ORIGINAL PAPER

Therapist Feelings of Incompetence and Suboptimal Processesin Psychotherapy

Anne Theriault • Nicola Gazzola

Published online: 7 April 2010

� Springer Science+Business Media, LLC 2010

Abstract This study focused on novice therapists’ feel-

ings of incompetence (FOI). FOI are moments where

therapists’ beliefs in their abilities, judgment, and/or

effectiveness is diminished, reduced, or challenged inter-

nally. In order to get at the subtleties of this internal and

subjective process, ten novice therapists were interviewed

for approximately 90 min using a semi-structured inter-

view protocol. The interviews were analyzed by two

researchers using procedures adapted from grounded the-

ory methodology with the aim of developing thick

descriptions and a conceptual structure. Findings indicate

that novice therapists struggle with FOI, which vary in

nature and intensity, and that FOI are multiply determined

and complex. Implications for supervision and for psy-

chotherapy process are discussed.

Keywords Therapist self-doubt �Feelings of Incompetence � Professional issues

Therapists’ feelings of self-doubt, insecurity, and uncer-

tainty about their effectiveness are among the most fre-

quently reported hazards of the psychotherapeutic profession

regardless of the experience level of the practitioner. When

therapists are asked to describe what contributes to their

difficulties, stress, and burnout, they often report experi-

encing doubts about their competence. The nomenclature

utilized by researchers to report this experience is varied: (a)

perceptions that their efforts are inconsequential (Deutsch

1984), (b) self-perceived incompetence (Davis et al. 1987),

(c) low perceived mastery (Orlinsky et al. 1999), (d) pro-

fessional self-doubts (Daniels 1974; Farber and Heifetz

1981; Hellman et al. 1986), (e) a sense of failure (Howard

et al. 1969; Norcross and Guy 2007), (f) self-perceived

failure (Mearns 1990), (g) ‘‘doubts about their own thera-

peutic effectiveness’’ (Mahoney 1997, p. 15), (h) acute per-

formance anxiety and fear (Skovholt and Ronnestad 2003),

and (j) self-criticism about performance (Hill et al. 2007).

Although this phenomenon is labeled differently across

studies, the pervasiveness of this experience is underscored

in the psychotherapy literature; the number of therapists

reporting experiences of self-doubt regarding their thera-

peutic effectiveness is between 42% and 83.2% (Mahoney

1991; Orlinsky et al. 1999). In this paper we will refer to this

cluster of thematically related experiences as a therapist’s

feelings of incompetence (FOI).

A variety of negative consequences have been associ-

ated with FOI, such as stress (Farber and Heifetz 1981),

burnout (Hannigan et al. 2004), premature exit from the

field of psychotherapy (Theriault and Gazzola 2008a, b),

and experiencing personal problems (Mahoney 1997).

Very often the personal life of the therapist is compromised

because of FOI and related experiences (Guy 2000).

While an important aspect of FOI is their impact on the

therapists’ well being, a number of process disturbances have

also been associated with FOI. Hahn (2004) reports that

therapists’ FOI are associated with clients’ feelings of shame

which have a deleterious effect on the therapeutic alliance

(Watson and Greenberg 2000). Therapists concede that FOI

can lead to premature or delayed termination (Brady et al.

1996), alliance ruptures and untimely interpretations (Strean

1993) as well as disengagement and withdrawal (Theriault

and Gazzola 2006). Because therapists are often unequipped

to recognize and cope with FOI (Theriault and Gazzola

2008a, b), they may not be able to prevent these self-doubts

A. Theriault (&) � N. Gazzola

Faculty of Education, University of Ottawa, 145 Jean Jacques

Lussier, Ottawa, ON K1N 6N5, Canada

e-mail: atheriau@uottawa.ca

123

J Contemp Psychother (2010) 40:233–243

DOI 10.1007/s10879-010-9147-z

from contributing to a distracting type of self-awareness at the

expense of productive levels of self-involvement in the

therapeutic relationship (Fauth and Williams 2005).

Although FOI are reported by therapists in all experi-

ence levels (Orlinsky et al. 1999; Theriault and Gazzola

2006, 2008a, b) they are particularly prevalent among

novice clinicians. A study by Orlinsky and his associates

(1999) examined the relationship between experience and

insecurity and they underscored the prevalence of self-

doubts about competence, especially among novice clini-

cians. The results indicated that self-perceived low mastery

was reported by 83.2% of novice therapists with

0–1.33 years of experience, 69.2% of therapists with 1.33–

3.15 years of experience, and just over half (52.3%) of

therapists with 3.15–5 years of experience. Indeed, acute

performance anxiety can seriously tax the novice therapist

(Skovholt and Ronnestad 2003).

