PSYCHOTHERAPY SEVEN DEADLY SIN! (2)
Preface: This is part 2 of this article. I would advice you go through the first instalment to understand the broader background. Also, note that I'd be defining each "sin" first in terms of their virtuous opposite before then elaborating on them. This way, we are introduced at once to both the vice and the virtue, and I also kill two conceptual birds with one shot. The arrangement is such that the 'sins' are in the order of decreasing significance, with the first seven being the most consequential.
Disclaimer: Okay, it's not really seven. More like twelve, but the number seven has an eternal mystic about it, steeped in religious myths and, thus, having more metaphysical flavour. So, consider the title a mere literary device.
PS: I realized after I already published the first part that the list isn't up to 12 as claimed. It is one short of that number. But I thought it's actually a good thing since I'm convinced there must be at least one virtue/vice that I must have left out according to others' reckoning. So, consider the 12th to be something of your own choosing, a sort of readers' contributory blank check. Thus, I would love to hear what other important psychotherapist qualities you, readers, think I have omitted to include.
Without further delay, here are the seven-but-not-seven deadly sins in psychotherapy:
Psychological naivety
Defined in its virtuous opposite, it is the virtue of psychological mindedness, sensitivity and sensibility to psychological nuances of intra and interpersonal games. Psychological naivety is thus comparable to what Scot Lilienfeld, in a broader context of epistemology, referred to as "naive realism": "the assumption that the world is precisely as we see it". This, according to Khaneman, is also realized in the intuitive assumption that “what you see is all there is”. In the specific context of psychotherapy, psychological naivety is akin to a tendency to attach uncritical and/or immoderate significance to observed verbal and nonverbal interpersonal behaviours/cues without a continuous attempting to situate, extend, and interpret them in context while also including our own self in that context. It is the propensity to wholly believe and accept everything the client does and say as true (or as false) without caution and/or internalized (or verbalized) interrogation. In short, psychological naivety underlies the deficit in the interpretive skill that enables a psychological observer to know the amount of weight to attach to each emerging percept per time and context. (For more on this concept, check out the first part.)
Argumentation
The virtue of strategic consenting or socratic engagement; knowing when to attack, retreat, engage, or concede a point. This is often a beginner's mistake when professional insecurity and self-doubt is at their highest. The need to defend one's ego against these feelings is often realized through needless contentions and assertions with the client. The young practitioner, at this stage, still equates professional certification with professional superiority and wields it like a staff of authority. He doesn't know yet that qualification merely confers the right of practice, not the right to be deferred to. While qualification is attained once and for all, respect and deference is earned continually. Asides the fledgling practitioner, the overconfident, self-regarding, and contentious practitioner is also much susceptible to commiting the sin of argumentation. These are often betrayed not by their lack of experience but by the very nature of their personality. They regard any challenge by the client to their theories, methods, and suggestions as an affront (or even an assault) to their professional integrity. They're thus provoked to self-defense, attacking the client in equal breath with the goal of putting them back in their 'rightful' place of passive reception. Generally, psychotherapists who are most guilty of this fault are yet to realize and accept the fact that theirs is a discipline with a popular appeal and a very low bar for the virtue of common sense. In other words, there are many who are astute psychologists by intellectual inclination and gifted with acute perceptive skill though never formally studying psychology. And there are other clients who, though are not so psychologically gifted, are superior critical thinkers and interlocutor than the trained psychotherapist. The practitioner who fails to appreciate this fact always risks walking into a self-constructed trap to make a professional ass of themselves. To lose an argument with a client makes you look stupid and breeds resentment towards your client while creating in the client a sense of superiority which effectively nullifies the vital element of 'perceived superiority' that is needed as part of the nonspecific therapeutic factors driving client submission, bonding and change. Thus, the professional who unskillfully engages in argument and 'loses' becomes demystified and demoted in the vital relational esteem of their client. A competent practitioner often refrains from the very tempting bait to engage in argument, and when he slips or feels compelled by some perceived necessity, knows when to back down or concede with grace. He recognizes in his clients the need to be valued and actively strokes it rather than choke it. He has no difficulty genuinely using the three powerful words: "you are right".
