Clinical concepts: The paradox of professional humility
Therapy Today, May 2024

'Love yourself as a person, doubt yourself as a therapist?’ – the title of this paper published by the Norwegian academic Helene Nissen-Lie and colleagues in 2017 has intrigued me ever since I came across it.¹ The research was an exploration of some of the factors influencing therapist effectiveness, including a seemingly contradictory correlation – that therapists who reported high levels of professional self-doubt tended to have clients who reported the best therapeutic alliances and outcomes of therapy. The study built on several years of research, together with colleagues Helge Rønnestad, David Orlinsky and others, into the ‘person of the therapist’ for Nissen-Lie, which is ongoing.

‘We started out not predicting the findings that we actually got, which is always exciting,’ Nissen-Lie told me over Zoom from her home city of Oslo, where she is Professor of Clinical Psychology at the University of Oslo. ‘We found that the more you admitted that you had difficulty in comprehending your client or helping the client, or the more you doubted yourself in your clinical effectiveness, the better the client thought the collaboration was. It was surprising – we believed that less, not more, doubt would be beneficial to the client.’

Perhaps what makes the research all the more intriguing is the caveat in the title – ‘love yourself as a person’. The best client outcomes were seen in therapists who expressed more doubt about their professional efficacy but who had a nurturing ‘personal introject’ – in other words, a strong sense of self and positive relationship with themselves. So what Nissen-Lie and colleagues had identifed wasn’t simply about lack of confidence – it was about a different quality altogether. Although first labelled professional self-doubt, Nissen-Lie came to realise that this quality might be better described as professional humility.  

Humility has been described as a warmth-based virtue characterised by both interpersonal and intrapersonal qualities. Interpersonally, it describes having an accurate view of the self, including an understanding of strengths and weaknesses. Intrapersonally, humility describes a way of being that is other – rather than self-orientated and focused on connection.² In therapists, professional humility has been defined as having three layers: ‘trait humility’ or personality; clinical humility such as attitude to practice or client work; and cultural humility – an awareness and valuing of client differences.³ 

Emerging concept 

Therapist humility has been identified as an ‘emerging concept’ in the field of research into therapist effects,⁴ but as Nissen-Lie points out, the Danish philosopher Søren Kierkegaard had already observed that ‘all true helping begins with a humbling’ in 1859. The importance of humility was also recognised two decades ago by Helge Rønnestad and Thomas Skovholt who identified the quality in so-called ‘master therapists’. An important and necessary part of therapist development, according to Rønnestad and Skovholt, is going through a ‘series of humiliations’ in their interactions with clients.⁵ One of the characteristics of the ‘senior professional phase’ is an acceptance of our limitations as a therapist, they say, with practitioners at this stage in their career likely to ‘express more humility and see themselves as less powerful change agents’. Other writers have also recognised the importance of humility in therapists – in 1999 Val Wosket in her now classic text The Therapeutic Use of Self (Routledge) observed that ‘a sense of humility is the best companion the therapist can hope for’.⁶ The process of gaining wisdom and experience as a therapist, she says, is like a period of mourning, as we relinquish the ‘quest for omnipotence’ and learn to see ourselves as ‘vulnerable and ordinary’.  

Therapist effects 

Why professional humility has remained under the radar until recently is perhaps a reflection of the lack of research generally into the ‘person of the therapist’. Although most modalities acknowledge the importance of the use of self in the therapeutic process, and we know that therapist effects account for up to 15% of the variance in treatment outcome,⁷ the contribution of the individual practitioner has been neglected in much of the prior research, says Nissen-Lie. ‘The profession has focused on research on which method or therapeutic school is the most effective – the horse-race debate – and we have of course focused on the patient, on who benefits more from psychotherapy and who benefits less, and how long it takes to reach sustainable change, but less on the psychotherapist,’ she says. ‘However, back to the original texts of Freud and Jung, as well as Strupp and Rogers, you do find that they care about the person of the psychotherapist.’ 

Nissen-Lie describes herself as ‘incredibly lucky’ to have joined a large-scale study⁸ for her master’s thesis that involved hundreds of psychotherapists in the Norwegian healthcare system on their own professional development, their experiences and what they saw as important values and goals in psychotherapy, their private lives and their backgrounds, which formed part of the international study on the development of psychotherapists,⁹ and it was from this research that her interest in the professional self-doubt began to emerge. ‘This international team, including many from Great Britain, had conducted an elaborate qualitative research study looking at different situations that therapists themselves said were challenging or difficult in some way. For example, we all want to like our clients, but sometimes it’s not easy – clients have often experienced relational distress and difcult situations, and they might take it out in therapy, which can be tricky, so one difficulty we looked at was the challenge of liking our client. Another difficulty was feeling bogged down with a client’s circumstances, whether financial, health or otherwise, and the frustration a therapist may feel knowing they can’t really change or influence that situation.’

The study then asked the clients of each therapist to rate these experiences of therapy. ‘Since these were challenging situations we believed that these constructs would maybe relate to clients’ evaluations of the therapeutic alliance, and also outcomes, but all in a negative fashion. We expected that the more doubt or negative feelings a therapist has, the more bogged down or frustrated they feel, the poorer the outcomes and the poorer the alliance would be for the client. But in fact that did not turn out to be the case. A therapist doubting themself and whether they’re helpful or not was a positive predictor of patient ratings of the therapeutic alliance. So the more they admitted that they had difculty in comprehending a client, helping the client, the more they doubted themself in their clinical effectiveness, the better the client thought that the collaboration was, or the more he or she thought that the therapist liked him or her.’ The study also found that higher professional self-doubt in a therapist was correlated with reported positive change in their client’s difficulties in relationships with other people.  

