Dr. Miller is director of Mental Health for Salt Lake County, 2001 South State St., Suite N4300, Salt Lake City, UT 84190-2000 (e-mail, firstname.lastname@example.org). Marcia Kraft Goin, M.D., Ph.D., and Norman Clemens, M.D., served as guest editors for this column.
The objective of this study was to identify common and distinctive characteristics of "passionately committed psychotherapists" who work in the community mental health system with patients who are seriously mentally ill. Passionate commitment to the profession of psychotherapy is exemplified by psychotherapists who have labored in the occupation, sometimes for many years—and in full awareness of the perils and challenges of this occupation—yet who would describe themselves as having found the vocation that suits them better than any other. What are the personal characteristics of such a person, and what qualities distinguish him or her from psychotherapists who become disaffected, experience burnout, and either change professions or continue in a career of "quiet desperation"?
The study was both a replication and extension of the work of Dlugos (1,2), who studied psychotherapists in New York, most of whom were in private practice. The purpose of this exploratory study was to initiate a body of knowledge about the characteristics that practicing psychotherapists should nurture in themselves, that program supervisors should seek in the people whom they hire, and that training programs should develop in their trainees. These distinctive characteristics may help psychotherapists to find and sustain long-term career satisfaction while working with consumers who are seriously mentally ill.
Psychotherapists practicing in Utah's public mental health system were asked to identify peers who met the identified criteria for "passionate commitment" to their work. Those who were named independently by two or more peers were asked to participate in a semistructured interview with the investigator. Data derived from 15 interviews conducted between May 2004 and April 2005 were analyzed through use of grounded theory methodology. After analysis of 15 interview transcripts, the data were determined to be dense and consistent enough that categories could be developed. Preliminary categories were validated in a consensus activity with two independent raters.
Analysis of the interviews with these passionately committed psychotherapists revealed that they did indeed have common and distinctive ways of describing themselves and their relationships with psychotherapy and their clients. The results for these community mental health psychotherapists are highly similar to those for the individuals in private practice interviewed by Dlugos. Six general themes were identified by all subjects: balance between work and nonwork passions, adaptiveness and openness, transcendence, intentional learning, personal fit with role, and passion-supporting beliefs.
The distinctive characteristics are described in this section, and are illustrated with quotations from the interviews.
Balance between work and nonwork passions
All of the passionately committed psychotherapists who were interviewed identified in some way the importance of balance in their lives. These psychotherapists often expressed strong sentiment about the importance of balance. The word "balance" was not used in the questioning protocol; it emerged spontaneously in every one of the interviews. It is, perhaps, reassuring that these individuals have varied passions and do not devote their interests and energies exclusively to their careers. The theme is illustrated with quotations from the interviews.
"I think that in the beginning, people would have said that I was passionate in my work. I think they would have said that in graduate school and at different points in my life. But I think that in this role, with comprehensive, real difficult cases, I don't think I could sustain my passion if I didn't have a balanced personal life. Because I think this job—and it has, a couple of years ago—can take over, and so I've learned that even with passion, without balance I will burn out."
Adaptiveness and openness
Consistent with research on resiliency or stress hardiness, passionately committed psychotherapists described an ability to view obstacles as challenges. The ability to view challenges favorably is facilitated by the fact that although these psychotherapists expressed a commitment to life-long learning of the technical aspects of psychotherapy, they have a well-developed confidence in the "core skills" of psychotherapy—for example, rapport building and empathic communication. Despite the self assurance of these individuals, or perhaps because of it, they expressed an openness and even "hunger" for feedback from supervision.
"It's challenging—it's using that creative process. Oh, I think the most difficult things in life are also immensely rewarding."
Transcendence refers to the belief that the practice of psychotherapy has extraordinary significance. This category is defined by its two subcategories, recognizing the spiritual nature of psychotherapy and locating the significance of psychotherapy within communal and social responsibility.
