Clinical concepts
therapist e ff ects 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 e ff ective – the horse-race debate – and we have of course focused on the patient, on who bene fi ts more from psychotherapy and who bene fi ts 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 fi nd that they care about the person of the psychotherapist.’ Nissen-Lie describes herself as ‘incredibly lucky’ to have joined a large-scale study 8 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 di ff erent situations that therapists themselves said were challenging or di ffi cult 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 di ffi cult situations, and they might take it out in therapy, which can be tricky, so one di ffi culty we looked at was the challenge of liking our client. Another di ffi culty was feeling bogged down with a client’s circumstances, whether fi nancial, health or otherwise, and the frustration a therapist may feel knowing they can’t really change or in fl uence 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 di ffi culty in comprehending a client, helping the client, the more they doubted themself in their clinical e ff ectiveness, 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 di ffi culties in relationships with other people. One of the aims of Nissen-Lie’s 2017 study was to follow up on these fi ndings by asking what elements are needed before professional self-doubt can be of bene fi t to the client, speci fi cally 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 ‘re fl ect on their own share of di ffi culties 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 di ffi culties without judging themselves. Why humility matters Developing a level of con fi dence in both your e ff ectiveness as a practitioner and in the process of therapy itself is of course an important and perhaps natural part of career development. But con fi dence is ‘Could a commitment to honest self-reflection,
complex, and Nissen-Lie points out that, like other professionals, therapists are not immune to the ‘Dunning-Krüger’ e ff ect 10 – the tendency for the worst performers in any fi eld to overestimate their performance and, conversely, the top performers to underestimate their e ff ectiveness. ‘It may be that the most con fi dent 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 US 12 conducted a study with data from 1,300 patients and their 50 therapists, and they found that when therapists were rating their own perceived e ff ectiveness, those who underestimated their e ff ectiveness 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 e ff ectiveness.’ She adds that a similar fi nding 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 speci fi c, and so not necessarily relevant for Chinese clients. But the fi ndings so far indicate that the fi ndings 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,
32 THERAPY TODAY MAY 2024 underpinned by self-compassion, help us develop our humility?’
Made with FlippingBook Online newsletter maker