The Open Psychology Journal




ISSN: 1874-3501 ― Volume 12, 2019
RESEARCH ARTICLE

The Importance of Reflection: An Exploratory Analysis on How Prospective Psychotherapists Learn Self-Determination



Bo Nurmi1, 2, Clive S. Michelsen3, Torsten Norlander2, 3 , *
1 School of Education, Humanities and Social Sciences, Halmstad University, Halmstad, Sweden
2 Center for Research and Development, Evidens University College, Gothenburg, Sweden
3 Center for Research and Development, Sciens College, Malmö, Sweden

Abstract

Background:

Learning to become a psychotherapist is a complicated process. Research on this topic has been limited and there is little consensus on how to assess therapeutic skills. SP/SR (Self-Reflection/Self-Practice) has emerged as a theory and method for learning psychotherapy. In this article students' reflections on how to become a psychotherapist has been studied from a phenomenological perspective.

Objective:

The aim of the present exploratory study was to generate preliminary hypotheses for future investigations in order to elucidate the complicated processes that occur during the therapist training programs.

Methods:

Five prospective psychotherapists were recruited to the present investigation, who all studied at the penultimate semester at Evidens University College, Gothenburg, Sweden. Unstructured qualitative in-depth interviews were used followed by phenomenological analysis.

Results:

Analysis yielded 252 meaning units and 12 categories which in turn led to four overarching themes: Learning as a visit to the dentist (when learning becomes painful because certain issues are not resolved); Learning as theatre (when the students just perform what is expected in order to pass); Learning as post-training soreness (when the learning process is challenging on a relevant level); Learning as reflections (when the students seek the intrinsic meaning).

Conclusion:

The study provided a basis for preliminary hypotheses for future investigations: reflections are helpful for managing the challenges described in the four themes. This, in turn, led to the formulation of some proposals for research questions for future investigations.

Keywords: Cognitive behavioral therapy, Phenomenological analysis, Psychotherapist training, Self-determination, Self-practice, Self-reflection.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 197
Last Page: 204
Publisher Id: TOPSYJ-12-197
DOI: 10.2174/1874350101912010197

Article History:

Received Date: 24/03/2019
Revision Received Date: 22/06/2019
Acceptance Date: 20/08/2019
Electronic publication date: 30/09/2019
Collection year: 2019

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© 2019 Psychotherapist et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Center for Research and Development, Evidens University College, Packhusplatsen 2, SE-411 13 Göteborg, Sweden; Tel: +46 70 662 11 89, Fax: +46 31 711 04 42;
E-mail: at.norlander@mailbox.tele2.se






1. INTRODUCTION

After World War II, a researcher-practitioner model, the so-called “Boulder model”, became dominant in university programs within clinical psychology [1Nielsen K. On learning psychotherapy from clients. Nordic Psychol 2008; 60: 163-82.
[http://dx.doi.org/10.1027/1901-2276.60.3.163]
, 2Willig C. Introducing qualitative research in psychology: Adventures in theory and method 2013.]. It is characterized by the fact that the student is firstly educated as a scientist and, secondly, as a therapist. The model is based upon the assumption that it is through knowledge of research that the therapist gains access to tools for assessment and treatment of mental illness [3Recker Rayburn N, Davison GC. Curriculum and training reform in clinical psychology: Improving the integration of science and practice. Appl Prev Psychol 2001; 10: 265-73.
[http://dx.doi.org/10.1016/S0962-1849(01)80003-2]
]. From this perspective, the psychotherapeutic process can be understood as a matter of identifying the right evidence-based method or technique and using it to obtain the best possible treatment results [4Berger LS. Issues in psychoanalysis and psychology: Annotated collected papers 2002.]. It should be noted that this perspective has not been uncontested [1Nielsen K. On learning psychotherapy from clients. Nordic Psychol 2008; 60: 163-82.
[http://dx.doi.org/10.1027/1901-2276.60.3.163]
, 5Giorgi A. Psychology as a human science A phenomenologically based approach 1970.]. Not all practitioners perceive scientific knowledge to be practically useful by itself [6Polkinghorne DE. Practice and human sciences 2004.]. Nor it has been easy to combine the demand for scientific knowledge with practical vocational training [7Beck JG, Castonguay LG, Chronis-Tuscano A, et al. Principles for training in evidence-based psychology: Recommendations for the graduate curricula in clinical psychology. Clin Psychol Sci Pract 2014; 21: 410-24.
[http://dx.doi.org/10.1111/cpsp.12079]
, 8Luebbe AM, Radcliffe AM, Callands TA, Green D, Thorn BE. Evidence-based practice in psychology: Perceptions of graduate students in scientist-practitioner programs. J Clin Psychol 2007; 63(7): 643-55.
[http://dx.doi.org/10.1002/jclp.20379] [PMID: 17551937]
].