Models of Therapist Development

Developmental models of therapist growth also propose an

intensity of anxiety about performance (more general than

FOI) that gradually declines as trainees accede to progressive

stages of professional development (Loganbill et al. 1981;

Skovholt and Ronnestad 2003; Stoltenberg 2005). This

struggle is alternately labeled insecurity, anxiety about per-

formance, professional confidence, and sense of competence

but the theme converges around professional self-doubts and

FOI. While weakened by semantic impreciseness, develop-

mental theorists generally seem to agree that therapists’

sense of their competence (or professional self-confidence)

is a key component of growth and maturation.

The notion that FOI decrease with experience has

intuitive appeal however, not all opinions are unequivocal.

Although some of the models of therapist development

have received at least partial support (Bernard and Good-

year 2004, 2009), the research in this area has generally

been criticized for its lack of methodological and concep-

tual rigor and for its exclusive focus on trainees (Ellis and

Ladany 1997; Holloway 1992). Empirical studies that track

and thicken the description of the FOI experience beyond

the training years are lacking.

Another notable limitation is the lack of clear distinction in

these models between objective and subjective perceptions of

competency. For example the Integrated Developmental

Model (IDM model) proposes to describe how competency

evolves yet it uses self-perceptions of one’s ability to be

effective interchangeably with actual competency and effec-

tiveness (Stoltenberg 1981; Stoltenberg et al. 1998).

A notable exception to the focus on the training years

are Ronnestad and Skovohlt (2003) who incorporate

purely subjective professional self-confidence as a central

progressive feature across the six phases of development in

their lifelong learning model. The evolution of perceived

competency is clearly self-referential and traced across the

professional life. The stages, however, have received little

empirical support, especially those that go beyond training

(Bernard and Goodyear 2009) and the construct of self-

confidence is somewhat sketchy. Developmental models in

general have been criticized as being too simplistic (Rus-

sell et al. 1984). Indeed, in-depth investigations of FOI

among seasoned clinicians reveal that the experience is

multiply determined and much more complex than the

obvious correlation of confidence and experience (Theria-

ult and Gazzola 2005, 2006).

Among seasoned clinicians, FOI vary in both degree and

type from mild concern about technique to deep concern

regarding therapist identity. They have identifiable sources

and a variety of possible consequences that range from

increased intentionality within sessions to complete

detachment from the client. There are dynamic intra- and

interpersonal processes that may contaminate the thera-

pist’s self-evaluation process as well as the therapeutic

process in general. While experience is a potent moderator

of FOI, it is but one of a large number of determinants

(Theriault and Gazzola 2008a, b). Seasoned therapists

decry the lack of preparation for this aspect of professional

practice and several wonder aloud whether early-career

anguish resulting from self-doubts might have been cur-

tailed had they been forewarned about FOI (Gazzola and

Theriault 2007). Retroactive accounts by seasoned clini-

cians suggest that while some forms of FOI may abate with

experience others forms may in fact be exacerbated. Fur-

thermore, a sense of competence is not a static milestone to

be achieved in phase bound increments but rather a

dynamic flowing process in experienced clinicians.

The empirical evidence cited above provides a compel-

ling backdrop for the purpose of this study. FOI and related

emotions (e.g., doubts about one’s effectiveness, insecurity)

are prominent and they persist throughout one’s psycho-

therapeutic career in different forms and intensities. They are

potentially quite destructive for the therapist and can disturb

the therapeutic process. The developmental models that we

as a profession rely onto understand the experience of

becoming a professional provide a compelling but vague and

unsubstantiated portrait of therapist self-doubt and feelings

of incompetence, especially beyond the training years. We

would like to build on the existing knowledge by focusing

exclusively on subjective FOI among novices and by pro-

viding an empirical footing for the discourse.

Particularly, we were interested in discovering the mul-

tiple dimensions of self-doubt and the experiential com-

plexity of the phenomenon of questioning one’s competence.

We suspected that FOI were not one-dimensional or solely a

result of inexperience, therefore we were compelled by the

234 J Contemp Psychother (2010) 40:233–243

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following questions: (a) How do novice clinicians describe

self-doubts, insecurities, and FOI? (i.e., What is the nature of

their subjective experiences of FOI?); (b) What are the key

components and dimensions of this experience from their

perspective?; and (c) What are the sources of FOI?

We decided to proceed with procedures borrowed from

grounded theory methodology in order to ensure methodo-

logical rigor and systematic manipulation of empirical data,

qualities often decried as absent in critical reviews of research

supporting developmental models. We define FOI as ‘‘the

therapists’ belief in their ability, judgment, and/or effective-

ness in their role as therapists is diminished, reduced, or

challenged internally’’ (Theriault and Gazzola 2005). This

definition of FOI provided the parameters for a common

understanding among the researchers and operated as a

backdrop during research decisions such as when to prompt

and include interview material for analysis. However, this

definition was not provided to participants during interviews.

