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What Therapists Want

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It’s Certainly Not Money or Fame!

By Barry Duncan

A close-up look at a 20-year, multinational study that captures the heart of therapists’ aspirations---and perhaps the soul of our professional identity.

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—we knew at the outset that devoting our lives to trying to assuage human misery wouldn’t be a walk in the park. Still, given the increasing hardships of the profession, many of us do grow battle weary and begin to wonder why we enlisted in the first place. So what keeps us from succumbing to burnout or getting a job that’s more fun—like tarring roofs in Miami in August or draining septic tanks?

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 (both contributors to the venerable Handbook of Psychotherapy and Behavior Change) not only has the answer, 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 as a collaborative project with members of the Society for Psychotherapy Research. What’s fascinating about the results of this longitudinal study is the consistency of response across therapist training, nationality, gender, and theoretical orientation. The study portrays psychotherapy as a unified field, despite what our warring professional organizations and theories often tell us. The specific findings reaffirm some characteristics therapists already know about themselves, and includes new, illuminating details. Therapists stay in the profession, 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. Therapists have a deep need to think of themselves as learning more and getting better at what they do over time. As they accrue the hard-earned lessons offered by different settings, modalities, orientations, and populations, they want to come out on the positive end of any reappraisal of their experience. It’s a feeling common to people in many professions and walks of life: the better you think you are at something, the more invested you are in doing it.

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.

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