Within the field of Cognitive Behavioral Therapy (CBT), it was only in the 1990s that the idea of ​​experience-based education began to have a real impact. From the 1990s onwards, great emphasis was placed on a combination of experience-based teaching and reflection [9Turton W. Honing cognitive behaviour therapy skills through experiential learning. Ment Health Pract 2012; 10: 33-5.
[http://dx.doi.org/10.7748/mhp2012.07.15.10.33.c9199]
] with Beck [10Beck JS. Cognitive behavior therapy: Basics and beyond 2011.] and Padesky [11Padesky C. Developing cognitive therapist competency: Teaching and supervision models.Frontiers of Cognitive Therapy 1996; 266-92.] among others advocating the importance of having personal experience of psychotherapeutic methods as well as reflecting on these experiences. Despite this Bennett-Levy [12Bennett-Levy J. Therapist Skills: A cognitive model of their acquisition and refinement. Behav Cogn Psychother 2006; 34: 57-78.
[http://dx.doi.org/10.1017/S1352465805002420]
] notes that earlier experimental research has only to a small extent devoted itself to study reflection processes. Later studies studied the importance of reflection as well as personal experience of psychotherapeutic methods and how they affected learning. One such study [13Bennett-Levy J, McManus F, Westling BE, Fennell M. Acquiring and refining CBT skills and competencies: Which training methods are perceived to be most effective? Behav Cogn Psychother 2009; 37(5): 571-83.
[http://dx.doi.org/10.1017/S1352465809990270] [PMID: 19703329]
] showed that educational elements such as reading, lectures and modeling primarily contributed to declarative knowledge. However, exercises, where the participants were allowed to practice something in combination with modeling and reflection, were better for procedural knowledge. The study also showed that personal experiences of therapeutic methods combined with reflections were particularly important for developing therapeutic skills.

Historically, personal therapy has not had the same importance for practitioners of CBT as for other psychotherapeutic orientations [14Orlinsky DE, Schofield MJ, Schroder T, Kazantzis N. Utilization of personal therapy by psychotherapists: A practice-friendly review and a new study. J Clin Psychol 2011; 67(8): 828-42.
[http://dx.doi.org/10.1002/jclp.20821] [PMID: 21717462]
, 15Orlinsky DE, Botermans J-F, Ronnestad MH. Towards an empirically-grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Aust Psychol 2001; 36: 139-48.
[http://dx.doi.org/10.1080/00050060108259646]
]. CBT practitioners rank personal therapy as significantly less important for their professional development as compared to practitioners of other psychotherapy approaches. This is not surprising since research has not been able to demonstrate that personal therapies have any impact on clinical activities [16Bennett-Levy J, Thwaites R, Chaddock A, Davis M. Reflective practice in cognitive behavioral therapy: The engine of lifelong learning.Reflective practice in Psychotherapy and Counselling 2009; 115-35.].

