It seems obvious that you can become a better clinician than your supervisors if your supervisors are less intelligent, less robust, less empathic, or simply less interested in clinical work than you are. But what if they’re not? Does their ability to recognize patterns, apply ideas, and develop a working alliance set a cap on what you can learn?

The problem of achieving clinical excellence requires some discussion of what is meant by that term. Unfortunately, clinical work is an enterprise that lacks widespread agreement on what constitutes excellence. Is it measured by ratings of peers, peers who may not be able to recognize excellence because of their own deficits? Is it measured by approval from clients, clients who may be biased for a host of reasons to overestimate the efficacy of the treatment? If you teach someone fencing, nearly everyone agrees on who won a particular match. In clinical work, one therapist’s success is another’s irrelevance.

Still, for the sake of this discussion, the major clinical theories agree that problematic patterns— relational paradigms, behaviors, beliefs, and organizing principles—will govern the client’s approach to the therapist. Working on problematic patterns in the office is effective because, in Skinner’s phrasing, the variables that control behavior in the office are probably those that control behavior elsewhere. Pattern recognition can be taught, but can a trainee learn finer discriminations that the ones the supervisor makes? If not, the whole field can only be going downhill on this variable; If so, then how?

For example, a man was violently ejected from an airplane after he refused to give up his seat, and it turned out he had a criminal history. To me, the sort of person who would disobey the flight attendants might be the sort of person who disobeys other rules. Indeed, many civil rights activists have a history of not conforming their behavior to societal expectations. I can teach trainees to notice these kinds of patterns, but can they get better at it than I am?

1. Become even more resilient and psychologically-minded than your supervisor. Find a good therapist and hold nothing back. Approach conflict with friends and colleagues. Speak truth to power. Fall in love. Accept but don’t coddle yourself.

2. Learn more patterns. Pattern recognition is limited by the patterns you know. Popular fiction and melodrama, in books, film, or television, repeat the same old patterns. Find new stories by reading literature, watching great films, and discovering unique twists from each client.

3. Check your privilege. Your supervisors inevitably abused their power and exercised various privileges at your expense. It means there’s always room for improvement. Check your own by thoroughly screening the positive feedback you receive from subordinates and clients for toadyism.

4. Become multilingual. Learn your supervisors’ theoretical orientations and then learn one or two more. Learn, especially, each client’s theoretical orientation. New perspectives foster new ideas.

5. Evaluate your position on the learning curve. “Those with limited knowledge … suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it” (Kruger & Dunning, 1999, p. 1134). In the give and take of improvisational, mutual therapy, a relative beginner with accurate self-appraisal might be more effective than people who think they are experts when they merely have experience. The former will enlist the client as an ally in the process; the latter may not.

6. Enjoy the adventure of improving more than the status of expertise. Find like-minded colleagues to challenge you. Ask what you could do better. Make “Excelsior!” your banner, but (unlike Longfellow’s mountain climber) be reasonable about how fast you can go uphill.

7. Distinguish surpassing your supervisors on their learning curves from surpassing them on your learning curve. Therapy is a personal business. You first learn to say what any therapist would say to any client. Then, you learn what any therapist of a given theoretical orientation would say to any client. Then, you learn what any therapist of a given theoretical orientation would say to this particular client. Finally, you learn to say what only you would say (while playing the role of therapist) to only this client. You can definitely surpass your supervisors at saying what only you would say.

References

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

This post was recently published in The Colorado Psychologist.

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