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When you look at everything involved in being a therapist, it鈥檚 no surprise that many of us battle with self-doubt on a regular basis. For a start we鈥檙e 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鈥檚 impossible to ever fully master 鈥� our task being to understand another鈥檚 experience while also accepting that no one can ever fully understand another鈥檚 experience. We are also trained to question and be comfortable with 鈥榥ot knowing鈥� and uncertainty.

Doubts aren鈥檛 always limited to our own abilities as practitioners 鈥� sometimes the questioning is about the process itself. It doesn鈥檛 help that our profession is still often misunderstood, with public perception varying from dismissing what we do as 鈥榯ea and sympathy鈥� 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鈥檚 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 鈥榤ystery鈥� dimension to therapy. His own practice and years of research into resilient and expert therapists has led him to conclude that 鈥榤ost of the time, during our work, we don鈥檛 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.鈥�¹

Experience

Indeed, self-doubt is not just experienced by novice practitioners 鈥� one study found that the number one worry in a sample of practitioners with a mean of 11 years of professional practice was 鈥榰nsure how best to deal with the patient鈥�.² Canadian academics Anne Th茅riault and Nicola Gazzola, who carried out a series of studies in the early 2000s into therapists鈥� feelings of incompetence (FOI) 鈥� which they defined as 鈥榤oments where therapists鈥� beliefs in their abilities, judgment, and/or effectiveness are diminished, reduced, or challenged internally鈥� 鈥� found that experience did not automatically protect against FOI as therapists鈥� self-expectations were often raised with experience, making them more vulnerable to self-doubt. They also found experienced therapists can 鈥榬egress鈥� to previous levels of self-doubt under certain circumstances, such as a challenging client.^3,4,5 As Skovholt puts it: 鈥楾he 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?鈥�¹

Although not surprisingly, self-doubt does tend to be more prevalent when we first start out 鈥� it鈥檚 experienced by 83.2% of newly qualified practitioners according to one study 鈥� 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 鈥� a sense of competence is not 鈥榓 static milestone to be achieved in phase-bound increments but rather a dynamic flowing process in experienced clinicians鈥�.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鈥檚 and client鈥檚 perceptions of outcome. Sources of doubt vary from 鈥榤ild concern about technique to deep concern regarding therapist identity鈥�, according to research by Th茅riault and Gazzola.⁷ They concluded that sources of professional doubt can be divided into four levels, starting with doubt about the 鈥榤echanics鈥� of therapy, signified by questions such as: 鈥楢m I not saying this right? Where to go from here? What do I say next? Should I try this technique?鈥� Next-level doubt focuses on the immediate impact of therapy, characterised by questions such as: 鈥楧id 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?鈥� Classified as 鈥榣evel three鈥� is doubt about a therapist鈥檚 capacity to be effective as a clinician, triggering questions such as: 鈥楧o I have enough training? Am I capable of doing what needs to be done? Can I reach the objectives? Am I a competent practitioner?鈥� Doubt that relates to personal ability and shortcomings is classed as level four, characterised by questions such as: 鈥業s 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?鈥�⁵

The nature of a profession with confidentiality at its core means we can鈥檛 rely on some of the counterbalances against 鈥榠mposter syndrome鈥� available to people in other professions, including offloading to friends and family. Integrative practitioner Christine Foster, qualified since 2001, sums it up like this: 鈥楶eriods 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.鈥�

Triggers

Research has found that a common trigger for both new and more experienced practitioners is assuming too much responsibility for client outcomes 鈥� 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 鈥榓ggressive or extremely challenging鈥�. Another says: 鈥業 notice the 鈥渘ot good enough鈥� feeling particularly around the time of renewing and updating directory profiles, whenever I have to justify myself, and say 鈥渢his is how I do what I do鈥�.鈥� Self promotion can also trigger self-doubt for integrative private practitioner Rachel Kaminetsky: 鈥楾herapists who are a whizz at marketing can make me doubt myself 鈥� I still cannot seem to figure out what to say about therapy on social media to put myself out there,鈥� she says.

