Uncertainty in Psychotherapy

Part 1 of 3:

Attention Psychotherapists...You’re Going to Fail!

And there’s nothing you can do about it! You have to fail. You must fail... If you want to succeed. 

To foster a patient who loves himself, warts and all, therapists must accept and own their foibles and follies. To the best of my knowledge, there is no greater strength than the courage to look our demons straight in the eye. This is a question - “what are your strengths and weaknesses?” - you will face at comprehensive exams and internship interviews; my answer always begins, “they are one-and-the-same: my greatest strength is how I have grown from my weaknesses.” 

Artful depiction of a new therapists emotional experience of themselves with imposter syndrome; a Beetlejuice-esque lighting of a nightmare-reality, hiding in a crouched, nearly fetal position, wishing to disappear behind dark sunglasses.

However, weaknesses can be exponentially difficult for beginning therapists: we are supposed to be some sort of an expert, right? Yet amongst the terrors we may face the first time we sit across from a client is often a sense of stark incompetence. But what should we, psychotherapists in training, do about this? 

Embrace it! Love it! The day that I can predict, and thereby be prepared for, everything that will happen in a session is the day I will retire. In fact, I hope I don't come anywhere near this point in my career by the time of my retirement. What draws me to psychotherapy is the complexity of the human experience: we are the luckiest profession to be afforded the opportunity to see the world through another human being’s eyes! 

Yet, there is a catch. Because of the complexity of the human phenomenological experience, each person’s way of perceiving the world is not only unique and distinct, but also ever-changing, developing and growing - especially during the course of psychotherapy. It has been my professional experience that seeing the world through the patient’s eyes results in the most effective therapy. Consequently, I would argue psychotherapy innately involves novelty - new terrain to tread - with every session. Therefore a psychotherapist can never be, with certainty, completely prepared for what might arise in a session. So the catch is that many beginning psychotherapists misinterpret this innate level of uncertainty as incompetence, rather than a feeling of incompetence.

Therapy innately involves novelty, and novelty precludes the possibility of being completely prepared. This leaves therapists vulnerable to feeling incompetent. The sooner we can accept and embrace uncertainty, the more quickly we can help those who are suffering. We can, and must, admit we are mere humans: perfectly imperfect. When we can accept the imperfections of the human condition, our patients can begin to do the same. 

Maybe part of being competent is being prepared to be unprepared. To be certain that uncertainty will ensue. To be sure to admit when we are unsure. And to be devoted to continued learning.

Part 2 of 3:

Technical Discussion of Uncertainty:

• Supportive vs Expressive Therapy

• Certainty and Uncertainty as they pertain to Depression and Anxiety, respectively

• Yerkes Dodson Arousal-Performance Curve

CRACK! It sounded like an ancient oak-tree finally giving way to the weight of ages, snapping right beside my ear. But it wasn't. Something. Something fiery. Ripped through the sky and crashed into the soft, rain-soaked earth of the forest. Trees pummeled in its path and the forest floor razed to bedrock. Courage gathered, my boots lead the way up the familiar path into the wood. Misty fog played smoke and mirrors as the mud sucked me back, echoing my nerves. The fog grew thicker, nearing the site of the crash-landing - the heat of the fiery object boiling in a stew of muck and mire. What was it? Poking at its edges with an old hand-worn walking stick - the first side porous like scoria lava rock. A few steps further, smooth and cracked basidian. The other side clinked with each tap of the walking stick like a wrought iron railing. Each new perspective shedding light on what this thing could be - a chunk of deep-earth spat out by a volcano? A meteor that melted the sandy-loam of the earth it landed in, creating an amalgam of ferrous glass? An old satellite no longer satiliting, recklessly forgotten and left to fall to earth?

Therapy often involves circling a psychological phenomenon that is recurrent in the client's life. Each pass, we learn more about it - how we define it, where it came from, what it's function is, and how we can empathically address it to improve the client's functioning and, hopefully, happiness. Each symptom or event often leads back to this place - it is parsimony - one problem underlying an array of experiences means you are onto something. Putting this into words is called a conceptualization.