While the definition of FOI was deliberately left vague

for the participants to provide their phenomenological take

on the experience, several assumptions that were reflected

in the definition were held by the researchers and influ-

enced the interactions. The researchers’ working precepts

were that FOI are subjective cognitive-emotional experi-

ences that may or may not be reflective of objective per-

formance indicators. In other words, feeling inadequate

does not necessarily imply being inadequate. Secondly, the

experience of FOI is principally an intrapersonal experi-

ence; it is self-induced and is a product of reflexivity.

Method

Sampling

Purposive sampling was the method of choice: Participants

were selected because they had some characteristics

defined as central to the study. A pool of potential partic-

ipants were identified by the second author and contacted

by a research assistant (RA) to enlist their participation in

the study. Participants were therapists that had recently

(1–5 years prior to the study) graduated from a Master’s-

level training program where the first and second authors

worked (i.e., they were former students of the program). The

RA contacted them and interviewed them. He had previously

met only one of the participants when they had been peers in

a classroom. Code names were given to all participants by the

RA from the moment of informed consent. The students were

all complete strangers to the first author who was hired

subsequent to their graduation. The second author, who had

previous contact with the participants as their professor was

kept unaware of the true identity of the participants; he

neither knew who had agreed to participate nor did he have

access the participant—code key at any time during the study

or subsequently.

Participants

Ten participants were interviewed once. The interviews

ranged from 45 to 90 min and were recorded on audio-

cassettes and subsequently transcribed verbatim. This

resulted in approximately 300 pages of typed text. A basic

set of criteria for the selection of participants reflected the

ideology of the study. The participants (a) were novice

therapists who had between 1 and 5 years of clinical

experience (direct counseling/therapeutic involvement with

clients/patients), (b) were actively engaged in the practice

of psychotherapy at the time of the study (the focus of the

study was on ongoing struggles and a practicing therapist

would offer a contemporary/present day view into the

experience as opposed to a possibly diluted, retrospective

analysis of an experience removed in time), and (c) had a

minimum of a Master’s degree in either clinical or coun-

seling psychology (this criterion was established to offer

some uniformity to the sample base). We used the

parameters specified by Orlinsky et al. (1999) to define

‘‘novice therapists.’’ These were practicing clinicians with

experience levels ranging from 0 to 5 years because

5 years is the point beyond which less than 50% of ther-

apists report FOI in the study by Orlinsky et al. (1999).

Participant Demographic Data

The participants included nine women and one man with an

average of 2 years and 2 months of psychotherapy expe-

rience. Five participants were between 20 and 30 years old,

two were between 30 and 40, three were between 40 and

50, and one was between 50 and 60 years old. The par-

ticipants’ self-identified primary theoretical orientations

were cognitive behavioral (3), humanistic/existential (3),

solution–focused (2), eclectic (1), and art/play therapy (1).

Four of the participants worked for non-profit community

counselling agencies, three participants worked in institu-

tions of higher education (university and college), two were

in private practice, and one worked in a hospital. Half of

our participants did not engage in supervision whereas the

other half received ongoing supervision. While three par-

ticipants received approximately 8–10 h of individual

supervision per month, the other two received 1 h per

month. Only one candidate also engaged in group super-

vision and this occurred for 3 h every 2 weeks.

Data Collection

A structured questionnaire was used to gather basic

demographic data about the therapists who participated in

J Contemp Psychother (2010) 40:233–243 235

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the study. A semi-structured interview protocol was adap-

ted from previous research studies on FOI originally con-

ducted by Theriault and Gazzola (2003). It included a pool

of potential questions and prompts addressing the research

question to be implemented at the interviewer’s discretion

in accordance with the principles of semi-structured inter-

viewing delineated by Gorden (1992). A typical opening

question was as follows: ‘‘The literature suggests that many

therapists experience moments where they feel uncertain

about what they are doing in therapy, feelings of being

incompetent. Does this sound familiar/have you had these

types of feelings? If the answer is yes, prompt for exam-

ple.’’ The interview schedule evolved across interviews to

reflect queries into emergent categories, relationships, and

insights as is the usual practice in grounded theory whereby

data collection is guided by prior data analysis (Strauss and

Corbin 1998). All interviews were conducted by the

research assistant, a 25-year-old male who was himself a

novice clinician in his first year of counselling practice.

Data Analysis

Adaptation of Grounded Theory Methodology

Select procedures proposed by Strauss and Corbin’s (1998)

grounded theory method guided the discovery process. A

grounded theory approach was selected because it affords a

level of rigor from the standpoint of constructivist criteria. The

approach also permits a level of interpretation that fits with the

objectives of conceptual ordering established a priori.

Also, because the researchers conducted this study

within a larger research program consisting of multiple

studies using grounded theory, methodological uniformity

across studies was also a concern in terms of secondary use

of data to contribute to a more formal theory to be elabo-

rated at a future point in time.

