Research on Psychotherapists: Implications for Psychotherapy

David E. Orlinsky
University of Chicago

Paper presented at the 1st European Congress on Psychotherapy on Psychotherapy in a Unified Europe
Barcelona, 5-9 September 2000

I.

My topic in this research symposium focuses on psychotherapists rather than

psychotherapy directly. We psychotherapists are interesting people; but, more

significantly, I think one can learn some important things about psychotherapy by

studying psychotherapists. Thus I will report some findings from a large-scale

international study of the experiences, qualities, and development of

psychotherapists, and discuss with you what those findings imply about the nature

of psychotherapy.

Let me begin by asking you to think of the connection between psychotherapy

and psychotherapists. There are two views that one can take of this connection. In

the first view, which is the dominant one, psychotherapy is seen as a method for

treating psychological disorders that consists of specific procedures having

demonstrated efficacy. In this view, psychotherapists are seen as persons who have

been trained to administer these procedures correctly. The healing effect on

patients is attributed to the procedures that are used, rather than to the therapist

who administers them, and psychotherapists are seen as basically interchangeable

so long as they are adequately trained. The plausibility of this view to us as

Orlinsky: Research on Psychotherapists 2

researchers and therapists is supported by the technological culture in which we

live, and in which we seek recognition for our profession. It is a culture that

emphasizes efficiency and objectivity, and is most comfortable with explanations

that refer to impersonal “mechanisms of change.”

In the second view, psychotherapists are seen as individuals who generally

have been trained in one of the mental health professions, but who in addition

possess certain personal talents: a gift for understanding the experiences and

feelings of other people, and for helping them cope with difficult or distressing life

situations. We adopt this view implicitly when, in choosing a therapist for

ourselves or someone close to us, we think about who would be the best therapist

for that particular person, rather than simply which type of treatment to

recommend. In this case, a healing effect is attributed to the therapist or the

relationship that we think the therapist will have with the patient, rather than just

to the treatment procedure. We recognize, in effect, that one therapist may be

better for a particular patient than some other, even though both therapists have

comparable levels of technical knowledge and professional experience.

I want now to present some findings that I think shed an interesting light on

these two views of psychotherapy and psychotherapists. The findings come from a

collaborative international study in which I have participated with many

colleagues for more than a decade. My collaborators on this project are some four
Orlinsky: Research on Psychotherapists 3

or five dozen colleagues participating in the Collaborative Research Network of

the Society for Psychotherapy Research (Orlinsky et al., 1999). A core group of 10

or 12 persons has provided leadership for the project during the 1990s, including

(in alphabetical order): Dr. Hansruedi Ambuehl of Switzerland, Dr. Jean-François

Botermans of Belgium, Prof. Manfred Cierpka of Germany, Drs. John and Marcia

Davis in the U.K., Drs. Alice Dazord and Paul Gerin of France, Prof. Helge

Rønnestad of Norway, and Dr. Ulrike Willutzki of Germany.

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Show Table 1 here.
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Beginning in 1989, our group designed and conducted an on-going survey of

psychotherapists of different professions, diverse theoretical orientations, and

varied career levels, in many different countries. You can see in Table 1, which

shows the characteristics of our sample, that those countries so far most

prominently include Germany, the United States, Norway, South Korea,

Switzerland, Portugal, Spain, Denmark, Belgium, Sweden, France, Russia, and

Israel, as well as several that have not yet been fully entered into our data base. (I

would like to take this opportunity to give my thanks to Prof. Avila-Espada and

his colleague, Prof. Isabel Caro, for collecting data on psychotherapists in Spain,

to Prof. Kaechele for consistently supporting our data collections in Germany.)

Our sample of nearly 5,000 psychotherapists at this point includes

approximately 1,400 psychiatrists; 2,800 psychologists; and another 700 social

Orlinsky: Research on Psychotherapists 4

workers, nurses, lay therapists, or other professionals.

