Clinical Culture and Effective Therapeutic Outcomes

The great psychotherapy debate is all about which type of therapy is better than the others, about which type of problems or which kinds of populations might get the most benefit from it compared to other types of therapy. Everywhere you look, the field is discussed in acronyms: the types of therapy are called CBT and EFT and DBT and IFS and a few hundred more. The problems are called BD  and BPD and MDD and ADHD and few hundred more too. As clinicians looking to get better at our job, we are taught that matching the right modality with the right client is the ticket to success. We are made to feel as if we are perpetually just one training course away from being a better therapist and more confidently helping our clients.

Down at the shop, we’ve had remarkable success with our clients. I get to hear success stories every day, and as I read between the lines in my supervision meetings with our counsellors I see a deep ethical commitment to client care alongside sophisticated analytics and technical approaches. But this isn’t all that different from many of the good therapists that I get a chance to talk with outside of our clinic.

At Nightingale Counselling, we began our work rooted in that obvious way of thinking. We hire counsellors that have an obvious connection to some part of psychotherapeutic work that seems to align with who they are as a person and what their clinical experience has taught them about effective practice. And we look for those practitioners who are eager to continue down the road of lifelong education. For those people that we select to join our community, we do everything we can to support their learning, including paying for some or all of their courses and external supervision. So, on the one hand, we find it pretty hard to find much wrong with that way of thinking about professional practice.

But something began to change for us as I watched our team in action. I started asking a different question about where effective therapy originates. Is it really a question of an individual therapist executing the right healthcare modality that leads to long term results and successful practices? Or was that question something of a red herring?

Red herring

As both a practicing psychotherapist and a clinical leader, I spend about the same amount of time each week talking with my clients as I do thinking about and talking with other therapists. The way that I think about good psychotherapy is split right down the middle, considering the short term practices that help clients in the moment but also the long term habits that create therapists who avoid burnout, compassion fatigue, and passion fatigue and can, therefore, be there to help as many people as possible over the lifetime of a good career. It turns out there’s much more to this story than which modality is best.

What really stands out for me is that our counsellors aren’t burning out. They aren’t becoming jaded and cynical. They aren’t separating themselves from their clients or referring to outsiders as “civilians” as often happens in front line environments. Our counsellors aren’t becoming lost in silos of independent work, losing touch with norms of practice. Nightingale therapists are genuinely using their role in the clinical community to actualize a completely different model of the therapeutic career. And it’s working.

When I look around our office these days, I see more and more faces turned towards each other. What began as a top-down effort to avoid the problems of top-down hierarchies, has slowly been transforming into a passionate, voluntary, collaborative community of clinical care. Therapy requires clinicians to do more than just proficiently execute the best available evidence-based techniques to create change for our clients. It asks us to do this in a profoundly authentic and vulnerable manner—it asks us to do so without forms of detachment that can make this kind of technical mastery easier in other pursuits. We really do have to do our work and not just do it. I think this is why a genuine, democratic clinical community is at least as important here as in any other health care practice. We need to share ideas with each other but also share experiences.

It hasn’t been an easy or obvious path to get here. It began with a top-down commitment to these ideas, and more often than not we—my partner hart and I—wrote them out in abstract and theoretical varieties. We talked a lot in the early days about flat hierarchies and the bidirectional transfer of knowledge, and we took many of our early understanding from something the biomedical community calls the Learning Health System. These were important contributions to our team, and they laid down our conviction to spend our time and resources developing culture in this way. But as I look back, we missed key parts of the process. Most importantly, we didn’t quite understand how to find the right people, those therapists who understood what we did about the meaning of helping and being helped by our peers.Path

Early on, some therapists joined Nightingale who really just wanted to come in, make some money, and get out. Others really wanted to want to spend time in community, but couldn’t actually prioritize the time. These folks have always been really attractive members of our team, people who seemed to get good enough results with their caseloads, and often had helpful contributions to make to the group when they did make them. And so we would hold on to these relationships, and often agonize over them. But over time, the people who “get it” tend to stick around, and those that don’t, well… they don’t. And this has proven to be one of the best things that has happened here at Nightingale.

Our leadership has learned so much from this organic and grassroots development of the clinical community, and we are now guiding the future with at least as much emphasis on these forces as the evidence surrounding quality improvement and lifelong learning in other medical fields.

One of my strongest takeaways from our experience with the Nightingale continues to be that the prevailing wisdom about what makes for good therapy is just mostly wrong. And this is not an academic debate. In a free-market landscape where clients are routinely searching for someone to help them with their most serious problems, they are marketed to in bizarre and misleading ways. The best counsellors, I believe, turn out to be people who are deeply and personally engaged in their work (whatever modality or style that might be) and have access to a large and ready supply of resources to help their clients and to help them in their helping of clients. They turn out to be team players, which is totally shocking in a field which is marked by an individual sitting in a room with another individual. It just doesn’t look like a team sport, and yet it seems it is. Therapists are often sensitive, compassionate, and introspective people, who don’t naturally gravitate towards teams no matter how articulate they might be about the dangers of isolation and the benefits of community.

But at Nightingale, we’ve seen the results of pulling together intelligent team players. If I ever decide to go back for that PhD, I think there is important research to do about the external-to-therapy factors that promote long term best therapeutic practices. Because if the vibrancy and energizing joy with which our own team practices therapy can be replicated in other clinics, this is the project that I’d like to be a part of.

 

Shane Trudell, Clinical Director, Dec ’23