March 1st, 2015

Learning to trust the process

The interviews are over, the rankings have been submitted, and the cloud has delivered the names of our interns for the next training year. All of that is done but I am still thinking about an answer one of our applicants gave to my standard question about how he imagined his unique strengths and challenges would influence his performance in our program.

After explaining what made him the ideal candidate for the position, he said simply that he was still learning to trust the process. He was talking about the process of psychotherapy but I am thinking about that and something more.

Doing psychotherapy is not easy. Two people sit together in room, the patient looking for a way to relieve distress and the therapist applying the principles of psychological science in an artful way to bring about the desired change. Every encounter combines known and unknown elements, from the initial greetings to the opening silence, the first words spoken by the patient, his subsequent train of associations and the carefully considered response of the therapist at every juncture of the interaction. Depending on when and where you went to graduate school and where you did your clinical training, you were taught to look at psychotherapy through the lenses of different theoretical orientations.

In my generation, the psychodynamic orientation predominated and we learned to pay attention to behavioral manifestations of pre-conscious or unconscious thoughts, wishes, feelings and impulses. When the interplay of id, ego, and superego generated intrapsychic conflict, insight or self-understanding became the key to solving the resulting problems in living. Ego psychology taught us to respect and encourage the individual’s striving for active mastery. Relational theories highlighted the importance of early interactions with attachment figures in developing a healthy sense of self.

Today, the conduct of psychotherapy owes more to cognitive behavioral models of the person and methodologies for promoting change with Dialectical Behavior Therapy or DBT as a prime example. Evidence based techniques abound and our procedures are becoming more clearly focused on specific diagnostic entities or symptom clusters. We have Cognitive Restructuring for PTSD, CBT for psychosis, Motivational Interviewing to promote behavior change, and a host of other techniques, each with its own prescribed way of  doing psychotherapy.

As useful as our expanded toolbox may be, we still begin with two people in a room and a silence hanging heavily between them. How do we treat the silence? Is it something to tolerate as an unavoidable delay or appreciate as the matrix of creative change? I remember a personable young man with schizophrenia who never tired of telling me how fascinated he was with psychology and asking me what he should talk about in our therapy sessions. To discourage his habit of filling my voicemail with random thoughts, I suggested he write down what he wanted to tell me. The unintended consequence of my brilliant suggestion was a laundry list of topics that he proceeded to read one by one in our therapy sessions after first asking in what order he should read them.

One day, he was caught in a rainstorm on the way to the office and his list all but disintegrated. He salvaged what he could in a paper bag and pulled out one scrap at a time to read me its contents. Forget the list, I said, and just speak your thoughts. The mind has a way of finding words for what is most important. He looked at me skeptically but took my advice. The process was already at work.

It is not easy to trust the process of doing psychotherapy or, for that matter, any process over which we do not have complete control. We have a carefully worked out procedure for selecting interns and trainees, complete with multiple readers for every application, key variables to track and rate during interviews and a final group discussion of each candidate’s strengths and areas for development. Before the meeting begins, I have a good idea of where I stand on the applicants I interviewed but I did not see them all. I trust my colleagues as they trust me. Two hours later, we emerge with a decision that always feels right. The procedure makes it possible but the process makes it happen.

It is an axiom of the scientific method that the more we know about every variable that influences an outcome, the better able we will be to produce the results we desire. I couldn’t arrange for my patient to get caught in a rainstorm, but at least I learned from it. And let’s not forget those unconscious processes that shake us out of our routine ways of thinking and produce surprising results. Descartes is said to have invented analytical geometry in a vision and Stephen King once explained that the “boys in the basement” write his novels.

There are times in every life when we can’t imagine a good outcome from our current circumstances or even conceive of the possibility that we will survive. Loss of a loved one, our health, a job or our place in the world can change everything. Even the necessary changes that come with new stages in life, offering exciting possibilities and unknown dangers, can fill us with anxiety. The next time someone tells me they are learning to trust the process, I will simply answer, so am I.

Alan Bodnar is a psychologist at the Worcester Recovery Center and Hospital.

By Alan Bodnar Ph.D.

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