of most competitors. But nope: we still have no evidence that any one treatment model is more effective than others for the vast majority of problems we see in therapy.
Okay, but at least most of us practitioners get a bit better with time and experience, right? Alas, available research shows that on average, therapists don’t have better client outcomes over time, even if we feel more confident in our work as we gain experience.
But I don’t despair, and neither should you. Even though we can be certain about so little, psychotherapy truly does work for a majority of clients. How does it do this? In part by creating a state of necessary, benign illusion.
To begin, we now have countless studies that show the biggest influence on outcomes—aside from client factors like prior functioning and motivation—is the relationship that we therapists create with our clients. It’s clear that some of us are better at this than others. When looking at the impact of therapist factors on outcomes, one researcher estimated that the most effective of us would have an 85 percent success rate for client outcomes, while the least effective would score a worrisome 18 percent. That’s a big difference, given what we know about what little effect training, or the model we use, or how long we’ve been practicing seem to matter.
Scott Miller, founder of the International Center for Clinical Excellence, has pointed out for years that we therapists aren’t good at assessing whether we’re in the top or bottom half of these percentages. When asked, we overwhelmingly place ourselves above the split.
There are some well-established competencies—for example, empathy—that do seem to help therapists create productive therapeutic relationships. I’d like to suggest an additional, perhaps less visible one: that some therapists have learned to work flexibly with the paradox of knowledge and illusion.
To understand this paradox, let’s turn to our animal brethren—the fox and the hedgehog. The English philosopher and historian Isaiah Berlin proposed that Western civilization has been shaped by two sorts of major thinkers: foxes, who know many things, and hedgehogs, who know one big thing. Aristotle was a fox; Karl Marx was a hedgehog. William James was a fox; Martin Luther was a hedgehog. A few psychologists have since glommed onto this idea in places like business and policy schools, using it to illustrate how holding tight to ideology can cost your company money or mire your community in useless bureaucracy.
When we look at our own field, we see that, by and large, psychotherapy models have been created by hedgehogs who knew one big thing extremely well. I’m talking here about people like Sigmund Freud, Carl Jung, B. F. Skinner, Carl Rogers, Aaron Beck, Jay Haley, Virginia Satir, Joseph Wolpe, and Murray Bowen. During the 20th century, our profession was dominated by these brilliant, single-minded innovators, many of whom were reluctant to recognize the value of knowledge outside their explanatory system. In my early years of practice, I can remember becoming so enamored of Rogers and the encounter group movement he inspired that I thought if we could get every member of Congress into a personal growth group based on Rogerian principles—well, imagine how the world would be transformed!
“It’s More Complicated Than That”
But the 21st century, I think, increasingly belongs to intellectually flexible, broad-ranging foxes. Fox therapists know that nothing in the landscape of therapy is as simple, or as local, as it once was. They know that human problems are about genes and epigenetics, the brain and the environment, the unconscious and conscious, behavior and cognitions and emotion, the family and the microenvironment, the economy, social institutions, race, gender, social class, morality, spirituality, politics, the broader culture, history, and the ecosphere.
If the hedgehog’s cry was “Eureka! I’ve found it!” the fox’s mantra, in the memorable phrasing of Psychotherapy Networker founder Rich Simon, is “I think it’s more complicated than that.”
In my own world, I’ve come to appreciate an observation by Richard Lewontin, the Harvard geneticist and social critic, who maintains that “human behavior is the product of many weak forces.” We now know more clearly that there are multiple contributing factors to human problems, but few singular, overwhelming causes that alone are sufficient to create and maintain these dilemmas. Poverty, for example, contributes to family and community breakdown, but many poor families and poor communities hold together and raise successful children. Marital distress is associated with poor problem-solving skills, but many couples who aren’t good problem-solvers are nonetheless quite happy. Most psychosocial problems arise from countless influences interacting simultaneously, most of which are weak when standing alone. My own corollary to Lewontin’s dictum is that, just as many of these weak forces lead to problems, at least as many carve pathways to healing.
Nevertheless, many therapists still tend to isolate and highlight one or two of their favorite forces as the cause of a given problem, and they make that call based on their training, ideologies, values, and politics. They may conclude that depression is primarily about neurotransmitters or faulty cognitions, or attachment wounds, or anger turned inward. They assume that marital distress arises inexorably from poor communication skills, or low self-esteem, or unconscious conflicts, or family-of-origin influences, or skewed gender roles. But the fox therapist doesn’t say “or.” She says yes, and yes, and yes, and, most importantly, that it depends on the person and the situation, and on how those internal forces interact with each other and with external ones.
Salvador Minuchin once talked about a case in which the therapist operated from a purely structural family-therapy perspective with a young boy who kept tumbling out of his seat at school. The reaction to this behavior was consternation from his teacher and worry from his parents and his puzzled doctors, who found no organic cause. A family assessment revealed boundary and parenting problems to work on, but nothing changed the child’s behavior. Then the therapist thought to inquire about the nuts-and-bolts particulars of his falling incidents, only to discover that the boy sometimes couldn’t read the teacher’s writing when she wrote on a board in the far corner of the classroom. Not being able to read the board, the boy would lean forward into the aisle, sometimes losing his balance. A pair of glasses solved the problem.
