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Orlinsky & Ronnestad's "How psychotherapists develop": what maintains commitment, fascination & care in our work?

I wrote a few days ago about Orlinsky & Ronnestad's very interesting 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.  I said that when describing the main findings from their study (p.161) they commented "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." ... 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 (Orlinsky, Ronnestad, & Willutzki, 2004)."  In other words, therapists & clients either both win or both lose.  Therapists who have high Healing Involvement in their work are likely to love and be deeply engaged in what they do ... while at the same time, they are likely to be more effective and helpful for their clients.  Therapists who have low Healing Involvement are likely to struggle with disengagement & burnout, while their clients will tend to do poorly.  And these findings extend to other kinds of work besides psychotherapy.  As Robert Pirsig wrote in his book "Zen and the art of motorcycle maintenance" - "... care and Quality are internal and external aspects of the same thing.  A person who sees Quality and feels it as he works is a person who cares.  A person who cares about what he sees and does is a person who's bound to have some characteristics of Quality." 

So what did Orlinsky & Ronnestad discover in their 15 year study about how psychotherapists develop & maintain high levels of Healing Involvement and Effective Practice?  One major recommendation they make is that therapists keep a very honest eye on how they're functioning.  This is important for them personally and for clients who come to see them ... therapist and client are likely to sink or swim together.  Therapists who are over-stressed and over-stretched in their work are unlikely to be helping clients as much as they could.  Fascinatingly, Orlinsky & Ronnestad found that "Of the many variables we assessed, Currently Experienced Growth was by far the strongest predictor of Healing Involvement; similarly, Currently Experienced Depletion was by far the strongest predictor of Stressful Involvement."  These two variables - Currently Experienced Growth and Currently Experienced Depletion - were assessed with a simple ten-item questionnaire given both in appendix F of their book and also reproduced in Barry Duncan's "On becoming a better therapist".

Answers to this self-assessment exercise are rated on a 6-point scale from 0 = not at all, to 5 = very much.  Questions are of the form "Do you feel you are changing as a therapist?", "Does this change feel like progress or improvement?" and even "Do you feel a growing sense of enthusiasm about therapy?".  Very real challenges when one has already been working at the "coal face" for several decades!  For more on how a sense of enthusiasm and development as a therapist can be nourished see "Orlinsky & Ronnestad's "How psychotherapists develop": three of the key recommendations"

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