An attempt to create a theoretical framework for self-practice and self-reflection is the model “Self-Practice/Self-Reflection” (SP/SR) [17Bennett-Levy J. Experiencing CBT from the inside out: A self-practice/self-reflection workbook for therapists 2015.]. According to the model, the prospective therapist should experience to use CBT methods i.e., Self-Practice (SP) and then reflect on these experiences, i.e., self-reflection (SR). In addition to being a method for professional development, SP/SR is also a method for helping psychotherapists take care of the personal side of being a psychotherapist [18Bennett-Levy J, Thwaites R. Self and self-reflection in the therapeutic relationship: A conceptual map and practical strategies for the training, supervision and self-supervision of interpersonal skills.The therapeutic relationship in the cognitive behavioural psychotherapies 2007; 255-81.]. It is a structured and manual-based process in which the uses of specific CBT techniques are followed by reflection [17Bennett-Levy J. Experiencing CBT from the inside out: A self-practice/self-reflection workbook for therapists 2015.]. The model is based upon the assumption that with help of reflections to refine his/her explanatory and procedural knowledge the psychotherapist will be able to increase his/her own CBT skills. The importance of reflections becomes particularly significant when treating complex patients, since greater flexibility from the psychotherapist is then needed [19Milne D, Claydon T, Blackburn IM, James I. Rationale for a new measure of competence in therapy. Behav Cogn Psychother 2001; 29: 21-33.
[http://dx.doi.org/10.1017/S1352465801001047]
]. Studies have shown that the SP/SR model can help prospective therapists to become more skilled at making case conceptualizations [20Haarhoff B, Gibson K, Flett R. Improving the quality of cognitive behaviour therapy case conceptualization: The role of self-practice/self-reflection. Behav Cogn Psychother 2011; 39(3): 323-39.
[http://dx.doi.org/10.1017/S1352465810000871] [PMID: 21320361]
], gaining a better understanding of the therapeutic role and processes of change [21Bennett-Levy J, Turner F, Beaty T, Smith M, Paterson B, Farmer S. The value of self-practice of cognitive therapy techniques and self-reflection in the training of cognitive therapists. Behav Cogn Psychother 2001; 29: 203-20.
[http://dx.doi.org/10.1017/S1352465801002077]
], better on conveying conceptual knowledge of what CBT is [22Bennett-Levy J, Lee N, Travers K, Pohlman S, Hamernik E. Cognitive therapy from the inside: Enhancing therapist skills through practicing what we preach. Behav Cogn Psychother 2003; 31: 143-58.
[http://dx.doi.org/10.1017/S1352465803002029]
], as well as better self-confidence in the professional role as a psychotherapist [21Bennett-Levy J, Turner F, Beaty T, Smith M, Paterson B, Farmer S. The value of self-practice of cognitive therapy techniques and self-reflection in the training of cognitive therapists. Behav Cogn Psychother 2001; 29: 203-20.
[http://dx.doi.org/10.1017/S1352465801002077]
]. SP/SR contributes to the development of meta-competencies [23Fernández-Álvarez H, Castañeiras C, Wyss G. Commentary on three articles on self-practice/self-reflection in Cognitive-Behavioural Therapy. Aust Psychol 2015; 50: 335-9.
[http://dx.doi.org/10.1111/ap.12156]
] which can be useful within the framework of supervision.

Not only will prospective psychotherapists benefit from the method. Bennett-Levy and associates [13Bennett-Levy J, McManus F, Westling BE, Fennell M. Acquiring and refining CBT skills and competencies: Which training methods are perceived to be most effective? Behav Cogn Psychother 2009; 37(5): 571-83.
[http://dx.doi.org/10.1017/S1352465809990270] [PMID: 19703329]
] showed that SP/SR is important in recurrent training for practicing psychotherapists in terms of technical skills, and interaction skills. This result was corroborated by a review [24Gale C, Schröder T. Experiences of self-practice/self-reflection in cognitive behavioural therapy: A meta-synthesis of qualitative studies. Psychol Psychother 2014; 87(4): 373-92.
[http://dx.doi.org/10.1111/papt.12026] [PMID: 24677534]
] of ten articles and in a recent study with experienced psychotherapists [25Davis ML, Thwaites R, Freeston MH, Bennett-Levy J. A measurable impact of a self-practice/self-reflection programme on the therapeutic skills of experienced cognitive-behavioural therapists. Clin Psychol Psychother 2015; 22(2): 176-84.
[http://dx.doi.org/10.1002/cpp.1884] [PMID: 24464966]
]. However, the SP/SR research has been criticized [26McGillivray J, Gurtman C, Boganin C, Sheen J. Self-practice and self-reflection in training of psychological interventions and therapist skills development: A qualitative meta-synthesis review. Aust Psychol 2015; 50: 434-44.
[http://dx.doi.org/10.1111/ap.12158]
] for methodological weaknesses in, among other things, differences in results between quantitative and qualitative research and for the method to be time-consuming [27McGinn LK. Enhancing Cognitive-Behavioral Therapy (CBT) skill acquisition through experiential and reflective learning: A commentary on studies examining the impact of self-practice and self-reflection in CBT. Aust Psychol 2015; 50: 340-3.
[http://dx.doi.org/10.1111/ap.12153]
].

The focus of the present study coincides with the extensive literature on how to learn to become a CBT psychotherapist [7, 11, 25, 28, 29]. The aim of the present study was to generate hypothesis that helps explain the complicated learning processes facilitated by self-reflection in cognitive-behavioral therapy trainees.

