Dealing with the demon doubt
Therapy Today, March 2023

When you look at everything involved in being a therapist, it’s no surprise that many of us battle with self-doubt on a regular basis. For a start we’re trained to be reflective and pay attention to our inner experience, so when doubts are there, however small, we are well aware of them. Our job is, in many ways, one that’s impossible to ever fully master – our task being to understand another’s experience while also accepting that no one can ever fully understand another’s experience. We are also trained to question and be comfortable with ‘not knowing’ and uncertainty.

Doubts aren’t always limited to our own abilities as practitioners – sometimes the questioning is about the process itself. It doesn’t help that our profession is still often misunderstood, with public perception varying from dismissing what we do as ‘tea and sympathy’ to heaping responsibility at our door for rising mental health problems, particularly in young people, because our services are not more available or affordable.

We also lack reliable markers of success, even when we measure client outcomes. Research tells us that change in therapy depends on a number of factors, including client readiness and the client’s external environment and resources, such as family support, health and financial security. All these factors mean there will always be, what has been described by Professor Thomas Skovholt as, a ‘mystery’ dimension to therapy. His own practice and years of research into resilient and expert therapists has led him to conclude that ‘most of the time, during our work, we don’t know the answers to important questions: Am I any good at counselling? Do I really help people? What are the active ingredients? These are enduring questions in year one of practice, in year five of practice and in year 10 of practice.’¹

Experience

Indeed, self-doubt is not just experienced by novice practitioners – one study found that the number one worry in a sample of practitioners with a mean of 11 years of professional practice was ‘unsure how best to deal with the patient’.² Canadian academics Anne Thériault and Nicola Gazzola, who carried out a series of studies in the early 2000s into therapists’ feelings of incompetence (FOI) – which they defined as ‘moments where therapists’ beliefs in their abilities, judgment, and/or effectiveness are diminished, reduced, or challenged internally’ – found that experience did not automatically protect against FOI as therapists’ self-expectations were often raised with experience, making them more vulnerable to self-doubt. They also found experienced therapists can ‘regress’ to previous levels of self-doubt under certain circumstances, such as a challenging client.^3,4,5 As Skovholt puts it: ‘The hallmark feature of counselling and psychotherapy is ambiguity. Our work lacks a certain precision craved by practitioners and persistently sought by researchers. How do we manage the ambiguity, the uncertainty, and negotiate the convoluted material presented to us by our clients so we do not find ourselves lost?’¹

Although not surprisingly, self-doubt does tend to be more prevalent when we first start out – it’s experienced by 83.2% of newly qualified practitioners according to one study – the same research found that more than half of therapists (52.3%) still questioned their professional effectiveness after five years of experience.⁶ And while some forms of feelings of incompetence abate with experience, other forms may in fact be exacerbated – a sense of competence is not ‘a static milestone to be achieved in phase-bound increments but rather a dynamic flowing process in experienced clinicians’.⁵

Sources of doubt

Lack of knowledge was the most commonly acknowledged source of self-doubt in a 2006 study of experienced therapists.³ Other factors cited included a lack of strength in the counselling relationship, personal factors and a discrepancy between the counsellor’s and client’s perceptions of outcome. Sources of doubt vary from ‘mild concern about technique to deep concern regarding therapist identity’, according to research by Thériault and Gazzola.⁷ They concluded that sources of professional doubt can be divided into four levels, starting with doubt about the ‘mechanics’ of therapy, signified by questions such as: ‘Am I not saying this right? Where to go from here? What do I say next? Should I try this technique?’ Next-level doubt focuses on the immediate impact of therapy, characterised by questions such as: ‘Did this work? How did the client respond when I said that? Is what the client saying related to what I just said? Why is he not engaged with what I said?’ Classified as ‘level three’ is doubt about a therapist’s capacity to be effective as a clinician, triggering questions such as: ‘Do I have enough training? Am I capable of doing what needs to be done? Can I reach the objectives? Am I a competent practitioner?’ Doubt that relates to personal ability and shortcomings is classed as level four, characterised by questions such as: ‘Is it me? What if something fundamental is missing in my personality? Who am I that I should be doing this? Do I have it in me to give?’⁵

The nature of a profession with confidentiality at its core means we can’t rely on some of the counterbalances against ‘imposter syndrome’ available to people in other professions, including offloading to friends and family. Integrative practitioner Christine Foster, qualified since 2001, sums it up like this: ‘Periods of self-doubt can impact personal relationships as we can appear withdrawn and distracted. In a different profession, we could talk it through with our loved ones or partners.’