Theoretical dogmatism
The virtue of openmindedness, knowing that theories are made for therapy and not therapy for theories. This vice doesn't appear to manifest according to experience or gender or professional background or any other such variable. One finds it in any practitioner who is closeminded and associates with a particular school of psychotherapy. Founders (and by extension their followers) of theoretical or methodological schools are also often susceptible to this fault. Personally, I have come to sense that psychological theories, strictly applied, don't serve much the function of judiciously (or even sufficiently) explaining a psychopathology or a symptom as much as they serve as the vehicle through which explanatory coherence is achieved. They are not the active ingredients of case formulation, rather they seem more suited to be used as the conveyor belt or the 'scaffolding' for constructing the active or potent explanatory edifice. In a more fundamental sense, theories, by their very epistemic nature (being nomothetic), are anti-therapy. Psychotherapy is the arena where the philosophy of radical individualism is practically realized. Theories, on their part, aggregate entities for explanatory economy. The competent practitioner, therefore, doesn't subject the observed or reported symptoms to the mandate or stipulations of a theory, but rather subject theories to the dictates of symptomatic logic. A theoretically flexible and truly eclectic psychotherapist is, therefore, continually parsing and recombining theories in ways that best account for the constellation of presented symptomatology. She refuses to be enslaved to any one theoretical orientation and rather choose to serve the interest of the manifest symptoms, which is the same as serving the interest of the client. She takes the symptoms as the starting point, and work her way to appropriate combination of theories, and not the other way round. This way, if faithfully done, she may be rewarded with novel atheoretical perceptions and perhaps the discovery of the germ of a new theory. There are some clinical presentations that can be explained without reference to many of the existing theories, but one can't know this if one's professional thinking has been completely hijacked by theoretical orthodoxy.
(NB: the above critic of theories apply only in the specific arena of psychotherapy.)
Self-commendation
The virtue of critical self-reflection, appraising oneself in balanced measure of praise and chastisement. Self-commendation may at first seem to the casual thinker a desirable and positive quality. Maybe it is if understood as merely meaning complimenting oneself or validating oneself when engaged in a task or labouring in a context where one's effort isn't appreciated (e.g working under a hard-driving boss or toiling away in obscurity for a popular figure). However, the meaning and the context being here examined is different. First the meaning: self-commendation is here understood to mean a reflexive tendency and an uncritical attitude in how the self is appraised with regard to a specific function or task. Then the context: the specific function in this case would be as a psychotherapist, and the context would be in a therapy relationship. This specificity is important because the requirements and functional standards needed to effectively execute a therapeutic encounter is necessarily higher than in other relationships and this, precisely because the stakes are higher. Why can't a psychotherapist afford the simple indulgence of uncritical self-commendation? First, it is intellectually lazy and also suggests an underlying tendency to engage with clients in like manner, that is, superficially. Second, it is professionally irresponsible. It amounts to blowing one's professional trumpet. It's like a pharmacist or a scientist commending themselves, because implicit in such act is the belief that their works and products have passed muster and deserving of general recommendation. In reality, this is often far from the truth and one sees these kinds of unbridled self-promotion more among the self-help and woowoo professional class, but also among ill-bred psychotherapists. Third, it is therapeutically injurious. How? By blinding or oppositioning the therapist's awareness to self-corrective insights and psychologically positioning him to deny complicity in poor therapy outcomes. Uncritical self-commendation is steadfastly incompatible with reflective practice because it engenders an ego-syntonic state that is, however, aversive to negative feedback. Hence, a psychotherapist who is too inclined to self-commendation would also be highly disinclined to self-castigation. There's no doubt that self-commendation has an ego-protective effect, but when it's done reflexively and exclusively, it becomes a hindrance to professional self-expansion.