"I still am amazed at the very unnamable things that happen in psychotherapy and the power that that relationship holds and the very real almost transpersonal events that take place. I can't describe it better than that."
"I do believe that part of what clicks for me is the sense of helping them, that I'm making the world a better place. It sounds corny, but it really does feel like that—like I'm not just out there trying to market something that won't better someone's life, you know, the latest VCR or DVD or whatever, it's not like a marketing technology."
Very prominent in the data from these interviews is the fact that these passionately committed psychotherapists valued personal growth and learning. No mention was made by any of the interviewees about feeling stale on the job or needing to add diversity to the job role. Instead, they emphasized that they felt that they were continually growing in the job and that their personal growth was inextricably linked to their growth as psychotherapists.
"My own ability to experience enlightenment is linked to my willingness to share and teach it to others, which makes it more available to me. Nothing ever goes to completion if it is just me trying to become enlightened, but if it's me trying to help others have it, it can."
Not surprisingly, the passionately committed psychotherapists described that they have a natural fit with their role as psychotherapists. The responses to the question from the protocol, "What are your energizers on the job?" were consistent: "Getting to spend time with patients."
The study yielded some insight into what constitutes this goodness of fit: a strong "will to intimacy" with patients, a personal motivation to practice psychotherapy, stimulation derived from the aesthetic form of psychotherapy, and the sense of finding the unique qualities of their patients. Descriptions of the importance of intimacy, and even "loving" clients, were common. The psychotherapists' descriptions of the relationship that they seek with clients were materially different from that which might be found in formal training programs.
One psychotherapist talked poignantly about a client who had committed suicide. "I think it was a personal loss more than anything. I really loved this kid. He was the kind of kid that I really saw myself, you know, getting a wedding invitation in the mail 15 years from now, saying 'I'm in New York, and I've found the perfect woman.' This was a kid I kind of knew would be around. For me it was more than professional, way more than professional. It was just more that I really, really liked him."
Another described what is energizing about the practice of psychotherapy. "Making that connection with clients, not as a patient and therapist but on a very personal level. I look for that all the time. That is my joy."
Passionately committed psychotherapists did not view psychotherapy as stressful. This is a key and distinctive characteristic of these individuals. Data from the interviews revealed that they have implicit ways of thinking about psychotherapy that eases the burden of the psychotherapist. These passion-supporting beliefs fall into two subcategories: a strength-based orientation toward the patient and equality of relationship with the patient. The passionately committed psychotherapists were optimistic about their clients. This strengths-based orientation is more than a personal value of these psychotherapists; it may also serve an important function in preserving their energy and passion for the work.
One psychotherapist said, "And the other thing is work from a solution focus, use a strength-based view. If you can see the strengths and believe in people, then this will be a lot easier for you, because that is just the opposite of burnout." Another said, "I never see myself as the expert. I don't take that approach with my clients. I am not the expert. You know, you're the expert. You're inside your own skin. You know your own answers. We're going to work together and I'm going to help you find those answers, but they're your answers."
Because the concept "passionately committed psychotherapists" is a novel one, it became apparent that the extant research could not provide a basis for formulation of any hypotheses before the study was undertaken. Therefore, this study was defined as an exploratory investigation. A weakness in this approach is the lack of a comparison group. The findings of this study could be substantially strengthened by the addition of comparison group to assist in determining which of the identified characteristics are distinctive to this group of passionately committed psychotherapists.
This study is also limited by the fact that conclusions cannot be drawn that passionately committed psychotherapists are effective psychotherapists—it is not known whether outcomes for the clients of this group of therapists are better than those for other clients.
It is, nonetheless, heartening to learn that some psychotherapists are flourishing in a climate in which many find their passion for their work compromised by regulatory requirements, managed care demands, high-risk patients, or other frustrations. An examination of their personal traits provides hope that they may be acquired by other therapists with conscientious effort. Students, practicing psychotherapists, human service employers, and graduate training programs can all benefit from an increased understanding of the characteristics of those who flourish while doing the important and difficult work of psychotherapy.