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Muddling Through
a weblog about knowing believing and getting better

Muddling Through

Robert "Bob" Fancher, Ph.D. Updated: Apr 15th 2010

An elder statesman of the training institute I attended (let's call him Bill Breyer) claimed, "I know within ten minutes of meeting a new patient how the entire course of therapy is going to go." That was quite a boast: since this was a psychoanalytic institute, he expected to see patients at least twice a week for years.

older man thinkingBut I believed him back then. After all, he was the teacher, an estimable character-with a bluestocking practice in Manhattan, respectable teaching posts at several schools, leadership posts of significant professional organizations, and even a handful of publications. I aspired to be like him. I wanted that same level of expertise.

Twenty-five years later, the very idea seems preposterous to me.

In the therapy room, we do the best we can under conditions unfavorable to knowing what's going on with our patients at all.

Persons in distress try to describe their difficulties, limited by the boundaries of their skills at self-observation and description, the risk of humiliation, and the fear that things may be worse than they want to admit.

They do not know which things from the outside world to report in therapy-that would require already knowing where the problem lies, what variables contribute to the problem, and what items of everyday life count as values of those variables. They're surely in no position to report especially accurately, or with great acumen, even when they do talk about the right things.

The conditions of the therapeutic encounter bear almost no resemblance to the conditions under which patients live. Therapists listen and observe in highly artificial environs. Our observations have little necessary connection to what happens in the patient's life out in the world.

The things we generally believe about patients-the psychological beliefs we bring to bear on their problems-lack anything resembling completeness, coherence, and conclusiveness. Very little of what any given therapist believes about human psychology rises to the level of a scientific truth-or other disciplined discovery.

The beliefs we deploy in helping patients vary wildly from day to day, depending on what we've been reading lately, who we've had lunch with, whether we've had a fight with our spouse, what the previous patient was talking about, and a thousand other things that prime us cognitively.

And being finite and human, we cannot escape our own needs and limitations, no matter how well trained we may be or how pure our intentions. For instance, minimizing awareness of our uncertainty decreases our anxiety, and that drives us to overestimate what we know and what we can do. In therapy, we (therapists and patients alike) work under conditions of radical uncertainty. We're muddling through.

So I don't believe for a minute that, in the sense he meant it, Bill Breyer was right.

Now, I don't think he was lying or confabulating. Allowing (charitably) for a certain amount of exaggeration to make his point, he was probably reporting something true about his experience, as he summarized it in memory. I'm sure, though, that he misunderstood his experience.

Over his decades of practice, I suspect he had routinized his ways of seeing patients, how he explained their problems to them, what sorts of reactions from them he reinforced, and thus how he shaped the course of their treatment. He knew his craft, and he was probably quite good at it. He knew-in the way a whittler knows wood, a farmer knows cattle, or con man knows a mark-which sorts of people he could shape which ways. I think he was saying, in effect, "At this point in my career, I pretty well know what I can make of someone."

Of course, Bill thought he was predicting the natural history of a process. He believed he was predicting how things would go, not reporting how he would make them go.

And there's the rub. If we reflect accurately on what we really know, we can come close to despair at the weakness of our intellectual resources. But in treatment, stuff happens. People change. They feel better-and may even get better. And they attribute their improvement to our work. (Well, most of them do). But they-and we-most likely misunderstand just what has happened in the therapeutic encounter.

With this post, I am starting a blog to be called "Muddling Through", to be published on Mental Help Net. "Muddling Through" will explore, and try to come to terms with, the actual nature of the therapy enterprise. Though we may be less boastful than Bill Breyer, none of us are much different. We believe more than we know, we know less than we think, and we're apt to misunderstand our experience.

We can't eliminate that-that's the human condition. But we can fight it them just as we fight against body odor and tooth decay. As therapists, we can be more reflective, so that we muddle through our therapeutic work more wisely, and to better effect.


Robert "Bob" Fancher, Ph.D.

Bob Fancher, Ph.D., is the author of Health and Suffering in America: The Context and Content of Mental Health Care and Pleasures of Small Motions: Mastering the Mental Game of Pocket Billiards. He is founder, CEO, CFO, marketing director, chief clinical officer, janitor, owner, and sole employee of Life Therapy Counseling Services in Portland, Oregon.

Reader Comments
Discuss this issue below or in our forums.

Self-"healing" - Tim - Jul 3rd 2011

Thanks for an interesting overview of your position. I appreciate your attempt to concisely summarise the general misconceptions about the aims, techniques and philosophical assumptions surrounding the psychotherapies, but also your acknowledgement of the successes, however mysterious and unpredictable they may turn out to be.

With this in mind - and with shameless awareness of the deep and unscientifically tesetd water I am entering into - I'm interested in your conception of selfhood. I'm not sure I know a great deal about your ultimate philosophical position on the nature of selfhood and the various dissonances and conflicts so many of us experience, but I did read a review of yours which clearly refuted the idea of a "true self" versus a "false self." Dated though these terms may be, I wonder whether you are casting a dim light in attempting to illuminate not only the fallaciousness of this prized notion, but perhaps even preconceiving the premise from which to view and evaluate its adequacy as a working model in the therapeutic goal of integration and wholeness (as far as this may be considered a goal in your experience!)

For sure, there seems to be alot to be said for the integration of the many "selves" we all employ or deny routinely, and for the idea that the vast majority of what we identify with as being ourselves has observable correlations with brain and nervous sytem activity. But this in itself does not preclude the possibility of a unified or core self which underlies these various phenomenal states. There are certain experiential reports of a self which carries with it the direct authority of "I AM", and which is prior to the personality as we usually understand it. This subjective experience often brings with it the feeling of having finally become - in the sense of having knowledge through identity, rather than knowledge through experience - what one IS or always has been in a sense which far transcends our ordinary understanding of identity.

This is no doubt a familiar idea to you, but I am interested in your thoughts nonetheless...


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