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.
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?
Wisdom is precisely what helps us avoid impediments to be present for our clients. But what exactly is wisdom, clinical or otherwise, and can it be learned or cultivated? If so, how exactly do we go about acquiring it?
What Is Wisdom?
While wisdom has been investigated by reviewing ancient texts from contemplative traditions and setting up laboratory experiments to see how people tackle complex, ambiguous life situations, one of the most fruitful approaches has been to look at implicit theories—our often unarticulated ideas about what makes a person wise. That was the inspiration behind a little study I conducted, in which I asked 30 seasoned clinicians to answer four questions: (1) What does it mean to be wise? (2) What are the particular qualities of a wise psychotherapist? (3) What gets in your way when it comes to being a wise therapist? and (4) Do you consider the cultivation of wisdom to be a treatment goal for your clients?
I discovered that when clinicians asked themselves these questions, their answers accorded pretty well with what researchers have found more broadly. Just grappling with the question seems to help us to become a little wiser, enriching our therapeutic work. But it can create conflicts for us in our practices, because, as we’ll see, wisdom can get in the way of following empirically supported protocols.
Here are some of the characteristics of wisdom identified by both researchers and the therapists who participated in my survey:
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.
But wise presence is possible. As Jon Kabat-Zinn said about speaking with the Dalai Lama, “You know, when talking with him, it feels like he’s really there with you, with genuine interest in the moment—not scanning the room for a better networking opportunity.”
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. Early in my career, a woman revealed to me that she was mortified to have had a sexual fantasy about Jesus while looking at a statue of him in church. It so happened that a gay supervisee had recently told me he’d had the same experience as an adolescent, and it was what first made him suspect he was gay. Excited by my new insight into these forbidden matters and wanting to relieve my client of her shame by normalizing her experience, I shared this information with her. She canceled the next appointment. When I called to ask why, she told me that she couldn’t work with a therapist who was so obviously perverted. As one of my early psychodynamic supervisors once put it, “The right interpretation at the wrong time is the wrong interpretation.”
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.
We also have another tradition that has the potential to boost wisdom—the supervisory relationship. We can use supervision to explore our blind spots and discover where our wounds and conditioning get in the way of seeing clearly. For therapy aimed at awakening or finding meaning in life, insight is essential. Using supervision to this end probably requires both our intention to grow wiser and wisdom in our supervisor—since it’s equally possible to use supervision just to gain approval for what we’re doing, collude in developing a simplistic view of our client’s difficulties, or otherwise reinforce therapeutic foolishness.
Intelligence. As Socrates put it, “The narrow intelligence flashing from the keen eye of the clever rogue” isn’t wisdom. Yet, being able to think clearly and logically (fluid intelligence) and having access to the knowledge needed to address the needs of the moment (crystallized intelligence) are necessary for wise action. As therapists, this means knowing something about psychopathology, lifespan development, diagnostic assessment, therapeutic methods, and cultural differences. It also means being able to hold multiple theoretical viewpoints lightly.
Transcending Conventional Concepts. This is the aspect of wisdom most emphasized in Eastern contemplative traditions. In Buddhist psychology, it involves gaining direct understanding of the three marks of existence: impermanence (anicca), unsatisfactoriness (dhukka), and no-self (anatta)—and is an explicit aim of mindfulness practice.
Impermanence (anicca). This is simply the awareness that everything changes or, more accurately (since “things” are culturally conditioned constructs), that all phenomena are in constant flux. This is how any physicist or biologist would describe the universe—atoms and energy in constant movement—but it’s not how we usually see the world.
How might psychotherapy be different if we actually understood this? For starters, we wouldn’t be so surprised by illness, aging, and death, not to mention divorce, job loss, and car accidents. I’m amazed by how often I resist change as a therapist. I don’t want my client to feel worse, to be disappointed, or to leave treatment. Remembering this during a session can be eye opening. It can help us see the big picture and not be so driven by our fears or wishes of the moment, which is an asset in whatever kind of treatment we’re doing.
Unsatisfactoriness (dhukka). This is a reality of the human mind. It’s what has been poorly translated as “life is suffering,” giving Buddhism the reputation of being a gloomy spiritual philosophy. A more accurate translation might be that life is difficult for everyone, and we repeatedly experience dissatisfaction. My favorite articulation of this principle comes from the great Western philosopher–sage Rosanne Rosannadanna, who pointed out, “If it ain’t one thing, it’s another.”
How might insight into unsatisfactoriness change our daily experience as therapists? Personally, when I’m conscious of my mind’s capacity to make itself miserable no matter what my circumstance, I lighten up on needing sessions to go a certain way. Vacations are wonderful teachers in this regard. When I observe my mind worrying that it might rain when I’m in the Caribbean or that there might not be enough snow for good skiing when I’m in Vermont, I appreciate the hopelessness of finding happiness by getting my ducks in a row.
No-Self (anatta). This is the most challenging aspect of Eastern wisdom for most of us in the West to grasp, but is arguably the key insight in Buddhist psychology. It doesn’t mean that our bodies don’t exist or that we don’t have a name, zip code, or social security number. It refers instead to the fact that we’re interdependent organisms, constantly exchanging molecules with the rest of the world—part of the web of life. Our thoughts of being a separate “I” are misunderstandings, born of living in a narrative stream starring “me” (actually, mine stars “me”; yours stars “you”). If we observe our experience carefully, try as we might, we never find the little homunculus inside, the little man or woman who is “me,” but just discover an endless stream of sensations, thoughts, and images. We realize that the mind and brain are, as neuroscientist Wolf Singer puts it, like “an orchestra without a conductor.”
Can We Become Wiser?
As we all know, therapists today face a lot of pressures that don’t support the pursuit of wisdom. We’re encouraged by payers to resolve symptoms quickly and cheaply and move on to the next client. While this can sometimes constitute wise, compassionate action, often it doesn’t. We aren’t afforded much time for introspection or metabolizing the feelings that come up in a session, not to mention time for supervision, reflection, meditation, or other supports for seeing the big picture. Our clients are themselves discouraged from introspection by the pharmaceutical industry, which offers images of unbalanced neurotransmitters to explain their difficulties (the ads neglect to list “may lead to an unexamined life” among possible side effects).
So what are we to do? Despite these 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" by Ronald Siegel. The full version is available in the March/April 2013 issue, Clinical Wisdom: Who Needs It?
Photo © Ralph Butler