Several years ago, while in graduate school in New York, I attended a lecture by a famous psychoanalyst who was advocating for a special place for psychoanalysis in todayâs society. The world, he argued, has become too fast paced and goal oriented. People are pushed into acting without thinking, behaving without contemplating, and are leading overly productive lives. In fact, he suggested that Nikeâs advertising sloganââJust Do Itââbest symbolizes our time.
âNike-ism,â he argued, âis everything that psychoanalysis is not.â And our duty as therapists is to preserve the countercultural force of psychotherapy opposing this tideâagainst rushing and doing too much and thinking too little.
âWell,â I told my friend as we listened to the enthusiastic applause of the audience. âI kinda like that slogan.â
âWhy?â she asked.
âLook at this room!â I answered. âEverything is so slow, so predictable. Donât you think analysts need to hurry up sometimes? Get a kick to their backside on occasion? Otherwise, it can all become a grand festival of nodding and sighing and snoozing. I donât think psychotherapy is about that at all.â
The dichotomy between doing and being is central to the way therapists view psychotherapy, both as a special practice in the world and as a helpful way to distinguish between different types of therapy: between the more concrete, results-driven types and the slower, more contemplative ones.
I was first taught this distinction as a contribution of Donald Winnicott, who perceived âbeingâ as a special manner in which analysts are present in the room, one that allows patients to open up, to freely associate, and to delve deeper into their experiences and their meaning. The uncle in the funeral whoâs constantly moving around and asking how he can be helpful is in a doing state, our professor told us; the friend whoâs sitting in silence and holding the bereaved personâs hand is being.
Throughout my training and career, being was held as an ideal of psychotherapy. Let everyone else be obsessed with results and achievements; therapy will stand in its unique position as a bastion of a different, quieter kind of presence, a promise to stop time and create a space unlike any other in modern society.
But what happens when therapists actually need to do something? Like building a large publicly funded treatment and training center from scratch?
After a long period in New York, I returned home to Israel, relearned doing therapy in Hebrew, and readjusted myself to the Middle East, which mostly meant answering questions about why I was dressed in a button-down shirt all the time. âAre you going to a wedding later?â
Then, three years ago, I became the clinical director of Headspace in Jerusalem. Originally from Australia, itâs an organization that provides tailored and holistic mental health support and early intervention to young people, 12 to 25 years old. Our main clinical service is focused and brief psychotherapeutic interventions.
"Therapy requires a pause, a space for reflectionâand frequently, that means resisting the urge to act."
After a year of preparation, I was able to recruit four therapists. In two years, we grew to a team of 20 therapists, supervisors, and students-in-training, and we treat about 500 young people annually. In other words, we worked in a hurry.
Throughout these two years, weâve encountered innumerable dilemmas and challenges, points of friction and disagreement, and a general question thatâs been hovering over us: how do you create a great training culture, one in which therapists become substantially better at what they do?
Vision vs. Reality
If someone asks me (and sometimes people do) about my clinical vision for our center, I say that therapists are much more important than the model they practice, that they need real feedback (including metrics) about their work, and that the treatment approach should be personalized and tailored to the specific patient. And, importantly, the main focus of training and improvement should be the cultivation of therapistsâ core abilities and skills, rather than reliance on specific models. To me, our theoretical approach as a large publicly funded center should be âwhatever works,â prioritizing clinical outcome over anything else.
Nice vision, perhaps, but the problem is that most of the therapists Iâve met, in Israel as well as the US, donât believe in it. Instead, the buzzword around the clinic seems to be professional. If weâre learning a particular model or intervention, if weâre reading a complicated psychodynamic article, if weâre learning theoryâwe are being professional. If weâre not doing any of thatâwe are not. And not being seen as such, especially for a young center like ours, headed by a clinical director in his 30s, feels scary. What will the adults (the established clinical places in the city) think of us?
Despite growing evidence that questions the presumed differences between therapeutic modalities, weâre still, I think, very much in the model-specific era of psychotherapy. So when someone is presenting a case at Headspace, the comments about how a therapist listens, connects, challenges, uses her tone of voice are generally perceived as less interesting and shallower than a sophisticated interpretation based on a theory or a particular model. This happens regularly, even though many people, myself included, believe that these intangibles (or common factors, as theyâre known) affect psychotherapeutic outcomes more than anything else.
Luckily, weâre not the first ones to struggle with this challenge. One of the leaders in the focus on common factors and the application of outcome metrics and feedback in psychotherapy is Robbie Babins-Wagner from the Calgary Counselling Centre. I was fortunate to meet her in person and learned two vital things from her: implementing an outcome-based approach in a clinical center takes many years, and most therapists will be against it.
