TIFT #80: Confronting Therapist Anxiety

tift Jul 04, 2023


The Dunning-Kruger Effect describes the fact that people of low competence tend to think they are highly skilled. At the same time, social researchers, Dunning and Kruger (1999), in a classic article, note that:

“Top-scoring individuals know that they are better than the average, but they are not convinced of how superior their performance is to others. The problem, in this case, is not that experts don't know how well-informed they are; they tend to believe that everyone else is also knowledgeable.”

What they really mean is that we can’t help wondering if someone else would do a better job or if we should have taken a different approach. Maybe we can consider our doubts a badge of (possible) excellence. But meanwhile, they keep on nagging us. And how can we really be sure? We never get to find out if the same case, handled differently, would have a better outcome. I hear a lot of talk about self-care for therapists, but it tends to focus on the stress we experience from sitting with painful and difficult, even insoluble, problems and the stress of feeling responsible when we have so little control. What isn’t often mentioned is anxiety about whether we could or should be better therapists.

The Righteous Disciple

One common solution is to proclaim allegiance to a particular school of therapy and it’s leader. That might feel good and there might even be studies and statistics to back up claims for that therapy, but if we are honest with ourselves or allow our doubts free reign, inevitably, we begin to wonder. What about those who advocate techniques in opposition to those of our chosen brand of therapy. Could they be right? What if I broke one or other of the taboos of my school? Would that really ruin my effectiveness? Or might it liberate my practice and allow me to be more successful.

How can one navigate when every therapy says it is “the one,” the very best way to practice and has history, credentials, and colleagues who agree. Lives and well being are at stake. Our success as professionals is at stake. Would my patient have done better if I had…. Or worse, would they have had a better result in therapy with my colleague?

How clinical practice keeps us (relatively) honest

Unlike philosophers, we have clinical reality to tell us what works and what doesn’t. As an individual, it is hard to connect success with specific aspects of technique, but we can see at least that some people get substantially better. We hope to learn from our successes as well as those that don’t go so well. That’s the beauty of clinical practice. We are all dealing with the same kinds of problems and the results face us with undeniable truth.

On the other hand, random impressions are not very reliable. Studies say that therapists don’t get better with time. Most of us have trouble accepting that and prefer to imagine that we learn from every case. The hope of doing better propels us ahead. We keep seeking, reading, learning, daring to share our experiences with others, looking for more satisfying answers. Meanwhile, therapist anxiety follows us wherever we go. 

Another solution: Deliberate Practice

The evidence is building that global self-evaluation does not, in fact, lead to growth. One thing the Deliberate Practice movement contributes is that it is far more effective to focus on a limited issue until change is achieved. Deliberate Practice means identifying specific skills within each person’s practice and systematically working to improve in one area, then going on to the next in one’s personal growth. Identifying areas for skill building is done through session taping, supervision, self examination, and client feedback. This approach has a great deal to offer to each of us, but does it remove therapist anxiety? Unfortunately, no.

The Deliberate Practice movement is excellent when it comes to improving skills in performing those components of psychotherapy that are common to every therapy, the well-known “common factors.” Where it has a limitation is in the approach to problem patterns that are unique and specific to the individual client. In that area, Deliberate Practice suggests following the concepts and techniques of a specific brand of therapy, which inevitably brings back anxiety about whether one’s choice of therapies is right.

We are back to the problem of living in a divided world where each therapy has its own hermetically sealed set of constructs and rationales, incompatible with those of other therapies that may be just as effective or better. That’s fertile ground for therapist anxiety to take root once again.

Is there an answer to the problem of incompatible therapies?  

Not much surprise from my previous writings, the solution proposed here is to understand how therapy really, really works. When we understand the universal and foundational processes underlying the action of therapy on specific problems we will be able to focus on the trans-theoretical skills needed to create conditions for change. Not only can such an understanding transcend theoretical barriers, but it can add further precision to technique. This makes sense, since technique in every brand of therapy has almost always evolved from one individual’s intuitive groping towards what produces change. Internally coherent theories and techniques are honed over time, but remain rooted in and limited by the conceptualizations of the founder.

