uncertainty, being uncertain, and refusing uncertainty: can therapists' ambition in the era of...

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Uncertainty

Being Uncertain

and

Refusing UncertaintyCan Therapists’ Ambition in the Era of Evidence-Based Practice Be

Counterproductive?

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660www.jamestobinphd.com

949-338-4388

Assistant Professor of Clinical Psychology, Argosy University

601 South Lewis StreetOrange, CA 92868

http://www.powerpointstyles.com/





A Vignette from Group

Supervision: The Boy Who

Played the Violin




“His mother is enmeshed with this boy and he needs to

differentiate from her.”




“The violin is a surrogate sibling for the boy that he must give up in order to mourn the death of his sister.”




“The father’s abandonment probably left the boy with

ambivalence about his own masculinity. The boy has chosen

an activity that is feminine in order to punish both parents and as a

way to protest his father’s philandering.”




“Why can’t he do both? Go to college then in the summers

go to Europe for his musical training?”




I Thought our Field Aspired to Avoid Premature Conclusions or Erroneous Assumptions?

Perhaps in the abstract .... but, unfortunately, it is not that way in reality (at least in my experience)!

The ubiquitous nature of “frozen constructions of meaning” (Young-Eisendrath, 1997, p. 648) in many academic, clinical,

and training contexts.




Nietzche

Nietzche (1873/1999, as cited in Kose, 2003, p. 214): “ ... all knowledge is ‘nothing but working with favorite

metaphors.’ ”




“Instrumental Fictions”

In Between Conviction and Uncertainty: Philosophical Guidelines for

Practicing Psychotherapists, Downing (2000) argued that clinicians are guided by a personal epistemology: organizing schemas that serve as a heuristic for understanding patients.

In his review of Downing’s book, Kose (2003) called these heuristics “instrumental fictions,” [which are] “motivated by the conviction or desire to know the truth and provide useful illusions that allow us to work toward the fulfillment of that desire” (my italics, p. 214).




Knowing So We Don’t Have to Think

“A lot of us use (or misuse) theories, articles we have read so that we do not have to think about what the patient is

communicating” (Witenberg, 1979, p. 277).

..... or have to get the patient to think about what he or she is saying (psychotherapy being a venue for self-

relatedness is not really discussed!)




The Reduction of Uncertainty is a Neurocognitive Certainty

There is a burgeoning literature on the neurophysiology and cognitive science of

uncertainty that centers on the role of emotion in information processing

(e.g., Baas, de Dreu, & Nijstad, 2012; Hirsh, Mar, & Peterson, 2012).




The Need to Reduce Uncertainty: Anxiety

(1) Anxiety emerges when there is a mismatch between predicted and actual sensory events: “.. there is a massive increase in entropy as

the individual’s well-delineated plan of action gives way to uncertainty about the

best way to construe the situation ... ” (Hirsch, Mar, & Peterson, 2012, p. 309).




The Need to Reduce Uncertainty: Structured Thinking

(2) Emotions associated with appraisals of uncertainty lead to more structured thinking

and ideation (Baas et al., 2012) and “[a]ttempts to minimize short-term entropy

at all costs through the adoption of rigid cognitive structures and behavioral patterns” (Hirsh et al., 2012, p. 314).




The Need to Reduce Uncertainty: Dogmatism

(3) ... “by willfully ignoring information that contradicts one’s worldview or refusing to

explore ... may in fact result in long-term adaptive failure despite the short-term

reduction in anxiety” (Hirsh et al., 2012, p. 314).




Evidence-Based Practice (EBP)

Ours is an environment of EBP, empirically-supported therapies (EST), and managed care (APA Presidential Task Force, 2006; Hunsley,

2007).

Symptom reduction and the use of ESTs has become “the standard of care.”

If progress doesn’t occur, something is wrong with the psychotherapist’s abilities or the

treatment provided or both (Wachtel, 2010).




There is Enormous Pressure on Therapists-in-Training

Not only to diagnose, intervene, and help, but to cure (the

“helping profession” has become “the curing

profession”).




The Helping Profession, the Curing Profession

Therapists-in-training are burdened with enormous expectations, many of which are misguided (see Misch’s 2000 paper “Great

Expectations: Mistaken Beliefs of Beginning Psychodynamic Psychotherapists”), and

many of which come from unresolved historical issues re: treating/healing a pathological

care giving figure (Miller, 1997).

These characterological predispositions are activated in the current environment of ESTs.




The Impact of these Issues is

Significant!




