In America, we’re supposed to know. We’re supposed to be decisive, not wishy-washy, sure, not wimpy, active, not passive. Americans figure out what they want, and then go get it. You hear it all the time, witness the iconic Nike slogan:
Just do it.
Of course, that’s understandable, in advertising. How many shoes (or cars, or widgets) would a company sell with the slogan, “It’s all so confusing?” How about a political candidate who campaigned on, “I do try to get it right – but then that’s not always possible?” We’re supposed to be sure. And we want to be told a product is the best, period, a candidate the greatest, period.
In the movie U-571, the head enlisted man lectures his captain, who has just been indecisive in front of the men,
“This is the Navy, where a commanding officer is a mighty and terrible thing – all knowing, all powerful…Those three words, ‘I don’t know’ , will kill a crew, dead as a depth charge…The skipper always knows what to do, whether he does or not.”
Makes sense, maybe – in war. But do we have to live our lives as if we’re at war? Do we have to adopt the forced bombast of the manufacturer of a hawked product, strutting around doing ‘great’ all the time, pretending we know exactly what we’re doing, definitive in our choices, and ‘weak’ if we are confused, or mistaken, or not aggressive?
Years ago, George Carlin based a whole comedy routine on this, when he compared football to baseball:
In football the object is for the quarterback, also known as the field general, to be on target with his aerial assault, riddling the defense by hitting his receivers with deadly accuracy in spite of the blitz, even if he has to use the shotgun. With short bullet passes and long bombs, he marches his troops into enemy territory, balancing this aerial assault with a sustained ground attack that punches holes in the forward wall of the enemy’s defensive line.
In baseball, the object is to go home! And to be safe! – I hope I’m safe at home!
A funny, funny routine – we laugh out loud, particularly as men, because we can immediately recognize the militaristic, macho, ‘code’ under which we all labor, whether we admit it or not, and whether we ascribe to it or not. It is ingrained in our society, and in all of us. The pot is constantly being stirred into a great stew: Our forefathers came here for freedom, to get away from the ingrown, hierarchical and effete British ways; we don’t depend on others but get things done on our own; we fight at the drop of a hat because we know what we stand for, and we’ll defend it to the last man. We know what’s right and what’s wrong, and we know what to do about it.
When there’s a problem, we identify it, assess it, and take immediate action: we know, and then we act.
Sound familiar? I constantly run across new therapy patients who ask the following questions about therapy, as if I am a personal trainer, or a physician treating the mumps:
Exactly what are we going to do? Give me details.
How long will this take? I don’t want to get involved with anything that takes a long time.
What can I read to make it go faster? What exercises can I do at home, what assignments: I need to get this thing over with.
But “this thing” is THEM! And the “it” in “make it go faster” is their own personal development! This way of thinking makes one into a defective product that needs to be fixed, and fixed quick. This way of thinking is fostered, and encouraged, by methods of therapy, self-help books, and websites that are ‘sure’ about what they do, and sure that it will work for you. In fact, therapists are encouraged to ‘market’ in this manner:
Find a specific niche, and fill it.
Do “solution-based”, short-term therapy (not dithering, time-consuming therapy).
Use proven, scientifically-validated therapeutic techniques.
And of course, always use Best Practices (the most terrifying, unassailable words in the medical lexicon).
Simply Google ‘Depression’ and you come up with: The most proven techniques for fighting depression. Wow, not only proven, but most proven: impressive!
But consider this: every breakthrough, every new idea, every realization, must come AFTER confusion and not knowing. There HAS to be unsureness and not knowing before there can be a higher-order of integration. You don’t go from absolute sureness to a new realization, because you don’t HAVE to, since you (purportedly) already know, right? There is no reason to explore any further if you know it all, if you’ve already reached a final and complete understanding of the situation, or of your opinions, or of yourself. So unsureness and confusion are Mandatory for growth in any realm. They say that Einstein was the one who discovered relativity because he was the one who could tolerate ‘not knowing’ for the longest, without coming to premature, and incomplete, conclusions, based on what “we know”.
Of course the search for better, faster methods of treating human beings is laudable, and can bring relief to some people, some of the time. When I started my practice years ago, the standard attitude of a new patient was, “Okay, Doc – so what do we do?” People didn’t have access to the Internet, to Googling “Therapy”, to reading up on techniques, and proven techniques, and most-proven techniques: they knew they felt bad and needed help. They had managed to find you somehow, some way, and you helped them. Sometimes I think those days weren’t so bad after all: at least they had gotten to you because someone had said, “Hey – this guy is good,” not “This guy does DBT,” (or CBT, or EFT, or EMDR, or the other alphabet-soup therapies). Not because these techniques don’t have a great deal to offer, but because, in fact, “research shows” that to a great extent, WHO does the technique is as important as the technique itself.
Much of what I’ve said above comes down to this: Therapy patients (like other human beings) like to feel in control. They like to know what’s going to happen, and when, and how. They want to know, not guess, to be sure, not doubtful.
