Why Would Anybody Become a Therapist?

Reflecting on the Soul of Our Professional Identity

Barry L. Duncan

It’s no secret to anybody in our field that this is a tough time to be a therapist. In public agencies, we’re underpaid, overworked, and held to unattainable “productivity standards” (24 to 28 client hours a week; 30 to 34 scheduled appointment hours to make up for cancellations and no-shows). We’re subjected to a continual onslaught of paperwork to secure payments, and frequently face cutbacks and layoff threats. While some of us still thrive in private practice, most of us make far less than we did during the “golden age” of fee-for-service insurance reimbursement. Furthermore, the nature of clinical work often is frustrating, even anxiety-provoking, exposing us to high levels of human suffering.

Adding insult to injury, the culture at large doesn’t seem to admire therapists particularly, or understand what we do. This point is clear if you take a moment to think about the portrayals of therapists by Dr. Marvin Monroe of The Simpsons or Jack Nicholson in Anger Management or Barbra Streisand in Meet the Fockers. Sure, good examples of competent clinicians exist, but they’re far outweighed by those that cast us as self-indulgent crackpots endlessly mouthing psychobabble. So, why would anybody choose to enter such a field?

To be sure, most of us didn’t choose this work because we thought we’d acquire the lifestyles of the rich and famous. A massive, 20-year, multinational study of 11,000 therapists conducted by researchers David Orlinsky of the University of Chicago and Michael Helge Rønnestad of the University of Oslo not only has the answers, but captures the heart of our aspirations and perhaps the soul of our professional identity.

For their book published in 2005, How Psychotherapists Develop, they collected and analyzed detailed reports from nearly 5,000 psychotherapists about the way they experienced their work and professional development. Since then, 6,000 more therapists have participated in the study. Therapists stay in the profession, they found, not because of material rewards or the prospect of professional advancement, but because—above all—they value connecting deeply with clients and helping them to improve. On top of that, the clinicians interviewed consistently reported a strong desire to continue learning about their profession, regardless of how long they’d been practicing. Professional growth was cited as a strong incentive and a major buffer for burnout across the board.

Orlinksy and Rønnestad termed both what therapists seek in their professional careers and the satisfaction they receive from the work they do healing involvement. This concept describes therapists’ reported experiences of being personally engaged, communicating a high level of empathy, and feeling effective and able to deal constructively with difficulties. Healing involvement represents us at our best—those times when we’re attuned to our clients and the path required for positive change becomes clearly visible; those times when we can almost feel the “texture” of our therapeutic connection and know that something powerful is happening. But what causes this, and more important, how can we make it happen more often?

We all know that healing involvement isn’t simply an inevitable outcome of sitting in an office with troubled and unhappy people for many years. According to Orlinsky and Rønnestad, it emerges from therapists’ cumulative career development, as they improve their clinical skills, increase their mastery, gradually surpass limitations, and gain a positive sense of their clinical development through the course of their careers.

But an even more powerful factor promoting healing involvement is what the authors call therapists’ sense of currently experienced growth—the feeling that we’re learning from our day-to-day clinical work, deepening and enhancing our understanding in every session. Orlinsky and Rønnestad suggest that this enlivening experience of current growth is fundamental to maintaining our positive work morale and clinical passion.

According to their study, the path to currently experienced growth is clear. It’s intimately connected to therapists’ experiences with clients and what they learn from them, and is unrelated to workshops and books trumpeting the latest and greatest advances in our field. Almost 97 percent of the therapists studied reported that learning from clients was a significant influence on their sense of development, with 84 percent rating the influence as “high.” It appears therapists genuinely believe that clients are the best teachers. But the finding that most impressed Orlinsky and Rønnestad was therapists’ inextinguishable passion to get better at what they do. Some 86 percent of the therapists in the study reported they were “highly motivated” to pursue professional development. It appears that no matter how long they’ve been in the business, therapists still want to learn more and get better.

To the question, “Why is our growth so important to us?” Orlinksky and Rønnestad posited a close link between healing involvement and currently experienced growth. The ongoing sense that we’re learning and developing in every session gives a sense of engagement, optimism, and openness to the daily grind of seeing clients. It fosters continual professional reflection, which, in turn, motivates us to seek out training, supervision, personal therapy, or whatever it takes to be able to feel that the developmental process is continuing. Borrowing a term from the late Johns Hopkins psychiatrist and common-factors theorist Jerome Frank, having a sense of currently experienced growth “remoralizes” therapists, repairing the abrasions and stressors of the work and minimizing the danger of falling into a routine and becoming disillusioned. “[It] is the balm that keeps our psychological skin permeable,” said Orlinsky. “Many believe that constantly hearing problems makes one emotionally callused and causes one to develop a ‘thick skin.’ But not therapists. We need ‘thin skin’—open, sensitive, and responsive—to connect with clients.” Currently experienced growth, then, is our greatest ally for sending the grim reaper of burnout packing—we need to feel we’re growing to fend off disenchantment.

