Doubt and the boundary of therapeutic confidence

Edmund P. Piper (2005)

The reliability of information psychotherapists are given to work with is not always dependable. This can be a problem when important clinical, relational, or criminal outcomes depend on uncorroborated renditions of critical events. The need for certainty in these circumstances is seldom accompanied by the means. Therapists are generally not in a position to reconcile doubts that arise from the limited, subjective, and sometimes contradictory information they've been given to work with. This study examined the incidence, influence, accommodation, and tolerance of therapists' doubt. Ninety-seven psychotherapists were surveyed about doubt's prevalence in their work, how they manage it, and whether doubting the factual bases for their conclusions limits their confidence to intervene. The subjective reliability of a supplied story (doubt-belief) and subsequent ability to act based on one's grasp of the described situation (therapeutic confidence), are distinguished as variables. The existence of a saturation point--where a therapist's doubts become great enough to preempt the confidence necessary to continue a treatment--is introduced and tested. Ninety-seven percent of the therapists sampled encountered therapy-effecting doubt in their work and reported diverse and proactive responses when confronted with factual uncertainty. The majority was inclined to actively pursue resolution, resist polarization, favor their suspicions, adjust for hyperbole, accept occasional dissimilitude as culturally normal, scrutinize peer input, use base rates to assess reliability, and let doubt pique their interest. Our survey did not find a significant relationship between doubt and therapeutic confidence, though their independence was substantiated. Their correspondence is apparently more complex (and possibly symbiotic) than simply correlative. The existence of a boundary to practitioner's therapeutic confidence was broadly supported by 97% of the sample with 20% having actually encountered it. Whether therapists respect their misgivings or simply accept what they are told verbatim is going to influence the relationship, the work, and ultimately its therapeutic potential. Evidence of doubt's ubiquity, the articulation of subjective reliability (doubt) and therapeutic confidence as distinct variables, and the substantiation of a boundary to clinician's confidence offer points of departure for further research on doubt and its sequelae.