I recently received a most wonderful gift in the mail from my oldest childhood friend in South Africa: the outstanding novel Hamnet by Maggie O’Farrell. The story has its base in fact (William Shakespeare’s early life, his marriage and his three children) but is also highly fictionalised, especially around the death of his only son (Hamnet) and the subsequent writing of the famous play Hamlet. Towards the end of the book, just before the opening night of the play, William Shakespeare’s thoughts are imagined as follows:
“He cannot tell, as he stands there, whether or not this new play is good. Sometimes … he thinks he has come close to what he wanted it to be; other times, he feels he has entirely missed the mark. It is good, it is bad, it is somewhere in between. How does a person ever tell?” (page 354)
This really hit home for me. I have often been haunted by this question: How do I know if my work as a psychologist is good? At school, and even at university, it was easy to feel a flush of satisfaction and acknowledgement when test results were good. But now that there are no formal tests, no quantitative assessments, no public nods of approval, how do I tell? I often think that knowing whether one has hit the mark comes more easily in other branches of health care: the dentist fixes the hole in the tooth, the client is pain free, and doesn’t return for the same issue on the same tooth; the physiotherapist manipulates, stretches and heals certain muscles, and after a few weeks, the client is mobile and able to resume normal activity, and again, only returns if there is another issue. The doctor assesses and prescribes, and can feel an immediate sense of success if the infection dwindles away, or the thyroid levels are restored to normal, or the wound healed up nicely. Job done! The patient is better!
For psychotherapists, the picture is a lot more murky. Clients come with immensely complex histories, often with mental health issues having persisted for many years or even decades. The people who reach out for our help are often embedded in complicated relationships with significant others, either in the present or in their past stories. Their personalities are complex, the way they relate is complex, and what they want from therapy is often complex. Often their goals (e.g. “I want my anxiety gone” or “I don’t want to feel this sad, help me to take it away”) are not even attainable or realistic! The therapist is no magician. There is no wand. There is no magic spell. There is no easy answer to difficult questions.
“Imposter syndrome” is a term that has become popularised recently. Wikipedia defines it as follows: it is a “psychological pattern in which an individual doubts their skills, talents, or accomplishments and has a persistent internalised fear of being exposed as a fraud”. I often think that psychotherapists are potentially more prone to suffer from this malady, as we do not always have the luxury of external numerical evidence to prove that we are doing our job well. Especially therapists (like me!) who work in a more eclectic fashion, and do not rely heavily on work sheets and assessment forms, could easily fall into the trap of believing that they are in some way fraudulent, or not good enough, despite numerous qualifications and potentially years of experience. Of course, “imposter syndrome” is not an either/or kind of diagnosis (as in, either you have it, or you don’t – e.g. like Covid or a tummy bug). Rather, it slides on a continuum, and in its “milder forms” it is not even necessarily a bad thing. In fact, a bit of humility is a wonderful protector against hubris and arrogance (which is detrimental to the therapeutic process!). Some self-doubt is good. Some understanding of our own limitations is good. But when we really start to doubt our value as a person, or as a therapist, and are consistently shackled by fears of being exposed as a fraud, we limit our own efficiency and ability to connect with clients. That is when we need to press pause, and to re-connect to a space in ourselves where we can balance humility and confidence. Dealing with imposter syndrome is a double process: (1) accepting and even “befriending” it as something that is universally recognised and experienced, seeing the good parts of it and not feeding into the spiral of “anxiety about anxiety” by ruminating about how awful and bad it is to feel these feelings, and (2) challenging it by finding your own emotional anchors, like knowing that you have indeed earned your degree through hard work, and that you do have many areas of knowledge and expertise, and that it is completely normal to feel off-balance if you are working with something you do not feel fully skilled in.
So … back to Shakespeare’s question: How can I tell if my work is good?
In my mind, the following guiding lights often help me on my path:
- Does the client come back?
Nowadays, with multiple clinics and therapists available, clients do vote with their feet. If people choose to come back for therapy (investing time, money and effort) it does mean they are getting something valuable from it. Even if their symptoms are not getting better fast, just having the secure space to download and process, is often worth every cent and second to them. I often re-assure myself that if most of my clients do not drop out of therapy pre-maturely, I must be doing at least something right! (The emphasis here is on the words most clients: of course, some clients will not come back, either because they didn’t like my style, or prefer to try someone else, or simply because they are not ready for the journey of therapy.
