Do You Avoid ‘Complex’ Cases? How to Build Confidence Treating your Clients

Blog post written by Dr. Ciara McEnteggart and Dr. Yvonne Barnes-Holmes

When we speak to Clinicians about working with Clients whose presentations are deemed ‘severe’ or ‘complex’, we hear the same concerns time and again:

• “I don’t feel skilled enough”
• “I don’t have the confidence”
• “I don’t have the experience”

Many Clinicians feel they’re doing the best for these Clients when they refer them to specialists or specialist clinics. With the labels “severe” and “complex”, the therapeutic community is typically referring to Clients reporting trauma, psychotic episodes, obsessive compulsions, bipolar experiences, and what is often referred to as personality disorders. What is also surprising is how many Clinicians don’t feel comfortable working with young people with severe difficulties. 

But are we really doing the best for these Clients when we turn them away, whatever our reasoning? Perhaps the very act of being turned away is itself harmful to Clients already in serious crisis? For them, the harmful, stigmatising narrative of being too ‘broken’ or too ‘unwell’ can only deepen when Clinicians themselves feel they are ‘not competent enough’ to provide the care these Clients desperately need. Of course, some Clients do need to be referred to specialist services, such as residential or acute care, where additional supports are available. But, is that really the answer for all of those Clients across that broad group? And will that always just be the answer?

A System That Has Failed You

So, why do so many Clinicians lack confidence with these Clients? Perhaps you recall when you were first qualified? Do you remember how scared you were of making a mistake that would cause harm to a Client? Do you remember the huge pressure you felt to always do things right? Many Clinicians tell us about early professional experiences working in busy services, feeling unskilled, unsupported, and overwhelmed by a large caseload that included complex Clients. Just this early professional experience alone leaves a deep mark. 

But what about the models you learned then, do they serve you better now that you are more experienced? That’s not what we hear. We also hear again and again that what made those early experiences even worse, and is still a huge drain on professional confidence, is that the models learned throughout your careers still don’t give you confidence with those Clients. This can’t be a reflection of your abilities. This is a reflection of the models that weren’t, and still aren’t, able to fully equip you for the challenges you face as a Clinician with many Clients.

So We Learn More Models, Right?

A rational next step for Clinicians, and one which they seem to take over and over throughout their careers, is to turn to additional models, newer models, popular models, specific models for specific Clients. But, even the most-extensively trained and experienced Clinicians we deal with still say… “I don’t feel prepared” for those Clients. The problem isn’t the Clinician’s experience, commitment, or competence; it’s model-based thinking itself.

Shifting Perspective: Why One Size Fits All Works

At first glance, the concept of ‘one size fits all’ seems reductive. But what if we shift our thinking? What if we think in terms of core human processes—not simple processes, not made-up processes, but processes that have been empirically established as explanations of complex behaviour? For instance, imagine if we think of every Client as a human being trapped by their lived history, who has ended up using a range of survival strategies to cope. And beneath the individual experiences, meanings, emotions, and responses lie universal processes shared by every single one of us.

Process-based Behaviour Therapy (PBBT) focuses on these core processes rather than on unreliable diagnostic categories that fail to capture lived experience and coping responses. By shifting our focus to understanding the processes that drive identity and behavior, we can approach every Client with the confidence that we have the tools to help them.

Practical Reflections to Build Confidence

1. Where Did Your Lack of Confidence Start?
   Reflect on your early professional experiences. Were you left unsupported or unprepared? Recognizing this can be the first step to building your confidence.
2. What Are You Doing Now to Address This?
   Are you avoiding complex cases? It’s okay to acknowledge this – it’s simply the first step in changing your perspective.
3. What Do You Need to Feel More Confident?
   Is it more training, peer support, or a shift in mindset? Identifying this can be a game-changer.

Engage with Peers and Broaden Your Understanding

Engage with colleagues and share your experiences. You’ll find you’re not alone; so many Clinicians feel the same. From our experience, engaging with and supporting non-professional networks can provide invaluable insight into psychological suffering on a more human level. In fact, engagement with networks such as these really helped us shape many of the most humane assumptions underlying PBBT. 

We Are All in This Together

We are all in the midst of a global crisis in mental health. Clients are suffering, and so are Clinicians; both struggling with feelings of inadequacy, burnout and hopelessness. But we don’t have to face this alone. By working together to shift our focus, we can build confidence and provide the care that complex Clients need. Remember, you are enough, and with the right tools, you can do more than you think.

If you would like to learn more about how PBBT can support you as a Clinician, get in touch with us.

Feel free to join us for an informational Webinar on 22nd January 2025 at 4pm. There, we will speak more about PBBT, the PBBT Institute, and our new Professional Diploma in PBBT. Applications for the Diploma are now open.