The wisdom of therapist uncertainty

"Uncertainty is your space for growth." – Angela, psychologist

Work hours for many are unpredictable. Political divisions, pandemics, and extreme weather add further unknowns to daily life. In an era that challenges mental health, it's easy to assume that therapists should be pillars of all-knowing sureness.   

One Fear to Rule them All

But growing evidence suggests that practitioners can benefit from leaning into their uncertainty in times of flux. Skillfully accepting and even embracing not-knowing is linked to better mental well-being and improved decision-making in both clinicians and their patients. "We need to help psychologists view uncertainty not as a horrible thing you need to minimize, but as an opportunity to learn and grow," says Elly Quinlan, a senior lecturer in psychology at the University of Tasmania and a leader in the study of uncertainty in clinical practice.

How humans contend with the unknown is a topic attracting attention in clinical psychology. This critical capacity is measured by gauging people's "intolerance for uncertainty," or the degree to which they view unknowns and the unsureness they spark as threatening or merely challenging. (Sample assessment component: "Unforeseen events upset me greatly.") (1) Importantly, being intolerant of uncertainty is now recognized as a transdiagnostic vulnerability factor for a range of disorders, including anxiety, depression, and obsessive-compulsive disorder. (2) As Canadian researcher Nicholas Carleton writes, this trait (and state) may be the "one fear to rule them all." (3)

As a result, leading psychologists are targeting uncertainty intolerance as a promising new way to treat many mental disorders. By taking on more unknowns in daily life, patients gain skill at meeting life's twists with a curious, open mind, rather than fearfully racing to eliminate uncertainty through denial or snap judgment. During one intervention, young adults tried answering their phones without caller ID. (4) An adult learning uncertainty tolerance in therapy challenged himself to delegate more at work. (5) Results are encouraging: in one recent study focused on bolstering uncertainty tolerance, worry and anxiety in people with generalized anxiety disorder fell after treatment to levels experienced by the general population. (6)

Now Quinlan and others increasingly see uncertainty tolerance as a needed skill for psychologists themselves to practice. Psychologists interviewed for a small quantitative study led by Quinlan reported primarily negative responses to situations filled with unknowns, such as an ethical dilemma or the challenge of selecting treatment for a high-risk patient. (7) The psychologists, who had diverse levels of experience, reported anxiety, feeling inadequate, frustration, and anger. Some avoided complex, ambiguous cases or left a client in order to escape uncertainty. "I actually could not resolve that uncertainty, so I shifted the client to another clinician," said one.  

Such markers of an inability to manage uncertainty are associated with both anxiety and with burnout, conditions that undermine well-being and decision-making skill. In one study of 252 psychologists, their uncertainty intolerance in client care and in daily life predicted burnout (8), a form of exhaustion that up to 40 percent of mental health providers experience today. (9) Uncertainty intolerance is also linked to overtesting, according to studies in primary care medicine. (10)

The Importance of Uncertainty Tolerance

In contrast, psychologists who accept the intrinsic uncertainty of their work and see not-knowing as an opportunity for learning, as discomfiting as that may be, tend to have higher mental well-being. Angela, a psychologist who participated in another of Quinlan's qualitative studies, advises younger peers to "treasure the darkness a bit. Uncertainty is your space for growth." (11) Uncertainty-agile clinicians ask, "What is this ambiguity or my uncertainty telling me?" instead of rushing to bury or eradicate the unknown, says Quinlan, whose research has inspired her to assure her trainees that it's okay, and even helpful, to not know.

By recognizing uncertainty as a path to wisdom, providers gain time and space to consider nuance and alternative perspectives. In a speed-driven world where experts are expected to be all-knowing and ultra-decisive, psychologists often "long for the magic wand" of the quick, clear answers, observes educational psychologist Daniela Mercieca of the University of Dundee. But "it is only by allowing ourselves to be uncertain that we are open to shock and surprise … and complexity." (12)

How can psychologists learn to recognize unsureness as an opportunity? Efforts to map uncertainty tolerance are so new that interventions to teach this skill set to practitioners are sparse in both psychology and in general medicine. One intervention found that training in non-judgmental mindfulness helped trainee psychologists become less stressed by uncertainty. (13) Other studies have shown that exposure to the visual arts or the humanities can boost uncertainty tolerance in medical students. (14) Quinlan plans to begin formally testing uncertainty-tolerance strategies for trainee psychologists in a few years. 

There may come a day when healthcare practitioners will be routinely taught to manage uncertainty as a way to improve their well-being and their efficacy. But until that time, perhaps clinicians can learn from the peers and patients around them who find wisdom in accepting life's inherent unpredictability and in realizing that at any one moment they might not know.

