Friday, January 3, 2014

Mindful Uncertainty: What is Psychotherapy?

Mindful Uncertainty:  I, Thou, and Empathy 

… in terms of technique: He should simply listen, and not bother about whether he is keeping anything in mind.

Anyone who hopes to learn the noble game of chess from books will soon discover that only the openings and end-games admit of an exhaustive systematic presentation and that the infinite variety of moves which develop after the opening defy any such description.…The rules which can be laid down for the practice of psycho-analytic treatment are subject to similar limitations.   
Sigmund Freud

A person always acts under conditions of uncertainty.
A person always has enough information to act on.   

The essential thing about human beings is that they make the decisions that resolve the uncertainties, and that's why we have all this business of choices and options and reasons. You need a player to do that. Were there such a thing as guaranteed knowledge, certainty, from which your behavior followed automatically, there'd be no place for people. You could be replaced by a computer immediately. The essential feature of people is that uncertainty, that people can and do easily operate under uncertainty, and that’s essential to being a person, in the same way that the uncertainty left by the rules of chess is essential to being a chess-player.     Peter Ossorio

The thing I am trying to say is that for the cook the two experiences are different: the slavish one who complies gets nothing from the experience except an increase in the feeling of dependence on authority, while the original one feels more real, and surprises herself (or himself) by what turns up in the mind in the course of the act of cooking. When we are surprised at ourselves, we are being creative, and we find we can trust our own unexpected originality. We shall not mind if those who consume the sausages fail to notice the surprising thing that was in the cooking of them, or if they do not show gustatory appreciation. 
D.W. Winnicott

Professional education involves cultivating skill and knowledge.  Psychologists are trained to recognize behavior patterns and to develop serviceable formulations in their attempts to be helpful.  Clinical students want to both “know” and to “know how” but are often uncomfortable with their uncertainty.  In time, most learn not to be. A good deal of clinical supervision involves supporting trainees while they manage their discomfort with clinical work's guaranteed uncertainty and ambiguity. It is understandable that many therapists-in-training yearn for technology, some precise set of tools that might give them the exactness and expertise they associate with professionalism. If only it were that simple. But people aren't that simple.

Although people make sense, we can't expect them to be less complex than they are. Our defining quality is that we engage in deliberate action. We make choices based on our changing sense of what we find personally significant, implemented all sorts of ways.  Since people's pathologies create restrictions in their ability to engage in deliberate action, as they become less ill, they become even more unpredictable.  

People are understandable rather than predictable.  This may be unsettling to the clinical observer. It shouldn't be. We diagnose illness, not health. Illness is simpler than health and can be categorized because it is more restricted. But even within the restrictions of pathology there is deliberate action and choice. The arena of play is only smaller. 

My job is to help students become experts in managing their uncertainty, in navigating ambiguity, in recognizing what is in flux, with no necessary outcome. They should become experts of uncertainty, able to precisely indicate what is in fact ambiguous and uncertain.  

The problem is not only that students are anxious about feeling uncertain, but that circumstances do not have a determined outcome. "What will be, will be" is not a belief I encourage. I do not accept the fatalism of destiny. I don't want my students too, either.

If therapy is to facilitate health, and if health involves an enhanced freedom to choose and create, then absolute prediction is antithetical to the practice. That's a tough lesson when security is tied to certainty. 

Empathic action and the I-Thou relationship, vital to psychotherapy, require embracing the incomplete understanding we actually have of one another. Starting with uncertainty, good psychotherapists discover who they sit with and act on what they discover in an ongoing improvisation.  Like it or not, each act is new. Mindfully ignorant, tolerant of uncertainty, good therapists know how to play their part in a unique and unscripted play.  Seasoned, they know they do not already know, and accept they are uncertain when and if they will acquire the needed knowing. The empathic therapist is an expert at playing this uncertainty game. It requires faith and skill. It requires patience and courage. 

My job is to be open to surprise, and to celebrate when surprise happens. People will surprise me.

I am certain my clients will show me something I don’t already know, something new to me. I expect it and am rarely disappointed. 

So how do we go about this?

Being open to surprise is central to psychoanalytic practice.  Freud required it of the analyst, and it has been essential to real psychotherapy ever since. Transference, pre-judgment, and stereotyping restricts surprise, coming as it does from a preformed schema or understanding.  Having a treatment plan can be problematic if it also carries an insistent demand for compliance. (I want my guides to know their way about, but not try to tell me where I must go). 

