Confident or humble? Which therapists perform better?
I’ve covered this week’s theme several times already in these blogs because it so prevalent. Many therapists’ working lives are made miserable by a pervasive feeling that they are not good enough. They feel anxious and lack confidence and perhaps through emotional reasoning, conclude they are not performing their jobs as effectively as others. However, there is a remarkable consistency in the literature: therapists’ confidence is not associated with better performance. As a clinic director for over 15 years now, I can tell you I could manipulate therapists’ confidence through allocating caseloads. We may not have perfect prognostic indicators but we know that client variables account for the overwhelming majority of variance in outcomes and we have a pretty reliable set of client characteristics we could select for to ensure the therapist seeing them would find them hard to help, including being unreliable in responding to written or phone call correspondence, difficulties understanding a simple set of screening questions or instructions, ambivalence about attending on a regular basis to work on the referral problem, having social-economic circumstances that preclude consistent attendance, difficulty taking turns in conversation, or reluctance to work on tasks outside of sessions. I have found all these factors to be far more important than diagnosis or symptom severity in determining who we can and cannot assist. Some therapists blame themselves when they can’t achieve the same apparent results as research trials in which participants are heavily screened and selected before the treatment clock starts ticking. Some of these therapists are the most diligent and conscientious people I’ve worked with, whose technique is excellent. Less commonly, we may encounter confident therapists, although perhaps more often among managers and trainers as they move into roles away from contact with real clients which protects them from feedback about the limits to their abilities. If it’s not clear why it matters how accurately we perceive our abilities, consider what services we advertise ourselves as providing. If someone we loved needed psychotherapy, would we feel confident they could find therapists competent in providing the services they need, based on therapists’ self-assessment of their competency and advertisement contents? In this week’s study, Constantino and colleagues (2023) compared therapists’ self-assessments of their effectiveness with objective data.
Client-reported questionnaire data was available for 1363 adults treated by 50 psychotherapists in an outpatient community mental health clinic in the mid-west of the United States. Whereas most studies of therapists’ perception of their competence uses global ratings, this study looked at therapists’ estimates of their effectiveness in treating specific issues. The study used the Treatment Outcome Package (TOP) questionnaire which provides 12 subscales of functioning: depression, quality of life, mania, panic/anxiety, psychosis, substance misuse, social conflict, sexual functioning, sleep, suicidality, violence, and work functioning. For each of these 12 areas, each therapist was classified as effective (meaning their average outcomes were above the case-mix-adjusted expected outcome for that domain), neutral (their average outcome was neither above nor below average), or ineffective (their average outcome was below the case-mix-adjusted outcome for that domain). So, with increased awareness that therapists fall prey to the Dunning-Kruger effect, are we getting more accurate at estimating our abilities?
Most therapists overestimated their effectiveness when working with anxiety (82% therapists overestimated), suicidality (82%), quality of life (80%), depression (76%), work functioning (70%) and social functioning (62%). Most therapists accurately estimated their effectiveness working with psychosis (62%), sleep (60%), mania (58%), substance misuse (54%) and sexual functioning (54%). No therapists underestimated their effectiveness.
Except for psychosis, where 79% therapists accurately estimated themselves as of neutral effectiveness, therapists were no better than chance at predicting their effectiveness (as determined by client-reported outcomes).
Finally, the extent to which therapists underestimate their effectiveness was associated with better client outcomes. After adjusting for client severity and treatment length, 2% variance in differences between client outcomes was due to differences between therapists. Half of this (2%) variance could be accounted for by differences in therapists’ tendency to underestimate their effectiveness – i.e., their humility. Conversely, the tendency for therapists to overestimate their effectiveness was associated with poorer client outcomes (~38% variance in the 2% therapist effect). Notably, the effects of humility or overconfidence were evident only for more severe cases, i.e., clients whose baseline severity was at least a standard deviation above average.
The authors speculate that humility may lead to better effectiveness via greater alertness to possible ruptures or signs of deterioration and improved responsiveness to correct these factors. They also speculated that clinician overconfidence might be especially off-putting to clients with more severe problems who may feel more readily invalidated, leading to poorer outcomes for those dyads. Both ideas seem plausible to me. The authors note that in the general population, humility is associated with increased acts of generosity, initiating helping behaviours toward strangers, and among physicians, humility is associated with greater patient satisfaction and trust. I would add that humble clinicians seem more willing to seek consultation and supervision regardless of whether they need it, and to recruit adjunctive services for clients, both of which have been found associated with better outcomes for severe clients. So, if you are lacking confidence and experiencing doubt in your abilities, I invite you to consider seeing this as a strength rather than a weakness.
Clinician Implications
If you struggle with doubts or low confidence in your abilities:
Even though it may not feel nice, it does not mean you are performing poorly. Could you see it as a side effect of conscientiousness and that you may be thinking more carefully about your performance than some of the colleagues you compare yourself to? Could it be a strength rather than a weakness?
If you haven’t already done some Acceptance and Commitment Therapy training, I would highly recommend it. Although it may or may not always be the most effective approach to take with your clients, it is an excellent orientation for clinicians managing their own thoughts and feelings in therapy. If you valued being the best clinician you could be, would you be willing to mindfully and gently hold your anxiety and doubts, for that greater purpose?
You should still consider your self-care and ability to limit the time you spend worrying about your clients. Confine the time you spend on working on formulating your cases, deliberate practice activities to improve your treatment delivery and sourcing adjunctive services to chosen work hours, then learn to switch attention away from it. Time spent reflecting on whether there are other ways to see your client’s difficulties, other people who might teach you something about working with them or other resources that could help, is worthwhile. Time spent worrying you are not good enough, comparing yourself to others, or whether you should change careers will not help you or your clients.
If you feel very confident in your abilities as a therapist, chances are you’ve skim-read to this point.
The article says you should be careful: overconfidence is common and associated with worse client outcomes.
Check you objectively monitor your outcomes in some way.
Check you ask your clients for meaningful feedback at the end of each session.
Consider watching a video recording of one of your own sessions, or if you are really confident, ask a colleague to review it and give you some feedback. And choose one of your more severe clients.
If you’re at this point and still feeling confident, perhaps you really are that good so make sure you’re offering a placement to a student as we need more of these!
For the original article, go to: https://psycnet.apa.org/doiLanding?doi=10.1037%2Fccp0000813
REFERENCES
Constantino, M. J., Boswell, J. F., Coyne, A. E., Muir, H. J., Gaines, A. N., & Kraus, D. R. (2023). Therapist perceptions of their own measurement-based, problem-specific effectiveness. Journal of Consulting and Clinical Psychology, 91(8), 474–484.