Recently, two young practitioners found that openly admitting uncertainty in their practice felt unexpectedly liberating. The opportunity arose in 2020 as cognitive behavioral therapist Layla Mofrad and psychologist Ashley Tiplady worked with Mark Freeston of the University of Newcastle to develop a group intervention to teach uncertainty tolerance to patients just starting to receive care for a range of disorders. (15) To model the intervention's content, they explicitly talked to one another and to patients about the program's unknowns, ranging from outcomes of this novel treatment to how a tech outage might affect the day's schedule.   

Most patients who completed the "Making Friends with Uncertainty" intervention showed significant improvements in their anxiety and depression and nearly half became more tolerant of uncertainty. Moreover, the facilitators themselves found that working with, not hiding from, uncertainty improved group solidarity and their own ability to be partners in care. "It's easy as a therapist to jump into trying to make things feel more certain … we tried to hold back from that," says Mofrad, adding that this approach returns therapy to its ideals. "The best therapy will always have an uncertain element, and the best therapists are those who will ask questions, be curious, and not stick to a rigid framework."

• Maggie Jackson is an award-winning journalist and author most recently of Uncertain: The Wisdom and Wonder of Being Unsure, nominated for a National Book Award and named a Top 10 Social Sciences book of 2023 by Library Journal.
• This article was originally published on Psychotherapy.net and is reproduced with kind permission.

References

1) Carleton, R. N.; Norton, P. J., & Asmundson, G. J. G. Fearing the unknown: A short version of the Intolerance of Uncertainty Scale. Journal of Anxiety Disorders, 21, 105-117.

(2, 15) Mofrad, L., Tiplady, A., Payne, D., & Freeston, M. (2020). Making friends with uncertainty: Experiences of developing a transdiagnostic group intervention targeting intolerance of uncertainty in IAPT: Feasibility, acceptability, and implications. The Cognitive Behaviour Therapist, 13 (49), 1-14.

(3) Carleton, R. N. (2016). Fear of the unknown: One fear to rule them all. Journal of Anxiety Disorders, 41, 5-21.  

(4) Unpublished material shared with the author by Stephanie Gorka and Nicholas Allan of Ohio State University's College of Medicine.

(5) Keith Bredemeier Assistant Professor at the University of Pennsylvania Perelman School of Medicine Center for the Treatment and Study of Anxiety, in discussion with the author, September, 2023.

(6) Dugas, M. J., Sexton, K. A., Herbert, E. A., Bouchard, S., Gouin, J-P., & Shafran, R. (2022). Behavioral experiments for intolerance of uncertainty: A randomized clinical trial for adults with generalized anxiety disorder. Behavior Therapy, 53 (6), 1147-1160. 

(7) Quinlan, E., Schilder, S., & Deane, F. P. (2021). `This wasn't in the manual': A qualitative exploration of tolerance of uncertainty in the practicing psychology context. Australian Psychologist, 56 (2), 154-167.

(8) Malouf, P., Quinlan, P., & Mohi, S. Predicting burnout in Australian mental health professionals: Uncertainty tolerance, impostorism, and psychological inflexibility. Clinical Psychologist, 27 (2), 186-195.

(9) O'Connor, K., Muller Neff, D., & Pitman, S. (2018). Burnout in mental health professionals: A systematic review and meta-analysis of prevalence and determinants. European Psychiatry, 53, 74-99.

(10) Korenstein, D., Scherer, L. D., Foy, A...Morgan, D. J. (2022). Clinician attitudes and beliefs associated with more aggressive diagnostic testing. American Journal of Medicine, 135 (7); also Lam, J. H., Pickles, K., Stanaway, F. F., & Bell, K. J. L. (2020). Why clinicians overtest: development of a thematic framework. BMC Health Services Research, 20 (1011),

(11) Fewings, E., & Quinlan, E. (2023). 'It hasn't gone away after 30 years.': Late-career Australian psychologists' experience of uncertainty throughout their career. Professional Psychology: Research and Practice, 54 (3), 221-230.

(12) Mercieca, D. (2009). Working with uncertainty: Reflections of an educational psychologist on working with children. Ethics and Social Welfare, 3 (2), 170-180.

(13) Pickard, J. A., Deane, F. P., & Gonsalvez, C. J. (2024). Effects of a brief mindfulness intervention program: Changes in mindfulness and self-compassion predict increased tolerance of uncertainty in trainee psychologists. Training and Education in Professional Psychology, 18 (1), 69-77. 

(14) Patel, P., Hancock, J., Rogers, M., & Pollard, S. R. (2022). Improving uncertainty tolerance in medical students: A scoping review. Medical Education, 56 (12), 1163-1173.