Triggers

Research has found that a common trigger for both new and more experienced practitioners is assuming too much responsibility for client outcomes – those who are more realistic about what can be achieved, and mindful of the significant role played by clients in creating change, find it easier to manage self-doubt.³

But sources are many and varied. One practitioner links periods of self-doubt to client behaviour that is ‘aggressive or extremely challenging’. Another says: ‘I notice the “not good enough” feeling particularly around the time of renewing and updating directory profiles, whenever I have to justify myself, and say “this is how I do what I do”.’ Self promotion can also trigger self-doubt for integrative private practitioner Rachel Kaminetsky: ‘Therapists who are a whizz at marketing can make me doubt myself – I still cannot seem to figure out what to say about therapy on social media to put myself out there,’ she says.

‘I also notice that sometimes asking or responding to questions from colleagues on various therapist groups on social media can be intimidating. I sometimes worry that if I ask a stupid question or respond foolishly I will appear to the therapist community like a lesser therapist, not very good, should know better and so on. Although when I do post, the response is usually positive, which encourages me and dispels some anxiety.’

Environment also matters. Private practitioner Nicola Hughes says: ‘In the past when I worked for organisations, I would often feel inferior and burnt out, but now I run my own practice I work to my strengths, which is working creatively. One of my triggers for self-doubt is coming across peers talking about something I don’t know about on social media, when I might need to remind myself I am worthy, and very experienced.’

Dr Alison Mackiewicz, who combines private practice with academic teaching, describes self-doubt as ‘coming in waves’: ‘Sometimes I will be fine for a few months, then I will take a dip in confidence.’

Another practitioner, Fariha, identifies a source of her doubt in her career journey: ‘I married young and didn’t start studying until I’d had four children. I think that has contributed to my lack of confidence, particularly with very educated clients. I was assigned a senior medical professional during the pandemic, who was paying the top fee the agency charges, and I felt very intimidated by the idea of working with them and what their expectations of me might be. A colleague reminded me that they were coming to counselling as a human being, not a consultant, and they were coming to get help, which I could give them. We actually worked really well together for several months, which helped build my confidence in both myself and the power of counselling to break down barriers.’

Personal impact

Frequent periods of self-doubt can be undermining – a recent study of IAPT therapists found a strong association between professional self-doubt and poor personal wellbeing.⁸ Other research has found a link to burnout – a recent study of Irish psychotherapists working in private practice found the impact of burnout makes private practitioners ‘question their capacity to perform their work effectively’, triggering what the researchers call ‘a professional identity crisis: “maybe I just don’t have what it takes?”’⁹ Lead researcher Stephanie Finan says: ‘Participants reported internalised standards whereby good therapists should be impervious to vulnerability, always available, energetic and enthusiastic about work, endlessly empathic, with a stoic approach to the intense stressors that can be inherent to the job. These possibly self-imposed standards created a chasm between how they felt they should be and how they perceived that they measured up against these ideals.’

Research from Sweden by Åsa Spännargård and colleagues meanwhile found that perception of competence was more important than work experience, education or age in protecting practitioners against burnout.¹⁰ ‘A psychotherapist who perceives that they have the competence to help patients is likely to feel less anxiety, more work satisfaction and reduced stress,’ says Spännargård. The study also found that a perception of low competence – study participants were asked to assess their own competence on a scale of 0-100 – was most likely to lead to burnout in women. ‘What I think is interesting is that healthy self-awareness and sensitivity to our limitations – something we use as a tool as a psychotherapist – can turn into self-examination,’ says Spännargård. ‘You need to have the meta perspective and to look at yourself because it’s an important thing to do when you are working with patients, but does it put you more at risk of self-doubt? We don’t know whether women in particular are open to this – it may be simply that women are more at risk because they are more likely to be doing this work.’

There is also a pressure on therapeutic practitioners to be continually developing says Spännargård: ‘It’s important to reflect upon your work and also to read and take notice of new research and to have different communities to discuss these things. But I think there is a problem for many practitioners today that they don’t have the time or opportunity to take part as much as they want to, and maybe they feel a pressure to do that in their free time – it’s what we call the “life puzzle” in Sweden. All this can lead to burnout, and what’s interesting for me is how we protect against this – we have supervision, but is there something else in our work that we need? In an era when everything is measured and the needs are bigger than the resources, it´s easy to feel incompetent even if you have the right education and experience to treat the patients. I think it’s important to add competencies and methods to prevent burnout and unhealthy self-doubt, and that also organisations have a responsibility in that process.’

