Knowledge doesn’t replace clinical skill

Some years ago, during the heyday of the self-esteem movement, I was invited to teach at a large weekend drug and alcohol conference. Most of the presenters talked about how critical it was to build up clients’ positive self-concepts to help them stop using drugs. But while everyone seemed convinced that self-esteem was important, when I asked my workshop group what exactly self-esteem was and, more important, how they could help clients enhance theirs, the room went quiet.

“OK,” I said. “Let’s imagine that I’m hooked on drugs. Help me improve my self-concept. Help me out. What should I do?”

“Well, you could use operant conditioning,” someone suggested.

“Great!” I responded. “Condition me. Show me what you can do to help me improve my self-esteem.”

The room got quiet again. “I’d start by helping you heal your past traumas,” another person eventually volunteered.

“OK,” I said. “Let’s imagine that I was sexually abused as a child. Show me how to build up my self-concept in a way that’ll heal that.”

Again, the room went quiet. My point in keeping up this line of questioning for almost 20 minutes was to make a clear distinction between what psychologist and communications theorist Paul Watzlawick called descriptive language—which tells you about something—and injunctive language—which tells you what to do. It’s the difference between describing a meal to someone and handing over a recipe.

The newest edition of the Diagnostic and Statistical Manual has more than 900 pages describing the different kinds of disorders that people have, but not a single page telling us what to do to resolve them. As therapists, we’re useless to our clients if all we can do is describe what’s wrong with them. We need to create vivid, living experiences for them that’ll help them change. All the expert knowledge in the world about therapy or different psychiatric conditions isn’t worth a thing if we don’t know what to do with it.

Nothing reflects this fundamental truth more than the current infatuation with brain science. I think it’s wonderful that we now have at least some understanding of neural connectivity, synapses, brain chemistry, and mirror neurons—all of which help us understand our ability to change the way we think and act, and to experience empathy and compassion. I have great respect for the value of doing valid research in such an inherently complex field. However, what I’ve found in a close reading of original neuroscience studies is that many of the uncertainties and complexities in brain science research don’t appear in the popularized material written for the general public—and for therapists. Even if we set aside all the uncertainties and assume that current neuroscience studies are valid and won’t be revised substantially by further research, the key question remains: What can neuroscience tell us about what to do differently when we’re working with a client?

In recent years, I’ve listened to many of the current experts in neuroscience talk about their interesting discoveries, and I’ve watched therapy demonstrations by the few who’ve tried to apply findings from the brain-imagery lab to actual therapy with a client, but so far, I haven’t seen any persuasive direct application of neuroscience to the practice of therapy.

Physicists found a while ago that the cosmos is made up of subatomic particles that interact in peculiar ways, and they went on to develop detailed and sometimes frighteningly effective recipes to put that information to practical use—think cell phones and hydrogen bombs. However, brain science has yet to translate its findings into effective or practical recipes for therapists. For instance, a lot of therapists are enthusiastic about the fact that they now know that a panic attack involves overactivation of the amygdala, but this knowledge doesn’t make them better therapists. Would they do their therapy any differently if they were told that a panic attack actually involved overactivation of the liver—or even the pineal gland, which Descartes believed to be the seat of the soul and the place where all thinking originated? I don’t think so.