Well, here’s a news flash: Therapists want to feel in control, too. People are complicated, unpredictable and changeable. Look, imagine having someone come to you for help: they are troubled, scared, and (maybe) a little desperate. They have already tried to do it themselves; they have tried to use will power, they may have read numerous self-help books about their problem; they have talked to friends about it. They want help, NOW. They don’t want to spend a lot of money, and they don’t want to spend a lot of time: the problem has most likely already taken a big chunk out of their lives and their potential happiness.
They tell you their story, then they look straight at you and say, “So – can you help me?”
You nod (looking confident, you hope).
But they’re only warming up:
“How? And exactly what will you do to me? And exactly how long will it take? And, oh yeah, how much will it cost me?”
How would you feel? To some extent, they’re putting their life in your hands, and they want (and deserve) answers. After all, they’ve already gotten a gunnysack-full of advice from friends, Better Homes and Gardens, Omni, Workout Illustrated, self-help books, and the Internet. So now, finally, at long last, they’ve come to you: The Real Deal. It’s Put up or Shut Up Time.
So, how would you feel? Well, if you’re like most people, you’d want a Technique – a Method, and a Sure-Fire one, a proven one, a most proven one, if you could get it, maybe even a (trumpets, please) Best Practice.
So, therapists, too, want to be sure. It’s hard to face someone and “not know.” After all, the old reliable medical model, from which we are all descended, will tell you that the patient has a specific disorder, and in case you’re not sure about that, just check the Diagnostic and Statistical Manual, Version V (it’s important to use Roman Numerals, like the Super Bowl – that way you KNOW it’s a big deal): the patient’s ‘condition’ is in there somewhere, for sure.
So now, as the therapist, you’re finally on safe ground: you not only know what you’re going to DO to them (your proven technique, remember?), but you even know what they’ve GOT (don’t worry, it’s got a long, impressive number, and that’s reassuring – go look it up, I’ll wait).
We’re all suckers for sureness, for knowing: it’s less scary, it gives us a form of security (hey, even false security is better than nothing, right?), and as therapists, it feels, well, more professional. Most non-physician therapists have had the uncomfortable experience of talking to a patient’s psychiatrist or family physician, the one who is supposed to dole out the medication. If they’re even willing to talk to you, a non-physician, at all, they want to hear ‘the goods’ and they want it in quick sound bites.
You want to say, with crisp efficiency, “I feel we’re talking Bipolar One here, with a possible secondary Adjustment Reaction,” not, “This guy doesn’t seem to know himself at all – I mean, he undermines everything he tries to do, and, well, he just seems to sit there waiting for, you know – something.” The latter would likely be followed by a sharp, disdainful silence, roughly translated, “Just what am I supposed to do with that, buddy? And by the way, where do you people get your training, if any?”
So, you want to have a technique, or approach, or method, going for you, and you want to know what they’ve got. And they want you to have a proven technique, or method, and they want you to know what they’ve got. So it’s clear why proven methods, and diagnostic slots, are so prevalent. Almost every young, or new, therapist I’ve ever had as a patient or a supervisee wanted to KNOW what to do, to fit in with a ‘school’ of treatment, and to know how to slot their patients into diagnostic categories. They want to know who they are, and they want to know what to do.
This reminds me of a man whom I had worked with for years. He had been an engineer, and a good one, but he found it emotionally unfulfilling. Partly because of his therapy, he became interested in becoming a therapist, and over a period of years, completed studies at a top psychology graduate program. He specialized in a behavioral technique that utilized a form of hypnosis for treating phobias and panic attacks. He prided himself on being more ‘scientific’ than I, much more specific and exact in his approach, and enjoyed pointing out to me that I was a throwback, groveling around in the dark ages of psychotherapy.
One day he was describing to me the treatment of a particularly difficult ‘case’ of panic attacks, with a male patient whom, I observed to myself, he seemed to enjoy and even identify with. At one point, he said, “Last time, we were in the middle of a session, and he kind of looks at me like we’re, you know, friends. And the funny thing is, I could feel it, too. I mean, I continued the procedure appropriately and everything, but I got a weird feeling that this other thing had a lot to do with what was happening, you know, like a wild card.” With that, my patient looked at me in apparent confusion.
I smiled and said, “Uh oh – looks like you were busy doing a technique, and a relationship broke out.”
All responsible therapy has to have structure, and even some ‘technique’; therapy is not just ‘let’s hang out and see what happens.’ But all responsible therapy also has to leave room for surprise, and creativity, and relationship, and for ‘not knowing.’ For human beings are not the mumps, or an ingrown toenail, for which exact, repeatable treatments are known.
I understand the forces that want to push therapy in that direction: it would be great, I suppose, if, after taking a course in a particular treatment modality, all therapists would be able to help their patients, regardless of their own personal shortcomings or the particulars of the patient’s problems. It would be wonderful, I guess, if, through some exact measure of treatment efficacy, therapists would be able to show that their treatment modality actually was better, that their prowess as therapists was demonstrably superior, perhaps even ‘most proven.’