2. METHODS

2.1. Participants

Five prospective psychotherapists were recruited to the present study, who all studied at the penultimate semester (i.e., semester five) at Evidens University College, Gothenburg, Sweden. Thus, they had undergone most of the theory and practice of the education. There were four women and one man aged 31 to 51 years. Three were trained psychologists, one was a nurse, and one was a counselor. When the students were admitted to the program, it was a prerequisite that they had either undergone personal therapy or currently participating in an ongoing one. Of the five students, three had undergone the requirements for personal therapy, while two had ongoing personal therapy. None of the students had received any training according to Self-Practice/Self-Reflection (SP/SR) or in other similar methods. The study participants are hereinafter referred to as respondents.

2.2. Procedure

Based on a list of names for a group of 19 students, the selection took place after a random procedure. Five students were asked and all of them accepted participation. The number of respondents was considered sufficient for an explorative study with unstructured interviews and with the aim of identifying hypotheses for future research [30Edebol H, Ake Bood S, Norlander T. Chronic whiplash-associated disorders and their treatment using flotation-REST (restricted environmental stimulation technique). Qual Health Res 2008; 18(4): 480-8.
[http://dx.doi.org/10.1177/1049732308315109] [PMID: 18354047]
-32Niklasson M, Niklasson I, Norlander T. Sensorimotor therapy: Physical and psychological regressions contributes to an improved kinesthetic and vestibular capacity in children and youth with motor difficulties and problems of concentration. Soc Behav Personal 2010; 38: 327-46.
[http://dx.doi.org/10.2224/sbp.2010.38.3.327]
]. All respondents received the study guidelines and related information. The purpose of the study was to investigate how students at the psychotherapist program reflect on their own learning process in terms of theoretical teaching, supervision and personal therapy. All parties agreed that all data was to be handled confidentially, and that the data collected as well as the digital tape recordings of the interviews, would be stored in a safe manner until a report has been published, then all content will be destroyed. The interviews were conducted at the premises of Evidens University College and continued until saturation was achieved [33Englander M. The interview: Data collection in descriptive phenomenological human scientific research. J Phenomenological Psychol 2012; 43: 13-35.
[http://dx.doi.org/10.1163/156916212X632943]
]. Interviews ranged in lengths of between 40 and 52 minutes each. At the completion of all interviews, respondents were asked whether or not they had anything to add, explain or comment on.

2.3. Data Collection Method

In order for the interviews to provide as rich a material as possible, unstructured qualitative in-depth interviews were used [33Englander M. The interview: Data collection in descriptive phenomenological human scientific research. J Phenomenological Psychol 2012; 43: 13-35.
[http://dx.doi.org/10.1163/156916212X632943]
, 34Kvale S. Interviews: An introduction to qualitative research interviewing 1996.], and these were based upon one or a couple opening questions. Respondents are then allowed to share their thoughts and reflections completely freely and spontaneously. During such an interview, the interviewer follows the respondent's story, avoids leading questions, but asks when needed questions such as “how” or “can you elaborate on that”. Two opening questions were used: (a) Can you describe something that you learned during the psychotherapist training that you perceive as important? (b) Can you describe something that you learned during the psychotherapist training that you did not feel significant? The nature of these issues is in line with Englanders [33Englander M. The interview: Data collection in descriptive phenomenological human scientific research. J Phenomenological Psychol 2012; 43: 13-35.
[http://dx.doi.org/10.1163/156916212X632943]
] and Kvales [34Kvale S. Interviews: An introduction to qualitative research interviewing 1996.] reasoning that an interview should begin by allowing the respondent to describe a situation where he/she experienced the phenomenon. In this study, the main phenomenon is the respondents' reflections on what the training for becoming a psychotherapist really is.

2.4. Data Analysis

The Empirical Phenomenological Psychological Method (EPP method) devised by Gunnar Karlsson [35Karlsson G. Psychological qualitative research from a phenomenological perspective 1995.] was used in processing the data. The EPP method contains five different steps:

  1. The interview transcriptions of each participant are read, until a good understanding, and “feeling” for the material is achieved
  2. Here one distinguish “small units”, called Meaning Units (MU). This does not follow rules of grammar but as the text alters, meaning breaks are made, independent of grammar.
  3. During this step each MU is transformed from language of the participant to the language of the researchers. An example of a transformation may be the statement “I am so damn cursed at [name of supervisor] when [name of supervisor] claims that I do not prepare myself for meetings with the clients” is transformed into: “R gets very upset when the supervisor questions the preparations for the meetings with the clients.”
  4. The transformed MUs are synthesized into categories. One seeks to describe “how” the phenomenon expresses itself and “what” the phenomenon is.
    1. Here the researchers move from the categories to more general themes or structures.