Nearly 60% of these therapists indicated they rely strongly on analytic or

psychodynamic concepts in their work; about 30% rely strongly on

humanistic/existential orientations; 20% were strongly influenced by cognitive

and cognitive-behavioral approaches; and 20% by systemic theories. (The figures

add to more than 100% because the therapists in our study were free to indicate

more than one theoretical influence.)

The therapists in our sample ranged in age from 21 to 91, and covered a broad

spectrum of experience levels from less than one year to more than 50 years in

practice. The average age was 42, and the average length of therapeutic practice

was 11 years.

Overall, 44% of the therapists had some private practice; 80% had experienced

at least one personal therapy; 53% were female, and 47% were male.

All these therapists participated in our study by completing a long

questionnaire called the Development of Psychotherapists Common Core

Questionnaire, consisting of several sections which ask therapists about their work

experiences, current practice, professional development, and personal

characteristics. The findings I will present are drawn from sections of the

questionnaire that focus on the psychotherapist’s experience of therapeutic work.

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Show Table 2 here.
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Orlinsky: Research on Psychotherapists 5

Table 2 shows those sections each consisted of from 10 to more than 20 items,

and focused successively on therapists’ typical treatment goals, their interpersonal

manner in relating to patients, their instrumental activity, their technical and

relational skills, the difficulties they experience in practice, their strategies for

coping with difficulties, and their subjective feelings during sessions.

The items within each section first were factor analyzed to determine the

dimensions on which therapists differ from one another. These analyses resulted in

the set of reliable empirical scales summarized in Table 2. For example, variations

in therapists’ interpersonal manner in relating to patients can be described in terms

of four dimensions: how Affirming (i.e., warm, accepting, and friendly) they feel

they are; how Attending (i.e., permissive, nurturant, and protective) they are; how

Dominant (i.e., directive and demanding) they are; and how Reserved (i.e.,

guarded and detached) they are.

It is not necessary for the purpose of this lecture to review all the dimensions

shown in Table 2, but it is important to understand how they were used.

Therapists’ scores on the dimensions reflecting the different aspects of therapeutic

work were intercorrelated, and those correlations in turn were factor analyzed to

determine the underlying patterns of therapeutic work experienced by

psychotherapists. This second level of analysis resulted in the definition of three

broad dimensions.
Orlinsky: Research on Psychotherapists 6

The first dimension can be described as Healing Involvement. Therapists with

high scores on this dimension experienced themselves as highly Affirming and

Attending in relating to patients, with a strong sense of personal Investment and

Efficacy in therapeutic work. They experienced themselves as having strong Basic

and Advanced Relational skills, and a high level of Technical Expertise. They tend

to rely on constructive strategies for coping when they encounter difficulties; for

example, Problem-Solving with the Patient, Seeking Consultation, and Self-

Reflection. They also report frequently feeling an intense and rewarding interest in

sessions, which closely resembles the “Flow” experience described by my

colleague, Prof. Csikszentmihalyi (1990) in general studies of work and leisure

activities.

The second broad dimension of therapeutic work was identified as one of

Stressful Involvement. It was defined primarily by therapists’ more frequent

experiences of difficulties, including Professional Self-Doubt, Frustration with

Cases, and Negative Personal Reactions to a patient. In addition to more frequent

difficulties, this pattern included a tendency to use Negative Coping strategies like

avoidance, and being critical of patients, in response to difficulties. Finally,

therapists experiencing Stressful Involvement reported having more frequent

feelings of Anxiety and Boredom during sessions.

Orlinsky: Research on Psychotherapists 7

A third, minor dimension was defined by therapists’ reports of being Dominant

and Reserved in relating to patients, which was called Controlling Involvement.

However, Healing Involvement and Stressful Involvement accounted for most of

the variation in how therapists experienced their therapeutic work. These

dimensions were relatively independent of one another statistically, meaning (for

example) that therapists who experienced high or low levels of Healing

Involvement could experience either high or low levels of Stressful Involvement.