Coding

The transcribed exchange was analyzed for thematic con-

tent using procedures inspired from grounded theory

methodology. Because the aim of the analysis was

description and conceptual ordering, we sought to organize

the data into discrete categories according to their dimen-

sions and properties. In light of Strauss and Corbin’s

(1998) concession that ‘the researcher can use some, but

not all, of the procedures to satisfy his or her research

purposes’ (Strauss and Corbin 1998, p. 288), we elected to

employ procedures called open coding and axial coding.

These systematic procedures position increasingly abstract

understandings of participant’s thoughts in relation to each

other through thematic coding of verbal content. The pro-

cedures were selected because they are both rigorous and

interpretive. Throughout the coding and categorizing pro-

cess, the constant comparative process was applied. In

order to refine themes and categories, instances of a phe-

nomenon were compared to each other to tease out subtle

differences and exceptions, or to further identify levels

within a category.

Open Coding

The most basic exercise in the process of open coding is to

label or name an idea, event, incident, or act using a descrip-

tive ‘‘code’’ that represents the data as faithfully as possible.

This exercise generally elicits a number of elementary labels

that can be synthesized along common elements into cate-

gories that are more abstract and comprehensive. As the

coding continues, some new categories are generated, others

eliminated, and still others relocated within the scheme under

different labels. They serve as basis from which to engage in

the next level of analysis, axial coding.

Axial Coding

Axial coding uncovers relationships between categories,

such as, for example, causal, cyclical, or interactional

patterns. Comparing instances of observed phenomena

allows for the specification of conditions that gave rise to a

category and the context in which it appears.

Coding and Auditing

The coding was conduct by the first author, a female

assistant professor who had been in private practice for

over 15 years prior to joining the faculty of the midsized

university where the study was conducted. Coding was also

done simultaneously by a novice clinician. Codes gener-

ated by both coders were amalgamated within one coding

scheme through a process of consensus that was held across

four meetings and numerous electronic exchanges of data

sets. While most themes identified by the two coders were

the same, several themes were identified solely by one or

the other. When this occurred the themes were incorporated

into the scheme when both agreed that they were relevant.

While this is not the usual procedure in grounded theory,

this modification was employed in order to guard against

potential bias by the first coder who had conducted similar

studies with experienced clinicians.

Enhancing Methodological Rigor

In addition to the protection against contamination by

previous analysis of similar data, the use of the second

coder served as an in vivo member check. This triangula-

tion ensured the viability of the data as the coder could

236 J Contemp Psychother (2010) 40:233–243

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check the evolving category scheme against his own

experience of FOI as a novice clinician. Other credibility

checks were naturally built into the interview process and

data analytic methods.

Participant Reflection and In Vivo Member Check

The interviewer systematically invited a period of reflex-

ivity at the end of each interview by asking for feedback

regarding the content and the process of the interview. A

typical set of questions to open the topic were: ‘‘How does

it feel to talk about this experience with me? Does talking

about feelings of inadequacy change your perception of

that experience in any way? Is there anything you would

like to add that you feel might be important in under-

standing feelings of incompetence?’’

Evolving Nature of Interview Protocol and Interviewer

Style

As is the nature of semi-structured interviewing in groun-

ded theory approaches, neither the exact wording nor the

order of questions was predetermined (Gorden 1992).

Rather the interview questions evolved to reflect and dee-

pen the ongoing analysis in an iterative process which

moves from data generation and data analysis to category

verification and elaboration. Emergent categories were

incorporated into subsequent queries and participants gui-

ded the interviewer to the salient aspects providing for the

ongoing refinement of the category scheme across inter-

views. Also, the interviewer paraphrased and offered ten-

tative interpretations that participants freely verified and

corrected throughout the interview. This interview process

and style offered the participants an ongoing opportunity to

correct, enrich, and add subtlety to the inductive process

thereby reinforcing the trustworthiness of the analysis.

Credibility Through Methodological Procedure

The set of procedures utilized to gather and analyze data is

clearly defined and systematic and they guard against

whimsical and idiosyncratic approaches to the data. For

example, the constant comparative method ensures that

categories that are not truly reflective of the lived experi-

ence shared by participants will be modified and rendered

accurate. Likewise, the fact that the interviews are recorded

and transcribed verbatim guards against retrospective dis-

tortion of data and selective memory.

Investigator Triangulation

When the analysis was complete, the second author, a male

associate professor who had accumulated 14 years of

clinical experience, conducted a thorough audit of all the

transcripts and resulting category scheme to ensure via-

bility and fit. This investigator triangulation (Denzin 1994)

was direct test of the credibility and viability of the con-

ceptual structure.

Verisimilitude

A final maneuver to enhance rigor invites the reader to

verify whether the interpretations and themes are faithful to

the disclosures they represent; Is the text telling the truth?

By providing ample and intact transcriptions, the writer

draws the audience ‘so closely into the subject’s world that

it can be palpably felt’ (Adler and Adler 1994, p. 381). The

inclusion of numerous and extensive verbatims and para-

phrases in Table 1 allows the reader to bear witness to the

fidelity of the analysis.