Managing doubt

Good supervision and peer support were indeed key in managing self-doubt for the practitioners I talked to for this article. ‘My supervisor has been brilliant,’ says Rachel Kaminetsky. ‘They have given me the encouragement and also reality check of what I am able to take on, and at this point I can trust my own instincts and experience when I see referrals. I still need them to remind me I’m human, when I think I should be better or expect too much.’

Private practitioner CherylAnn Stewart says that a sound sense of self along with the ability to self-reflect are also key. ‘I’m a relatively new practitioner and I qualified after a long career in other areas including social work, teaching and lecturing, and in all cases I knew I was better after a few years of practice than I was at first. So I was realistic about my abilities when I first started in private practice, but having reflected deeply on self-doubt in myself over the years I was able to accept my limitations without attacking myself, and instead ask, what do I need to become better? Are there any gaps in my skills or abilities? What support do I need to fill those gaps?’

Another practitioner commented: ‘As I have developed in confidence as a person, then I have been able to be more open to doubt and humility about my work.’

For Christine Foster, spending time ‘reflecting on the sessions and the client’s way of being’ helps manage self-doubt, but the key, she adds, is ‘to trust ourselves, trust our clients, be side by side with them on their journey, helping them to see any blind spots or the bigger picture, for them to take responsibility for themselves and also trust the counselling process’.

One practitioner who prefers to remain anonymous says: ‘I definitely have felt like just walking away from this profession on more than one occasion. Shortly after I qualified I was given a client who looked very challenging and complex on paper. I remember saying to the head of counselling, “You need to give this client to one of the grown-ups!” Her response was to tell me that actually I was one of the grown-ups, that I had qualified and that my work spoke for itself. Having her trust in me as someone I respected made me think again. And I am so glad I challenged my own thoughts and did work with that person as it was completely within my competence to do so and a very rewarding piece of work. But my first and instinctive reaction was “I can’t do this”.’

Her recommendation for managing doubt is simple: ‘Talk about it. I know that talking to colleagues helps – I have found that even those with more advanced qualifications have similar thoughts and worries and experiences to me. They also have clients they feel they are not working well with. They also worry it’s their fault.’

Client impact

It seems likely that periods of doubt have the potential to impact our practice and, indeed, Thériault and Gazzola’s research has found that the possible consequences of fear of incompetence for clients range from ‘increased intentionality (by therapists) within sessions’ to ‘complete detachment from the client’.^3,4,5

But we should bear in mind that self-perception of competence is not necessarily a reliable measure of actual competence.¹¹ And there is evidence that suggests that the presence of professional self-doubt can be beneficial for clients. ‘Therapists who are more aware of their natural limitations, and more realistic about the likelihood of poorer client outcomes, are more alert to indications that their clients are “off track”, enabling them more frequently to resolve barriers to therapeutic progress,’ concluded Macdonald and Mellor-Clark in their 2015 study into how feedback helps therapists overcome their limitations.¹² And a 2009 study of new counsellors found that fear of incompetence also inspired counsellors to read more, attend additional trainings and make use of supervision.¹³

Self-doubt at the start of therapy is particularly linked with better client outcomes – the researchers concluded it helped therapists remain ‘open, sensitive, reflexive’ at the start of the work while the therapeutic relationship is developed. Self-doubt that continues or increases as the work progresses is less constructive, however, and is linked to less favourable client outcomes.¹⁴

Most of the practitioners I spoke to managed to weather the storms of self-doubt by ensuring they had good supervision and peer support in place, using self-reflection and getting good CPD. But many also talked about the best defence being their own growing sense of self, and feeling centred about who they are and what they believe in. This may be the winning combination – research by Helene Nissen-Lie and colleagues found that the combination of having sound personal self-esteem (what they described as ‘self-concept’) and an awareness of professional self-doubt increases our effectiveness as practitioners and improves client outcomes.10 They concluded that professional self-doubt helps practitioners remain ‘open, sensitive, reflexive and taking responsibility for relationship struggles’ in therapy, an effect not seen in practitioners with both high personal self-concept and high professional self-confidence. Could their overall recommendation serve as a useful mantra for all practitioners: ‘Love yourself as a person, doubt yourself as a therapist’?