Resentment
The virtue of unconditional positive regard which should not be confused with unconditional respect - the former is consistently realizable, the latter is not. This also incorporates the virtue of relational honesty, willingness to discontinue or refer when resentment becomes difficult to eradicate. Therapeutic alliance is utterly impossible in an atmosphere of resentment. Resentment means the client is in a state of devalued humanity in our regard. I have had to make the distinction between unconditional regard and unconditional respect because I have always thought the former is impossible to consistently fullfil. And I think it is so because it confuses regard with respect. I know the two words are often used synonymously, but I think one can further split them definitionally to serve a crucial purpose here. Hence, while I see 'regard' as the esteem we bestow on someone, 'respect' is the esteem they earn from us. The former is a matter of courtesy and human decency, and the latter a necessary consequence of perceived relative status. One could thus be rightly and reasonably admonished to give regard, but not to accord respect. A feeling or sense of regard for another can be easily summoned, respect, however, is resistant to such contrived summoning. Hence, while someone can be deceived into feeling respected, the deceiver cannot be successfully compelled into according respect against his feelings. Besides, a sensible person would come to realize that it is better to be openly disrespected than to be accorded a phony respect. In fact, to disrespect openly may signal a greater respect than dishonest overt respect. The only condition under which even a gratuitous 'regard' is impossible is when the heart of the therapist has been suffused with too much resentment. The feeling of resentment has been rightly identified as the strongest predictor of divorce among married couples. It has been found that where the feeling of resentment already reigns supreme, a relationship can no longer be salvaged. Many things could create the feeling of resentment: but to my knowledge, the three primary sources are (1) when our overt attempts at friendliness is carelessly rebuffed, (2) when we perceive in the other a (set of) trait(s) that are fundamentally opposed to our own values (3) when our attempt to change/influence another is overtly resisted while they continue to extract benefits from us. There may be more but these are the broad sources that I think underlie the development of resentfulness. And by virtue of the nature of the task of psychotherapy, it is easy to see how it can easily trade in resentment.
Condescension
This is the virtue of relational egalitarian mindset which does not necessarily mean equality of standing. Condescension creates in a perceptive and self-regarding client a sense of being disrespected and undervalued. It lures client to self-assertion and arouses the impulse to passive aggression. My colleague of which I spoke in the first part of this piece is actually guilty of this 'sin'. And, thinking about it again, almost all the patients who fought back to reassert their ego had one thing in common: elements of narcissism. These are the type of client most sensitive to the perception of condescension in a therapist. And what undergirds the commission of this 'sin' is a combination of therapist's feeling of relative superiority as well as zero perception of respectable qualities in their client. I have come to discover, however, that a very curious mind can always find something to genuinely respect in another person. And since genuine respect is the best antidote to the condescending tendency in humans, therapists must learn to transcend the injunction of unconditional regard and aim for localized/specific respect (if generalized respect is impossible).
Value imposition
The virtue of value agnosticism which should not be confused with value indifference. Value agnosticism is critical of all value claims and professes no a priori allegiance to any value system (I know this is a tall order). Value imposition becomes inevitable in the presence of value allegiance, and sets the stage for clash of values in therapy which can outwardly manifest as resistance and brood resentment (on both sides). There's a fundamental difference between actual and professed values, where the latter often has its origin outside of the individual and the former invariably springs from within the individual. An individual can, with persuasive, manipulative, or coercive skills, be made to alter or change their professed values, but can never be made to truly alter their actual values. Also an individual can be unaware, in denial, or in conflict about their actual values. In healthy individuals, the two are almost perfectly aligned - this feat is due less to skill than to coincidence of personal (idiopathic) and social (normative) tendencies. The goal of psychotherapy is sometimes to help some individuals reconcile, if there's a split, their professed and actual values; if not in practice, then at least in awareness. Thoughtless value imposition only deepens this unnatural split.
