Three Tips for Boosting Your Clinical Wisdom

Strengthening the Therapeutic Alliance with Concern, Reflection, and Insight

Ronald Siegel

Maybe insurers and managed care companies are right: psychotherapists today should just faithfully match empirically validated treatments to presenting problems and, whenever possible, encourage clients to take medications rather than engage in more costly, labor-intensive psychotherapy. Indeed, more and more therapists are following this approach, even though it rankles many of us trained during an earlier, less cost-conscious era, when efficient symptom relief wasn’t seen as psychotherapy’s primary goal.

Within the older traditions originally inspired by psychoanalysis, self-knowledge had a place of honor in both treatment and training that it no longer occupies.

The question our field faces at this point is whether this older tradition that revered self-knowledge and clinical wisdom is still relevant. In today’s more strictly regulated, bottom line-driven mental health marketplace, should we care about anything beyond symptom relief? In fact, could it be that in a healthcare system that everyone agrees is too costly to sustain, tradition-bound concepts about clinical wisdom have become obsolete, a distraction from the task at hand, and a luxury that we can no longer afford?

The Value of Wisdom in Therapy Today

John grew up with a “typical guy” father, who saw women as subservient and lived his life as if the whole point was to be the dominant male in the primate troop (the advertising business, in his case). Deeply ashamed of his own emotional sensitivity, John felt constantly compelled to prove he wasn’t a “loser.”

In sessions with John, we explored the culturally conditioned roots of his problems, both in the structure of his family of origin and his understanding of traditional gender roles. As a practitioner trained in mindfulness practice, I even invited him to look at the illusory nature of his (and everyone else’s) self---how it was constructed moment to moment from arbitrary identifications with certain thoughts and feelings. It was not your typical 21st-century, symptom-focused treatment plan.

But how can a therapist without some grasp of how to live a rich and purposeful life, not to mention some perspective on the ocean of culture in which we all swim, help a client navigate these turbulent waters?

If I can’t open to my client’s hurt and anger because it scares me, if I need to hold on to my formulation of a problem to feel secure in my view of human nature, or if I need my client to think I’m smart, I’m unlikely to sustain a really effective treatment relationship. Wisdom is precisely what helps us avoid these impediments to be present for our clients.

Here are some of the characteristics of wisdom identified by both researchers and therapists alike:

Concern for Others. Therapists in the survey overwhelmingly cited genuine compassion---concern for the suffering of others and a desire to help---as an important quality of a wise psychotherapist. This involves putting our client’s needs above our own, moment to moment.

It begins by actually showing up for the session, which is no easy task. Sometimes we’re concerned about looking kind or capable, so we posture to boost our image instead of being honest: “I tried reaching your doctor, but wasn’t able to get in touch,” rather than admitting, “I’m sorry, I forgot to place the call.” Or we fail to really pay attention because we’re distracted by outside worries or can’t be with pain that hits too close to home. I’ve often found myself tuning out while listening to a story about metastatic cancer or a kid’s car accident because I couldn’t bear to think that it might happen to my own wife or child.

Reflective Attitude. While most of us value lively spontaneity in a therapist, impulsivity can be a real problem. Virtually all my therapeutic and supervisory blunders occurred because I acted first and thought second.

I’ve had many other unreflective moments in treatment, including “self-disclosing” just because I really wanted to tell my story, unthinkingly making a joke my client found offensive, suggesting a client confront a fear he wasn’t ready to acknowledge, and discussing violent fantasies as though they were normal when my client thought they were evil. Then there have been the inner unreflective moments, when I’ve become attached to facile, reductionist understandings of my clients’ difficulties.

Insight. The therapists I surveyed repeatedly mentioned that insight into our own inner experience and that of others---emotional intelligence---is an important element of wisdom. This involves: (1) Listening deeply, (2) Appreciating the factors that make us all experience the world differently, and (3) Being aware of the wounds and conditioning that inform our reactions to others. Insight helps us see that a “tired” client is actually depressed, or a confused client is having difficulty acknowledging anger toward her daughter. It also helps us understand why we’re reluctant to call a client we’ve neglected or are overly eager to please an intimidating one.

Can We Become Wiser?

Despite outside pressures, we might still adopt increasing our own wisdom, and that of our clients, as daily goals. This need not necessarily involve time-consuming, esoteric practices, though these can certainly support our efforts. We might simply look for ways to help everyone develop concern for others; see the effects of our actions short and long term, near and far; remind ourselves to reflect before acting; hold our ideas more lightly; and appreciate that everything changes and the mind constantly creates suffering by wishing things would be other than they are. We might especially try to notice how all of our self-preoccupation, engrossing as it is, alienates us from one another and makes everyone unhappy.

Who knows, if each of us tried to do this every day, we might all suffer less and live more awakened, less lonely lives. Just don’t tell the managed care companies.

This blog is excerpted from “Wisdom in Psychotherapy". Read the full article here. >>

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Topic: Professional Development | Mindfulness

Tags: conditioning | family | mental health | practices | psychotherapist | psychotherapists | psychotherapy | therapist | therapists | therapy | Virginia Satir | networker | Minuchin | wisdom | traditional | Perls | approaches | Ronald Siegel

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