We wise foxes don’t get overwhelmed by the complexity because we usually don’t need to know all the causes of a problem to address it effectively. In our more foxlike moments, we recognize many potential sources of therapeutic healing. We can bring in medication, insight, behavioral change, cognitive change, working on boundaries, and/or taking up an exercise regimen. Clients on their own sometimes get better when they get married, get divorced, move to a new neighborhood, get a new job, find religion, give up the religion of their childhood, work to change a particular family relationship, or accept the reality that the family relationship isn’t going to change.
Our list could also include larger forces, such as an improved economy, overcoming oppression, affirmative action policies that create opportunities, or a neighborhood school that hosts adult classes and becomes a focal point for a larger community. Healing can come in many forms, only a few of which occur in therapy. I once had a client locked in grief because his adult children had cut him off after a divorce. The most powerful healing occurred when he found a new love and life partner—something I may have contributed to his readiness for, but which took place outside the therapy hour. We’re often more like witnesses and midwives for change, rather than creators of it.
Stay Focused—and Flexible
Research that effectively dethroned the hedgehogs has led me to some strange and confusing places. I’ve discovered that the shift from hedgehog to fox has its own perils. The hedgehog therapist at least believes deeply in something. When I was one, I was a true-blue family-systems therapist. That’s all I thought I needed to do my work. I steadfastly avoiding focusing on superficial symptoms while exploring their systemic underpinnings. Here’s an embarrassing example: Some years ago, during an in-home family therapy session, I ignored the fact that the alcoholic grandmother was drinking while we were meeting. I wasn’t going to get caught up in symptoms!
But after adopting the habits of a fox therapist, I put myself at risk for a kind of mindless eclecticism. With great confidence and enthusiasm, I wielded an incoherent grab bag of therapeutic techniques—a dash of psychodynamic, a dollop of behavioral, a bracing dose of attachment.
Although I find value in the metaphor of a therapeutic approach as a necessary illusion, I know that we aren’t theatrical entertainers: we’re healers. I’ve discovered that being a fox doesn’t free me from the need for a set of clear, theoretical ideas and clinical practices. Nor can I justify eclectic therapy by saying that I use “whatever works” for the case. As a professional treating vulnerable people, I should have a strong rationale for what I do, and I should monitor whether it actually helps my clients.
So the challenge for me as a therapist in the fox era is to be self-critical and accountable while remaining flexible and open-minded. I’m a recovering hedgehog learning to be a fox without abandoning my integrity. And this means working with the paradox of belief and illusion.
On the one hand, effective therapy requires on the therapist’s part a conviction that conveys a solid plan. We should be able to say, “I hear your story, I can help you understand your story, and I have an approach to offer that I’m confident can make things better.” Even though a thousand other therapists might be suggesting a different approach at the same moment to their client, I must truly believe in what I am saying and draw the client into a shared reality with me. Then we can cocreate a path forward with hope.
But on the other hand, unless I have the humility that comes with the knowledge that we all live with abiding uncertainties and necessary illusions, I can become dangerously closed-minded. We professionals can impose on our clients and on society an endless stream of simplistic explanations and overblown solutions to life’s problems. I’ve witnessed many of these during my career. They take the form of legitimate insights turned into overblown fads, which rise and fade like pop music styles: the miracle of Prozac! The epidemic of codependency! The notion that childhood sexual abuse lies in the background of nearly every woman with an eating disorder! The view that every adult issue stems from family-of-origin problems—or nowadays, that everything is about attachment and trauma.
Although we’ve learned important partial truths, our hedgehog-like exaggerations of them, which may at first garner public attention and fill continuing education workshops, eventually lead to cynicism about therapists and our work. We go from TV’s 60 Minutes to a satirical skit on Saturday Night Live.
Back to the irresolvable paradox: despite my necessary doubt as a fox, I must take stands. When faced with a particular client, I need to be clear about what narrative to offer and what healing forces to draw on. Because I can’t practice all forms of therapy at once, I’ll be choosing to use some healing powers and not others. So I may focus on trauma or attachment or relational systems if those theories and models seem to fit. If treatment is successful and the client goes forth believing that the narrative I spun and the treatment approach I took were what really helped, then I’ve delivered an effective form of medicine—even if other medicines might also have done the job. The illusion that underpinned the work becomes benign, because while this approach was just one pathway to healing, it did help. In the end, as we now know, whatever path we offer a client, the effectiveness of the treatment may lie in us ourselves. I treasure the feedback I received from a men’s therapy group, whose consensus about my healing powers was, “You make sense.”
As this way of working becomes more ingrained, I imagine that the tension between the fox’s adaptive humility and the hedgehog’s wholehearted but partly illusory conviction will never leave me. I’ve grown comfortable in my recognition that the universe is infinite. And yet I must stand somewhere, and stand there firmly and graciously. Of this I’m certain. I guess I do know something for sure, after all.
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William Doherty, PhD, is professor of family social science and director of the Minnesota Couples on the Brink Project at the University of Minnesota. He’s the author of the forthcoming book, The Ethical Lives of Clients: Transcending Self-Interest in Psychotherapy.