The present analysis yielded 252 transformed MUs that in turn generated 12 categories. Each category illustrated a special perspective of the phenomena studied, and each category was described in a synopsis. Finally, the 12 categories were related and subordinated into three all-embracing categories, so-called index categories [36Nordén T, Eriksson A, Kjellgren A, Norlander T. Involving clients and their relatives and friends in psychiatric care: Case managers’ experiences of training in resource group assertive community treatment. PsyCh J 2012; 1(1): 15-27.
[http://dx.doi.org/10.1002/pchj.1] [PMID: 24294489]
].

3. RESULTS

3.1. Overview of Results

The data analysis generated 12 categories that could be grouped into three index categories: (I) the importance of agreeing on what CBT is, (II) the importance of exposing oneself, and (III) to mature as a psychotherapist. Content and examples of MUs are reported for each index category in this section. The examples of the MUs given in italics are the raw MUs. Thus, they are not the ones that were transformed, which were only used in the analysis. Later, in the Discussion section, we will examine whether it is possible to identify recurring themes that can shed light on the essence of the phenomenological analysis carried out. Table 1 provides a summary of the index categories as well as the number of MUs in each category.

Table 1
Overview: Index categories, categories and number of meaning units (MU).



3.2. Index Category I. The Importance of Agreeing on What CBT Is

Respondents claim that there are different ways of understanding and practicing cognitive behavioral therapy. This means prioritizing what is important in the education, which in turn leads to a kind of negotiation based on different definitions of CBT. The negotiation can be described as a process that determines which aspects of psychotherapy have the highest priority. Here is an example where a respondent describes a conflict that arose because of different priorities: “One has an idea that this is good therapy. This is how it looks when it's CBT. But when someone goes in and knocks that bubble and says it is completely wrong that you work this way ... Then I can think that it is the supervisor's role to address me ... over there somewhere and encourage me to find a new way, instead of just letting me meet the resistance from my fellow students. I don't want that, and then I don't do more than I have to do.” The interviews described different ways of defining CBT:

  1. CBT as a structured process. There should be an agenda for each session and problems and goals should be identified. When the conversation with the client or the psychotherapy in its entirety falls outside the scope, it is the task of the psychotherapist to restore the structure. Choosing a manual to deal with a particular problem is described as safe and effective. Overall, the structure is described as difficult to maintain, often in contrast to patients' wishes, needs or behavior, but also as a gain for the psychotherapist in the form of increased freedom: “How did I think here? So it is important that you have a plan, you have a structure for what we really do”.
  2. CBT as an interaction process. It is about prioritizing the relationship with the client. This is done by making the structure, both for individual sessions and the therapy in its entirety secondary in the therapeutic process. It is often justified by circumstances such as severe problems for a client where it becomes difficult to maintain a structure, or that some clients have greater need to establish strong relationships with the therapist rather than relating to structure: “So go into a more freer process then where we would not be controlled by all the templates because we still created a therapeutic foundation and the patient is very pleased with it”.
  3. CBT as a scientific process. A diagnosis-based treatment model is the preferred choice for scientifically-based methods and this approach seems to be the most appropriate one used today. Therapists are therefore trained to choose a particular treatment method or to use a prescribed manual to deal with a particular diagnosis. This is considered to be safe and effective, and it also provides the therapist with a sense of control: ”It feels more obvious, because now I know what I'm doing, which I didn't really know before. It feels safe because I now know that my method has a research support.”
  4. CBT as an exploratory process. A technique where the psychotherapist does not start from a predetermined treatment method but instead tries to construct an understanding of the problem together with the client. Empathetic treatment, body language, reflections, word selection and the client's childhood are considered to be of great importance: “Why be so pure? So there I go a little against because I do not feel that my creativity comes to use when I should only describe a patient based on point 1, point 2, point 3, paragraph 4, as the template requires of me”.

