To build better therapeutic alliance and trust with your clients, more training is not always the answer.
The Path to Clinical Confidence by Lynn Grodzki, published in the Psychotherapy Networker Magazine, March/April 2020
What would cause a therapist who has a PhD, a full practice, the respect of her peers, appreciation from her clients, and decades of experience in the field to feel unsuccessful?
Naome, a psychologist in private practice for 20 years, contacted me for business coaching. She told me that she struggles with a core sense of insecurity and was worried that her lack of self-assurance may point to a serious professional deficiency. “I think at this age and stage of life, I should feel good about my work. I have a successful practice, but I just don’t feel as confident as I thought I would at this point in my career,” she said, sighing loudly. “Maybe I need more training. One course I’m interested in costs $5,000 though, a pretty steep price for me right now.” She sighed again, and frankly, I felt like sighing too.
I’ve been tracking the number of times I’ve heard stories like Naome’s from the therapists I coach. Although they range in their clinical focus, experience level, age, and background, they all tend to agree that more training is the solution to their insecurity. But is their rush to seek ever-more competence in the face of low confidence always what’s needed? This question has led me to think a lot about clinical confidence lately. What is it? What’s the relationship between confidence and competence? How can we better help therapists develop a deeper sense of self-assurance about what they do?
Of course, I can relate to Naome’s struggle. Before going to grad school to get my MSW, I worked in the family business as the general manager for a scrap metal yard, a multimillion-dollar operation that required me to work in a hardhat and steel-toed boots. I was a single parent with a young son, and I was a woman doing what was perceived at the time as a man’s job. I had to learn to speak up and set boundaries, and to prove my worth over and over again. I brought this sense of fortitude into my clinical training, along with my experience of having been in psychotherapy for a decade while attending dozens of workshops and conferences out of sheer interest. When I graduated, I thought my grit and understanding of the field would translate into clinical confidence as I entered my new career, but I was wrong.
For years, I purchased weekly supervision from a trusted senior clinician, which helped me hone my craft but didn’t boost my confidence. With my first supervisor, each week I’d present a case and she’d listen, without evident emotion. Then she’d tell me what I was missing or had done in error. I took good notes and tried to put what she said into practice, coming back week after week for more. After one especially difficult case presentation, I felt discouraged about all the interventions I’d overlooked. I asked nervously if there was anything she thought I’d done well in the case. “Yes, I’m sure you did some things well,” she said almost nonchalantly.
“You never mention those things to me,” I said. “You only point out where I’m lacking. Why is that?”
She thought for a while. “That’s the way I was trained,” she admitted. “It never occurred to me to talk about what you’re doing well. I’m just trying to shore up the places where you’re not.” Her supervision process wasn’t unique, nor were the results: I gained more competence, but not more confidence.
When I teach continuing education classes or conduct workshops, I often ask the therapists in the room to raise a hand if they think they’ve spent $10,000 on training after completing their degree. Almost all hands go up. Then I ask if anyone has spent even more than that. Most hands stay up. It makes sense: we want to master our craft, and we study our chosen methods and models with great dedication.
But there’s a problem with this path when it comes to clinical confidence. Current studies from the fields of business, psychology, social sciences, child development, and even animal behavior show that confidence isn’t always tied to skills, ability, capacity, or even higher intelligence. So what does make us feel secure or self-assured in our roles? And relatedly, what’s the role of clinical confidence in the outcome of psychotherapy?
Studying the common factors theory back in 1936, psychologist Saul Rosenzweig made a startling discovery: the most robust factors in determining the outcome of psychotherapy were not, as expected, the methods or models used. Despite therapists’ attachment to their clinical approaches, he found that all methods tested were more or less equally effective. This result became known as the Dodo bird verdict, referencing the bird in Alice in Wonderland who announces that everybody wins and everybody gets a prize. Although this finding remains controversial, it’s been tested many times over the decades, with similar results. And many well-known researchers today, including Scott Miller, agree with the premise that none of the new and presumably improved clinical methods test better than the tried and true.