Only in the 21st Century has it become conceivable to identify change processes that address the unique, individual problems our clients present. Here we are talking about the informational contents and processing of the mind, rather than the architecture of the brain. While memory reconsolidation is not the only change mechanism relevant to psychotherapy, it is essential and central to enduring change for those entrenched maladaptive patterns that are unique to each client. Today, we know that, at least in the case of memory reconsolidation, technique must be aimed at setting specific limbic neural networks into an active state and simultaneously fostering a collision with specific disconfirming information. The level of precision is remarkably greater than “making the unconscious conscious” or “correcting irrational thoughts.” Using this new understanding we can further sharpen our therapeutic scalpel, all the while, gaining a “ring side seat” on the processes of change.

First a framework, then its application

We’re not done yet, but I’m going to divide this post into two parts, this one describing an anti-anxiety framework and in the next, its real world application to clinical practice. In this part, I outline an affect avoidance framework that supports practical use of recent neuroscience by articulating ten universal principles regarding problems psychotherapy aims to treat. In the next post I will demonstrate using the framework in an actual case to improve my own skills and combat therapist anxiety.

Integrating neurophysiology with clinical observation

The example I will work with in the next installment of this post is the case of Rachel, a single woman in her 30s, who is stuck, sabotaging her growth and progress in life through distractions and hard-to-resist impulses. Each time she commits to managing bad choices she ends up reverting to old patterns. Here is what the affect avoidance framework, along with the neurophysiology of memory reconsolidation, has to say about such an entrenched maladaptive pattern:

  1. Maladaptive patterns represent “coping gone awry,” the result of the mind’s efforts to deal with a major problem, one that, at the time when the response was first established, had no fully satisfactory solution.
  2. Neurophysiology tells us that the trigger for maladaptive responses is activation of limbic neural networks in locations such as the amygdala. That necessary link in the stimulus-response chain might be called “limbic emotion,” the mind’s internal signal that it has identified or is predicting a threat.
  3. Limbic emotion is not, itself, conscious, but is indirectly recognizable to the clinician by the presence of conscious affect.
  4. What threatens to trigger the dreaded limbic emotion is, in essentially every case, the prediction of a serious threat, as opposed to an opportunity. The threat is usually of existential proportions at the time the response is first “invented.”
  5. Understanding the specific circumstances that trigger limbic emotion is best accomplished in therapy by listening carefully to spontaneous, automatic thoughts (also known as free associations).
  6. Limbic emotion is, in effect, a proxy for the original insoluble problem. Maladaptive responses are “designed” to lower the intensity of limbic emotion, and are not always directly related to the predicted threat. In humans, the mind may be more interested in suppressing painful emotion (“killing the messenger”) than in actually solving the problem. Responses can almost always be seen as strategies for avoiding the experience of painful affect, the conscious manifestation of limbic emotion.
  7. Between the dreaded limbic emotion and generation of a response lies “implicit learning,” a schema or set of rules laid down in implicit memory to make sense of how life works and to support a strategy for controlling the triggering limbic emotion. We’ll see an example in the next part of this post.
  8. That implicit learning or schema is the specific informational content that psychotherapy most needs and seeks to rewrite.
  9. The mechanism of memory reconsolidation allows for rewriting of specific implicit learning, according to disconfirming information supplied through the therapy.
  10. Disconfirming information, when presented verbally, must pass from its initial conscious form to the nonverbal limbic form in which the original implicit learning is retained. Disconfirming information can also be nonverbal such as tone of voice, or even bodily, as in performing a previously prohibited movement.

To summarize, we therapists use affect to recognize when the old schema is in play (activated and ready for change). Then we seek “accurate empathy,” precise enough to understand the underlying rule and formulate specific disconfirming information in verbal, nonverbal, and bodily forms. Then memory reconsolidation can cause rewriting of the old implicit learning in a way that, once in for all, solves the original insoluble problem.

Next time

In the next part of this post, using the example of Rachel, in her 30s, who keeps sabotaging her success in life, I’ll describe how I’m working on my skills in bringing about activation of her old, dreaded limbic emotion and crafting new, disconfirming information with which her inner mind can rewrite the old schema and take the energy out of her self-defeating patterns.

Jeffery Smith MD


 Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. Journal of Personality and Social Psychology. 1999;77(6):1121-1134. doi:10.1037/0022-3514.77.6.1121


Photo credit:  Priscilla Du Preez, Unsplash

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