Truth, Effectiveness, And Mental Health: Part Two

Part One of this series can be found here.

I see about twenty-five patients most weeks, and probably say a few hundred things I do not know to be true. That pains me.

When I first finished my training, like nearly all therapists, I knew what to do. My training equipped me with a body of beliefs and practices I could bring to bear on most any situation that arose in the therapy room.

Two things changed. First, over time I got past the novice's beliefs that when the treatment didn't work, the fault lay with my not doing it right. Second, I realized that the beliefs I'd been taught were, in reality, poorly evidenced, some of them outright false.

That process started when I read Daniel Stern's work on infant development, which claims to show that most psychoanalytic beliefs are in error. As I've written before, I tried an experiment: to listen to, and interpret, my patients as if Stern's views were correct. The therapeutic encounter made just as much sense as before - what patients told me could be as easily interpreted in Sternian terms. And patients got better at about the same rate.

Then I got serious about studying social psychology, and I realized that much of what happens in the therapy room is a function of the social setting, not the patient's personal psychology.

And so forth and so forth. New knowledge undermined conventional clinical belief. I began to be much more aware of, and honest with myself and my patients about, the limits of my knowledge. I became painfully aware of the limits of human knowledge about the ills that beset us.

As you can imagine, I had a serious, protracted crisis about whether my work was legitimate at all, whether I should even be practicing. More profoundly, I struggled with severe concerns about whether the mental health professions themselves have any legitimate claim on patient's trust. I doubted anyone should be practicing.

Confucius said (for real) that the beginning of knowledge lies in knowing the extent of one's ignorance. Socrates said that if he had any wisdom, it lay in knowing that he knew nothing, rather than thinking, like "experts," that he knew something.

I found a great deal of solace in those considerations.

I came to think of myself as an "auxiliary mind." (I originally said, "ancillary mind," but too few people knew the word "ancillary.") I realized that when people are in pain, they have every right to use whatever mental capacity they can muster to try to find relief. The need for relief grants a moral imperative and legitimacy to using the best that's available, even when "the best available" is not so great.

I realized I could be an assistant people hired to help in that process. Thus my activities have exactly the moral legitimacy of anyone's efforts to improve their lot. It isn't my job to know more than the relevant body of human knowledge contains. (It isn't even my job, as a finite mind, to encompass the relevant body of human knowledge. All I can do is all I can do: systematically, consistently, deliberately keep learning.)

Patients hire me to bring to bear on their difficulties an enormous range of information, and a set of mental functions, that they can't bring to bear themselves - either because they haven't spent their lives studying suffering and its relief, or because their distress debilitates them.

Serving as a conscientious auxiliary mind: That seems to me a perfectly legitimate profession. But there's still the problem that no one knows much about mental distress and its relief. I'm pretty sure that, like Socrates, such wisdom as I have lies mainly in knowing the enormity of my ignorance.

That, I believe, is essential to being truthful in the therapy room-knowing one's ignorance, and being honest with one's self and one's patient's about it.

That doesn't mean we say nothing except things we know to be true. If we took that tact, we'd only utter generalities, banalities, and the obvious.

Rather, we make our best guesses, and we don't pretend they are more than guesses.

We give our utterances only the weight they deserve. And we take pains to know exactly what that weight is.

There's nothing wrong with believing something rather than nothing under conditions of uncertainty, even radical uncertainty. Most of life is like that. We have to believe something to guide our efforts. We can't wait around for human understanding to advance. We have to do the best we can with what we have. Being truthful in the therapeutic setting means knowing the extent of your ignorance and the actual evidentiary weight of your beliefs - and never pretending to know more than you know.

You don't have to do it that way. Most therapists (that I've known, or whose writings I've read) don't. You can help people feel better without being truthful. Indeed, you'll feel less anxious, and improve your self-esteem, if you kid yourself.

Why bother, then, with truthfulness? More on that next time.