So if decades of follow-up studies and metastudies can’t determine which methods are best, at least they can validate other factors that seem to be consistent in determining what works in psychotherapy, the most significant of which reference the therapeutic relationship. Studies continue to show that the therapeutic alliance accounts for as much as 40 percent of the outcome of therapy—and the client’s perception of the therapist’s confidence plays a large part in that.
So how do we help therapists develop confidence in their clinical work? Although most therapy and counseling programs teach how to actively listen, show empathy, ask questions, and impart understanding, these rapport skills aren’t necessarily what’s needed to project confidence. In The Confidence Code, authors Katty Kay and Claire Shipman cite study after study showing that accomplishment in professional settings correlates more closely with the skillset of confidence than with that of competence. Studies also show that children with a greater belief in their abilities performed better at school, even if they were less intelligent than their peers, and confident athletes perform better in their sport than more abled players.
As a business coach, I noticed early on that people with more confidence go further, faster. Their extroverted behavior helps them find more resources, gather more information, and often make more money. I’ve watched many of the therapists I work with who are more naturally confident mirror much of this business advantage in private practice: they have an easier time garnering referrals, achieving goals, and expressing a better felt sense of their work. Incidentally, they also tend to project calm, encourage hope, and offer a sense of security—qualities born of confidence that are clearly beneficial to their work.
The Repair Kit
Before I gave Naome the tools she’d need to build her confidence skills, I wanted to give her a sense of why—despite her competence and experience—they may not have come easily to her already. Robert Plomin and Kathryn Asbury, in their book G is for Genes, explain that confidence, like other character traits, may be encoded in our DNA. Studies suggest that genes can determine up to 50 percent of our personality.
When Naome told me she’s an introvert, I discussed with her the studies showing that introverts often project less confidence due to their smaller social circles, quiet demeanors, and softer voices. Extroverts who speak louder and more often seem to radiate more self-assurance. Of course, upbringing can affect confidence too.
Naome told me that as the middle child of a workaholic father and alcoholic mother, she grew up to be a people pleaser, constantly feeling pressure to be accommodating and perfectionistic. Playing sports or engaging in other team activities might have taught her some confidence-building skills, including getting comfortable with conflict and compartmentalizing failure to stay focused and resilient, but she wasn’t drawn to those kinds of experiences. Plus, she was raised with the tall-poppy rule. “Tall poppies get cut down first,” she explained. “In school, I was taught to be modest. Children who bragged were criticized, shamed, and sometimes even punished for drawing attention to themselves. It was dangerous to put myself above others.”
No wonder Naome had always had trouble asserting herself or talking about her professional accomplishments: it felt like boasting. “Also, my husband is a surgeon,” she told me. “Unlike in his work, there are few measures I can count on to know for sure if I’m doing my job well. When I compare my work to his, I guess I struggle with the imposter syndrome.”
To help her overcome all of this, I introduced her to my REPAIR kit, which offers specific steps she can take to relearn self-confidence and recover her natural sense of assurance. The steps of REPAIR are risk, emphasize, persist, act, initiate, rewire. It might sound simple, but natural confidence is like a muscle, and Naome needed to practice these behaviors to see results. With risk, for example, since people we consider confident take calculated risks regularly, I coached Naome to experiment with stepping outside her comfort zone. “I want you to stretch, but not stress your normal way of being,” I explained. “Like yoga, think about going a bit deeper into a stretch, but not to the point of injury.”
Confident people also emphasize their thoughts and opinions; they have a voice, in meetings, groups, by writing, teaching, or finding other ways to be heard. Although it’s unfortunate, studies suggest that in our culture, for a woman’s voice to be heard, it needs to be in her lower register, and louder and slower than she might normally speak. Naome speaks softly and tends to apologize frequently with a nervous laugh. I ask her to try to raise the volume and tell her about a bestselling book whose title got my attention: Girl, Stop Apologizing.
