Orlinsky & Ronnestad's "How psychotherapists develop": three key recommendations for maintaining effectiveness
Last updated on 12th December 2011
I have already written a couple of times on Orlinsky & Ronnestad's book "How psychotherapists develop: a study of therapeutic work and professional growth" which reports on their 15 year study of nearly 5,000 psychotherapists in a dozen countries. The first of these two posts looked generally at the book, documented how committed most therapists are to keep trying to increase their helpfulness, explored what is involved in effective therapeutic work, and made a distinction between what the authors call "Healing involvement" and "Stressful involvement". The second post highlighted that therapists & clients usually sink or swim together - really helpful therapeutic work for the client is typically also deeply fulfilling work for the therapist. Possibly somewhat counter-intuitively the authors reported that "Of the many variables we assessed, Currently Experienced Growth was by far the strongest predictor of Healing Involvement." I say "somewhat counter-intuitively" because one could argue from cold facts that a therapist who - in some kind of Emile Coue style - felt that "Every day, in every way, I'm getting better and better" wouldn't have their feet very solidly on the group. "Currently experienced growth" seems most potently about therapist morale, and only secondarily about actually gaining further therapeutic expertise. So Orlinksy & Ronnestad write (p. 129) "The high rates of commitment to continued development reported by therapists at all career levels, and the high degree of Currently Experienced Growth manifested by therapists at all career levels, point to the conclusion that much of this current growth serves to refresh the therapists' constantly challenged work morale and to regenerate their constantly eroded capacity to engage constructively with patients. However, some part of current growth also constitutes a gradual enhancement and expansion of therapeutic skill and capacity through new learning."
This underlining of the importance of re-charging our batteries, of re-connecting to our commitment to "be the best we can be" - whether as therapists, or in any other area of our lives - seems very important to understand. We are not mechanical systems that one fixes by putting in a new part to replace the one that has been malfunctioning. We are much more organic than this - for example, more like a garden that needs repeated love and care for it to flourish. This is highlighted very well in research on wellbeing. High levels of happiness and wellbeing aren't achieved by "putting in a new part". The "hedonic treadmill" means that we soon adapt to improved circumstances and typically revert quite quickly to how happy we were before the change took place. See an earlier blog post on this site - "Goal renewal boosts wellbeing" - and also Lyubomirsky & Sheldon's fine, free full text book chapter - "Change your actions, not your circumstances: an experimental test of the Sustainable Happiness Model" - for more information and practical suggestions about responding to the challenge of the hedonic treadmill.
In a somewhat similar way, we probably need to keep replenishing our interest & commitment to our work as health professionals & healers. As Hippocrates put it "Life is short, the art (craft) long." For me, a major source of inspiration is the constant river of newly emerging research. There is genuine reason to believe that I can repeatedly learn new information that allows me to help in situations where before I couldn't - what a joy! And this leads to exploring fresh methods and different types of work - see below for more on this. Another source of inspiration and challenge comes more directly from clients/patients. Trying to help this particular person with this particular constellation of problems can act as a springboard for new investigation & learning. Practice-based feedback can be of particular use here. And there is inspiration from meeting with colleagues and hearing of their journeys as therapists - the much-commented on experience that conference coffee break conversations can be fully as important as the lectures one has come to hear. And there is, for many of us, the internal dedication to our work - whether we use daily prayer, goodwill meditation practice or some other way of re-committing to this ancient calling to do what we can to help relieve suffering.
In "How psychotherapists develop" Orlinsky & Ronnestad base their conclusions on careful analysis of a huge amount of information from therapists and their practices. They note "Of the many variables we assessed, Currently Experienced Growth was by far the strongest predictor of Healing Involvement." They assessed Currently Experienced Growth with a simple set of six questions scored from 0 = Not at all ... to ... 5 = Very much. The questions were: In your recent therapeutic work, how much ... * Do you feel you are changing as a therapist? * Does this change feel like progress or improvement? *Do you feel you are overcoming past limitations as a therapist? *Do you feel you are becoming more skilful in practicing therapy? *Do you feel you are deepening your understanding of therapy? *Do you feel a growing sense of enthusiasm about doing therapy? Total score for the six questions was then divided by six to give an average score per question. They give (p.290) range and percentile scores for therapists grouped by experience into Novice, Apprentice, Graduate, Established, Seasoned and Senior. The "experience" here ranged from < 1.5 years for a Novice, through 1.5 to < 3.5 years for an Apprentice & 3.5 to < 7 years for a Graduate, to 7 to < 15 years for Established, 15 to < 25 for Seasoned, right up to an ancient Senior like me with 25 or more years of experience. Average scores for these groups were 3.3, 3.5, 3.5, 3.6, 3.5 & 3.5 respectively. I find this inspiring and quite extraordinary that therapists of many years experience can maintain their sense of growth, freshness and enthusiasm so well. Brilliant. Percentile scores are given as well with the lowest 20% scoring at or < 2.7 to 3.0 (depending on their group/years in practice), the lowest 40% at or < 3.2 to 3.5, the upper 40% scoring 3.7, 3.8 or more, and the highest 20% scoring 4.2 or more. These are important numbers. If you are a counsellor or psychotherapist, why not try scoring yourself on the six questions and see how you're doing. Click here for a PDF of the questions & typical scores. My suspicion is that there will be a similar process for other health professionals as well.
Orlinsky & Ronnestad provide a series of questionnaires to help therapists assess how they are doing in their practice. For many of us it would be well worth getting hold of this book, looking through it, and scoring ourselves on these assessment measures. The authors go on to make a series of suggestions which are especially relevant for the 50% or so of us who aren't flourishing therapeutically all that well. So one interesting finding from their research was that "More than anything else, more than even the number of years in practice, Cumulative Career Development was predicted by the breadth and depth of a therapist's experience across treatment modalities" (p.187). So the authors recommend considering diversifying one's therapy practice. By this I mean that one tries to expand beyond just one-to-one work to take in other forms of therapy like couples/family work & group therapy. Diversification can also involve assessment, research, teaching, supervision & consultation, as well as working with multiple types of patients & problems.
A second point Orlinsky & Ronnestad make is "A parallel recommendation can also be expressed as openness to different theoretical perspectives. Our finding in this study that theoretical breadth contributes significantly to experiencing therapy as Healing Involvement converges with Skovholt and Ronnestad's (1195) qualitative finding regarding the importance of active engagement in theory and openness to different theoretical perspectives. We suggest to therapists in stasis that they see what they can learn from other theoretical perspectives that might be applicable to their practice" (p. 197). And finally they go on to recommend supervision (and possibly personal therapy) saying "Supervision is another form of professional development activity that therapists at all career levels rated highly as a positive influence on current development ... Peer groups also can serve an important function for therapists ... and peer supervision is highly appreciated by many experienced practitioners as a means of continued professional development."
Mm ... plenty to think about here. Key seems to be nourishing our morale, enthusiasm and involvement as therapists. Personal health, curiosity, commitment, dedication, enjoyment, gratitude ... if we're flourishing as health practitioners, it's extremely likely that our patients will benefit much more from their interactions with us. As the authors write "More generally, our findings point to an unexpectedly strong influence of therapists' current work morale, both positive and negative, on their experience in therapeutic practice. The apparently vital importance of this variable has not been recognized in the psychotherapy research literature, and on the strength of our findings we believe it should receive serious attention." (p. 180)