Often, an approach thatâs seen as results driven can be perceived by therapists as cold and mechanical, something the âmanagementâ is doing for ulterior motives (funding) while overlooking the humanity and individuality of psychotherapy (the âbeingâ element), which is the very thing that drives change and motivates people to work as therapists. My challenge, and my role as a clinical director, is to persuade people that this is not so. I aim to show that by implementing a skill-specific, outcome- and feedback-driven approach, weâre actually prioritizing the human, intricate, unique aspects of psychotherapy and giving them center stage.
I was never trained to implement this approach myself, but Iâve realized that this is precisely what was missing in my otherwise diverse and enriching education. So I understood that I needed to start slowly, in increments. For instance, when therapists at the clinic were against using recordings for feedback (out of a concern for patientsâ privacy and therapistsâ fear of being exposed) I introduced it first to students in training, who started to record their sessions for supervisory purposes so they could share their impressions about doing it with the team. When a plan that included an outcome questionnaire after every session was seen as cumbersome (âWhat are we even learning with these basic questions? They tell us nothing about whatâs actually going on in the roomâ), we went with shorter and temporarily less frequent questionnaires.
Iâm not trying to convince anyone that a questionnaire can replace a sophisticated, human perception of the psychotherapeutic processâonly that it can add something to it. As we know, implementing change takes time and trusting relationships.
Fast vs. Slow
Therapy requires a pause, a space for reflection; and frequently, that means resisting the urge to act. In my experience, most therapists expect a working environment that allows and promotes a slow pace and opportunities for deep contemplation that arenât restricted to specific goals and results.
Our center grew fivefold in two years. In Jerusalem, the demand for free psychotherapy far exceeds the supply, with an average waiting time for individual sessions being around six months. Therefore, our goal, duty, and part of our ethos at Headspace is to make therapy accessible to all in the shortest time possible. So our pace has in fact been very âNike-y,â and weâve expanded quickly.
Naturally, the fast growth and the culture associated with it have created much tension and disrupted ideal working conditions for most therapists. Every new therapist that I presented to the team (at some point, almost every other month) was met with the same reaction from the staff: weâve just gotten to know each other; you promised that youâll finally slow down. To be at our best, the therapists complained, we need to feel some stability and continuity, not be rushed and confronted with change all the time.
It took me time to understand how important it is to shield therapists from the business demands and the âstart-upy,â quick-paced nature of our center. I banged my head more than once in trying to convince people that we must be fast, that we have to introduce new programs that meet our communityâs needs, that to significantly cut waiting time (which we did) we need to be efficient and quick. I spent countless team meetings trying to explain my position and the critical part of efficiency and agility in an organizational strive for excellence. I (and my colleagues still laugh at me for it) often used words like greatness, (as it is, in English, while talking in Hebrew)âuntil I realized that I didnât have to do that.
Today, I think the best clinical centers have two parallel paces: theyâre fast and slow at the same time. Outside the room, theyâre fast when they create new programs, partner with other organizations, and continually try to improve the service experience of clients. But theyâre slow inside the room, in seminars and group consultations. They take their time when thinking about patients and their struggles. Iâve come to think of the therapistsâ âslownessâ not as a predicament, but as a boon and a sign of good therapy.
The work on the fast vs. slow dilemma is, in my opinion, a work of separation and individuation: separating the operational, business part from the clinical part and enhancing both, individually and separately. Many organizations where Iâve worked mix and confuse the two. This is how a place becomes inefficient: everything is either psychodynamic and processed and talked about to no end (including the operational side), or shallow because the focus on efficiency pervades the therapy room and makes it feel a little dumb. A good center needs both qualities to exist at the same time; the dual pace allows it to be both efficient and deep.
Authority vs. Egalitarianism
Itâs safe to say that psychotherapy has become much less authoritarian since its inception as a medical service provided by physicians in Europe in the late 19th century. Therapists nowadays see themselves less as experts providing treatment to passive patients, and more as equal collaborators in a relational process. This change requires therapists to deal with questions of authority and expertise. In a collaborative process, what exactly is it that we therapists are experts on? And what is the source of our authority?
These questions are relevant not only in the room, but also outside of itâin graduate schools, training facilities, and clinics. Iâve been thinking quite a bit about my role as a clinical director in terms of implementing authority on the way we work with, and think about, patients. Once again, it seems to me that we face two opposing needs here. The therapists need guidance and a clear definition of what it is that weâre doingâwhat kind of psychotherapy we practice, and what we consider a success. In contrast, they also need freedom to be the best clinicians they can beâto bring their individuality, creativity, and humanity to the room. You canât really tell someone how to do therapy; you can only suggest a direction.