Therapy involves assessing where we are - Point A - and a goal, or where we want to get - Point B. However, therapists and clients often assume we start the work at Point B: processing whatever overwhelming emotion or trauma lays there. But there is a reason clients have just jumped to Point B themselves: there are barriers, resistances or defense mechanisms serving to self-preserve, protect oneself, from that overwhelming experience that first must be acknowledged, validated, and worked through to find alternative ways of self-management. This is the rocky mountain cliff, the thick valley forest, and the white-water rapids between Point A and Point B.

We often know our goal, but rarely what lies in our way. “There is a road, no simple highway” (Hunter, The Grateful Dead, 1970). At times, we may find that no matter what we try, we cannot seem to overcome the problem and reach our goal - our cabin on the hillside. No matter how hard we wish, for some problems there is no simple highway - no quick-fix, deus-ex-machina, five-step solution, or magic wand. These are the points in life when people most often turn to psychotherapy; they have tried everything and, to varying degrees, may have a fantasy psychotherapists have some top-secret piece of advice. Especially therapists-in-training who are excited about helping, anxious to prove their competence, and unfamiliar with the uncertainty of the therapeutic process might find themselves colluding with this client’s wish for a magic solution in order to reduce both parties’ uncertainty. But usually we fare better to recognize our own narcissism (urge to protect our professional self-esteem) and avoid playing along with the fantasy that we can provide a quick-fix. We must keep in mind “there is a road, no simple highway,” and along this road there are boulders neither we or our clients can foresee. Even more powerful than the solution is that we can go along for the ride, sharing in the uncertainty of the voyage. 

Therapy Note: I think of defense analysis, the intervention of Ego Psychology, in this part of therapy: "every time we reach to this subject, I feel a resistance, like the north-poles of two magnets pushing together. Do you feel that? What is happening for you?" We explain that this is normal - it is boundary setting and self-protection, our body and mind saying we are not ready for what is beyond this defense. However, we can explore this resistance, its familiarity, function, and maybe we can put it into words rather than symptoms and actions.

Wishful thinking, or the magic wand, is a hope that a swanky ski resort gondola, maybe even one that serves Swiss hot chocolate aboard, will glide us along the scenic route, past the hazards below and the painful emotions that keep our clients from Point B - the wellness and lives they wish and deserve to have. But unfortunately have to work for. While therapy can be hard, it is often rewarding and easier over time once we get used to the work.

Uncertainty

A focus of this series has been therapists misinterpreting uncertainty as incompetence, potentially threatening professional self-esteem. However, I believe uncertainty is a fundamental human anxiety. Our drive for knowledge and scientific advancement may be fueled by our discomfort with uncertainty. Religion, be it truth or tale, offers billions of people a sense of comfort in the certainty it provides. 

Existentialists are interested in our uncertainty in the process of “becoming” or self-actualization, finding meaning, living in conformity with our values, and death.

Psychoanalysts may be interested in the analysands’ uncertainty of their ability to fulfill drives (biological and relatedness needs) within the confines of their perception of the rules of the world (superego).

The Psychodynamic Diagnostic Manual demonstrates variations in treatment across diagnoses depending on how the client orients him or herself to the world in regards to Blatt’s polarities: relatedness versus self-definition. I believe it might be helpful to explore the experience of uncertainty in these polarities in terms of two common cognitive distortions: dichotomization and catastrophization. For example, a client who presents with a dichotomous hope of being comfortably enmeshed while catastrophizing about abandonment is struggling with anxious uncertainty in relationships. Conversely, a perfectionistic client who presents with a dichotomous drive to fulfill immense expectations while catastrophizing about all the things that could lead to failure is struggling with anxious uncertainty in self-definition. 

Gestalt therapists recognize an uncertainty-laden future orientation as a core source of anxiety; staying in the moment is a key focus of Gestalt therapy. One might say we are well when we feel we can handle the future’s uncertainty, anxious when we feel we cannot handle that uncertainty, and depressed when we are certain we cannot handle what the future may bring.

As discussed in Part 1 of this article, therapists struggle with their own uncertainty, yet coming to terms with this lays the path to helping the client to do so as well. Therapy itself is frequently experienced as uncomfortably uncertain by clients - sitting in this experience and tolerating it, in other words, exposure therapy to this uncertainty, is therapeutic itself.