One of the aims of Nissen-Lie’s 2017 study was to follow up on these findings by asking what elements are needed before professional self-doubt can be of beneft to the client, specifically in relation to the therapist’s relationship with themselves. ‘We found that if you combined those highest therapist scores on professional self-doubt with a nurturant self-caring interject, or the way you treat yourself as a person, the better for the client,’ she says. She concludes that therapists who are able to ‘reflect on their own share of difficulties in the therapeutic relationship but from a nurturing stance’ may serve as a role model for clients in their own relationships, allowing them to address difficulties without judging themselves.

Why humility matters

Developing a level of confdence in both your efectiveness as a practitioner and in the process of therapy itself is of course an important and perhaps natural part of career development. But confidence is  

complex, and Nissen-Lie points out that, like other professionals, therapists are not immune to the ‘Dunning-Krüger’ efect¹⁰ – the tendency for the worst performers in any feld to overestimate their performance and, conversely, the top performers to underestimate their effectiveness. ‘It may be that the most confident therapists don’t know what they don’t know, or the complexity of the area that they are in,’ she says.  

By contrast, more humble therapists are more likely to actively ‘seek and welcome feedback’,³ according to a study by Davis and Cuthbert, and improve their ‘teachability’ and openness to adjusting their approach based on feedback. And by learning from their mistakes, they argue, therapists can become better at handling ethical dilemmas. Humility also encourages us to be more ‘other orientated’ in our interactions, ‘transcending egotistical concerns and the attendant urge for defensiveness, self-serving manoeuvres’.² A 2015 study by Owen and colleagues found that when clients saw their therapists as humble they were more likely to risk great vulnerability, leading to better outcomes.¹¹ 

This paradox of humility can be seen across cultures, says Nissen-Lie. ‘Very recently researchers in the US¹² conducted a study with data from 1,300 patients and their 50 therapists, and they found that when therapists were rating their own perceived efectiveness, those who underestimated their effectiveness in a given domain – say depression, problems with violence, substance abuse and so on – had patients who reported better outcomes in those domains than patients whose therapists overestimated their effectiveness.’

She adds that a similar finding was reported by a German study.¹³ ‘The more modest and conservative the therapists rated the progress they imagined was taking place for their clients, the better the clients actually did, so there was a mismatch.’ There is also a yet to be published Chinese study, says Nissen-Lie: ‘The researchers in China wanted to check out whether the virtue of humility, so to speak, might be culturally specifc, and so not necessarily relevant for Chinese clients. But the findings so far indicate that the findings are replicated there as well. However, it should be mentioned that professional self-doubt had a negative impact in a sample of trainee therapists in Germany, so its positive effect might somehow depend on other factors.’¹⁴  

Humility is particularly important when dealing with clients whose cultural background differs from that of your own. Research by US psychologist Professor Joshua Hook, who has specialised in studying various aspects of humility, has found that clients who perceive their therapists as being more culturally humble report being more aligned with their therapists, and having better therapy outcomes.¹⁵ An essential element of cultural humility, according to Hook, is the acceptance by therapists of their limitations and underlying assumptions, and a willingness to remain open to when they have made missteps with clients from other cultures, and to address misunderstandings with the client in order to make repairs.

Cultivating humility 

One of the challenges with research in this area is that many studies rely on self-reports, and it can be hard to assess our own humility – it’s been argued that truly humble people may feel like it’s bragging to claim this as a personal virtue or characteristic.¹⁶ This might explain why a recent US study that replicated Nissen-Lie’s finding that therapists with higher levels of both self-doubt and self-efcacy had better client outcomes didn’t however find a similar link with therapists who reported higher levels of humility.¹⁷ Respondents to the study had to give themselves a Likert-style rating from ‘strongly agree’ to ‘strongly disagree’ for statements such as ‘I admit it when I don’t know how to do something’ – questions that may be hard to answer truly objectively. As the study researchers commented, we still don’t have a satisfactory way of measuring humility, and given that humility captures a broad range of attributes and attitudes, ‘it may be particularly difficult for therapists to gauge their own level of humility’.  

Although it may be the case that some people are naturally more humble than others – and that those people are drawn to helping professions – could a commitment to honest self-reflection, underpinned by self-compassion, help us develop our humility? ‘This is the key,’ says Nissen-Lie, referring to self-compassion: ‘In our data, we did not find that feeling anxious in sessions was a positive thing, and we need to be able to not react defensively to criticism from the client or when the client is not improving. You need to be open to seeking out supervision to try to better understand what is difficult for the client in working with you, and not go home feeling totally bogged down – “I’m a useless person, I don’t know what I’m doing, I should do something else”. If you have the sort of generosity referred to in the study title – you love yourself – you can allow yourself when necessary to also change path, to admit that this was not a very good way of helping this person, or that you misunderstood. So it’s not enough to be humble – you have to be willing to use whatever you gather from this openness, this stance, to improve.’

According to Hook, humility often develops as we mature, but it is influenced by our environment and whether we see humility modelled by others.¹⁸ We can also see humility modelled in inspirational public fgures, or learn about it from films or in reading fiction. Nissen-Lie suggests that trainers and supervisors could be role models to trainees by demonstrating a ‘tolerance for not knowing, embracing ambiguity and containing your shortcomings and limitations without fear of “losing face” or authority’.¹ As a simple starting point she says we could do worse than look to Kierkegaard and his thoughts on the ‘art of helping’: ‘Translated from the Danish, he said that the helper must first and foremost humble himself under the person who wants help, and thereby understand that to help is not to dominate but to serve. And to help is a willingness for the time being to tolerate being in the wrong, and not understanding what the other understands. I think that’s quite inspiring.’