But people are complex and complicated, and fortunately or unfortunately, when treating psychological problems, one size does NOT fit all. There are factors in play that mitigate against repeatability of approach from patient to patient, or easy ‘slotting’ of problems by the numbers, or even Roman Numerals. For example, there is the immediate sense of personal compatibility, or not, between the two parties, patient and therapist.
What if, when the patient walks into the room for the first session and starts talking, it feels like cats and dogs? What if the person reminds you of your Aunt Minnie, the one who always gave you an icy stare and treated you like a subhuman? Or your ex-spouse, the one who cheated on you, spent all the money, then kidnapped your child? Of course, as therapists we are trained to be ‘objective,’ to put aside our personal prejudices, and we all do our best to do so, but in the cases above, or related situations, doesn’t the patient perhaps deserve someone who does not have to overcome these things to be with him or her?
So, if you’re being honest with yourself, you are unsure about whether you are the right person for the job, or maybe about whether you can work with this particular problem. But, we are supposed to be sure, to know. How can we ‘not know’ and still be a good therapist? But the truth is, you don’t know, and how can you expect the patient to have the courage to face the unknown when you can’t, or won’t?
How do you ‘not know’ and still go forward? Well, there are at least three possible approaches:
- Ignore the feelings, trust your ‘technique’ and blast forward, hoping it all works out, and that the feelings are irrelevant ‘wild cards’.
- Refer the person to someone else, someone who, perhaps, would be more compatible or less triggered by them.
- Hold the issues (i.e. the possible incompatibility, or the feeling of being out of your depth) lightly, but importantly, and continue ahead, watching (inside and out) for what happens next. This way, you’re like a tennis player awaiting the serve: nimble, balanced, and ready to move in whatever direction is needed.
Approach number 3 is exactly what I did with a very difficult person I used to work with. He was an overwhelming, ‘force of nature’ type, very insecure, very loud, very sure of himself, a “Type A, Alpha Male,” in his own words. Even though he was very bright and very gifted (he dropped “Harvard” bombs on me at least three times in the first hour), he had been fired from several jobs in recent years, each time for his personality, not his work per se.
The first time he came in, it was clear he hated being there, in the position of a supplicant (his word), that is, not in control and having to depend on me. He quickly tried to take control, criticizing my office and my education (“So – no Ivy League for you, eh? What did you major in: remediation?”).
Once he had gotten those preliminary shots out of the way, he began his ‘interrogation’:
“So, what do you have to say for yourself?”
At this point, I was angry, a little overwhelmed, and I truly wanted to say, “I don’t know – I guess I haven’t had enough remediation,” but I couldn’t join him in his game of ‘who’s the top dog?’ if I wanted him to get better. I could feel the intensity of the forces that were driving him, the insecurity, the fear of being in a subordinate position (“one down”), and what he must have gone through to bring himself to seek help. But most of all, I could see he was trapped in an inner world of Always having to ‘know’, like a dinosaur stuck in the tar pits. If he lured me into competing with him, then even if I ‘won’, we both lost.
I knew my next statement could make or break the whole enterprise. I took a deep breath. “I don’t know what I have to say for myself, but I would like to help you. I’m not sure if I can, but I’d like the chance to try.”
He snorted in disgust, but then looked down and cleared this throat. His foot stopped wiggling, impatiently, for a moment, and, still looking down, he said, “Well, at least you aren’t pretending to be God in his heaven, like the others.”
“Oh, you’ve seen others?”
“Yeah – ‘experts’.” He named a couple of well-known local practitioners. His foot started wiggling again. “At least they’re supposed to be.”
I could feel the air in the room being let out, a little at a time. It felt like a relief to me, though his face was falling. He had given me an opening, a bone, though he probably didn’t realize it then, and I wanted to capitalize on it without alienating him.
“Wow, you must be pretty bad, if even the experts can’t help you.” Oops – had I gone too far?
His foot stopped again, and he gave a reluctant chuckle and smile, behind which I could see, for the first time, a vulnerable young boy. “Wise ass,” he said, standing up to take off his fancy blazer with the coat-of-arms buttons on it (his first layer of armor) and settle in for a while.
“Fair enough,” I replied.
We had begun our journey.
The “I don’t know” (a.k.a. inadequacy) had been flying around the room like a hot potato before I first spoke, waiting for someone to grab it. Once I caught it, with that, “…if I can” opening, we were in business. Now, we both “didn’t know”, but we had non-verbally agreed to not know together, wherever it took us.
Eventually, much of the pain that was locked up behind his superior attitude came to light, and he was able to be less defended, in front of both himself and me. His behavior in the world became more flexible and fitting to the actual situation, and, importantly, he began to have more space for other people’s needs and feelings, so that his intelligence and perceptiveness could become a tool instead of a weapon.
He could say, “I don’t know,” and he could appreciate it without disdain when others didn’t know; and when you can do both of these things, you can get to places beyond the known – places where only creativity, imagination and heart can take you.
Note: All clinical vignettes herein are significantly altered to protect patient confidentiality and privacy.