The independence of these two dimensions allowed us to construct a simple

typology of therapists’ work experiences by making a 2-by-2 classification of

therapists. Four distinct work experience profiles were defined by distinguishing

therapists who experienced either “much” or “not much” Healing Involvement,

and either “little” or “more than a little” Stressful Involvement (as shown in Table

3).

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Show Table 3 here.
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These profiles of therapeutic work are easily recognizable but not always so

easy to label. For the present, I propose naming the first work experience profile

“Healing Synergy.” In it, therapists reported experiencing “much” Healing

Involvement in working with patients, and “little” Stressful Involvement. I like the

term ‘synergy’ because it literally means ‘working together’ and, in this profile,

the therapist’s experience is one of working closely together with the patient, and
Orlinsky: Research on Psychotherapists 8

one in which all the various elements of therapy work together effectively. Fifty

percent of the therapists in our sample fit this profile, and they were by far the

largest group.

In the second of these four profiles, therapists reported experiencing “much”

Healing Involvement but also “more than a little” Stressful Involvement. Because

they felt their therapeutic work to be successful but also arduous and quite

demanding, I propose “Healing Despite Difficulty” as a name for this pattern.

Almost a fourth of our therapists fit this pattern, making it the second largest

group in our sample.

Next was a still smaller group of therapists who experienced “little” Stressful

Involvement but also “not much” Healing Involvement. This therapeutic work

profile might be described as “Disengaged Practice,” since the therapists in it seem

not to feel very involved with their patients or with their work, either positively or

negatively. Clearly they are practicing some form of therapy, but seem to

experience it in a detached or impersonal way. This pattern fit about one-sixth of

the therapists in our sample.

Finally, a fourth work profile was defined by therapists who experienced “more

than a little” Stressful Involvement and “not much” Healing Involvement. These

therapists evidently are trapped in a situation that I would describe as “Distressing

Practice.” They do not feel they are working well, or doing much good for their
Orlinsky: Research on Psychotherapists 9

patients. Their feelings of anxiety and boredom suggest that they at risk for, or

already suffering from “burnout,” and are probably in need of help themselves.

While this was the smallest group, including 10% of our sample, that number still

seems unfortunately high.

Nevertheless, it is noteworthy that nearly three-quarters of the thousands of

therapists we surveyed reported experiencing their work with patients strongly as a

Healing Involvement. For some of those therapists, this work was demanding or

taxing, but for most it was not very stressful. On the other hand, over a third of the

therapists reported their work with patients was at least moderately stressful, but

most of those also experienced it as a Healing Involvement despite the stress they

experienced in treating their patients.

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Show Table 4 here.
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An interesting light is shed on the four profiles by comparing their incidence

among therapists at different levels of professional experience. Table 4 shows that

the percentage of therapists who experience work as Healing Synergy is the largest

group at every level of professional experience, but also that the percentage who

experience Healing Synergy increases steadily over the course of the therapist’s

career, from 40% among novice therapists who have practiced for less than 18

months, up to 60% among senior therapists who have practice for more than 25

years. Moreover, the percentage of therapists who experience therapeutic work as

Orlinsky: Research on Psychotherapists 10

a Distressing Practice decreases steadily across career levels, from nearly 20%

among novice therapists to just six or seven percent among seasoned and senior

therapists. Disengaged Practice also decreases somewhat, especially among the

most senior therapists. This analysis, of course, cannot show how much the

difference between career levels is due to the gradual development of

psychotherapists, and how much to the continual departure from therapeutic

practice of those who find the work difficult and distressing. However, these

finding do support the validity of the work profile typology.

Coming back to my initial contrast between the two views of psychotherapists,

I think that most of those we studied can be described as doing therapy with ‘heart

and soul’ rather than cool detachment, and come closer to the image of therapists

as deeply involved and caring persons. Most psychotherapists experience

themselves as vital participants in the therapeutic process, personally involved in

their work with patients, and very much part of it. In this pattern of experience,

therapists also feel their work is more skillful and more effective for patients.

