My brother in law is the Sherlock Holmes of small engine repair [1].
Over the summer I was riding my lawnmower, hit a particularly thick clump of grass, and my lawnmower started to smoke. I jumped off and called my brother in law for advice.
"Oh it's the belt." He said without a doubt.
"The belt?" I asked.
"Yeah for the blades. I mean you can turn it on while I listen over the phone if you want." He said.
So I did. After about two seconds he piped up.
"Yeah it's the belt. What probably happened was when you hit that patch of thick grass, the blades tried to keep turning, but hit a soft spot in the belt and the belt began to smoke."
This guy had diagnosed my problem within two seconds and then confirmed it by listening to the sound of my engine over the phone.
The Sherlock Holmes of small engines indeed.
A few weeks later I mentioned that he was probably under appreciated by customers. He works at a small engine repair shop and can diagnose most problems in 10 minutes or less.
He makes it look too easy.
"Yeah, sometimes it sucks," He said. "Like we might charge 80$ for 10 minutes of work, but customers don't get that it took 20 years of working on engines to be able to fix the problem in 10 minutes. But it's the same for you I'm sure. You got your doctorate so you could learn how to do therapy and really fix people."
In that moment I felt a pang of imposter syndrome.
I'm not the Sherlock Holmes of therapy.
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A Contrarian View of Imposter Syndrome for Counselors
I think imposter syndrome has three parts.
It's the shame we feel...
when people expect us to be really good at something...
and we know we're not that good.
When clinicians confess that they feel like an imposter we typically focus on the first part, empathizing and validating so people won't feel shame. We empathize that we all feel we're not enough at times and we validate the hard work they've done to get to where they are.
I'm going to take a contrarian approach: let's focus on actually getting good.
Because, my hunch is, while you still may still struggle with shame, it's impossible to feel like an imposter if you're good at what you do.
For instance, I don't feel like an imposter when brushing my teeth or driving on the highway. I know how to do those things.
However, if I tell people I used to live in a city, they instantly assume things like, "oh that means you can parallel park."
Which I can't. So I feel like an imposter.
The question then becomes how do you actually know if you're a good therapists? Not just think you're good, but know you're good.
Over the past few years I've thought a lot about this question. Most researchers say that since we're really bad at self assessing our effectiveness, we have to use objective outcome measures.
I'm a big fan of this idea.
But the more I've thought about it, the more I've come to realize you don't have to do that. At least not starting out.
Tracking outcomes is incredibly time intensive and most of us just need to know if we're good enough.
As I've thought it over I've come to believe there are three metrics you can track right now to see (roughly) how good of a counselor you are.
Metric #1:1st Session Dropout Rate
Metric 1 is your 1st session dropout rate, because 1st session dropout sets the stage for the rest of your caseload. Basically the lower this number is the better.
The average 1st session dropout rate is 30% [2]. This means, for most counselors, 30% of clients don't return after the first session.
That's average though, and there's some nuance that goes into that. But, from personal experience let me say, don't let the industry standard set your expectations. If you're in private practice you could have a 1st session dropout rate of 0%. It's totally possible.
I know because my 1st session dropout rate is 0%. My dropouts start at session 3 and then I have a small cluster around session 5.
It wasn't always this way. A few years ago I couldn't build a caseload over 16 clients because my overall dropout rate was too high. And in grad school I almost didn't graduate because I couldn't get my hours. Clients kept dropping out. So I know from personal experience that you can improve.
That being said, if your 1st session dropout rate is 30% then you're good enough on that metric and cleared to move on to metric #2.
Metric #2: Joint terminations
Metric 2 is joint terminations. You want about 50%-64% of your clients to have a termination session with you. Joint terminations are usually client initiated, are negotiated between client and therapists, and end with a termination session.
There are two mistakes I've seen with this metric.
The first mistake is therapists saying, "Oh my joint termination number is pretty high. I had a client call me the other day and tell me they were done with therapy."
That's a client informing you they are dropping out. That's not what joint termination means.
The second mistake, which I made often, is not negotiating the termination with clients. I used to regularly give clients outcomes surveys. When they scored really well, indicating that their symptoms were in remission, I'd bring up termination and we'd terminate.
And then a month later I'd see them in the group practice lobby with another therapist.
Yeah.
Turns out I wasn't negotiating termination well with my clients. Instead they felt pushed out of therapy.
Starting in 2022 I changed how I do things. I don't have numbers for this yet, but for the first time I'm actually having joint termination sessions. Since this has started happening, something else has started happening.
I've had a few client generated referrals.
Metric #3: Client Generated Waitlist
Metric #3 is a client generated waitlist. Unlike the other two, this metric is not validated by the research.
But it just makes sense.
I mean there’s a reason Chick-fil-a always has a line backed to the highway and every Apple store has a line to the food court. When you do good work, people tell their friends.
The trick is you want a client generated waitlist. If most of your clients come from the local physician/pastor/principal that’s not the same as helping one client who then tells all their friends they have to see you.
Honestly I think this metric is the motherload. If you have a client generated waitlist, that means you're so good clients are knocking down the door to come see you.
The danger with this metric is maybe you're only really good at helping a certain type of client. So they refer to you while the rest of your caseload suffers.
For instance if while I occasionally get referrals from past couples, I've never gotten a referral from a teen. I'm better at helping couples than teens.
So what to do about this? Well instead of trying to be a better general therapist and getting more training on seeing teens, I'm doubling down on seeing couples.
Consider doing the same. If you're getting client generated referrals, take the time and identify what those referral sources have in common. Once you do that, boom, you just found your niche.
How to interpret your results.
So, how do you actually use this?
Ideally you'd look at your past 60 clients and see how you measure compared to the benchmarks.
Miss the benchmark for 1st session dropouts, then you probably need some coaching.
Hit the benchmark for joint terminations, then you're probably doing well enough as a therapist.
Hit the benchmark for client generated waitlist, then you're probably a rock star.
Just remember that these aren't absolutes. This is just a simplified way to get a rough estimate based on a few metrics. In most cases, this will be good enough [2].
Personally I'm at the point where I expect to have joint terminations but I don't yet have a client generated waitlist. Most of my referrals come from my Google listing. So I'm a decent therapist, but I'm no Sherlock Holmes.
The Sherlock Holmes of Therapy
In the old stories, Sherlock Holmes was accompanied by Dr. John Watson, who chronicles the journey of Sherlock Holmes.
I've a hunch that the writer made Watson a Doctor to show how brilliant Sherlock Holmes was. I mean, doctors are still considered the most educated and intelligent among us. So if Sherlock Holmes made a doctor look dumb, then his talents tower over the average man.
I realized a while ago that I would not be the Sherlock Holmes of therapy. I also know that I'm good enough. And I know that for certain because I know my numbers.
The funny thing is, while all the work I've done to become a better therapist hasn't made me the next Sherlock, I think it's made me into a decent Watson.
That's why I write this blog- to mix practical experience, a little math, and the research literature to chart the path for the next Sherlock Holmes.
And who knows? Maybe that's you. ;-)
Best,
Jordan (the Counselor)
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[note]
[1] A better comparison is to Milton Erickson MD, PhD. He was a psychotherapist with dozens of amazing stories of how fixed people's problems. But no one knows who he is. So I didn't use that analogy.
[2] Baseline numbers for dropouts and joint termination are taking from Miller, Hubble and Chow's book Better Results. For a more empirical method of analyzing your caseload I highly recommend you pick up a copy of their book.
If you liked this post, consider reading this next. I think you'll like it ;) It's more about the importance of tracking your metrics.