Empirical Research on Therapists’ Self-Schemas

These are the therapist’s cognitive, emotional, and behavioral reactions to

patients which are conscious and accessible to the therapist (the analogue of counter transference in cognitive

psychology).

A recent dissertation project (Cook, 2013) I chaired sought to compare the self-

schemas endorsed by novice vs. experienced therapists.




Predominant Self-Schemas for Novice Therapists

(1)Demanding Standards: “I have to cure all my patients. I must always meet the highest standards. My patients should do an excellent job. We should never waste time.”

(2) Abandonment: “If my patient is bothered with therapy, he or she might leave. It’s upsetting when patients terminate. I might end up with no patients.”

(3) Helplessness: “I feel I don’t know what to do. I fear I’ll make mistakes. I wonder if I’m really competent. Sometimes I feel like giving up.”




Predominant Self-Schemas for Experienced Therapists

Experienced therapists also highly endorsed the “Demanding Standards” and “Abandonment” self-schemas!

The third most highly endorsed self-schema was not “Helplessness” but “Excessive Self-Sacrifice”: “I should meet my patient’s needs. I should make them feel better. The patients’ needs often take precedence over my needs. I sometimes believe that I would do almost anything to meet their needs.”




The Intensity of the Psychotherapist’s Ambition

Appealing to the “client” and “doing an excellent job”– therapists are intent upon helping the patient feel better and do better, sometimes to an extreme level of intensity.

This is potentially a narcissistic position, i.e., both personally and professionally (it can be argued that the treatment is more about us and the field than about the patient).




Given These Circumstances,

Uncertainty Is Not Tolerated Nor Seen as

Potentially Useful!




The Imposition of Order and Certainty

A person coming for help, already in distress, is likely to want to create order – an old order – in such a paradoxical environment. The analyst or therapist, in response to what the patient imposes, is just as likely to impose an old order, in the form of theory, expertise, authority and his or her own psychological complexes” (Young-Eisendrath, 1997, p. 642).




What Ever Happened to the “Aha!” Moment?

There are few if any “aha moments”!

“It is hard to discover something if you already know what it is that you are looking for and where it is” (Duncan, 2010, p. 155).




Duncan’s Book “On Becoming a Better Therapist”




A Long Tradition of the Clinical Utility of Uncertainty

Jung’s transcendent function: “within the psychic space of the transcendent function, one is free to watch and wait, not compelled to assign meaning prematurely to images, affects, memories or actions …. [in order to make] the discovery of … a meaning that was not previously known” (Young-Eisendrath, 1997, p. 641).





Winnicott’s play space/transitional space.

John Keats’s famous letter which he wrote in 1817 to his brother about “negative capability” (i.e., the artist’s capacity to sustain him- or herself in the course of uncertainty; art is not what is done but what one is able to tolerate or take in).





Bion’s (1962, 1970): “not knowing” and approaching the clinical situation without memory or desire, based on Keats’ concept of negative capability.





Donnel Stern’s important works ,“Unformulated Experience: From Dissociation To Imagination in Psychoanalysis” (1997) and “Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment” (2009b) which describe his view of the mutually co-created discovery process in psychotherapy and psychoanalysis.




Implications for Training and Supervision

1.) Current professional socialization seems to center on being “expert,” “empirical,” and “objective.”

- An over-emphasis on these values/skills creates significant pressure and the tendency to act on

the patient.

- Leads to a preponderance of false-self phenomena.





2.) One of the most challenging experiences for trainees is learning to tolerate ambiguity and uncertainty (Lakovics, 1976).

- The supervisee must help build the trainee’s capacity for not-knowing – a “prerequisite for creative discovery” (Klugman, 2003, p.665).

- Supervision can be a “space for thinking” (Mollon, 1989) in addition to didactic learning.





3.) The trainee must become aware of his or her “patterns of organization” and “organizing principles” (Klugman, 2003, p. 666) (one’s personal heuristic), and how these relate to intentionality in treatment (i.e., what is the pragmatic connection between therapeutic self-schemas and intervention tendencies for the supervisee?).





4.) Need to debunk the myth that there is a correct way of doing everything in psychotherapy (e.g., What do you say when a patient arrives to a session late?).





5.) Witnessing as a major therapeutic competency:

- Stern (2009a) argued, “At the beginning of life, we need a witness to become a self” (p.701) and, “our witness is our partner in thought” (p. 707).





5.) More on witnessing: - Stern pays tribute to Harry Stack Sullivan who, according to Stern ,theorized that “we know ourselves reflected appraisals” (Stern, 2009b, p. 706).

- This idea is akin to Suzanne Johnson’s (2008) Emotionally-Focused Therapy (EFT) intervention of “heightening.”

