What Therapists Want

It’s Certainly Not Money or Fame!

Magazine Issue
May/June 2011
Placeholder Image for psychotherapynetworker.org

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.

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.

Further evidence of therapists’ self-assessment difficulties is found in a study by Brigham Young University’s Corinne Hannan, Michael Lambert, and colleagues, reported in the same issue of the Journal of Clinical Psychology: In Session. They compared therapist judgments of client deterioration with actuarial predictions for 550 clients (algorithms based on a large database of clients who completed the Outcome Questionnaire 45.2). The average deterioration rate for psychotherapy clients is about 8 percent, so about 40 clients in this study of 550 would likely worsen with treatment. Therapists accurately predicted deterioration in only 1 out of 550 cases. Thus, of the 40 clients who deteriorated, psychotherapists missed 39. In contrast, the actuarial method only missed 4.

It’s not that we’re naïve or stupid; 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.

There are some good reasons to take the risk, however. Consider the results of a 2009 investigation of client-outcome feedback that I conducted in Norway with psychologist Morten Anker and family therapy professor Jacqueline Sparks and published in the Journal of Consulting and Clinical Psychology. The largest randomized clinical trial of couples therapy ever done, it found that clients who gave their therapists feedback about the benefit and fit of services on two brief, four-item forms reached clinically significant change nearly four times more than non-feedback couples did. (Both measures are available to download for free at www.heartandsoulofchange.com.)

So it’s clear that clients benefit from the use of feedback forms, but so do we. Tracking outcomes improved the results of 9 out of 10 therapists in this study. In fact, Anne, a therapist in the low-effectiveness group without feedback became the therapist with the best results with feedback. This heartening finding suggests that, regardless of where you start in terms of your effectiveness, you, too, can be among the most successful therapists if you’re proactive about tracking your development.

As for the relationship of measuring outcomes to currently experienced growth, as Orlinsky and Rønnestad have shown, the old therapeutic cliché is true: therapists really do believe that clients are their best teachers. Clients provide the opportunity for constant learning about the human condition, different cultures, and worldviews, as well as the myriad ways that people transcend adversity and cope with the unthinkable. But while we learn a great deal almost by osmosis from our clients, tracking outcomes takes the notion that “the client is the best teacher” to a different, higher, and more immediately practical level. Tracking outcomes with clients not only focuses us more precisely on the here-and-now of sessions, it takes us beyond mere intuition and subjective impressions to quantifiable feedback about how the client is doing. We get unambiguous data about whether clients are benefiting and whether our services are a good fit for them. From their reactions and reflections, we receive information that we can use in figuring out the next step to take in therapy. In short, tracking outcomes enables your clients—especially those who aren’t responding well to your therapeutic business-as-usual—to teach you how to work better. In fact, clients who aren’t benefiting offer us the most opportunity for learning by helping us to step outside our comfort zones.

Recall Anne, one of the lowest-scoring Norwegian therapists, who became the best therapist when she collected client outcome and alliance feedback. Here are her reflections about the relationship between her clients’ feedback and her sense of currently experienced growth:

Discussing when clients were not benefiting helped me be more straightforward, more courageous. I inquired more directly about what we could do together. . . . Clients taught me how to handle it when I was not useful. Clients and I reflected more on their changes and on the sessions. We got more concrete regarding change, how it started, and what else would be helpful.

In all, collecting outcome data with clients helped me take risks and invite negative feedback. So I asked for it, showed I could handle it, validated it, and then incorporated it in the work. That’s what therapy’s all about—real collaboration.

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.

Attaining healing involvement requires two things: your investment in yourself and a recognition of your own growth and development. This, in turn, necessitates a commitment to tracking your outcomes.

Tracking outcomes enables a big-picture view of your cumulative career development and a microscopic view of your currently experienced growth. Both perspectives allow you to continually assess your development, challenge your assumptions, adjust to client preferences, and master new tools. Monitoring outcomes can help you survive—indeed thrive—in a profession under siege, yet still compelling; a profession that offers a lifetime training ground for human connection and growth, and frequently yields small victories that matter in the lives of those we see.


Illustration © Rob Colvin / Images.com / Corbis

Barry L. Duncan

Barry L. Duncan, PsyD, is a therapist, trainer and researcher with over 17,000 hours of clinical experience. He is a best-selling author of The Heart and Soul of Change: Delivering what Works in Therapy (APA, 2010), What’s Right with You and On Becoming a Better Therapist (APA, 2010). Dr. Duncan is a sought after media expert and has appeared on Oprah and The View. The author of over 100 publications and 15 books, Dr. Duncan travels the globe providing seminars and workshops.

Dr. Duncan is the director of the Heart and Soul of Change Project, a practice-driven, training and research initiative that focuses on what works in therapy, and more importantly, how to deliver it on the front lines. He has received numerous awards for his contributions to the mental health field, including the Wright State University School of Professional Psychology’s first annual “Outstanding Alumnus Award,” the Menninger Foundation’s 15th Annual Award for Scientific Writing for the book The Heart and Soul of Change, and the Psychotherapy Networker  “20th Anniversary All Time Top Ten Award” for the article “Exposing the Mythmakers,” recognizing it as one of the most influential features in the magazine’s history. Barry’s other books include The Heroic Client (2nd edition, Jossey Bass, 2004); Heroic Clients, Heroic Agencies: Partners for Change 2nd ed., 2010 Edition); the 2nd edition of Brief Intervention for School Problems (Guilford, 2007)