What I Wish I Knew When I Started Being a Therapist 35 Years Ago

By: George W. Rosenfeld

As a clinical psychologist I have completed almost 40,000 hours of psychotherapy in the past 35 years. These sessions have been in relative isolation, with input from a few colleagues and mentors and sporadic explorations of the treatment literature. My excellent graduate education at the University of Minnesota helped me start but became outdated as knowledge expanded and trends changed.

I was educated before the field was aware of the pervasive impact of sexual abuse, domestic violence, fatherless households, and the methamphetamine epidemic that has swept the western United States. Cultural diversity was not addressed.

This was in a time before brain imaging, managed care, the deinstitutionalization of the mentally ill, and the domination of evidence-based and cognitive-behavioral approaches. The feminization, desecularization, manualization, medicalization, and deprofessionalization of psychotherapy were still yet to come.

It seems probable that these trends will continue to mold the development of psychotherapy, leading a panel of experts to forecast the “expansion of evidence-based therapy, practice guidelines, behavioral medicine, and pharmacotherapy” (Norcross, Hedges, & Prochaska, 2002, p. 316).

No matter what direction the field takes, 35 years from now, new perspectives and discoveries will make today’s education and practice standards seem as antiquated as my training now seems to me, and the thoughts about treatment presented here will seem just as primitive as the treatment methods to which I was exposed.

Being a psychotherapist clearly requires adapting to constant change and constantly changing.
When I began as a therapist, my focus was on quieting my anxieties. I worried about being competent and accepted by colleagues and clients. I greeted clients with the hope of curing them or making them “normal.”

Now I am not even sure what normal is. As the saying goes, “Normal is what you think people are until you get to know them.” I tried to take away their problems, but being problem free is not a realistic goal. Life can involve moving from one damn thing to another. Clients are going to have more problems and continue to struggle with many of their same issues.

Clients were not born yesterday with a blank slate and infinite capacities to change. This is not a depressing or hopeless view. It describes the realistic boundaries in which we operate and makes improvement in clients’ lives so much more significant.

A great deal is accomplished when therapy helps clients to reduce their symptoms, become more realistic, advance to the next developmental stage, become less trapped in repetitive patterns, tolerate more affect so they do not subsequently resort to as many destructive behaviors and defenses, carry fewer unexamined secrets (often forged under stress in childhood), feel less worried, and be more able to participate and find pleasure in work, play, and relationships.

My interventions were initially aimed at making the most useful interpretations and understanding connections to the past. With experience I found that interpretations were rarely necessary or sufficient to create change, that often what I had to say was not as powerful as what the client had to say, and that dealing with the past was not always appreciated, possible, or helpful. As I developed as a therapist, I focused on acquiring a wide range of other techniques.

Now I value many approaches but see their usefulness as depending on the client’s situation and the therapeutic relationship. I focus less on pathology and resistances and more on the therapeutic relationship and getting to know the client’s background, hopes, strengths, feelings, relationships, present struggles, and achievements.

Because the influence of family members is so powerful, I rely more on family and conjoint (parent with youth) treatment than individual therapy for treating youths, especially when the client is young, unmotivated, or difficult to engage or believe. I now look for skills to build, and I focus more on the present and future than on the past.

Now I observe not only the client and I but our interaction and progress along a more mapped-out path. I watch us struggle with engaging in the therapeutic relationship, developing a treatment plan that meets our expectations, trying to accomplish our goals without being thrown off course by our personal needs and biases, and finally ending when the clients and I are enjoying each other the most.

I find myself trying to understand, attend to, and respond to so many aspects of the treatment
process, the client, myself, and our interaction that being a therapist seems an un-masterable task. It is similar to the tension-reduction exercise I try to teach to some clients. I ask them to place their hands almost together with the goal of making all five opposing fingertips almost, but not quite, touch each other. As they focus on one or two pairs of opposing fingers, others stray apart and need to be attended to and brought closer. It is an absorbing, mentally and emotionally taxing task that cannot be fully mastered.

References

George W. Rosenfeld, 2009, Beyond Evidence-Based Psychotherapy, Taylor & Francis Group, LLC

Read Also

Clinical Expertise

Cambridge Textbook of Effective Treatments in Psychiatry
Evidence-Based Practice in Psychology

Why should I bother with accreditation?
How should clinical psychologists behave?

Professional Use: Who Can Use the DSM-5
Working as Part of a Team

Models of Treatment for Mental Disorder
Introduction to Classification of psychiatric disorders and their principal treatments
Validity of psychiatric diagnoses