Additionally, building inherent confidence requires persistence and action. The muscle can’t be developed by self-reflection or quiet contemplation, as introverts are wont to do. Naome will need to find definite actions to take, including what she might initiate, bringing in the role of leadership. For example, when she said she wishes to overcome a sense of isolation and have a support group of colleagues, I asked if she could create this group. Given her hesitance, I shared my experience putting together a group of colleagues who met monthly to support each other in their defined goals. “This group has become an important anchor for me,” I said. “And it holds me accountable for my progress. I had to take the lead to create the kind of group I wanted to join, and it worked for me.”
Naome liked this example and between sessions contacted a few colleagues to start a peer supervision group. Out of six people she called, four accepted her invitation. She later told me of the trepidation she felt making those calls, but I let her know the leadership and courage she practiced would help her in the last step: rewiring.
Rewiring requires practicing confidence-building behaviors in spite of fear and anxiety. That’s why Naome needed a way to address the anxious or critical thoughts that might get in her way as she reclaimed her natural confidence. One strategy, suggested by Martin Seligman in Learned Optimism, is to use refutation, a type of self-talk that’s logical and succinct, mirroring the language a lawyer might use to knock down arguments in court. Another strategy, described by Kristen Neff in Self-Compassion, is to talk to yourself as you would a good, beloved friend. Naome thought the latter might work better for her.
With the six steps of the repair kit in place, Naome was ready to apply some additional specific strategies in her clinical practice.
When I entered the therapy field, I was taught that we social workers couldn’t use the word guarantee in regard to our work. This struck me as unfortunate. I’d worked in several businesses before becoming a therapist and knew the value of a guarantee. It left me wondering what could translate into certainty for our clients. What could we feel confidence in delivering? Even if we can’t guarantee the definitive results of any particular method or model, we can promise to deliver certain aspects of the therapist–client relationship, ones that are firmly under our control.
“What can you guarantee in your role as a psychotherapist? I asked Naome.
“That’s a hard question,” she said, thinking. “I can’t guarantee that anyone will be cured, or even that their symptoms will decrease. I can’t guarantee that they’ll meet their goals, or that they’ll even feel better, although of course I hope they will.” She stopped and looked hard at me.
“I agree, those are things you can’t promise. What can you guarantee?” I asked again. “What about being present? Can you guarantee a level of attention that you bring into a session?”
“Oh, yes, I can. I see what you mean. I can promise to be fully present, for each session, every time. I can promise to listen without judging, to do my best to understand my clients’ stories and relate in an honest and professional manner,” she said in a loud, clear voice. We went on to discuss how she could guarantee to bring all of her professional curiosity and awareness to a session, to be responsible for staying current with research, to help her clients stay invested as best she could. Naome was now on a roll.
“How often do you speak about this sense of commitment, presence, and focus?” I asked her.
She replied succinctly, “Never.”
We decided her next action step was to begin to talk more openly with colleagues, friends, family, and even clients when appropriate about the deep pride and personal investment she brings to her work. Why? Confidence is built, in part, on what we can control. Take Kobe Bryant, the great basketball player, as an example. He was a talented player as a teenager, but what really set him apart was his enormous confidence, which was not about his results on the court but his work ethic. He knew that he was willing to work harder than any of his competitors. He was dedicated to practicing before and after school, before and after games, on weekends and holidays. His confidence in his ability to work carried him through the less than successful phases of his early career. Over time, his competence caught up with his confidence.
The Power of Feedback and Seeing Results
I understood Naome’s struggle with the “imposter syndrome,” as she put it, or feelings of self-doubt and inadequacy. She worked in a vacuum, without measures or even feedback to give her needed data on her outcomes. Like many therapists, she was trained psychodynamically, which doesn’t lend itself to measurement the way more cognitive methods do. Although she was familiar with the work of Scott Miller and understood that routine outcome monitoring has been shown to enhance treatment results, she was concerned that getting client feedback would interfere with the pacing of the sessions, and that clients might want to please her rather than give her an honest response.
I empathized with her concerns, but I thought that she could take small steps toward applying the concept of a feedback-informed approach in some form. I’m not an expert in measures, but many clinicians I work with in private practice have shared with me the measures and evaluation surveys they use. I know there are numerous ways to incorporate feedback into a practice, and I ask the therapists I coach to figure out what feels comfortable for them.
