A Letter to Therapists: Professional Pressure to Perform and Your Downfall

I just finished my daughter’s first season of softball this past weekend. She did great! However, I look back to the start of the season and I remember how much I cringed when I realized she was beyond t-ball and was in the “strike zone” stage of softball. She couldn’t tell me what a strike or a ball was and I couldn’t figure out how to teach such a basic concept to her. Eventually, she figured it out. Through this process I was reminded that we don’t get to skip ahead of the learning phase in life. Fortunately, her learning was simple and showed progress, but not all learning is that straightforward. We are very excited for her growth next season and in any activity that she chooses to learn in the future.

I think a great example of learning not being “straightforward and simple” is that of learning how to be a therapist. As a therapist, we enter a profession that embraces a “closed door” career that often does not have the ability to view “how the work is done.” The inability to sit and watch others do the work that you’re learning to do can create significant barriers to excelling in your practice. There are two times in a career where an “imposter syndrome” can come up most frequently. The first is during pre-licensure as you adapt to a new position. The second is after licensure where you adapt to the perception of new standards of your work as well as the feeling of “I’m on my own.” Whether we are in the pre-licensed or newly licensed phase, the word that describes it best is “pressure.”

I think that “pressure” can be extremely helpful. I think I’d just sit on my couch watching tv or playing on my phone if I didn’t feel the pressure to accomplish things on my to-do list. However, there is a point where pressure begins to disable us. Everyone has a different burnout point where the pressure that we’ve been living with shifts something in our brain and causes us to become numb. I think this relates back to a time where we had lived amongst wolves and at a certain point, our brain said to us, “well, if you aren’t going to use the emotional pressure (i.e., fear) to get yourself out of this area with all these wolves, then I’ll help you out and start to numb your sensations so you can tolerate living.” Therapists often do not connect the pressure they put on themselves to this concept, but when they do, they’ll likely ask themselves “what are the wolves in my life and how do I deal with them differently?”

The biggest pressure, or wolves, that are present in a therapist’s life are that of the impact of inadequacy. If we don’t know how to do our jobs well, our clients get worse. If that is brought out of the “closed door” therapy session, then we might lose the jobs that we have worked so many years to attain. Since our profession is highly isolative (i.e., “closed door”), there is a constant suspicion that we aren’t working up to professional standards and the worst-case scenario is right around the corner. This suspicion is more intense in the pre-licensed and newly-licensed stages as the reality is that at this stage of a therapist’s profession, they are the most inadequate they’ll ever be.

Before we get into the question of “how can we deal with wolves differently,” I think that we should look at how we normally deal with them. A normal response to feeling inadequate during this period of development is to overcompensate. Therapists feeling pressure will overwrite their documentation, sign up for several trainings, and/or seek constant assurance from their clients that their clients want to continue seeing them.

• Overwriting documentation is on this list because feelings of inadequacy come with the sensation that “I’m going to be caught.” The thinking would be “if I’m going to get caught, I’m going to make sure that I’m covered by writing down a lot of content in my notes so an auditor would see that I know what I’m doing.” The problem with that, as well as the rest of these concepts, is the overcompensation we engage in only reinforces the thoughts we have about ourselves.
• Signing up for several trainings sounds logical. “If I don’t feel up to snuff, I should get more training to feel adequate.” The problem isn’t that seeking training is problematic. The problem is that these trainings don’t “quench our thirst.” In fact, the trend is to learn the new therapy on a superficial level and since that basic understanding of the skill isn’t a “game changer,” we move onto the next thing instead of delving deeper into mastery of that skill/theory/orientation/etc.
• Seeking assurance from clients is a good thing. Until it’s not. When a client comes into therapy, they often do not know about all the missing pieces in your skillset. Most clients that are new to therapy have no idea what is going on or supposed to be going on. They often read our confidence to determine how comfortable they feel with what we are talking about. If we are over-checking for buy in or rapport, we could be sending the message of “I’m not sure why you’re seeing me, I wouldn’t even see me!”
• I once employed a therapist who was so insecure about her skills that she had a “disclaimer” she would share with clients about her inadequacies. She was confused as to why her clients would stop sessions with her after her intake. As she role played her intake sessions, I was able to hear the problem. I relayed to her that her insecure “I’m not everyone’s cup of tea” comments (as well as several others) might be relaying to clients an “it’s not you, it’s me” message. This approach is well known to the general public as a “breakup technique” and clients who read it as such may “take the hint” and leave the therapeutic relationship.
• Seeking assurance from clients reminds me of a medical doctor telling their clients “I think you need to start on this antibiotic… does that sound right to you?” These sometimes-subtle messages we relay to our clients exacerbate our insecurity and pressure. Regardless if a client responds to these messages or not, we, as therapists, are creating a self-fulfilling prophecy.

Now that we have identified the problems, let’s look at dealing with pressure differently:

• Overwriting documentation can be managed with a simple “why did a therapist need to be in this session” question. If we answer that question, we can justify our presence.
• Signing up for trainings can be an effective way to build our skillset. Don’t stop at the intro training. We don’t have to be specialists in every type of therapy. We don’t even need to know how to work with every population (ex. I don’t work with or know how to work with eating disorders or autism). Our goal is that for the clients we choose to sit across from that we are able to offer them help towards healing. Basic training skills (those learned in graduate school) can often be enough to accomplish this goal. Don’t forget how much simple Rogerian techniques can impact a therapy session.
• Seeking assurance should be done through a collaborative and structured approach. I prefer asking my clients “how do you think we are doing” and “are we working on what needs to be worked on.” Other approaches are through satisfaction surveys that can be discussed in session.
• One other issue that causes pressure is “money guilt.” This would be the level of guilt that therapists feel for charging fees for a client to receive services from them. When a therapist feels like they’re inadequate and are receiving money for services, they can feel pressured to overcompensate. Instead of controlling sessions, flooding clients with homework, and not permitting pace and silence in sessions, we can slow down, breathe through the internal pressure, and remember that a client can get a lifelong change in your session through an accepting glance or a single sentence. Quality over quantity.

Since this isn’t an exhaustive list, if you find yourself struggling with this issue, please seek your own therapy. Every therapist should have their own therapist.

The final area that needs to be addressed is “you are in a career that will require your continued growth throughout your entire career.” You will not be able to give the level of therapy at 23 years old as you will at 73 years old, and that’s okay. As much as you want those 50 years of experience under your belt for the first client of your career, it will only come with time. Even therapists whom you admire were much worse at their jobs early in their career and will be much better than they are now later in their career. In order to adapt to this idea, I think it’s helpful to remember that even the worst player on the team can hit the game winning shot.

• Think back to a client who you had at the first place you ever worked and something you created in the session that helped them. Now think about a client you have now and remember something you did that was impactful. Lastly, think of your future and imagine being able to help a client in a new and different way. As you think of past, present, and future, imagine each version of yourself holding hands as your skills will have changed but the help you offer remained consistent throughout your career.

I hope this blog was helpful for you. I hope that you understand that you’re not alone in your internal pressure. I hope that between this blog, colleagues you can consult with, and your own therapist, you are able to decrease the overcompensation. I hope you see the pitfalls of overcompensation and have identified an approach that feels livable for you in your sessions. I hope you can get away from your own struggles so the help you have to offer doesn’t have to battle through your insecurities. Good luck and keep pushing through.

Jason Temple, LMFT