Can We Afford It?
By Ronald Siegel
It wasn’t their research results or bestselling books that set apart Freud, Rogers, Minuchin, and Satir. They seemed to have a sense of what really mattered. Today have conceptions about clinical wisdom become obsolete?
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. An analyst needed first to be analyzed to even imagine being an effective healer. In approaches as varied as Jungian, Gestalt, Ericksonian, and many forms of family therapy, insight into one’s own psyche—and interest in exploring its darker recesses—was considered a prerequisite to helping others understand themselves.
However, self-knowledge was only a step along the journey to the true prize: the treasured capacity for therapeutic wisdom embodied by the giants of our field—whether Sigmund Freud and Carl Jung or later innovators such as Fritz Perls, Carl Rogers, Milton Erickson, Salvador Minuchin, or Virginia Satir. What set these figures apart wasn’t their research findings, their place on the bestseller list, or even their distinctive clinical method. It was that they seemed to understand life so deeply and had such a penetrating sense of what really mattered that we believed they’d show us (and through us, our clients) a path to well-being and a more meaningful life if we studied them closely enough.
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
The overarching question too often ignored amid the time and economic pressures that shape much of contemporary psychotherapy is, what are we trying to accomplish? An insurer’s interest in quick symptom relief may be shared by a client and therapist, but what happens when this isn’t the case? For example, 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.”
He wasn’t a particularly unusual client, and we could have proceeded along a well-travelled path common today: having him take prescribed medication for his depression, teaching him relaxation techniques to deal with his stress, and providing a round of cognitive-behavioral therapy to help him replace self-critical thoughts with more realistic ones. But as his therapist, I thought he needed more. So 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.
Not only does this kind of approach go against the tide of today’s therapeutic trends, it also raises the question of what equips a therapist to lead a client in such a nonstandardized exploration. This kind of therapeutic work includes challenging dominant societal assumptions about identity, happiness, and the purpose of life. It’s hard to imagine that it will go well without at least a bit of therapeutic wisdom. 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?
Even if all interested parties only want symptom relief, ignoring the cultivation of wisdom may still be a problem. Focusing exclusively on empirically supported techniques runs the risk of failing to develop the primary instrument of treatment—us. Even as much of the therapy literature, modeled after double-blind pharmaceutical research, has tried to eliminate the therapist as a variable, metanalyses like those of Bruce Wampold and others keep showing that we can’t take ourselves out of the equation. Again and again, we learn how much the therapeutic relationship matters.
Of course, this is self-evident to any old-school clinician. 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. 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?