- Is there some form of change, or deepening, or broadening, or growth in my client, even if very gradual?
Of course, people embark on the therapy journey with the expectation of something changing for the better. And rightly so! As therapists we need to be attuned to this, and we need to check in with ourselves and our clients on how we are tracking regularly. Sometimes we need to be patient with this though … as said before, most clients do not come to us with only one easily fixable “malfunction” in the system. On the contrary, they come with complex life stories, deeply embedded patterns, and longstanding tricky mental “maps” that fuel their feelings, actions and relationships. I tend to be quite impatient and results-driven in general, hence, I constantly have to slow myself down, re-calibrate my expectations, and re-define the therapeutic goals. Therapists with a notion to be “fixers” (again, I am putting my hand up here!) have to work harder at having a realistic, fluid and flexible picture of what therapeutic success would look like. A huge reduction in anxiety symptoms as main goal is, for example, a tricky goal. Much rather, having a goal like increased engagement in life, despite the anxiety symptoms, would indicate growth in the client. Similarly, “not feeling so sad anymore” is an almost unattainable goal for the depressed client – we’d rather distil the preferred future picture to be one of finding some joy, some motivation, the perception of some colour… despite lingering sadness. For clients with troubled inter-personal relationships, our aim would never be “perfect” conflict-free friendships, but rather an opening up to be able to experience some moments of closeness and emotional intimacy with someone else. Along the way on the journey we stop and pause to celebrate small wins, and we acknowledge that it is in an imperfect life that we can manage to find joy and purpose.
- Is the therapeutic relationship strong?
Checking in to “the space between us” is often a helpful way to ascertain whether we are actually going somewhere, even if at a slow pace. I need to ask myself: does this client feel that I have empathy for where she is at? Does she feel I have her back? Does she feel I am involved, and care enough to help her navigate her way out of unhappy and unhelpful patterns? Even if the going is slow, and even if it sometimes feel like we take a few steps forward and then a few steps back, does she know that this space and this relationship is solid, strong and supportive?
- Do I have a clear sense of boundaries in my relationship with my client?
Not everything about the therapeutic journey is about the therapist! Sometimes our work is stifled by where the client is at, by their lack of motivation, and by whether they actually do try out some suggestions or set “homework” tasks. I do not have the power to force anyone to do anything. (Even if I strongly believe it would benefit them greatly!) In the end, both therapist and client are co-architects of the therapy, and I cannot shoulder the weight of helping the client change on my own. If, on reflection, I do discover that part of feeling of stifled therapy, does belong to me, I need to try and get a grip on it and pull myself up. Examples of things that are indeed mine to better would be my own tiredness, potential burn-out, being too rushed, some prejudice I hold, or having events in my own life that may cloud my interaction with my client. This is where regular supervision is absolutely essential to tease out what is happening in me, in the client, and in the space between us. Without my two current supervisors I certainly would have felt a bit lost in this department!
In conclusion: Maybe part of coming to terms with the ever-present reality of the questions “Is my work good?” and “How can I tell?” lies in purely accepting them as inevitable issues in living a conscious, reflective life. The most famous words by Socrates act as inspiration to dig deeper as therapists and as human beings: “The unexamined life is not worth living” becomes an adage to help us know that reflection will bring joy and pain… but that it is fully worth it. Sitting with the discomfort of holding our own imperfections and the satisfaction of holding our successes (professionally and personally) opens up a space to grow and to live fully. Humility makes us approachable and relatable as clinicians; and confidence inspires trust and safety in the therapeutic relationship for our clients. We need both these elements to create a space of change and growth.
And when there is significant, noticeable change and growth in clients, and they explicitly express their gratitude about the positive impact of therapy, then I can indeed bask in the warmth of a job well done. This is truly a sense of deep satisfaction!
Is my work good?
Maybe I will never really know fully.
And I can start making peace with that.
Felix & Sage Psychology