Repurposing process measures to train psychotherapists: Training outcomes using a new approach

Aims: First, this paper presents the rationale for a novel approach to training counsellors in which measures for psychotherapy process research are taught to students before moving on to teaching basic empathic reflections and interventions. The rationale for this is that client process measures can be re‐purposed to help orient and sensitise trainees to key in‐session moments. Second, we present a training outcome study that assesses the effectiveness of this approach. Method: Using an experiential‐integrative therapy approach, a 13‐week training program was used to teach psychotherapy skills and process research measures to22 clinical graduate students taken from two cohorts. As part of the course, trainees conducted several single sessions with volunteer clients on four separate occasions. Training outcomes were measured using both trainee and client reports. Results: Compared to baseline, therapists reported significant and steady gains (all p's<.05) in session management, reducing their anxious self‐awareness, and in improved sense of self‐efficacy, with the latter having the largest effect (partial Eta Sq.=.381). Discussion: While the findings provide some support for a new training strategy, a dismantling design is needed next to more closely examine the process‐measure approach to training.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Stress in Clinical Psychology Trainees: Current Research Status and Future Directions

The purpose of this article is to present the current status of the literature related to stress in clinical psychology trainees (CPTs), and to offer research directions for investigating stress in this population and ways to enhance self‐care in these individuals. The following conclusions emerge from the review: (1) CPTs are vulnerable to elevated stress; (2) undue stress can negatively impact CPTs' personal and professional functioning and, in turn, result in less than optimal standards of care for clients; (3) there is a dearth of studies on stress in this population and no published intervention studies; (4) incorporating self‐care strategies into clinical psychology training is recommended; and (5) “third‐wave” cognitive behaviour therapy stress management interventions have been efficacious in comparable populations. In view of the potential costs of elevated stress to trainees themselves and their clients, research on stress and stress management in this population is of a high priority. Broad research agendas are proposed for these two domains. Modifications to clinical training programmes to reduce trainee stress are required and should be evidence‐based and systematically revaluated.     

Developing Metacompetence in Low Intensity Cognitive‐Behavioural Therapy (CBT) Interventions: Evaluating a Self‐Practice/Self‐Reflection Programme for Experienced Low Intensity CBT Practitioners

Self‐practice/self‐reflection (SP/SR) is a targeted training and professional development strategy in which clinicians practice cognitive‐behavioural therapy (CBT) techniques and processes on themselves and then working through a structured process of self‐reflection. Previous studies with CBT trainees and experienced mental health practitioners have found that SP/SR or experiencing CBT “from the inside out” has been perceived by participants as increasing competency in a number of important areas and increasing therapist flexibility and artistry. Low intensity (LI) practitioners are identified as a relatively new addition to mental health service delivery in the UK. These workers are differentiated from traditional mental health practitioners by a shorter training period, the delivery of a circumscribed number of CBT interventions, and a very high weekly patient load. This study, the first of its kind, reports outcomes from an SP/SR programme undertaken by seven experienced LI CBT practitioners. Participants used the following measures to track their experience of the programme: time spent on programme, personal‐ and therapy‐related belief rating, goals attained, and perceived skill rated for average and most difficult patients. Results showed a positive change in work‐related skill and behaviour change, particularly when working with the more difficult patients. The findings are consistent with those found in other groups of therapists (e.g., trainee CBT therapists and highly experienced CBT therapists), suggesting that SP/SR may be a valuable addition to LI intensity training and professional development. These findings are discussed in the context of the particular needs of LI practitioners.     

Comment on “The Self‐Care of Psychologists and Mental Health Professionals” (Dattilio, 2015)

Professor Frank Dattilio's article “The Self‐care of Psychologists and Mental Health Professionals” provides an overview of stress and related mental health problems among psychologists, and a proposition that psychologists are not vigilant in regard to self‐care. Dattilio offers a range of self‐care strategies and recommendations, and highlights self‐care practices within various psychology frameworks, and concludes with some “healthy tips” for managing stress. In my commentary I underscore Dattilio's message that self‐care is of critical importance in psychology practice, given the responsibility of caring for others inherent in the work psychologists undertake. However, I raise additional points of consideration and suggest an alternative approach to addressing the self‐care needs of the profession. My commentary makes the following points: (a) the need to distinguish between psychology trainees and practising qualified psychologists when addressing stress and self‐care requirements in the profession; (b) the importance of developing a culture of self‐care among psychologists by providing self‐care instruction during training; (c) the need to temper research findings on stress and mental health among psychologists by the methodological weakness of the studies in this area; (d) adhering to the recent call from colleagues to shift from a focus on pathology and punishment to a positive acceptance, mindfulness, and values‐based approach for encouraging self‐care among psychologists; (e) the use of a systematic framework for organising the presentation of self‐care strategies that makes them more accessible; and (f) an appeal to professional bodies to take their responsibility in promoting self‐care in the profession.     

