Clinical Wisdom – Who Needs It

In the March/April Issue of the Psychotherapy Networker, the question of whether clinical wisdom - knowledge and intuition that a therapist gains over years of experience - has any place in today’s culture. As the magazine’s editor, Richard Simon, puts it: “The search for wisdom is out of sync with our entire culture, which much of the time is one of hurry and distraction, shallow questions and quick answers, short attention spans, and chronic restlessness.” 

He adds that the pioneers in the field of psychotherapy knew that good therapists were not just technique dispensing machines. They knew that being a good therapist required genuine insight into what it means to be a human being. Today, however, the emphasis is on quick fixes, and “short term, empirically supported manualized and medicalized therapy,” not to mention a pill for every ill. And too often, the “empirically supported” therapy treatments are based on poorly constructed, symptom counting studies that neglect underlying personality. Not to mention our relationships!

People who dismiss all widespread clinical experience and wisdom as "anecdotal" probably think it necessary to devise a scientific experiment to actually prove that the sky appears blue to the human eye at noon local time on a cloudless sunny day on the equator.

Simon comments that for therapists there are marketing plans to revise, website statistics to crunch, and referral sources to cultivate. Who has time to be wise?

This is a horrific trend, and as I have pointed out several times in this blog, it is not just biological psychiatrists and managed care insurance companies that push for it. The culture at large demands it more and more. And yet we wonder why so many people feel that their lives are empty, and fill their time with narcissistic pursuits or crass materialism.

In the lead article of the magazine, psychologist Ronald Siegel makes the following valuable points. We in the profession all need to keep making them, both to our fellow mental health professionals and to the public at large. Unfortunately, too many people in our fields are, when one gets right down to it, wimps. When managed care insurance companies say, “Jump,” they ask, “How high?"

• Even though the therapy literature, modeled after double-blind drug research, has tried to eliminate the person of the therapist as a variable, studies consistently show that the most important variable in therapy success is the patient’s relationship with the therapist. It has proven far more important than any therapy technique.

•  Patients do need to feel deeply understood by their therapist, and for the therapist to really be there with them, in order for them to be helped to find a way to overcome suffering and lead a fulfilling life.

• Sometimes when patients' despair seems to be increasing rather than decreasing, it is actually a sign that they are finally beginning to grapple with their most troubling issues. It can therefore be a sign of progress rather than that therapy is going in the wrong direction. A wise therapist will know, in a given instance, which of these two possibilities is occuring.

• It should be OK for the therapist to not immediately know what to do with a patient during a session. Sometimes it takes a lot of time to figure things out. People are complicated. Managed care insurance does not want clinicians to ever acknowledge this fact to their patients, especially when that would involve longer treatment. 

I would add: a very troubling manifestation of this problem is that, a long time ago when I first trained, we would write down our conclusion after taking an initial history and doing an examination as a diagnostic impression, rather than as “the” diagnosis - just in case later information changed the apparent clinical picture. This was true in all of medicine, not just psychiatry. Now, the insurance companies demand a diagnosis right off the bat, or they will not pay the insurance claim. The initial diagnosis then stays in the patient’s insurance records even if it is later changed to something entirely different by the clinician, and gets listed as a “pre-existing condition.” Therefore, patients buying a new policy are refused future coverage for a condition that they never even had!

• When therapists are stuck with a particular treatment ideology, they often ignore information that does not fit with their preconceived model, and elaborate on any information that supports their ideas. Of course we all do that to some extent, but therapists do need to be aware of this tendency. When I was in training, some of my supervisors used to refer to the “Procrustean bed” when discussing any “one size fits all" model. Having never actually read the myth, I missed the nuances of what the phrase meant. Procrustes lived on busy road and invited travelers to spend the night on his grand iron bed. If the traveler was too tall for the bed, he would cut off their feet. If they were too short, he would stretch them to fit!

• The symptom-focused approach leads therapists to focus solely on the “problem du jour,” and miss the larger problem of dealing with the many ways a given patient clings to behaviors that seems to bring on his or her own difficulties.

• People who learn how to be introspective are much likelier to do well in therapy than those who do not.  Siegel adds, “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).”

 Now that’s wisdom.