Results

Participants readily recognized the experience of FOI as

ongoing aspects of their professional and personal lives. As

such they were relieved to offer candid examples and to detail

rich descriptions of their struggles with self-doubt. The anal-

ysis of the data yielded three principal categories; phenome-

nological hues, depth and nature of FOI, and sources of FOI.

Phenomenological Hues of FOI

Within the main category of phenomenological experience

of FOI, three salient subcategories emerged; familiarity and

pervasiveness of FOI, nuances of the subjective experience

of FOI, and emotionality.

Familiarity and Pervasiveness

Nine of the ten novice clinicians interviewed expressed a

high level of familiarity with FOI. They admitted that the

struggle with self-doubts and feelings of being incompetent

was a common experience of counseling from their per-

spective. FOI occupied an important part of their reflec-

tions about counselling. One of the participants declared

‘‘I can’t think of a day when I don’t experience that.’’ The

dissenting therapist experienced FOI as ‘‘lurking right

beneath the surface’’ and ‘‘likely to pop up at any time’’ but

she did not put FOI at the forefront of her conscious

deliberations as the others had.

Nuances of the Subjective Experience of FOI

Therapists described experiencing FOI as transitory and

pervasive. That is, they experienced them both as ‘‘split

J Contemp Psychother (2010) 40:233–243 237

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second moments between their interactions’’ and across

time in global level self-evaluations. FOI were described

both as fleeting, moment-bound experiences and more

widespread and free floating. For example:

‘‘Maybe I’m completely incompetent and that’s why I

don’t see any movement in what’s happening.’’ So

there’s that kind of lack of movement in general and

then there’s just like moments within a session where

I think ‘‘I don’t know where to go, I have no idea

what to do, oh, my god maybe I’m just not there

(laugh) somehow.’’

Participants used a variety of terms to define their

understanding of FOI such as ‘‘unsure,’’ ‘‘uncertain,’’

‘‘lost,’’ ‘‘not going anywhere,’’ ‘‘not able to find something

that works,’’ ‘‘running out of things to try,’’ ‘‘cannot make

a shift,’’ and ‘‘fear that it’s not working.’’

Emotionality

Self-doubts and feelings of incompetence pulled for a wide

range of emotions, some quite intense. For example,

participants disclosed helplessness, anger, anxiety, dis-

couragement, feeling burdened, feeling ‘‘shaken-up,’’

frustrated, and powerless. While participants struggled to

contain and manage these feelings, the work/home

boundary became more porous in the presence of FOI.

Therapists’ after-hour ruminations were replete with FOI-

related themes. The depth and intensity of the emotions

were related to the nature of the self-doubt.

Depth and Nature of FOI

FOI subsume self-doubting processes that vary along a

continuum in terms of the intensity experienced by the

clinician and the level of anguish generated. The self-

doubting processes also contained a number of themes that

we regrouped under four distinct subcategories: (a) pro-

cedural uncertainty, (b) micro-outcomes, (c) professional

insecurity, and (d) self and identity doubts. Disclosures

from transcripts coupled with extrapolation from our own

experience allowed us to position the themes within levels

that represent increasing levels of depth, from one to four,

respectively.

Table 1 Category one: Depth

and nature of self-doubting

processes among novice

therapists

Depth of

FOI;Thematic label Nature of self-doubt Paraphrased examples

Level 1 Procedural and

technical

uncertainty

Self-doubts about

‘the mechanics’

of therapy

• Am I not saying this right?

• Where to go from here?

• What do I say next? Is that a

useful question?

• I am afraid to do the wrong thing.

Should I try this technique?

• Was it something I said?

Level 2 Being bound to

micro-outcomes

Self-doubts about the

immediate impact

of therapy

• Did 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?

Level 3 Professional

insecurity

Self-doubts about my

capacity to be

effective as a clinician

• Do I have enough training?

• Am I capable of doing what

needs to be done?

• Can I reach the objectives?

• Am I a competent practitioner?

Level 4 Self and identity

doubts

Preoccupations about my

adequacy as a person,

character flaws, and personal

shortcomings

• Is it me? What if there something

fundamental missing in my

personality?

• Who am I that I should be doing

this?

• Doubting own intention, like a

fraud-imposter phenomenon

• Do I have it in me give?

238 J Contemp Psychother (2010) 40:233–243

123

In level 1 self-doubt, procedural uncertainty dominated.

The therapist’s main preoccupation was regarding techni-

cal maneuvers and the adequacy of specific interventions

chosen. For example, one participant said: ‘‘What the hell

was I thinking when I said this?’’

In level two, the therapist was concerned with the

immediate result of an intervention, the micro outcome.

‘‘Did it work?’’ reflects this level of preoccupation. At the

third level, professional insecurity, the self-doubts moved

beyond the immediate level of intervention and began to

include the therapist’s professional self. One participant

said: ‘‘How come I can’t figure out what it is they need?’’

