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In Part 2 of this series, I defined the term “clinical wisdom” and how it can be employed in psychotherapy, as, for example, to begin with, in the management of expectations about treatment on the parts of both therapist and patient or client. Here, in Part 5, I discuss some other examples of what I mean by “clinical wisdom” in terms of what it is—and what it is not.
Conveying Clinical Wisdom Is Not Giving Advice
Here is a little secret that some patients (and psychotherapists) might find surprising: Clinical wisdom is not about advice-giving. It is, for the most part, never conveyed or communicated by telling patients what not to do, what to do, or how to do it. Psychotherapists seldom (if ever) proffer such direct advice per se to patients regarding how they should live their lives or what major decisions to make. It would be presumptuous, counterproductive, grandiose, and, arguably, unethical to do so. This is always the patient’s responsibility, and theirs alone, which is one example of the clinical wisdom existential therapists consistently try to encourage, communicate, and convey to them in therapy.
Most people enter therapy with the conscious or unconscious expectation or wish that the therapist will, like a parent, teacher, priest, rabbi, etc., or, for that matter, close friend or confidante, counsel or concretely advise them, if not overtly tell them what to do with their lives, believing that this is our professional role. But this is clearly one of the major misconceptions people (and some therapists or counselors) bring to therapy. Yes, it is true that, as Rollo May (1991) observes, “therapists belong to a strange profession. It is partly religion. . . .We cannot deny that we . . . therapists deal with people’s moral and spiritual questions and that we fill the role of father [or mother] confessor as part of our armamentarium, as [originally] shown in Freud’s position behind and unseen by the person confessing.”
Indeed, this confessional and unburdening quality of psychotherapy, like the ancient healing rite of confession in the Catholic church, may play a significant part in what actually makes therapy therapeutic. Nevertheless, we as psychotherapists do not want to advise or counsel our clients or patients how to conduct their lives, what to value or believe in, what political party to support, and which choices to make but, rather, encourage and support them in discovering for themselves their own intrinsic freedom and responsibility, despite the inevitable discomfort, doubts, and anxiety of doing so. Having said that, this is an admittedly extraordinarily challenging therapeutic stance to maintain, since the clinician’s own conscious and unconscious beliefs, biases, prejudices, values, preferences, traits, etc. permeate our presumably neutral clinical persona despite our best efforts to prevent them from “leaking” out.
Helping Without Helping; Caring Without Caring
It is, if truth be told, what happens within this crucial therapeutic alliance, container, or what Jungians refer to as sacred temenos that really matters. (See Part 6 of this series.) While being supportive and caring, we as clinicians must allow our patients to wrestle with these spiritual and existential conundrums on their own without telling them what to do one way or the other (i.e., without interference or rescuing). Here I am reminded of a dream one of Jung’s patients recounted to him in which she was buried up to her neck in a pit of burning embers and desperately begging the nearby Dr. Jung to help her out of it. Instead, in the dream, Jung approached his suffering patient, placed his hand gently on her shoulder, and firmly pushed her even further down into the fiery hole, saying, “Not out, but through.” This is itself a core kind of clinical wisdom. How to care but, at the same time, not care. To help, but not help. To practice a type of Buddhistic detachment from both the therapeutic process and outcome while remaining nonetheless fully committed and empathically present. Certainly, the psychotherapist can and sometimes must make certain clinical recommendations or, in some cases, prescriptions to the patient, but even then, it must be remembered and emphasized that the person is free and responsible to accept or reject such recommendations as they will and must be permitted to do so.
So, transmitting clinical wisdom is something very different than telling someone how to live their life, which fosters dependency rather than independence and self-reliance, something antithetical to the therapy project. Moreover, everyone in the patient’s circle has already provided practical, well-intentioned (but typically unsolicited) advice such as, for instance, stop drinking, meditate, start dating, etc., to no avail. Such seemingly good advice suffers from three shortcomings: First, the advice tends typically to be totally generic and not tailored to the specific situation or person; second, the person receiving the advice may not have requested it nor recognize what makes it necessary or advisable; and third, the recipient of said advice would need to consciously choose to follow it consistently in opposition to their neurotic tendencies not to. It can be a fine line. In psychotherapy, the focus is not on providing advice, much of which the patient has probably heard before, but rather on addressing their resistance, unwillingness, refusal, fear, or inability to accept and put it into practice and what prevents that from happening. And, much more importantly, to learn to listen to themselves rather than others, including the therapist, to trust and courageously follow their own inner daimon (see Diamond, 1996), voice, guidance, instincts, or direction with as much integrity and authenticity as practically possible.
Will, Freedom, Responsibility, and Clinical Wisdom
Thus, when we speak about “clinical wisdom,” we are not talking about explicitly or implicitly advising or counseling our patients or clients but drawing upon and bringing to bear indirectly, subtly, or implicitly, or, in some situations, sharing openly, some of these esoteric secrets with them for their consideration. To some extent, psychotherapy conveys clinical wisdom to the client or patient partly in the form of valuable psychological, philosophical, or spiritual information and knowledge relevant to their present predicament. But ultimately, as with solicited or unsolicited advice, it is purely the patient’s responsibility (and a direct expression of their own free will) to choose how or whether to accept and apply such clinical wisdom to themselves and their own situations as they see fit. This recognition of the inherent inefficacy and, in some cases, counterproductivity of giving patients or clients advice—due to the person rebelling against or resisting being told what to do or not to do by some external authority figure or perhaps following the advice and then blaming or crediting the clinician for the outcome instead of themselves—may itself mark the beginning of some real clinical wisdom.