- I describe this to students and supervises as “editing the scene.”





6.) Trainees must be encouraged to use their subjective self-experience and to be, at times, spontaneous (e.g., “Did you tell your patient something about what you were thinking or feeling?” – the response is invariably, “No!”).

-“You mean we can tell the patient what we really think?” (see Renik,1996, 1999)




Conclusion

“In truth, we have all felt the burdens of clients’ expectations that we fix their problems …. Understandably, though, we adopt these therapeutic roles because that is how we’ve been trained, or we just don’t know what else to do. Our limited tolerance for uncertainty ....




Conclusion

“.... together with client’s expectations of us, also restricts our sense of adventure and co-discovery, influencing us toward cookie-cutter practices and away from the great, beautiful, and largely unknown territory of a client’s path to change” (Duncan, 2010, p. 149).




References

• APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. America Psychologist, 61, 271-285.

• Baas, M., de Dreu, C., & Nijstad, B.A. (2012).

Emotions that associate with uncertainty lead to structured ideation. Emotion, 12, 1004-1014.

• Bion, W.R. (1962). Learning from experience. London: Heinemann.

• Bion, W.R. (1970). Attention and interpretation. London: Tavistock.




References

• Cook, D.C. (2013). A comparison of therapist schemas: A quantitative study. Argosy University, Orange County, CA.

• Downing, J. N. (2000). Beyond conviction and uncertainty: Philosophical guidelines for practicing psychotherapists. Albany: State University of New York.

• Duncan, B.L. (2010). On becoming a better therapist. Washington, D.C.: American Psychological Association.

• Hirsh, J. B., Mar, R.A., & Peterson, J.B. (2012). Psychological entropy: A framework for understanding uncertainty-related anxiety. Psychological Review, 119, 304-320.




References

• Hunsley, J. (2007). Addressing key challenges in evidence-based practice in psychology. Professional Psychology: Research and Practice, 38, 113-121.

• Johnson, S. (2008). Emotionally focused couple therapy. In A.S. Gurman (Ed.), Clinical handbook of couple therapy (pp. 107-137). New York: The Guilford Press.

• Klugman, D. (2003). The figuration of reality: Psychoanalysis, animism, and the ‘pathetic fallacy.’ Psychoanalytic Psychology, 20, 660-676.




References

• Kose, G. (2003). Book review [Review of the book Between conviction and uncertainty: Philosophical guidelines for practicing psychotherapists, by J. N. Downing]. Journal of Psychotherapy Integration, 13, 211-215.

• Lakovics, M. (1976). Some problems in learning to do ‘good psychotherapy. The American Journal of Psychiatry, 133, 834-837.

• Miller, A. (1997). The drama of the gifted child. The search for the true self. New York: Basic Books.

• Misch, D.A. (2000). Great expectations: Mistaken beliefs of beginning psychodynamic psychotherapists.

American Journal of Psychotherapy, 54, 172-203.




References

• Mollon, P. (1989). Anxiety, supervision and a space for thinking: Some narcissistic perils for clinical psychologists in learning psychotherapy. British Journal of Medical Psychology, 62, 113-122.

• Nietzsche, F. (1873/1999). On truth and lies in a non- moral sense. In D. Breazeale (Ed. & Trans.), Philosophy and truth: Selections from Nietzsche’s notebooks of the early 1870’s. Amherst, NY: Humanity

Books.

• Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495-517.

• Renik, O. (1999). Getting real in analysis. Journal of Analytical Psychology, 44, 167-187.




References

• Stern, D. (1997). Unformulated experience: From dissociation in psychoanalysis. Hillsdale, N.J.:

Analytic Press.

• Stern, D. (2009a). Partners in thought: A clinical process theory of narrative. The Psychoanalytic Quarterly, 3, 701-731.

• Stern, D. (2009b). Partners in thought: Working with unformulated experience, dissociation, and enactment. New York: Routledge.




References

• Wachtel, P. L. (2010). Beyond ‘ESTs’: Problematic assumptions in the pursuit of evidence-based practice. Psychoanalytic Psychology, 27, 251-272.

• Witenberg, E.G. (1978). The inevitability of uncertainty. Journal of the American Academy of Psychoanalysis, 6, 275-279.

• Young-Eisendrath, P. (1997). Jungian constructivism and the value of uncertainty. Journal of Analytic Psychology, 42, 637-652.




James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660www.jamestobinphd.com

949-338-4388

Assistant Professor of Clinical Psychology, Argosy University601 South Lewis Street

Orange, CA 92868

For additional instruction contact



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