The preoccupation was about the capacity to be effective

globally as a clinician. In level 4, self-and identity doubts,

the personhood of the therapist was called into question.

The therapists feared that some profound character flaw or

personal shortcoming may prevent them from becoming

the therapists they would like to be. This deeper more

pervasive level was more difficult to disclose and haunted

these therapists. For example:

It’s much more threatening…. It has a moral quality

to it…. It’s that I’m not in touch with some feelings,

not willing to be in touch with some feelings…. I

don’t have this in me to give.

Many of the participants spontaneously alluded to an

experiential gradient of emotionality that depended on the

nature of thematic content of the self-doubting process.

Using the participant disclosures and our own experiences

as guides we established a relational trend between nature

of self-doubt and depth of experiencing of FOI. At the

lighter end of the continuum FOI were experienced as

minor aggravations, more fleeting and context-bound. They

were easier to classify and cope with. For example:

Participant: Um, well, when it comes to, you know,

questions like, you know ‘‘why did I ask

that open, or, close ended question? I should

have asked this.

Interviewer: ’’Right.

Participant: O.K., that’s, I sort of see that as a surface

level thing, yeah, it bothers me but it

doesn’t really hit my core.

Um, well, when it comes to, you know, questions like, you

know ‘‘why did I ask that open, or, close ended question? I

should have asked this.’’Interviewer:Right.Partici-

pant:O.K., that’s, I sort of see that as a surface level thing,

yeah, it bothers me but it doesn’t really hit my core.

At the deeper ends are FOI that were tied into personal

identity issues, they contaminated self-image and were

more likely to immobilize the therapist. The therapist’s

level of experiential distress was related to the nature of the

self-doubts (see Table 1).

Sources of FOI

Participants in the study reported that their FOI had a

variety of origins. They provided detailed information

about where the FOI stemmed by direct identification of

causes as well as through multiple examples. These were

grouped under 5 subcategories: (a) permissible fallibility,

(b) professional, (c) process issues, (d) pressure, and (e)

personal sources.

Permissible Fallibility

Therapists realized the limits of their influence on clients

and also invoked human limitations as bases for their FOI.

They usually were able to absolve themselves from guilt or

torment when FOI were related to this source by internal

prompts such as ‘‘it’s ok to be still learning,’’ ‘‘I’m only

human,’’ ‘‘I can’t be all things to all people.’’ Several

therapists went so far as to value FOI stemming from this

source because they ‘‘provided a humbling experience,’’

kept them on their toes, and fuelled their intentionality.

Thus FOI were considered by some to be conditionally

positive, that is, they could be used to bolster mindfulness

and used as a motivator for professional and personal

growth.

Professional Sources

A majority of the participants focused on professional

issues as the main source of FOI. Principally they attributed

FOI to lack of knowledge, experience, and training. Lack

of knowledge was cited by all participants and was the

most popular source of FOI. They described a chronic

unsatisfied need for ever more tools, a state we labeled the

‘‘empty toolbox syndrome.’’ Therapists with this incessant

need to acquire more skills and techniques seem to hang on

the notion that when a sufficient number of techniques

were acquired, the feeling of FOI would abate once and for

all. As such they frequently criticized their training pro-

grams for falling short of this ideal and many displayed a

type of yearning what we labeled ‘‘one workshop away

from being good-enough.’’

Process Issues

Noxious elements in the dynamic exchange between ther-

apist and client and specific elements of the process could

induce FOI. Therapists reported experiencing FOI when

there were serious impediments to the therapeutic rela-

tionship, when they were blinded to the person by the

problem, and also when there were unclear boundaries

around responsibility for change. For example, many

therapists described having assumed full responsibility for

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123

therapeutic progress and movement and having felt that if

they saw no progress they were at fault. They also

described shifts in their FOI when they started to question

their role in the change process. Likewise, they decried the

increased intensity of FOI that accompanied playing the

‘‘expert role.’’ For example:

And I know that I have a bit of a tendency to want to

just fix them and do all the right stuff for them, but

sometimes that’s not possible, I guess that’s part

of…. I guess that’s controlling on my behalf

(laugh)…thinking I’m a little more important than I

really am.

When they adopted stances that were decentralizing of

their own power and empowered the client to assume some

responsibility for therapeutic movement, FOI decreased.

These shifts were not permanent and therapists had not

consolidated their role or permanently fixed the boundaries

around who is responsible for change. There were ongoing

internal struggles and dynamic debates regarding these two

process issues.

Other process issues that were fingered as responsible

for FOI were discrepancies between process and outcome

and between theoretical and applied counseling. In the

former, therapists described poor results despite what

appeared to them as a productive and positive process. In

the latter, a revered strategy failed; therapists became dis-

illusioned when a prized intervention failed to deliver the

promised results. One therapist described it as the

‘‘moment when you realize that the client is more complex

than the theory.’’ In other examples provided, therapists

exposed the struggles created when outcomes are unpre-

dictable or ambiguous.