Ego-inflation
The virtue of modesty, vigilance against the hubris of realized expertise, client reverence and conferred praise. It necessarily precedes the sin of condescension and is a slippery slope into uncritical self-commendation. A sturdy ego is actually good for impressive self-presentation and could, as a result, serve a therapeutic purpose. How? Confidence (or lack of it) can be sensed or at least felt by those we interact with. When a client experiences a therapist as genuinely confident and relaxed, the same mind state is telepathically transmitted to the client, engendering a synchronous atmosphere of relaxed confidences. The same is true of an anxious, insecure therapist. Overconfidence is, however, a different matter. It's not the product of a sturdy and well-balanced ego, but of an inflated one. An inflated ego only achieves the interpersonal result of intimidation and renders its subjects immune to both internal and external negative feedbacks. This isn't up on my list because, compared to other faults, it's venal and, in certain contexts and senses (eg politics, business, crime, sports), could even be regarded as a strength.
Simplification
This ought to be up there among the prestigious seven, but its transgressive quality is highly contextual and conditional. It is the virtue of being able to deal in complexity, uncertainty, and scepticism. Those who are terrified by these psycho-epistemic states of mind escape into the comfort of simplification. When we're confronted with something greater than our mind, the tendency is to reduce it to something our mind can better represent. While this is a good mechanism in personal daily survival struggles, it is a terrible thing to do when dealing with another person's life. And as we know, psychotherapy is not about the therapist at all: it's about the strange other. People who are often compelled to seek therapy are almost always those humans whose psychology is anything but simple. In fact, it is the complexity of their inner world that makes the task of reducing existence to a set of simple rules difficult for them. A therapist who is incapable of holding and contemplating complexity becomes a real iatrogenic threat to the psychologically complex client. What happens in this situation of epistemic-phenomenological mismatch is that the epistemologically limited therapist would be driven (by unconscious forces of meaning-making) to reduce, stereotype, pigeonhole, and simplify the phenomenological realities of the client. One often finds that the therapist who is guilty of the seventh ‘sin’ (value imposition) would almost always be guilty of simplification. A mind that recognizes complexity would hardly be capable of imposing any one value, especially on another human being. And in circumstances where they must do so, would do so with every bit of caution. But simplification has a positive flip side (in fact, all the sins do): in the arena of psychoeducation. A therapist who is skilled in simplifying the most complex concepts into their most basic elements would achieve outsized results that belie their overall competence level. But even this isn't as simple as it seems. First, psychoeducation isn't something that's always indicated. One must know when and when not to, how much is too much, and what to psychoeducate about. Hence, the timing, the measure, and the delivery, are the complex dimensions of an otherwise simple task.
Irritability
This is a very venal sin, but when unbridled can become destructive. Irritability is a psychological property of the human organism that is mostly biologically determined. But it is highly susceptible to interpersonal and environmental triggers. It is the chief task of an irritable psychotherapist to be aware of his triggers and to work assiduously to constantly minimize or avoid or guard against them. There's nothing as invalidating and disappointing as the sight of an irritable therapist: the client is likely to immediately assume they are the cause of their therapist's irritable mood. A number of client factors can provoke an irritable therapist into expressing irritable behaviour: resistance, slow progress, dullness of mind, excessive talking, teasing, argument, and antisocial behaviour. A vulnerable therapist who allows her Irritability an overt manifestation has effectively lost respect with the client, except she handles it skillfully. This is especially critical when dealing with narcissistic and antisocial personalities: knowing they've succeeded in getting under the skin of their smug and self-regarding therapist is akin to the sensation experienced when a man successfully gets a woman into bed.
Ignorance
This encompasses everything. Ignorance about the self and its limits, about the client and their yearnings, about therapy and its trappings, about relationship and its movements, about knowledge and its dynamism, and about life and its complexities. It is the vice of self-satisfaction and all the other psychotherapy ‘sins’ aforementioned. It is the virtue of philia for knowledge, understanding, and wisdom. And it's attained not only by reading but also through introspection and experience - the more varied the better.