Siblings as Selfobjects in Childhood: An Interview Study of Factors and Consequences

This study explores the factors psychotherapists working with adult clients identify as contributing to their clients' use in childhood of relationships with siblings to meet selfobject needs or the use of clients by their siblings for selfobject purposes in childhood, and the consequences of this to the children's intrapsychic development as evidenced in their adult psychotherapy. Using interviews with six psychotherapists practicing within the framework of self psychology, this research determines that the emotional and physical unavailability of parents was a common factor causing children to use their siblings for selfobject purposes. The research also explores the lasting impact of these selfobject ties on the psychological development of both the child using a sibling for selfobject purposes and the child who serves this function for another, as well as the role of psychotherapy in understanding these relationships. These findings give psychotherapists from a variety of disciplines, including social work, an enhanced conceptual framework from which to consider the role of siblings in psychological development.     

The role of self‐image as a predictor of psychotherapy outcome

The present study examined the relationship between self‐image and outcome in psychotherapy. Patients (n = 170) received treatment‐as‐usual at a university clinic, and met diagnostic criteria for mostly anxiety and depression related disorders. Self‐image was measured with the Structural Analysis of Social Behavior (SASB‐I) introject pre and post‐treatment. Using multiple regression analyses, higher levels of Self‐ignore and Self‐blame pre‐treatment predicted a poorer treatment outcome in terms of symptoms (SCL‐90‐R) and interpersonal problems (IIP‐64), respectively. Increase in Self‐love and decrease in Self‐blame (pre to post) predicted reduced symptoms at post‐treatment, whereas decrease in Self‐attack and Self‐control, as well as increase in Self‐affirm, predicted reduced interpersonal problems. The results suggest that self‐image improvement may be important in order to achieve a good outcome in psychotherapy.     

Commentary on Three Articles on Self‐practice/Self‐reflection in Cognitive‐Behavioural Therapy

The commentary embraces three valuable contributions to the development of professional practice: (a) engagement with self‐practice/self‐reflection as a professional self‐development: the role of therapist beliefs; (b) spontaneous self‐practice of cognitive‐behavioural therapy (CBT) by aboriginal counsellors during and following CBT training: a retrospective analysis of the facilitating conditions and impact; (c) developing metacompetence in low intensity CBT interventions: evaluating a self‐practice/self‐reflection programme for experienced low intensity CBT practitioners. Each article provides different perspectives of the self‐practice and self‐reflection benefits for efficient therapy and their use as powerful resources in therapeutic training skills in general and CBT in particular. Conclusions of their contributions close the commentary.     

Experiences of Countertransference: Reports of Clinical Psychology Students

While historically linked with psychoanalysis, countertransference is recognised as an important component of the experience of therapists, regardless of the therapeutic modality. This study considers the implications of this for the training of psychologists. Fifty‐five clinical psychology trainees from four university training programmes completed an anonymous questionnaire that collected written reports of countertransference experiences, ratings of confidence in managing these responses, and supervision in this regard. The reports were analysed using a process of thematic analysis. Several themes emerged including a desire to protect or rescue clients, feeling criticised or controlled by clients, feeling helpless, and feeling disengaged. Trainees varied in their reports of awareness of countertransference and the regularity of supervision in this regard. The majority reported a lack of confidence in managing their responses, and all reported interest in learning about countertransference. The implications for reflective practice in postgraduate psychology training are discussed.     

Therapists' Use of Religious and Spiritual Interventions in Christian Counseling: A Preliminary Report

This study explored the use of religious and spiritual interventions in counseling by Christian therapists (N = 100). Use of religious and spiritual interventions correlated with personal religiousness and clinical training involving religious clients and religious and spiritual interventions. Course work involving either psychology or theology did not correlate with use of or self‐reported competency in using religious and spiritual interventions. Self‐reported competency was associated with personal religiousness; professional beliefs, attitudes, and values; personal experiences with counseling; and clinical training involving religious clients and religious and spiritual interventions. It is suggested that training programs incorporate clinical rotations, workshops, and supervision involving religious clients and religious and spiritual interventions to teach therapists to use religious and spiritual interventions in counseling.     