Finally, therapists identified certain client characteristics

that could induce FOI: unmotivated, perceived fragility,

high stakes clients, critical clients, aggressive clients with

intense affect, and high levels of anguish among others.

Also, therapists provided several labels and diagnostic

categories that could elicit FOI from them, such as bor-

derline, violent, deeply depressed, suicidal, and psychotic.

Throughout our analysis of the data we repeatedly

encountered a second order phenomenon that we labeled

‘‘FOI feeds unto itself.’’ This subcategory regroups

instances where FOI were a by-product of attempts to cope

with and manage FOI. For example, one therapist descri-

bed a process where she became more vigilant as a result of

FOI. This hyperawareness magnified all elements of the

process including her own insecurities and self-doubts thus

feeding into the FOI. In another example, the therapist

described becoming more intentional and self-reflecting

with a new client in response to what she labeled ‘‘stranger

danger.’’ The increased self-scrutiny invited FOI. Rigid

over-adherence to a theoretical model used to counter FOI

provoked more FOI in a third participant. This therapist

described an uncharacteristic reliance on her theoretical

model and prescriptions to fend off FOI.

Pressure

A fourth source of FOI for novice therapists was pressure.

This pressure could be self-induced or external. Internal

pressure was the result of numerous self-imposed and

perceived imperatives. Therapists declared the following,

among others: primo non nocere! Be great! Fix it! Hurry

up! You’re it—the client’s last chance! It’s now or never!

Give them a bang for their Buck! Internal pressure also

resulted when therapists attempted to respect an artificial

agenda. That is, when they insisted on following a plan that

did not match the client’s agenda, internal pressure ensued.

For example, therapists described being invested in keep-

ing things positive or sticking to their therapeutic goals

when clients strayed into other topics.

External forms of pressure were also identified as FOI

producing. Third party payers, referral sources, and

supervisors were all identified as potential sources of

external pressure conducive to FOI. These players were

viewed as critical witnesses with an evaluative function.

Several therapists mentioned their reputation and risks of

damage thereof as sources of pressure.

Personal

A number of the sources of FOI identified by therapists

were personal. Several participants admitted that their

personality traits left them vulnerable to FOI. They rec-

ognized that they emphasized weakness and had perfec-

tionist tendencies. Others declared being overly sensitive to

criticism in general and having a deep need to be liked.

Therapists also attributed some of their FOI moments to

their state at the time (e.g., feeling tired, hungry, or ill,

etc.).

Therapists personal values often interfered with their

usual ways of practice, leaving the door open to FOI. For

example when a client’s behavior violated a therapist’s

value, they were not as able to be objective and were

unable to maintain a therapeutic distance. As a result, their

self-doubt increased. Other situations exposed conflicts

between the therapist’s values and the therapeutic contract.

Finally, therapists’ personal wounds and unfinished busi-

ness from their histories fuelled FOI. When client problems

too closely paralleled those of the therapist, boundaries

became more easily blurred and therapists felt more

uncertain. When therapist wounds were exposed, a com-

mon response was to take some distance. Being too

removed, however, jeopardized the relationship and the

therapists’ FOI surged. Also, clients who were critical and

240 J Contemp Psychother (2010) 40:233–243

123

distant, at times, reminded therapists of similar experiences

from their upbringing and stimulated profound self-esteem

dilemmas.

Relational Trends Between Sources of FOI and Their

Depth/Nature

Several of the participants indicated that the depth of FOI

experienced depended on the source of the FOI. For

example novice 3 makes a link between a process source

(sub-category = serious impediment to therapeutic rela-

tionship) and a ‘deeper’ feeling of FOI. For example:

But it’s usually when a client gets really, really upset

to a point where you’ve got to end the visit, either

because they need you to or because for your safety

you need to. So, those are moments when I have felt

that deeper feeling that I talked about…like, that sits

with you a little longer.

Levels of depth of FOI generally progressed across the

source from permissible infallibility, professional, pres-

sure, process, to personal, respectively. (See Fig. 1)

We must stipulate that while the links made were

compelling, they were made tentatively and sporadically.

Direct questioning of subsequent participants hailed sket-

chy associations as well. As a result, this glimpse into the

relational trends between categories is informed by our

own preconceptions as well as participant disclosure.

Discussion

The ten participants in our study reported that they fre-

quently experience FOI. They were able to provide rich,

contextual insights into how their feelings of inadequacy

and incompetence were stimulated and experienced. These

specifications into the nature of FOI in this particular

subset of practicing novice clinicians shed light on the

nagging questions of what happens to this element of

therapist difficulty after the training years described by

most developmental theories. Our findings also lend

empirical support for Ronnestad and Skovholt’s (2003)

assertions that novice therapists struggle with issues of

insecurity, lack of confidence, and doubts about their

competency.