Reductionism and deterministic theory are rarely helpful with the intimacy of psychotherapy.  At best, they provide a security blanket, soothing when they don’t cover up or obscure.

Freud’s "free association" was developed as a method of liberation from the neurotic and culturally unexamined. He insisted that our developing bodies must be considered, that “anatomy is destiny” and that “the child is the father of the man”.  His theories unraveled the wefts and warps of development and sexuality. Freud wanted us mindful of our primate body, insisting that our animal nature is a condition essential to treatment and understanding.

But our nature is a reminder, not a predictor. 

Good clinical teaching takes us beyond the limited scope of theory, even good theory, and brings us back again and again to observation and description.  Good description invites freedom, especially as it invites re-description and the negotiation of the description's accuracy and use.  

Not already having the answers, skilled clinicians know they must go out and look, and then look again. They know they will have to share and negotiate what they think they see for it to be helpful.

So where to look? And how can we explore effectively and successfully?

The Parameters of Intentional Action help identify what one might need to know to understand what someone is doing.  These parameters also serve as a reminder of what we don’t know. Knowing that we don’t know is an essential aspect of empathy. It is good to remember to be careful of what we presume.  Wrongly presuming may lead to empathic rupture and the hurtful recognition of being misunderstood. 

Part of the therapist's job is to look carefully and share what is found with kindness and toleration. The improvisation of sharing facilitates accuracy and collaboration. To negotiate understanding is an act of respect.

My friend and colleague Ray Bergner has pointed out that psychotherapy should be governed by policies rather than hard and fast rules. Policies guide rather than restrict and are applied as a default position unless there is reason enough not to. 

As a psychoanalyst, I try to be guided by an attitude, the Analytic Attitude, a set of policies that Roy Schafer distilled from Freud’s papers on technique.  Below, I have modified Schafer's policies given my concerns (and with some reminders from Ray Bergner, 2013).

1. Regard and treat the client as an agent.

2. Regard and treat the client as a person who is to be given the benefit of the doubt.

3. Engage the client as an ally and collaborator.  Be on the client’s side.

4. Act with respect and appreciation of the client’s ordeal and possibilities.

5. Be non-insistent.

6. Attempt to be helpful without zeal.

7. Avoid making promises.

8. Cultivate non-directive “free association” by inviting non-coerced honesty.

9. Attempt empathic neutrality, confrontation, and interpretation over direct suggestion.

10. Avoid rigid "black/white, either/or" thinking; and when appropriate, confront it.  Invite the acceptance of a multiplicity of useful meanings along with inherent ambiguity and uncertainty. 

11. Maintain focus on the subjective state of the client and of the client’s understanding of their circumstances. Go only as fast as the client can manage. 

12. When appropriate, interpret transference and resistance, mindful of ambiguity and uncertainty. 

13. Maintain a zone of safety and toleration.

14. Practice kindness.  

Policies are to be followed until there is sufficient reason to do something else. This is a matter of clinical judgment. This requires experience in navigating uncertainty. 

---unlike in math---there isn't a difference between an ambiguous conclusion and an unambiguous one. All conclusions, in behavior, are ambiguous.  Peter Ossorio


  1. Wynn: 99% enthusiasm for this, 1% "No'. A person is NOT a deliberate actor; a person does engage in deliberate action. Deliberate modifies action, not person. They are not equivalent.

    "They know they do not already know and are not sure they will acquire the needed knowing." I don't recognize this as accurate. Instead, 'The therapist knows she does not know, and has practical assurance she will acquire the needed knowledge." She in fact may not, but that almost never happens with master therapists, and it is a real surprise when it does.

    1. Careful use of language is a vital aspect of Descriptive Psychology and Tony's first comment is correct and my entry has been so corrected. I am ambivalent about the second point. Competent therapists have a practical assurance that they are skilled at looking and thinking about their client's personalities and circumstances but in the end may or may not come up with "the needed knowledge". Therapist's who are surprised by not having a satisfying answer may be either those with greater mastery than I can claim or are those who are almost always satisfied with the narratives they construct.

  2. Thank you very much for writing such an interesting article on this topic. This has really made me think and I hope to read more. psychotherapy singapore