3.3. Index Category II. The Importance of Exposing Oneself

All respondents described various assessment situations where they had exposed themselves before fellow students or teachers/supervisors in a way which was perceived as uncomfortable:

  1. Feelings of being exposed. Characteristic for the feeling of being exposed is that what you share is representative of your own psychotherapist style and in this way your professional knowledge is subject to the judgment of others. The following example illustrates how a respondent ponders on how case reports may be perceived: ”The question of why it is uncomfortable for me to write case reports… I have not considered that before. But it's probably about performance anxiety. That I feel examined. And it makes me nervous. That I do feel uncomfortable. And also... I don’t know what is expected of me ... It feels very uncertain.”
  2. Ability to cope with exposed situations. Respondents describe occasions when they have to expose themselves as stressful, but they also admit that this experience may be of importance for their own learning. Respondents describe how report writing, exercise sessions and video feedback in supervision can be perceived as ranging from mildly stressful to very stressful, arousing negative thoughts, anxiety and shame. Being able to handle those reactions are described as a central part of developing as a psychotherapist. One respondent described it as a workout and another as going to the dentist: “I think it is like exercise pain. It may not be nice, but it is not dangerous… quite okay and natural. And I would not have liked to experience this elsewhere ...this is after all the safest place I have.”/ “Well, that's it. It's like going to a dentist. It's something you have to do. So the teeth don´t rot.”
  3. Advantages with exposed situations. While processes during the training are described as both challenging and in some cases painful, clear advantages are also described. It can be about dealing with one’s own shortcomings and disturbing behaviors or learning to accept feelings like shame and anxiety. One respondent stated the following: “I had some strange behaviors during a therapeutic session that I had not previously been aware of. But thanks to the video feedback this was noticed and now I do my best to extinguish that behavior, or at least think about it.”

3.4. Index Category III. To Mature As A Psychotherapist

A recurring reasoning suggests that psychotherapist education is part of a maturation process. Maturity process is described as knowledge development where new skills, as well as, personal development are important. Knowledge development is the aptitude to learn and to adapt with continuity newly learned skills and abilities over time so that they can become part of one’s therapeutic toolbox and leading to an improved professional competency resulting in self-determination. When the benefits of video feedback and related reflections are highlighted, Cognitive Therapy Scale (CTS-R) is also described [37Blackburn IM, James IA, Milne DL, et al. The Revised Cognitive Therapy Scale (CTS-R): Psychometric properties. Behav Cogn Psychother 2001; 29: 431-46.
[http://dx.doi.org/10.1017/S1352465801004040]
] and the assessment based thereon as a tool to identify and change behavior. The CTS-R scale will help identify and delimit something that should be repeated.

On questions about what they think they have learned so far during the psychotherapist program, all respondents described that they have been helped to deal with various deficiencies or problems related to how they should perform psychotherapy. An example of a respondent who has gradually become more open to taking in new perspectives follows: “Childhood and CBT have not been exactly obvious. (…) First, I claimed that this is not CBT. It's something I shouldn't be doing. I was a little provoked. Should we adopt this CBT method in our therapies? So, I’ve contemplated much about this. In the past, I might have had simplified thinking about depression or anxiety. But now one thinks that it is perhaps depression, as a kind of secondary effect of childhood experiences.” Respondents described three obstacles in the maturation process:

  1. If the distance between the supervisor's opinion and the student's is too great. This indicates a process in which the respondent becomes aware of the fact that supervisor does not share the respondent's opinion and therefore has problems in the negotiation of what should be prioritized: “And I think it is the role of the supervisor to meet me there somewhere and to lure me out, instead it was only resistance.”
  2. Too much emphasis on respondents' shortcomings. The descriptions of their education often show a problem-focused process where learning is defined based on the ability to correct errors. Respondents rarely define learning as identifying strengths and working from these. All in all, it seems as they perceive that learning to become a psychotherapist is partly about identifying one's own deficiencies, reflecting on them and remedying them in order to become a more skilled psychotherapist: “If there were any tokens that would have fallen down then it should have fallen down now you think. I can't feel that it does. It feels like such ... impossible to do right.”
  3. Theatrical show. A third obstacle is that the presentation of oneself in the role of a psychotherapist can become a theatrical display. This seems to be part of a process where difficulties in negotiating on what is to be prioritized lead to a sort of surrendering: “Then it feels more like it becomes an act. Not what I really should have as a therapeutic skill. I show something to the one who is going to examine me, and then it suddenly looks right… It's not a real reality.”