Implications for Supervision and Training

Beyond providing some support for theoretical claims

regarding FOI, our study provides a more detailed

description of this element in the development of the

therapist’s professional-self. It exposes some of the previ-

ously unexamined complexity of this internal experience.

Increased self-knowledge regarding FOI can help therapists

prevent erosion of their professional self-confidence as well

as increase mindfulness regarding how their FOI are being

played out in the therapeutic process; ‘‘Praemonitus, pra-

emunita -forewarned-forearmed’’ (Skovholt and Ronnestad

2003, p. 56). Thus, normalizing the FOI experience among

novice therapists is a worthy implication of our findings.

More detailed and contextualized knowledge of this phe-

nomenon can also be used to address the specifics of novice

struggles and avoid cookie cutter type of interventions that

are often decried as a major weakness of supervisory

interventions within developmental models (Ladany 2004).

For example, a common supervisor response and pre-

scription for supervisee angst is to become more structured

and directive. Our findings suggest that while this style

may attenuate FOI in certain circumstances, it may

aggravate it in others and may also lead to a narrowing of

supervisee experience in supervision (Gazzola and The-

riault 2007). While supervisors may want to be attuned to

supervisees’ need for instruction, this approach will not

provide reassurance for every manifestation of professional

self-doubt. For instance, FOI that stem from personal

sources may require another type of corrective. FOI are

normal and follow a developmental trend but they are also

complex and ever present. Preventative and corrective

strategies need to be tailored to reflect the nature, depth,

and provenance of the FOI. It behooves the supervisor to

respect the multiple dimensions of this experience and to

be mindful of the very individual phenomenology of this

internal challenge. To do otherwise is to risk coming across

as coercive and insisting on irrelevant structure and

ProfoundModerateMild Intensity

Note: Arrows represent the tendency towards increased intensity from left to right.

Permissible Professional Pressure Process Personal Sources

Level 1 Procedural and

technical uncertainty

Level 2 Being bound to micro outcomes

Level 3 Professional uncertainty

Level 4 Self and identity

doubts

Depth and Nature of Self-Doubts

Fig. 1 Axial representation of

relational trends between the

sources and depth and nature

categories. Note: Arrows

represent the tendency towards

increased intensity from left to

right

J Contemp Psychother (2010) 40:233–243 241

123

instructions (cf. Gazzola and Theriault 2007). Also, while

FOI may decrease and/or take different forms with expe-

rience (see Theriault and Gazzola 2008a, b), a lackadaisical

reliance on experience to counter the damaging effects of

FOI is potentially neglectful. Forewarned counselors are

better equipped to cope with FOI (Theriault and Gazzola

2005) and educating them about this aspect of the profes-

sion is imperative in proactive self-care training. Our

results could be useful for preventative and precautionary

work at the graduate level.

Implications for Research

This study contributes nuance and context to the FOI of

novices described in theories of therapist development.

Similar studies have begun to buttress such knowledge for

seasoned clinicians as well (Theriault and Gazzola 2005,

2006, 2008a, b). Further inquiry with therapists -in-training

and at different stages of career development will continue

to fortify and enrich our understanding of how therapists

struggle with FOI across levels of development. These

understandings can then be consolidated through compar-

ative studies and through studies that use a quantitative

approach.

Limitations

Because the authors had previously conducted FOI

research with seasoned clinicians, the risk of preconfigur-

ing the categories during data analysis was a concern.

Three measures were taken to minimize this potential

contamination. The first author and coder bracketed pre-

conceived themes and coded the data with a fresh slate.

Secondly, a second coder was used to ensure that catego-

ries reflected the data at hand. He was privy to bracketed

themes and was sensitized to the possibility of cross-over

from previous research. The second coder was a novice

clinician who had the added benefit of viability; he was

able to ascertain the level of fit between the evolving cat-

egory scheme and his own experience of the phenomenon.

Thirdly, a thorough audit of each transcript and category

scheme was performed by an experienced researcher.

Another limitation of the study is the added pull for

impression management that the topic may generate. While

nine of the ten participants and interviewer were strangers

to each other (the tenth participant was a remote acquain-

tance), disclosing doubts about competence is very sensi-

tive and there is always the possibility that participants

filtered some aspects of their experience to avoid uncom-

fortable levels of vulnerability. Also, as in all grounded

studies, the category scheme is an abstract representation of

responses that were provided by a limited subset of the

population of novice therapists. The extent conceptual

structure may not apply to all novice therapists and appli-

cations of the findings from the study to other groups ought

to be considered tentatively. The results depict the con-

ceptual ordering and reveal a thick description of the

experience of FOI among these particular novices but we

do not claim to have elaborated a formal theory with uni-

versal merit. Rather, in the spirit of discovery-oriented

research, the category scheme ought to be used to generate

ideas and hypotheses about FOI experiences among novice

clinicians.

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