Muddling Through

An elder statesman of the training institute I attended (let's call him Bill Breyer) claimed, "I know within ten minutes of meeting a new patient how the entire course of therapy is going to go." That was quite a boast: since this was a psychoanalytic institute, he expected to see patients at least twice a week for years.

But I believed him back then. After all, he was the teacher, an estimable character-with a bluestocking practice in Manhattan, respectable teaching posts at several schools, leadership posts of significant professional organizations, and even a handful of publications. I aspired to be like him. I wanted that same level of expertise.

Twenty-five years later, the very idea seems preposterous to me.

In the therapy room, we do the best we can under conditions unfavorable to knowing what's going on with our patients at all.

Persons in distress try to describe their difficulties, limited by the boundaries of their skills at self-observation and description, the risk of humiliation, and the fear that things may be worse than they want to admit.

They do not know which things from the outside world to report in therapy-that would require already knowing where the problem lies, what variables contribute to the problem, and what items of everyday life count as values of those variables. They're surely in no position to report especially accurately, or with great acumen, even when they do talk about the right things.

The conditions of the therapeutic encounter bear almost no resemblance to the conditions under which patients live. Therapists listen and observe in highly artificial environs. Our observations have little necessary connection to what happens in the patient's life out in the world.

The things we generally believe about patients-the psychological beliefs we bring to bear on their problems-lack anything resembling completeness, coherence, and conclusiveness. Very little of what any given therapist believes about human psychology rises to the level of a scientific truth-or other disciplined discovery.

The beliefs we deploy in helping patients vary wildly from day to day, depending on what we've been reading lately, who we've had lunch with, whether we've had a fight with our spouse, what the previous patient was talking about, and a thousand other things that prime us cognitively.

And being finite and human, we cannot escape our own needs and limitations, no matter how well trained we may be or how pure our intentions. For instance, minimizing awareness of our uncertainty decreases our anxiety, and that drives us to overestimate what we know and what we can do. In therapy, we (therapists and patients alike) work under conditions of radical uncertainty. We're muddling through.

So I don't believe for a minute that, in the sense he meant it, Bill Breyer was right.

Now, I don't think he was lying or confabulating. Allowing (charitably) for a certain amount of exaggeration to make his point, he was probably reporting something true about his experience, as he summarized it in memory. I'm sure, though, that he misunderstood his experience.

Over his decades of practice, I suspect he had routinized his ways of seeing patients, how he explained their problems to them, what sorts of reactions from them he reinforced, and thus how he shaped the course of their treatment. He knew his craft, and he was probably quite good at it. He knew-in the way a whittler knows wood, a farmer knows cattle, or con man knows a mark-which sorts of people he could shape which ways. I think he was saying, in effect, "At this point in my career, I pretty well know what I can make of someone."

Of course, Bill thought he was predicting the natural history of a process. He believed he was predicting how things would go, not reporting how he would make them go.

And there's the rub. If we reflect accurately on what we really know, we can come close to despair at the weakness of our intellectual resources. But in treatment, stuff happens. People change. They feel better-and may even get better. And they attribute their improvement to our work. (Well, most of them do). But they-and we-most likely misunderstand just what has happened in the therapeutic encounter.

With this post, I am starting a blog to be called "Muddling Through", to be published on Mental Help Net. "Muddling Through" will explore, and try to come to terms with, the actual nature of the therapy enterprise. Though we may be less boastful than Bill Breyer, none of us are much different. We believe more than we know, we know less than we think, and we're apt to misunderstand our experience.

We can't eliminate that-that's the human condition. But we can fight it them just as we fight against body odor and tooth decay. As therapists, we can be more reflective, so that we muddle through our therapeutic work more wisely, and to better effect.