Transferences

How do we know whose stuff we are dealing with at any moment in therapy? Simply, we can’t. It’s usually some of both. However we can remain reflective with one eye turned inwards toward our emotions (the other eye attending to the client). This will allow us to be aware of our emotions so that we can begin to wonder to what degree they are from our past or a reaction to the client. The client’s past being played out in therapy is often called transference, and at times we might be pulled into playing along in what we refer to as an enactment. This enactment can be a complimentary role - being a saviour or persecutor when the client experiences themselves as a victim, or it can be identified in which we feel the same as the client. [The identified role often comes out in supervision: a therapist feels stuck with a demanding client and wants their supervisor to give tangible advice to get "unstuck," putting the same demands on their supervisor they feel from their client. Processing this builds empathy and opens doors to ways to approach this sense of need for support.] Our reaction to the client's transference as well as our past being played out in therapy is called countertransference. The unique, co-created phenomenon between any two people (therapist and client) is called the analytic third (the first and second being the therapist and client, the third being a gestalt). Some approaches to therapy have historically sought to eradicate countertransference via psychotherapy for therapists-in-training. The more common contemporary belief is that, while therapy is good for everyone, countertransference and “enacting” past interpersonal relationships is inevitable; we must remain aware and reflective of where emotions are originating in order to determine the best approach to take with our clients. In moments of uncertainty, we turn to "what's happening right now, for you, for me, between us, right on the surface?" See the article on therapeutic focus, working from surface to depth.

Therapist’s Approach? 

Does the therapist aim to reduce anxiety, or to encourage the client toward anxiety-provoking material to gain new ways of experiencing? Many theoretical orientations offer both anxiolytic and anxiety-provoking interventions, which can affect the client's sense of uncertainty. Problem-focused orientations often refer to anxiety-reducing interventions as symptom-management, while exposure involves facing anxiety. In depth psychology orientations, supportive psychotherapy reduces anxiety while expressive (or interpretive) interventions increase the client’s experiencing of emotional material.

Supportive therapy can be comforting, build coping skills for resilience, and reduce anxiety.

Interpretive or Expressive therapies hold our feet-to-the-fire, so to speak, and help us face and thereby change psychological problems. This can be exposure to phobias, processing trauma, or facing problematic parts of ourselves and behavior. It often increases anxiety in the moment, but leads to lasting change. However, it may not be appropriate at certain moments of therapy if the client may need more supportive approaches to prepare them to tolerate these experiences.

Existential Analyst, Frankl, describes relieving the existential anxiety (meaninglessness) of a woman on her deathbed by elucidating the meaningful things she had done that will never cease to exist. Conversely, Mann’s Time-Limited Dynamic Therapy highlights weekly that the client’s time in therapy is running out - a microcosm of our time running out on earth from the day of our birth.

Perls, a leader in Gestalt Therapy, described himself as an excellent frustrator. 

Many Dynamic therapists see themselves as a frustrator. Not only can the therapist be a frustrator when encouraging the client toward experiencing anxiety-provoking material, but increasingly throughout therapy as the client’s transference develops: the client begins to see the therapist like the parental frustrator who inhibited childhood impulses. Similarly, Davanloo calls himself a relentless healer. Therapists like Davanloo and Kernberg, amongst other interventions, point out (interpret) the client’s transference from the first session. 

Conversely, supportive interventions decrease anxiety. Fonagy, an attachment theorist, helps clients with mentalization, similar to self-reflectiveness in mindfulness-based therapies like ACT and DBT, to self-regulate affect. Developmentalists might be interested in a corrective emotional experience; rather than interpreting client transference, reacting differently toward the client than the client’s parents did during childhood. Kohut might address a client’s hostility, “I’m realizing I came off as equally uncaring as your father when I reacted that way. That must have been difficult considering your friends have also been distant lately.” 

How to approach the client depends on more client and therapist personality factors than can be covered here: severity of illness, type of illness and characteristic defense mechanisms and cognitive style, introversion versus extroversion, relatedness versus self-definition, and degree of emotional distress, to name a few.

