One of the hardest things about being a therapist is worrying about questions that have no clear answer. Do I properly understand what my client needs? Would a different approach be more effective? Should I have comforted them when they were upset more quickly? Or was letting them sit in that distress a moment longer what they needed to understand themselves?
Reading research related to mental health doesn’t make things much clearer. Any neat causal theory that attempts to explain mental illness is an oversimplification. A dizzying range of both biological and environmental factors have been shown to play a role. Confusingly, research suggests people can present with similar symptoms that have different causes. One person’s depression largely caused by environmental factors, another by genetic sensitivities.
The research on treatment is similarly unclear. Medication works for some people but not others, therapies with completely different approaches often have similar results. Talk to enough people who have recovered from mental illness and what stands out is how different their stories are. One person will say accepting their depression and being kinder to themselves helped them get better, another that it was only when they took responsibility and demanded more from themselves that things improved. Some clients with addiction say complete abstinence worked for them, others say giving up on abstinence in favour of moderation helped them break the cycle of binges. To be a therapist is to try and help a client find a path that you yourself cannot see.
The best therapeutic modalities are honest about this uncertainty. They warn that a therapist who thinks they know exactly what a client needs is probably suffering from overconfidence. Motivational interviewing talks about partnership, psychodynamic therapists’ “neutrality” and CBT therapists “collaborative empiricism,” but the underlying message is the same: The client is the expert in their own life, and their ideas about what is wrong and what needs to happen are likely to be at least as accurate as the therapist’s.
Every now and then a group of therapists becomes bored with these constraints. They will market their approach as guaranteed to help with any mental illness, have a model that makes sweeping generalisations about mental distress. Therapy becomes more about teaching the client the model than actually listening to them. Usually it doesn’t take long for their approach to backfire. A recent article in The Cut is a great example of this. It details the excesses of a private treatment facility ran by a charismatic yet overconfident IFS practitioner. Therapists told clients they knew exactly what was wrong with them, told them to cut ties with their family, made them adopt concepts and ideas that left them more disturbed. Unsurprisingly this led to significant harm. People were left estranged from their families, convinced they had suffered things that hadn’t actually happened.
The history of therapy and psychology is littered with similar examples. The refrigerator mother theory of autism, rebirthing therapy, recovered memories. All of them are examples of therapists becoming sick of the murky, cautious work of therapy and wanting something more definite. Wanting to tell people exactly what is wrong with them, what they need to do to get better. What is often striking about these stories is the energy and enthusiasm with which these therapists worked. To feel like you know exactly what each client needs and that you can give it to them must be an intoxicating feeling.
In my weaker moments I sometimes wonder if changing the way I work could reduce the amount of uncertainty I feel. Maybe if I used a manualised approach with every client I wouldn’t spend so much time doubting myself. If the client didn’t get better it would be the model’s fault, not mine. In the end though I always decide that would be dishonest. How could I tell a client they need to adopt a particular approach when I know that other approaches can be just as effective? Or tell them they need to learn a particular skill that many happy people never use? The only way therapy makes sense for me is that every therapeutic engagement is unique to each client, and that’s where the doubt creeps in.
Before I became a therapist I was a banker. I put together business loans that my credit team would agree to. When I made a mistake it was always clear what had gone wrong: I hadn’t applied the right lending policy, forgotten to ask the client to fill out a particular form. My job was to follow a process as closely as possible, if I did things differently or was creative it was almost always a mistake. As I was working on this piece I was reminded of how I hated that feeling. It made me think that I should be more grateful of how uncertain my current job is. Being a therapist allows me to wrestle with questions that have no clear answer, experiment with new approaches to difficult problems. While at times I can find the existential anguish that comes with it challenging, I know I’d like the alternative even less.
I also believe that the feeling of uncertainty makes me a better therapist. It keeps me open minded, forces me to listen more closely, pushes me to try new things. If therapy is most effective when it is collaborative, how can it truly be collaborative if the therapist knows exactly where they want to go? It is only when both the client and the therapist feel somewhat lost, are both closely listening to each other for a sense of direction that collaboration can emerge.
This isn’t to say being a good therapist means being passive. To be passive is also a decision, and clients need more from us than simple reflections. The paradox of being a therapist is you are forced to take a position whilst being aware that your position could be wrong. Perhaps learning to embrace this uncertainty without becoming overwhelmed by it is the fundamental challenge of therapy.