鈥業 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.鈥�

Environment also matters. Private practitioner Nicola Hughes says: 鈥業n 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鈥檛 know about on social media, when I might need to remind myself I am worthy, and very experienced.鈥�

Dr Alison Mackiewicz, who combines private practice with academic teaching, describes self-doubt as 鈥榗oming in waves鈥�: 鈥楽ometimes I will be fine for a few months, then I will take a dip in confidence.鈥�

Another practitioner, Fariha, identifies a source of her doubt in her career journey: 鈥業 married young and didn鈥檛 start studying until I鈥檇 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.鈥�

Personal impact

Frequent periods of self-doubt can be undermining 鈥� 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 鈥� a recent study of Irish psychotherapists working in private practice found the impact of burnout makes private practitioners 鈥榪uestion their capacity to perform their work effectively鈥�, triggering what the researchers call 鈥榓 professional identity crisis: 鈥渕aybe I just don鈥檛 have what it takes?鈥濃��⁹ Lead researcher Stephanie Finan says: 鈥楶articipants 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.鈥�

Research from Sweden by 脜sa Sp盲nnarg氓rd and colleagues meanwhile found that perception of competence was more important than work experience, education or age in protecting practitioners against burnout.¹⁰ 鈥楢 psychotherapist who perceives that they have the competence to help patients is likely to feel less anxiety, more work satisfaction and reduced stress,鈥� says Sp盲nnarg氓rd. The study also found that a perception of low competence 鈥� study participants were asked to assess their own competence on a scale of 0-100 鈥� was most likely to lead to burnout in women. 鈥榃hat I think is interesting is that healthy self-awareness and sensitivity to our limitations 鈥� something we use as a tool as a psychotherapist 鈥� can turn into self-examination,鈥� says Sp盲nnarg氓rd. 鈥榊ou need to have the meta perspective and to look at yourself because it鈥檚 an important thing to do when you are working with patients, but does it put you more at risk of self-doubt? We don鈥檛 know whether women in particular are open to this 鈥� it may be simply that women are more at risk because they are more likely to be doing this work.鈥�

There is also a pressure on therapeutic practitioners to be continually developing says Sp盲nnarg氓rd: 鈥業t鈥檚 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鈥檛 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 鈥� it鈥檚 what we call the 鈥渓ife puzzle鈥� in Sweden. All this can lead to burnout, and what鈥檚 interesting for me is how we protect against this 鈥� 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麓s easy to feel incompetent even if you have the right education and experience to treat the patients. I think it鈥檚 important to add competencies and methods to prevent burnout and unhealthy self-doubt, and that also organisations have a responsibility in that process.鈥�

Managing doubt

Good supervision and peer support were indeed key in managing self-doubt for the practitioners I talked to for this article. 鈥楳y supervisor has been brilliant,鈥� says Rachel Kaminetsky. 鈥楾hey 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鈥檓 human, when I think I should be better or expect too much.鈥�

Private practitioner CherylAnn Stewart says that a sound sense of self along with the ability to self-reflect are also key. 鈥業鈥檓 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?鈥�

Another practitioner commented: 鈥楢s I have developed in confidence as a person, then I have been able to be more open to doubt and humility about my work.鈥�

For Christine Foster, spending time 鈥榬eflecting on the sessions and the client鈥檚 way of being鈥� helps manage self-doubt, but the key, she adds, is 鈥榯o 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鈥�.

One practitioner who prefers to remain anonymous says: 鈥業 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, 鈥淵ou need to give this client to one of the grown-ups!鈥� 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 鈥淚 can鈥檛 do this鈥�.鈥�

Her recommendation for managing doubt is simple: 鈥楾alk about it. I know that talking to colleagues helps 鈥� 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鈥檚 their fault.鈥�

Client impact

It seems likely that periods of doubt have the potential to impact our practice and, indeed, Th茅riault and Gazzola鈥檚 research has found that the possible consequences of fear of incompetence for clients range from 鈥榠ncreased intentionality (by therapists) within sessions鈥� to 鈥榗omplete detachment from the client鈥�.^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. 鈥楾herapists 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 鈥渙ff track鈥�, enabling them more frequently to resolve barriers to therapeutic progress,鈥� 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 鈥� the researchers concluded it helped therapists remain 鈥榦pen, sensitive, reflexive鈥� 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 鈥� research by Helene Nissen-Lie and colleagues found that the combination of having sound personal self-esteem (what they described as 鈥榮elf-concept鈥�) 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 鈥榦pen, sensitive, reflexive and taking responsibility for relationship struggles鈥� 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: 鈥楲ove yourself as a person, doubt yourself as a therapist鈥�?