Arousal-Performance Curve

Performance, whether in therapy or sports, is associated with level of arousal. Emotional arousal can determine the client’s motivation in therapy. High levels of distress lead to inhibiting anxiety; a client will shut down and may experience panic. Too little emotional arousal results in loss of motivation and disengagement. Either too much or too little emotion can result in a client leaving therapy. Anxiety-provoking approaches to therapy (ie., 7 out of 10) can give clients motivation as well as new, meaningful experiences, that can in-turn be processed more reflectively during periods of lower emotional arousal later in the session (ie., 3 out of 10). Conversely, clients who come into therapy with marked emotional dysregulation might benefit from anxiety-reducing interventions that prepare them for deeper levels of emotional processing later in therapy. Clients with more severe anxiety, borderline personality organizations or PTSD may have a narrower “therapeutic window” or a more peaked curve (more quickly distressed and more easily bored). This can help determine whether to encourage the client to experience the uncertainty during therapy, or to reduce anxiety by reducing uncertainty.

Part 3 of 3:

Closing

Imagine the Yerkes Dodson curve repeated, side by side over time. We have a sine wave

Everything in life - sleep and wake, psychotherapy, relationships and interactions, hunger and satiety, medications and physiology, finances - follows a sinusoidal wave, give or take some variations to its normality. As we reach a peak, forces pull us back to the norm, baseline, and beyond it into a rebound. In terms of the physiology of psychology, one term is the opponent process. Our biology aims for homeostasis, but overshoots and causes a rebound or withdrawal. Staring at the sun and looking away leaves a green flash where our neurons are coping for the overstimulation. Staring at a bright image and removing it leaves the negatives of the original images colors. Coming down or withdrawal from a drug - medicinal or recreational - is significantly impacted by this process. Many people treated with high-dose opiate analgesics overdose when taking their normal regimen but in a new room. Imagine a patient bedridden and receiving and administration of opioids at 9am and 9pm daily. That time and place are conditioned to prepare the body for the medication - it could trigger cravings and withdrawal, but underlying is a physiological attempt to pre-emptively maintain homeostasis. Let's imagine this person is feeling particularly well one day, ventures to the kitchen to take meds with breakfast and overdoses despite the same dosage and regimen. Why? The environment is not triggering the homeostatic physiological mechanisms that decreased the medications effects.

Icarus depicts a constant unconscious decision making about approaching anxiety and the inherent risks, or avoiding and wallowing in the mire of depression

As we connect with a human being - therapy, romantically, socially - we reach a peak in intensity including physiological and emotional arousal. While this is the goal of human nature and meaning - connectedness - it also induces anxiety about disconnection, judgement and vulnerability due to this level of connectedness, and fear of loss. We often have a competing urge to pull away. Even if not, naturally the interaction ends eventually and we disconnect, moving toward the opposite polarity of the sine wave: isolation that causes both comfort and loneliness or even meaninglessness and despair. We are caught between this bind, this dance, of vulnerable connection and painful isolation. Daedalus reminds Icarus not to fly too close to the sun, for it would be too hot and melt his waxen wings, nor too close to the sea for it mist would weigh his wings down and he would crash into the swail.

Therapy moves along a sinusoidal wave, often having multiple peaks and valleys in a single session as we approach emotionally meaningful content - whether from the client's life or the interaction between client and therapist. Then this moment is processed, and we are brought down to a baseline. The content that was initially a peak in arousal - ideally in the 4-6 range on a scale of 1-10 - is now more manageable and new content is accessible. Be it processing, exposure, a combination of another phenomenon. This may happen naturally, or may need to be conscious on the part of the therapist and eventually the client can internalize this - the skill and the internalization of the therapist as a newer, healthier object (internalized parental figure) - for increased resilience and emotional regulation ("oh, yes, these are the early signs I'm triggers. It is ok, just an emotional and physiological boundary, and I can set it verbally. Let's stop and breathe.")

These peaks are often marked by sense of uncertainty and consequent anxiety. But provides the opportunity for us to sit in this state, to tolerate it, with the client, and be ok. We are ok.