TEACHING SELF‐CONTROL WITH QUALITATIVELY DIFFERENT REINFORCERS

This study examined the effectiveness of using qualitatively different reinforcers to teach self‐control to an adolescent boy who had been diagnosed with an intellectual disability. First, he was instructed to engage in an activity without programmed reinforcement. Next, he was instructed to engage in the activity under a two‐choice fixed‐duration schedule of reinforcement. Finally, he was exposed to self‐control training, during which the delay to a more preferred reinforcer was initially short and then increased incrementally relative to the delay to a less preferred reinforcer. Self‐control training effectively increased time on task to earn the delayed reinforcer.     

Integrating mindfulness as self-care into counselling and psychotherapy training

Aim: Within the last 10 years, mindfulness has quickly moved into the mainstream of behavioural medicine, psychotherapy, and counselling. This article examines the potential of applying mindfulness practices to the training of counsellors and psychotherapists. Method: Several qualitative research projects conducted over the past nine years are summarised. Findings: Mindfulness training can enhance the physical and psychological wellbeing of trainees. Implications for training: Mindfulness training is a specific way that training programmes can teach students strategies of self-care that can help prevent burnout, compassion fatigue, and vicarious traumatisation.     

“Out on the edge of my comfort”: Trainee counsellor/psychotherapists' experiences of spirituality in therapy—A qualitative exploration

The integration of spirituality into counselling and psychotherapy poses complex challenges. Personal spirituality, professional competency and ethical considerations may impact on trainees' experiences of integrating spirituality into therapy. This study adopted an inductive, qualitative approach to explore trainee counsellor/psychotherapists' experiences and perceptions of integrating spirituality into therapy. Six trainee counsellors and psychotherapists were recruited using purposive sampling from a professional counsellor and psychotherapist training institution in the UK. In‐depth, semi‐structured interviews were conducted, audio‐recorded and transcribed verbatim. Thematic analysis of the interviews revealed two overarching themes: spirituality provides support but needs a warning; and spirituality is relevant but undervalued. These themes encompass a wide range of trainee concerns associated with integrating spirituality into therapy. Participants reported that they felt unprepared to work therapeutically with clients' spiritual beliefs. However, the value of spirituality in providing support to both the trainee and their clients was highlighted by several participants. Some participants described integrating clients' spirituality as having a positive impact on the therapeutic relationship, but often felt threatening to the trainee. This research has implications that are important for counselling and psychotherapy training and developing enhanced consideration of client spirituality and the interpersonal environment in which therapy is delivered.     

Integrating Spirituality and Religion Into Psychotherapy: Persistent Dilemmas,Ethical Issues,and a Proposed Decision-Making Process

Religion and spirituality are important aspects of the lives of most psychotherapy clients. Unfortunately, many psychotherapists lack the training to effectively and ethically address these issues with their clients. At times, religious or spiritual concerns may be relevant to the reasons clients seek treatment, either as areas of conflict or distress for clients or as sources of strength and support that the psychotherapist may access to enhance the benefit of psychotherapy. This article reviews persistent ethical issues and dilemmas relevant to providing psychotherapy to clients for whom issues of religion and spirituality are clinically relevant. Ethical considerations include assessment, advertising and public statements, informed consent, competence, boundary issues and multiple relationships, cooperation with other professionals, and how to effectively integrate religious and spiritual interventions into ongoing psychotherapy. A decision-making process is presented to guide psychotherapists in their clinical work with clients for whom religious and spiritual issues are salient or clearly linked to their presenting problems.     

A qualitative study of client experiences of working with novice counsellors

Aims: This paper reports on a qualitative analysis of written accounts by clients who participated in a counselling relationship with beginning-level trainees. The purpose of the study was to explore how clients experience the process of counselling with novice practitioners. Method: Consensual qualitative research was used for data analysis. Findings: Three general thematic categories were identified – client perceptions of self in counselling; client perceptions of the counsellor; and client perception of the counselling process. Conclusions: Overall, the findings suggest that these clients saw the interpersonal qualities and skills of the counsellor as major contributors to their experience. Implications: Clinical training of novices should start by developing the interpersonal and collaborative skills of trainees.     

Should psychotherapists disclose their own psychological problems?

