In my blog post about Barry Duncan's book "On becoming a better therapist", I mentioned three major influences that had helped form that work.  I've already written about the first two - "The heart & soul of change: delivering what works in therapy (2nd edition)" and "The Norway feedback project: a clear and sensible way to make psychotherapy more helpful".  The third influence Duncan cites is Orlinsky & Ronnestad's "How psychotherapists develop: a study of therapeutic work and professional growth".  Now this seems a jump sideways.  As the book's dust jacket states " ... based on a 15-year study of psychotherapists' experiences and careers ... the authors and their collaborators collected richly detailed reports from nearly 5,000 psychotherapists of all career levels, professions, and theoretical orientations in more than a dozen countries worldwide ... this landmark work emphasizes to researchers the importance of the psychotherapist's contribution to effective treatment, offers guidance to teachers and supervisors of psychotherapists, and - not least - promises to satisfy the curiosity of therapists at all career levels about how their own experiences ... compare with those of their peers and colleagues."

So why did this work inform Duncan's book?  Well, for a series of reasons - not least because Orlinsky & Ronnestad document so clearly how psychotherapists are definitely interested in " ... becoming a better therapist".  They asked more than 4,700 subjects "How important to you is your further development as a psychotherapist?" and reported (p.104) "Replying on a 6-point scale (0 = not at all, 5 = very), 65% of therapists gave it the highest possible rating, and another 21% gave it the next highest rating.  Thus, 86% of the total sample appears highly motivated to pursue further professional development."

The Orlinsky & Ronnestad book is full of interesting insights and nuggets of information.  I like their comment (p.6) "We think that virtually all psychotherapists, when effective, do the following for their patients, in various measures according to the varying needs of their patients.  They listen facilitatively, that is, attentively and respectfully (although not always with respect for patients' self-imposed and self-defeating limitations); they provide support, helping to calm, comfort, and console; they help solve patients' problems by reframing those problems, by proposing effective problem-solving strategies, or by exploring possible alternative solutions; and they offer counsel, providing information, instruction, or advice.  That is also what most patients hope to find in a psychotherapist: someone well equipped and ready to listen well, provide needed support, help solve problems, and counsel wisely.  Patients may also find in therapists a model of maturity whose internalization strengthens them."

When describing the main findings from their study (p.161) they write "Analyses of many specific aspects of therapeutic work, described by a large and diverse group of therapists, resulted in the depiction of two inclusive modes of participation identified as Healing Involvement and Stressful Involvement.  Healing Involvement reflects a mode of participation in which therapists experience themselves as personally committed and affirming in relating to patients, engaging at a high level of basic empathic and communication skills, conscious of Flow-type feelings during sessions, having a sense of efficacy in general, and dealing constructively with difficulties encountered if problems in treatment arose.  By contrast Stressful Involvement is a pattern of therapist experience characterized by frequent difficulties in practice, unconstructive efforts to deal with those difficulties by avoiding therapeutic engagement, and feelings of boredom and anxiety during sessions."  Unsurprisingly, we as real-world therapists are familiar with both of these states.  Orlinsky & Ronnestad characterize Effective Practice as involving much Healing Involvement and little Stressful Involvement.  About 50% of therapists in their large study sample were involved in Effective Practice according to these criteria.   

They go on to comment (p.178-9) "There is, in fact, a striking similarity between the depiction of effective therapeutic process based on 50 years of process-outcome research and the therapeutic work dimension of Healing Involvement.  On the basis of our most recent review of process-outcome research (Orlinsky, Ronnestad, & Willutzki, 2004) ... two broad conclusions can be drawn about the nature of effective therapy.  First, therapeutic process and outcomes are largely determined by what patients bring to treatment by way of deficits and resources and by how patients experience and utilize their therapists' help.  The second conclusion is that the quality of the therapeutic bond or alliance between patient and therapist exerts a highly consistent and often powerful influence on therapeutic outcomes.  Regarding the first conclusion, the accumulated research clearly demonstrates the importance of patients' responsiveness to therapist interventions.  The patient's cooperativeness with and openness to the therapist's interventions are crucial mediators of their effectiveness (note how relevant this makes regular monitoring of the working alliance, checking carefully - and not assuming - that therapist & client are 'on the same page') ... The second point, focusing more on the therapist's contribution, is also more directly relevant to our study.  Positive therapeutic outcomes are robustly predicted when therapists are experienced as being personally engaged rather than detached, collaborative rather than directive, empathic, and warmly affirming.  This is especially true when these therapist attributes are experienced from the patients' perspective, but it is also true when process and outcome are observed and evaluated by outside observers or by therapists themselves.  This pattern of relating to patients is the same as therapists experience in Healing Involvement." 

For further thoughts about this book, see the blog post "Orlinsky & Ronnestad ... What maintains commitment, fascination & care in our work?"