What should I focus on to improve as a therapist? What can I ignore?

Bruce Wampold has a great chapter in “The Cycle of Excellence” (2017) where he summarizes characteristics and actions of effective therapists: 

• Verbal fluency

• Warmth and empathy

• Emotional expression

• Persuasiveness

• Hopefulness

• Problem focus

• Delivery of a cogent treatment 

• Professional self-doubt

• Deliberate practice

Further, he shared a research overview of the traits and actions that are not related to outcome: 

• Age

• Gender

• Theoretical orientation

• Adherence to treatment protocol

• Self-reported social skills

• Rated competence delivering specific ingredients of treatment

• Responses to interview questions about clinical skills

Lots to reflect on there. I encourage you to identify (through reflecting, reviewing video, asking your supervisor etc) which of these you would most benefit from working on, and then get specific about what skills to acquire and practice to that end. All of the above elements of effective therapists are skill-based and can be improved. Further, many newer therapists are younger and worry about being seen as too new or young—but there it is, right from the research: age not related to client outcome. 

It’s common for newer therapists to feel anxious and then seek comfort by over-focusing on a theoretical orientation that tells you what to do, how therapy works, and so on. However:

We’re experiencing “the cacophony of the 'protocols for syndromes' era of evidence-based care,” (Steven Hayes). In 1992, Lambert summarized outcome research and found that, simply put, 85% of what makes therapy work is extratherapeutic, common, and client factors, with only 15% relating to technique. In 2008 Imel and Wampold reported that 30 to 70% of variance in therapy outcome was caused by common factors, and in a 2014 lit review by Laska et al., they reported that only 1% of variance in outcome was due to treatment method! You could also look up the ‘psychotherapy dodo bird verdict’ and read “The Great Psychotherapy Debate” (2015) for more info.

Yes, you need to employ a theoretical orientation, but the research encourages us to focus more on the importance of humanity than merely technical approaches. It’s far more important to be a good, connected presence in the room than to have mastered 20 manualized approaches for each client issue. Wampold, among many others, suggested we need a cogent approach, with no particular one being much better or worse in most cases (though there seem to be some exceptions to this).

Most clients are fairly eager to share their story of what brought them in; help them explore that and feel understood. What happens in a first session is reasonably predictable, which often becomes reassuring for new therapists. Consider that you’ve been building relationships your whole life, so you have lots of existing, transferrable skills.

And if you read anything about best personality types for therapists and yours doesn’t seem to be a match: relax! Everyone is a shitty therapist at the beginning. Or at least, the 600+ therapists I’ve watched developed all were, and so was I. Diversity of therapists is great because an equally diverse clientele seeks therapy. 

Imposter Syndrome

Grad school and subsequent training programs are one of the most common places to feel imposter syndrome. It’s when we doubt our accomplishments or talents and have a fear of being exposed as a fraud. It’s the feeling that obviously everyone else deserves to be here and does the hard work, but I’m just not getting it and should leave before I’m kicked out. 

You’ve probably already felt it, and you likely will feel a lot more if any of your training involves seeing others do therapy or having peers/supervisors observe your sessions. Just talking to other therapists can bring on the feeling, seeing them seem so calm before a first session, for example. There are many articles and videos about this; check some out and realize you’re not alone! Annoyingly optimistic attitude: feeling this discomfort is a good opportunity to practice some emotional regulation and containment. And if you missed it, Bruce has ‘professional self-doubt’ on his list of effective characteristics above, a balanced version of this feeling is healthy, closer to “beginner’s mind” than imposter.

Anyway, for right now it may help to focus on some “microskills”, the alliance, and on the list above. Start by being a good person to be in a room with, rather than an over-focus on orientation, intervention, or worksheets. Trust the process!  

TLDR: rapport > orientation

Engagement:

• What strengths do you think you bring to this role?

• What makes you feel inadequate for this role? Did the above lists mention that at all?

• Try to share with some peers about your experiences with imposter syndrome, and ask about theirs

• What’s it like for you to consider that the orientation we work from has such a tiny impact on therapy? It seems strange to put so much emphasis on something that has such a small impact on outcome

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