Nevertheless, a minority of those we studied must be described, from their own

reports, as disengaged, restrained, and dispassionate in their therapeutic practice.

They come closer to the image of therapists as basically interchangeable providers

of objective treatment procedures.

My argument is not that the personal qualities of the therapist are the only
Orlinsky: Research on Psychotherapists 11

effective element in therapy, or that the therapist’s experience of therapeutic work

is necessarily the best source of evidence about what makes therapeutic processes

effective. However, I believe the view of therapeutic work that characterizes the

large majority of therapists in our study is broadly consistent with the cumulative

findings of 50 years of research on psychotherapy, which I would summarize in

the following points. First, a wide variety of treatment methods have been shown

to be effective in controlled studies, but there has not been strong evidence

demonstrating the consistent superiority of any one type of therapy, despite

extraordinary efforts to do so. Second, in comparative studies of treatment,

variation in patient outcomes is often as great or greater within treatment groups

than between different treatments. This implies that other factors than treatment

methods actively influence treatment outcomes. Finally, in a very large number of

studies, a consistent association has been demonstrated between patients’

improvement in treatment and their experience of a positive relationship with their

psychotherapist. Taken together, these often replicated findings imply that the

effectiveness of psychotherapy does not stem exclusively, or even primarily, from

the impersonal application of treatment procedures, but rather from the quality of

therapists’ interpersonal involvements with their patients, and the experiences that

are evoked for the patient through those involvements. Specific treatment methods

certainly exist, and some of them are demonstrably effective, but they do not exist,
Orlinsky: Research on Psychotherapists 12

and are not effective, independently of the persons in and through whose

interactions they occur. What those persons bring to therapy, as therapist and

patient, and how they work together as a particular patient-therapist pair, appears

more influential in determining outcome than the specific techniques associated

with various types of treatment.

Researchers and others who have closely observed the interactions of patients

and therapists in therapy have often described it metaphorically as a dance. The

steps of the dance may be compared with the techniques of therapy -- but the way

that partners execute those steps together may be compared with the therapeutic

relationship. One can hardly overlook the fact that some partners dance together

with uncommon grace; still others dance together awkwardly but manage to get

where they need to go; while a few step painfully on each other’s toes, and should

be advised to sit down or seek different partners.

Let me conclude with the following questions. Do the various steps define

dance more than the relationship that exists between partners? Do the various

technical methods define psychotherapy more than the relationship between

therapist and patient? Borrowing words from the famous Irish poet, William

Butler Yeats (1952), I would ask about therapy as he did about dance:

O body swayed to music, O brightening glance,

How can we know the dancer from the dance?”

Orlinsky: Research on Psychotherapists 13

References

Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York: Harper &

Row.

Orlinsky, D. E., Ambuehl, H., Rønnestad, M. H., Davis, J. D., Gerin, P., Davis, M., Willutzki,

U., Botermans, J-F., Dazord, A., Cierpka, M., and Aapro, N., Buchheim, P., Bae, S.,

Davidson, C., Friis-Jorgensen, E., Joo, E., Kalmykova, E., Meyerberg, J., Northcut, T., Parks,

B., Scherb, E., Schröder, T., Shefler, G., Stiwne, D., Stuart, S., Tarragona, M., Vasco, A. B.,

Wiseman, H. (1999). The development of psychotherapists: Concepts, questions, and

methods of a collaborative international study. Psychotherapy Research, 9(2).

W. B. Yeats (1952). “Among School Children.” The Collected Poems of W. B. Yeats, p. 214.

New York: Macmillan.