Naome decided she could pose a few “soft” feedback-oriented questions into her ongoing sessions, like: How do you feel about continuing to come for therapy? Do you feel understood and listened to by me? Is there more I should know about you—your history or current situation—to be of help? Do our conversations make sense to you? Are you satisfied with the results you are getting? Is there anything I can do better to help you stay involved with your treatment?
She tried this strategy with several of her clients and found some were relieved to have a chance to assess and talk about progress in this way; others, however, were resistant to this approach and felt that it interfered with the sessions. Clearly, learning to solicit feedback would be an ongoing process for Naome, one that would require her to take risks and explore new options. Still, she recognized that getting feedback, even in a relatively subjective, nonroutine manner, gave her more confidence about the direction of her work and allowed her to feel more secure about her overall effectiveness.
I believe that progress in therapy is a regular occurrence, regardless of the method a therapist uses. So my goal is to help therapists attune the observable signs of this progress in every session and define them as results. Keeping the focus on small signals of growth, rather than the big shifts that take place over time outside of sessions, allows therapists to feel more secure about the immediate value of their work.
“In session, do you ever hear clients have a new insight or articulate something in a different way?” I asked Naome. “Or have you observed a client rising to the occasion, say in couples therapy, to be vulnerable with a partner? What about someone using self-control or self-regulation, right in the session, that you know is a result of the process of therapy?”
“I see those things a lot,” Naome said. “I usually jot them down in my notes after the session. Are you saying that these small shifts constitute results?”
“These changes in observable behavior are part of what therapy sessions produce. What if you made note of them out loud, right then and there, with your client?” I asked. “These small, sometimes micro, bits of progress are how change occurs over time. And highlighting them might bring about an awareness of accomplishment, progress, and return on investment for both you and your clients.” Although doing this felt uncomfortable to Naome, she agreed to try.
The Beauty of Tall Poppies
I often recommend that therapists learn how to talk positively about their work and successes to balance the tendency to focus on the hard, complex cases in our caseloads, causing us to forget that our work can be a delight. To help Naome do this, we role-played her telling a simple, positive success story to friends and family curious about how her work is going.
Of course, she had to be careful to protect client confidentiality, but I watched her face light up as she highlighted a successful session with a client who’d had difficulty expressing emotions other than anger and disdain. Then in one session, he’d teared up when talking about his appreciation of her as a good listener and a safe person to talk with. Naome knew this was an observable measure of progress. She took a risk and told him about her observation in the moment. He took her action as an indication of her attentiveness and teared up again.
In telling this success story, Naomi realized, “If someone asks me how my work is going, I can say that I’m taking new risks with good results. I’m able to spot real change in the moment and bring it to a client’s awareness. Then the client and I discuss what it feels like to see progress and know how therapy is working. It’s leading to some authentic and powerful moments with clients. When this happens, I feel lucky to be in my line of work.”
When our work had come to an end, we agreed that she could return for an additional session if needed, but for now her job was to practice the confidence-building skills she’d learned. Each therapist I work with has unique challenges. Some need to know how to retain clients or convert new ones from a first session to ongoing treatment. Some want to know how to approach negotiations with clients who push at boundaries. Newer therapists often need to know how to simplify complex cases so they can structure the work more easily. Therapists at all stages who are uncomfortable with the topic of money need to be better able to “state their fee with a smile.” Meeting all of these challenges requires a certain level of clinical confidence.
In The Confidence Code, Kay and Shipman posit that we can learn to approach confidence in a way that’s less mysterious and more pragmatic. “How refreshing,” they write, “to view confidence, at least in part, as a simple, concrete tool; an extremely useful compass, perhaps, if we could just get the darn thing working.”
Naome was an accomplished clinician who didn’t feel successful. But the compass we devised helped her navigate a path to clarify her own value, find her voice, and take risks to get the measured feedback and evidence of progress she needed to appreciate her own effectiveness and the depth of her capacity to help the clients she served.