Background: Self‐disclosures by psychotherapists can encompass a wide array of content, including information about the personal life of the psychotherapist. Aim: The goal of this study was to empirically assess reactions to psychotherapists disclosing their own personal problems to clients with similar problems. Methodology: This study explored participants' (n = 155) reactions to vignettes describing psychotherapists as either disclosing or not disclosing their own history of psychological problems to clients presenting with similar problems. Findings: Compared to otherwise identical vignettes featuring psychotherapists who did not self‐disclose, vignettes featuring psychotherapists who self‐disclosed were rated more positively in a variety of ways. Specifically, psychotherapists in the vignettes featuring self‐disclosure were perceived as possessing a higher level of favourable personal qualities and as more likely to establish strong working relationships with clients and achieve success in therapy. Limitations of the method and alternate explanations for the results are considered. Implications: Implications regarding the judicious use by psychotherapists of self‐disclosure regarding their own past psychological problems are discussed.     

Workers' self‐objectification and tendencies to conform to others

Recent research showed that workers' self‐objectification—their self‐perception as objects rather than human beings—leads to detrimental intrapersonal consequences. In the present research, we explored whether this phenomenon may also affect interpersonal relations, by increasing workers' tendencies to conform. In a correlational study, Italian workers who perceived their work as more objectifying self‐objectified more—self‐attributed less human mental states and self‐perceive as more instrument‐like than human‐like—and, in turn, were more inclined to conform with others. The second study experimentally confirmed this pattern, showing that British workers who recalled an objectifying (vs. a non‐objectifying) work experience self‐objectified more. Self‐perception as instrument‐like was associated, in turn, with an increased tendency to adapt to others' opinions. The implications for organizational and social psychology are discussed.     

Trainee psychotherapy effectiveness at a psychodynamic training clinic: a practice-based study

The degree to which clinical experience is a significant factor in predicting positive psychotherapeutic outcomes is an open question. Empirical studies comparing experienced and beginning practitioners on differences in client outcomes have yielded mixed results. While multiple sources have indicated that trainees are generally effective therapists, few of these studies have examined the effectiveness of graduate-level therapists in a psychodynamic training program. In this study, conducted in the United States, we use a practice-based research approach to examine the outcomes of clients working with trainees at a community mental health clinic in the northeast United States. The theoretical orientation identified by the clinic and training program is psychodynamic with an interpersonal and/or relational emphasis. Results indicated that clients working with trainees at this clinic demonstrated improvement across several indicators of symptoms and psychosocial functioning over the time they received treatment. Implications for training and service reimbursement are discussed.     

The Emphasis on Cognitive‐Behavioural Therapy within Clinical Psychology Training at Australian and New Zealand Universities: A Survey of Program Directors

Surveys of clinical psychologists' self‐reports of professional practice exist in Australia and New Zealand, but comparatively little data exist on the training available in universities. The present study was designed to gather data on the training and assessment of cognitive–behavioural therapy (CBT). A semi‐structured phone interview was designed for use with clinical psychology training directors, or equivalent, in Australia and New Zealand. Out of a total of 48 universities in the region, 40 clinical directors were successfully contacted: One declined involvement, and 39 agreed to participate, yielding a response rate of 81% (six in New Zealand and 33 in Australia). The data showed that it is common for clinical training programmes in our region to provide clinical trainees with foundational knowledge in CBT (i.e., 29 of the 39 surveyed). However, CBT is mainly incorporated into the auspices of clinical training programmes, there is a wide range of assessment methods to evaluate competence in providing therapy, and relatively few academic units exist that focus exclusively on CBT.     

The Self‐Ambivalence Measure: A psychometric investigation

The purpose of this study was to assess the psychometric properties of the Self‐Ambivalence Measure and its subscales developed by Bhar and Kyrios. The factor structure, reliability, and validity of the measure were examined utilising a non‐clinical sample of 415 participants who completed self‐report measures of aspects of the self. Results indicated that the Self‐Ambivalence Measure exhibited levels of internal consistency and convergent and divergent validity, warranting its use in further research. In contrast to earlier research finding a two‐factor structure, a three‐factor structure was found to best fit the current sample and the factors were labelled Self‐Worth Ambivalence, Moral Ambivalence, and Public Self‐consciousness. This solution separated internal aspects of self‐ambivalence from social aspects which were conceptualised as an aspect of lovability. A discussion of implications is provided.