Orlinsky: Research on Psychotherapists 14

Table 1.
Collaborative Research Network Psychotherapist Sample [N = 4,923] †

Nation N % Profession N %
Germany 1059 21.7 Psychology 2810 57.3
USA 844 17.3 Medicine 1378 28.1
Norway 804 16.5 Social Work 280 5.7
S. Korea 538 11.0 Lay Therapist§ 214 4.4
Switzerland 263 5.4 Nursing 91 1.9
Portugal 188 3.8 Other 135 2.8
Spain 182 3.7 Salient Theory*
Denmark 158 3.2 Analytic-Dynamic 2784 57.6
Belgium 132 2.7 Behavioral 688 14.1
Sweden 117 2.4 Cognitive 1154 23.9
France 117 2.4 Humanistic 1507 31.2
Russia 110 2.3 Systemic 1008 20.9
Israel 100 2.0 Other 580 13.4
Other 311 5.6 Uncommitted 545 13.8
Gender Practice Setting
Female 2580 53.0 Some inpatient 1400 28.4
practice
Male 2288 47.0 Some private practice 2165 44.0
Age Practice Duration
Mean / s.d. 42.4 10.6 Mean / s.d. 11.3 8.9
Range 21.4 90.7 Range 0.1 53.0
† - Processed as of January 2000.
§ - Psychotherapist, psychoanalyst, or counselor, with no profession specified.
* - Salient = 4 or 5 on a 0-5 scale; multiple endorsements allowed.
Orlinsky: Research on Psychotherapists 15

Table 2.
Dimensions of Therapists’ Work Experience

Facet Items Dimensions*

Treatment Goals 15 [E.g. help patients have a strong sense of self-

worth and identity; decrease symptoms; etc.]

1. Affirming (warm, accepting, friendly)

Interpersonal 17 2. Attending (permissive, nurturant, protective)
Manner
3. Dominant (directive, demanding)
4. Reserved (guarded, reserved, detached)

10 1. Investment (involved, committed)

Instrumental
2. Efficacy (skill, organized, effective)
Activity
3. Bafflement (confused, unhelpful)

12 1. Basic relational skills (e.g., empathy)

Therapeutic Skills 2. Technical expertise (technique, mastery)
3. Advanced relational skills (management
of transference-countertransference issues)

Difficulties in 20 1. Professional self-doubt

Practice 2. Frustrating treatment case
3. Negative personal reaction

1. Self-reflection
Coping Strategies 26 2. Seeking consultation
3. Problem-solving with patient
4. Seeking alternative satisfaction
5. Reframing the helping contract
6. Negative coping (avoidance/attack)

Feelings in Session 12 1. ‘Flow’ (stimulated, inspired, engrossed)

2. Anxiety (anxious, pressured, overwhelmed)
Orlinsky: Research on Psychotherapists 16

3. Boredom (inattentive, drowsy, bored)

I. HEALING INVOLVEMENT
Second-Order Factors
II. STRESSFUL INVOLVEMENT
[III. CONTROLLING INVOLVEMENT]

* Determined by factor analysis.

Orlinsky: Research on Psychotherapists 17

Table 3.
Typology of Work Experience Profiles

Stressful Involvement

Healing Little More than a little

Involvement
EFFECTIVE PRACTICE CHALLENGING PRACTICE
Much [Healing Synergy] [Healing Despite Difficulty]
49.7% 22.6%

DISENGAGED DISTRESSING
Not much PRACTICE PRACTICE
17.3% 10.4%
Orlinsky: Research on Psychotherapists 18

Table 4.
Work Experience Profiles by Therapist Experience Level [%]

Effective Challenging Disengaged Distressing

CAREER LEVEL N Practice Practice Practice Practice
Novice 330 39.4 21.8 19.4 19.4
<1.5 yrs

Apprentice 372 38.2 22.8 22.8 16.1

1.5 to <3.5 yrs

Graduate 627 43.7 23.0 19.6 13.7

3.5 to <7 yrs

Established 1149 52.9 22.5 16.9 7.7

7 to 15 yrs

Seasoned 849 54.7 24.1 14.3 6.9

15 to <25 yrs

Senior 239 60.3 20.9 12.6 6.3

25 to <55 yrs