In addition, a good clinical center has to have an atmosphere that promotes camaraderie, a sense of ease between people, and a joy in being part of a group and an organization. It trickles down to the treatments themselves and to the way therapists discuss cases and seek consultation from one another. But what happens when leadership and staff have sharply different ideas about the clinical direction, the nature of the work, and the priorities of the clinic? It seems to me that such situations are commonplace, and this has definitely been true at Headspace.
"Too often, an approach thatâs seen as results driven can be perceived by therapists as cold and mechanical."
Take the issue of supervision. Remembering my own experience, I wanted to provide a different model of supervision, one that operated on an as-needed basis. Iâd struggled in my own training with the tedious re-creation of sessions every week, which had felt ineffective and boring. Iâd imagined that probably everyone felt that way in training. But I was wrong. It took several months of arguments between me and the therapists until I realized that my position had been an empathic failure: Iâd failed to understand that they needed something other than what I didâthat to feel safe and competent, they needed the weekly holding environment of supervisors. Realizing that, I switched to the more classic, regularly scheduled form of supervision, which enhanced our mutual trust. The therapists felt heard and respected, and the authority over best practice was mutual and shared.
I think a similar process of diffusion of authority is present in our clinical seminars. Most therapists come to Headspace with significant skepticism about the brief therapy model and its possibilities. My reaction to that in the beginning was to double down on the merits of our model in a car-salesman kind of way, promising too much. With time, I realized that not only is it beneficial for our discussions to allow for skepticism, itâs a more efficient way to convince people that weâre doing something worthwhile. Only by allowing a critical, open discussionâin which everyoneâs an expertâcan the group come to see the value of its own work.
Therapists, by and large, are not binary creatures: they value nuance and allow for complications. So, in our discussions, weâve come, gradually, to appreciate differences of opinion. As people have become more comfortable with each other and more secure in their therapeutic work, theyâve also become more open. This is true of me as well: as Iâve become more secure in my position as a director, Iâve become less pushy. Iâm trying to present my ideas with more humor and less certainty, while allowing a dialogue with opposing views. But Iâve never changed my mind about the crucial elements: the spirit of the place has to be productive and joyful, and therapy, more than anything else, has to be a humanistic endeavor, in which the therapistsâ originality and creativity are the main factors of change.
Individuality vs. Cohesion
Adding to my beliefâand sustained by a growing body of researchâin the therapistsâ characteristics as the crucial element of change in psychotherapy is a belief in matching therapists and patients. While great therapists can usually work with a diverse population of patients, even the best ones do better with some patients and not others.
Weâve recruited therapists from almost all available therapeutic professions: clinical psychology, social work, neuropsychology, art therapy, and so on. Theyâre all expected to do the same workâprimarily individual and group psychotherapyâbut each with a different emphasis. Despite some resistance in the beginning, therapists at Headspace accepted the model I proposed, in which the person who performs the intake is encouraged to think about a person in the team who will be most appropriate to work with the patient. And I believe that the best way to ensure a good match is simply to get to know your colleagues.
To some people at Headspace, this method at first seemed a little self-indulgent, stemming from the belief that public community centers like ours should be able to work with everyone. And this is certainly what I was used to in every public clinic Iâd trained in: Iâd just gotten whoever was assigned to me, sometimes even before Iâd started working and people knew who I was. However, I believe that a more intuitive method of matching is actually the best way to elevate the level of service and our clinical work.
Such a method, I believe, allows for real diversity in clinical staff. Not everyone is equally good at everything: some therapists are better with concrete, exposure-based work on anxiety; others are experts with patients with health disorders; still others are great with younger patients who are less verbal. Our patient-based approach, together with a diverse group of therapists, allows us to tailor an appropriate intervention, provided by a therapist who is comfortable with it, to a specific patient who needs it. The cohesive part then becomes the common factors that should be shared among therapists: the ability to form and maintain a relationship, an empathic understanding, the use of humor and self-disclosure, the ability to provide hope, and so forth. The way each therapist does it in the room is individual and unique.
The reason I like the Nike sloganââJust Do Itââis because I think that in some clinical circumstances, being active is the deepest and most appropriate way to be. As a therapist, I always tried to combine different approaches and rejected the wars between modalities. I found that for some patients, active behavioral interventionsâeven in the midst of a psychodynamically informed treatmentâwere often the best, most empathic, interventions. Today, as the clinical director of a center that tries to be patient centered, I believe this even more stronglyâthat, at times, action trumps reflection, and making someone move might be the best thing we can offer. At the clinic, weâre trying to combine being with doing, efficiency with depth, agility with contemplation. Sometimes we failâbut sometimes, when weâre lucky, weâre just able to do it.
Valery Hazanov, PhD, holds a doctorate in clinical psychology from Columbia University. Heâs the clinical director of headspace Jerusalem, a public psychology treatment center.