3 Tips for New Therapists

New therapists can feel pretty vulnerable. Transitioning from education to practice is a huge leap, and there isn't much of a bridge.

Educationally, students get their first taste of doing therapy through a pre-internship practicum. Here in Massachusetts, they practice the role of therapist for 20 sessions with another student or two. Armed only with their book smarts, some have literally looked at me, wide-eyed, and said, "What do I do?" The work is supervised and they're given feedback to hopefully provide enough of a foundation to transition somewhat more confidently to internship. Still, 20 hours isn't much when dealing with interpersonal dynamics littered with complications needing resolution. Thus, upon entering internships, the insecurity can linger.

Despite doing as well as one could hope for in the practicum, more than one has said, as they head toward internship, "Who am I to be a therapist to someone with real problems? I'm not grounded in a particular theory. I don't have a toolbox full of special skills to wield. I feel like an imposter." It is for just this stage in a therapist's career that I wrote Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness (Routledge, 2024). The chapters provide new therapists material not learned in classes, that may not arise in supervision and could otherwise take years to figure out, like building better therapeutic alliances and refining the diagnostic process.

But even before all that, new therapists need to know that they have what it takes to enter more confidently into the setting in which the above can be put to use.

I recently began catching up senior practitioners who have positively influenced me over the years and asked them to reflect on their careers and share what they'd like new generations of therapists to know. On May 31, 2024, I had the pleasure of spending some time with the esteemed psychoanalyst Nancy McWilliams and getting her thoughts on the topic. I asked McWilliams what transtheoretical advice she'd like to pass on to the new generations.

She first stressed that it's helpful for therapists to have experience of their own therapy. Dr. McWilliams detailed, "That way they can deeply internalize the fact that therapy is helpful and that it's the relationship itself that helps the most. I think a lot of the impostor feelings that new therapists complain about have to do with the absence of the once-unquestioned norm that therapists should have their own experience with psychotherapy."

Dr. McWilliams then provided these three more practice-related tips:

1. "You already know the most important things you need to know to be a good therapist."

McWilliams explained that, if you're in this field, you care about people, you're curious about them, and are interested in making honest discoveries about what makes you and them tick. These are the ingredients of a good therapeutic relationship. "We know from all the empirical literature that it's the therapeutic relationship that matters more than the particular technique." She said that the specific qualities in therapists that patients most associate with good outcomes (citing Miller and Moyers, 2021) are genuine respect, curiosity, honesty, and a willingness to struggle alongside patients. McWilliams observed, "These are all the things that tend to be true of people who are attracted to the field."

2. "Don't get distracted by the fact that there are a zillion techniques you could learn."

McWilliams offered, "I think all the focus on evidence-based practice skills therapists are 'supposed' to learn is undermining the natural confidence of people who know they're good with people."

She added that, unfortunately, therapists may lose sight of her first point and feel a need to quickly compile an arsenal of specific techniques from all of the evidence-based practice skills they're constantly hearing about. "When patients look back on successful treatment, it's rarely a particular interpretation or particular skill they were taught. They remember the genuineness of the therapist."

"The problem with such a big focus on all kinds of skills," McWilliams continued, "is when something gets stuck in treatment, the therapist can think, 'It must be because there's some technique I haven't learned,' and if you experience a roadblock while working with a patient and experience it as 'Oh, my god! I must not have learned some skill, and therefore must not be a good enough therapist,' you have nowhere to go."

She suggested instead that it's more effective to rely on those natural people skills and consider, "OK, can we collaborate on understanding what's not going right here? Like am I maybe not understanding you, or maybe there's something you don't really went to change, or something?"

3. "Admit when you don't understand."

McWilliams shared that early on she'd try to show a lot of empathy as her main tool in forging therapeutic relationships. "I learned you were supposed to find some way to make it clear you empathized with the patient—saying things like, 'I get it, you're really depressed. Sometimes its so bad you don't want to live,' and turn myself into a pretzel sometimes to get it across that I understood them and was thus empathic." One patient, McWilliams said, would rage at her and often leave the sessions. On the way out the door they'd accuse her of not understanding, even though McWilliams was accurately reflecting back her objective understanding of the patient's struggle.

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This particular patient led McWilliams to realize that she sometimes really didn't get it. In this specific case, she had never been as depressed as this patient, who ultimately reacted to a sense that McWilliams didn’t understand and wasn’t acknowledging that. It wasn’t genuine. "I came back and said, 'You're right. I don't get it. I've never been as depressed as you are. It looks like hell.'"

That was the point when the patient felt that maybe they could work her, she recalled. "Paradoxically," she reflected, "it was as if they took my admission to actually having an earlier deficit in empathy as empathic."

When patients have a reaction to you, McWilliams advised, there's probably some grain of truth to their discontent, and you have to work with it. Admitting that you may not understand can lead to more collaborative discussions and even save the therapeutic relationship.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual's provider or formal supervision if you're a practitioner or student.