Acknowledging the Limits of Psychotherapy, Even if You’re an Expert

In a world in which branding and marketing determine your ability to become successful, you have to remain humble. This is true in any field that purports to help others, especially psychotherapy.

The other day, I had a session with a client who told me she wanted to become an expert, noting that her job made her feel insecure, unsure, and anxious, as she never had the sense that she knew what to do. In turn, I told her that while I consider myself to be an expert in psychotherapy, possessing a deep understanding of four different treatment modalities, I’m not an expert in healing people. She struggled with the paradox. How can I be highly skilled, yet not consistently produce stellar results? Because skill isn’t enough, at least not in my field.

Therapists seldom speak about the struggles we have in achieving clinical success because we run businesses, social media accounts, and have academic careers; we need to appear to know what we’re doing. So, we often hide the shame associated with our less than spectacular therapeutic records. Therapy, like some forms of medicine, is an inherently chaotic discipline; any field related to human relationships is. And manuals don’t always help us in navigating them; experience doesn’t always, either. Earlier in the year, I read Andrew Scull’s Desperate Remedies, a book about the fraught histories of psychiatry and psychology. And saying that I was disappointed and worried would be an understatement. According to Scull’s research, which I highly recommend exploring, mental health is as much of a struggle for many as it was one hundred years ago; one would hope for a little more progress in that timeframe. And I see it all of the time. So much of my work, the client’s work, feels fruitless. But more of it feels Sisyphean, although at least there’s progress.

The therapists of Twitter and TikTok won’t tell you that the data in the field aren’t exciting, with success rates hovering at around 60% for the more mild to moderate mental illnesses (some studies argue less) and much less so for the more severe ones. We get excited about innovations in mental health, like deep brain stimulation surgery, but more often than not, they’re revealed to be only mildly effective. And I’m of the opinion that, on the whole, we should try our best to reveal some of these flaws because so many of our patients come to believe that their ailments are their faults, especially when an expert can’t help them solve them. There’s certainly a tinge of hopelessness in that revelation, but with it comes some relief, for everyone involved.

Experts attempt to utilize their insight to resolve, and I would argue dominate, some problem. They express their profound insight and tell you exactly how to conquer it. But it just doesn’t work that way with people. The myriad factors that contribute to mental illness make psychotherapy an incredibly challenging endeavor. If you successfully help alter a belief, there are ten more just like it. If you help your client change jobs, there will be problems with the next one. When they leave one bad relationship, they somehow find themselves in another. So, you have to be really careful about taking a short-term perspective of success. Things aren’t always what they appear to be.

And while the above-mentioned client is desperately trying to feel in control, I remind her that control is mostly an illusion, regardless of your degree of mastery. When I was a younger therapist, so certain of my methods, I failed to ask: why were some patients unwilling to engage with them? And after finally asking, I was somewhat surprised by what I learned – emotions are, sometimes, so overwhelming and make people feel so certain of their attached beliefs that utilizing their newly acquired skills just doesn’t come to mind; and, at other times, the skills simply don’t work that well. Thus, in the face of another’s suffocating feelings, I’m frequently reminded of my own ineptitude.

Additionally, I can miss the mark on what a client needs, such as an ear or sympathy. But, while some would argue, and have to me, that therapists don’t know more than the average person about difficult emotions, I would respond by simply saying that we aren’t sages. Much of what we do requires improvisation as well as sticking to the script; it requires sympathy as much as penetrating insight; and it requires a high degree of humility. We might be experts in the field, but we aren’t experts on specific individuals. And it’s okay if they aren’t experts on themselves, either.

Check out our episode with Andrew Scull below:

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