The Importance of Measuring Outcomes

Achieving a sense of healing involvement requires a continual evaluation of where we are compared to where we’ve been. We must keep examining our clinical experiences, looking for evidence of our therapeutic mastery and mining our sessions for the golden moments that replenish us. But if our sense of healing involvement with clients is tied to our ongoing sense of making a difference, how do we know we’re truly helping? You know when a roof is tarred or a tank drained, but how do you know when psychotherapy is beneficial? Therapeutic outcomes are hard to define and harder to measure.

The research literature offers strong evidence that therapists aren’t good judges of their own performance. Consider a study by Vanderbilt University researcher Leonard Bickman and associates reported in 2005 in the Journal of Clinical Psychology: In Session in which clinicians of all types were asked to rate their job performance from A+ to F. About 66 percent ranked themselves A or better. Not one therapist rated him- or herself as being below average! If you remember how the Bell Curve works, you know that this isn’t logically possible.

It’s not that we’re naïve; it’s simply hard, if not impossible, to accurately assess your effectiveness on a client-by-client basis. For this, you need some quantitative standard as a reference point—you need to measure outcomes. I can hear you groan, but I’m not talking about outcome measurement for the sake of bureaucratic “accountability” to funding sources or for justifying your existence by demonstrating your “proof of value” or “return on investment.” Rather, measuring outcomes allows you to cut through the ambiguity of therapy, using objective evidence from your practice to help you discern your clinical development without falling prey to that perennial bugaboo of the therapeutic endeavor: wishful thinking. Taking the time to measure outcomes relates directly to both having an awareness of our mastery over time and experiencing a sense of current growth.

How does outcome measurement further cumulative career development and currently experienced growth—the two keys to greater healing involvement with clients? First, cumulative career development is another way of saying that we’re “getting better all the time.” The routine collection of outcome data allows you to determine your effectiveness over time, and gives you a base for trying out and accurately evaluating new strategies. Begin simply by entering your outcome scores into a database, and keeping track of them on an ongoing basis: intake and final session scores, average change score (the difference between average intake and final session scores), and, ultimately, the percent of your clients who benefit. If you can review and assess your clinical work through the years, you can actually learn from your experience, rather than simply repeating it and hoping for the best.

Of course, finding out how effective you really are can be risky business. What if you find out that you’re not so good? What if you discover that you’re—say it isn’t so!—just average? Measuring outcomes takes courage, but so did walking into a consulting room for the first time to counsel someone in distress—and so does doing it day in and day out.

The Orlinsky and Rønnestad study contains important information about who we are and what we have to do to remain a vital force in our clients’ lives. It shows that our professional growth is a necessary part of our identity, as is our need to harvest the experiences that replenish us. It’s not enough to be soft-hearted and empathetic. Therapists need to have a keen sense of reality-testing to keep their heads above water in this field and make sure their work continues to be fulfilling.


This blog is excerpted from "What Therapists Want" by Barry Duncan. The full version is available in the May/June 2011 issue, Achieving Excellence: Do We Need a New Model?

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Photo © Rob Colvin/Images.com/Corbis

Topic: Professional Development | Anxiety/Depression | Business of Therapy

Tags: depression | empathy | psychotherapy | PTSD | relationships | therapist | therapy | healing | networker | burnout | Barry Duncan

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Saturday, January 2, 2021 1:50:16 PM | posted by Marcia Gibson
Can anyone recommend a program where I could keep track of outcome data? I agree it is very important to get a reasonable and accurate sense of how one is doing as a therapist. I am just not sure how to begin. Thank you

Thursday, June 2, 2016 9:13:23 PM | posted by Cheryl A. Underhill
Excellent article on the reason I still feel rewarded (after almost 19 years in private practice) in working with folks to be the best they can be...in spite of the challenges with billing and payment (you are so right). Well put. Thank you for the encouragement.

Saturday, November 7, 2015 11:17:25 PM | posted by Dave
A Response To Mary:

From my own observations and perspective of long term employment in the private nonprofit agency world the sources of "burn out" for therapists is often, not always,
the robust, to put it nicely, documentation requirements of current CCO's and the Mental Health Systems that support our work and organizational missions. It is not necessarily the amount of client contact, unless it is truly out of balance, or inadequate or meaningful clinical supervision is absent or inconsistent, or/and the range of clients exceeds the professional scope of the therapist. Perhaps in your work environment those demands or standards are set by you and your professional license standards.

Tuesday, November 3, 2015 12:42:10 AM | posted by Mary
I don't think seeing 24-28 clients a week is a lot. That is less than a 40 hour work week. I see 20-30 clients a week and I run a group practice. We are out of network and don't participate in any insurance panels nor do we have a sliding scale. I think therapists don't actually work hard enough and that's why they make poor incomes. In the corporate world, people work 40-60 hours per week. That's why they make more money than therapists.