4. DISCUSSION

4.1. Four Themes Emerged

When analyzing the material gathered from the five interviews four recurring themes arose in the three index categories as well as in the categories and which were also abundantly represented at the MU level: (A) Learning as a visit to the dentist (when learning becomes painful because certain issues are not resolved); (B). Learning as theatre (when the students just perform what is expected in order to pass); (C) Learning as post training soreness (when the learning process is challenging on a relevant level); (D) Learning as reflections (when the students seek the intrinsic meaning).

4.2. Theme A. Learning As A Visit To The Dentist – A Painful Process

When the prospective psychotherapists encounter new challenges and demands, learning is, according to statements from our respondents, likely to become too painful and can be likened to an unwanted dentist's visit. The result usually leads to professional development, but the process is characterized by some discomfort and takes time. There was consensus in regard to an identified problem or focus during the supervisory examination hearings. The student did not communicate the nature of the problem nor did the student know its importance. When the student begins to work with the problem by exposing himself/herself, significant negative experiences were triggered such as thoughts of disaster, depression, fear or anxiety. Exposure is thus done, but what is shown represents different things for the student himself/herself and for supervisors and fellow students. The process is exacerbated if the reflections together with the fellow students and the supervisor take place on a superficial level, which forces the student to alone deal with the problem and the feelings that have been raised. It is taken for granted that the students should be able to successfully identify their own problems, weaknesses, and thereby increase their ability for self-reflection and self-determination. Therefore, it becomes especially important to be cognizant of any constructive reflections between fellow students and supervisors so that these can be fully appreciated during the early stage of their psychotherapy education.

Theme A shows a structured and in-depth review of problems and what they represent for the student is missing [12Bennett-Levy J. Therapist Skills: A cognitive model of their acquisition and refinement. Behav Cogn Psychother 2006; 34: 57-78.
[http://dx.doi.org/10.1017/S1352465805002420]
, 17Bennett-Levy J. Experiencing CBT from the inside out: A self-practice/self-reflection workbook for therapists 2015., 29Muse K, McManus F. A systematic review of methods for assessing competence in cognitive-behavioural therapy. Clin Psychol Rev 2013; 33(3): 484-99.
[http://dx.doi.org/10.1016/j.cpr.2013.01.010] [PMID: 23454222]
]. There may be several reasons why a student chooses not to talk about painful experiences. Nonetheless, there are various solutions that can be adopted in addressing the identified issues. One possible approach is that there may be a lack of security with the group [7Beck JG, Castonguay LG, Chronis-Tuscano A, et al. Principles for training in evidence-based psychology: Recommendations for the graduate curricula in clinical psychology. Clin Psychol Sci Pract 2014; 21: 410-24.
[http://dx.doi.org/10.1111/cpsp.12079]
, 11Padesky C. Developing cognitive therapist competency: Teaching and supervision models.Frontiers of Cognitive Therapy 1996; 266-92., 25Davis ML, Thwaites R, Freeston MH, Bennett-Levy J. A measurable impact of a self-practice/self-reflection programme on the therapeutic skills of experienced cognitive-behavioural therapists. Clin Psychol Psychother 2015; 22(2): 176-84.
[http://dx.doi.org/10.1002/cpp.1884] [PMID: 24464966]
, 28Jervelycke A, Larsson B, Norlander T. Attitudes to group assessments: Prospective psychotherapists’ experiences of being assessed by fellow students. Open J Med Psychol 2017; 6: 179-96.
[http://dx.doi.org/10.4236/ojmp.2017.63015]
]. A possible alternative to exposing one-self in front of a group is to keep a diary of psychotherapeutic experiences [9Turton W. Honing cognitive behaviour therapy skills through experiential learning. Ment Health Pract 2012; 10: 33-5.
[http://dx.doi.org/10.7748/mhp2012.07.15.10.33.c9199]
]. Such a diary could contain questions that enable further self-reflection. Another and perhaps more modern method is SP/SR blogs where the students have the opportunity to reflect on their learning [38Farrand P, Perry J, Linsley S. Enhancing Self-Practice/Self-Reflection (SP/SR) approach to cognitive behaviour training through the use of reflective blogs. Behav Cogn Psychother 2010; 38(4): 473-7.
[http://dx.doi.org/10.1017/S1352465810000238] [PMID: 20459878]
].

4.3. Theme B. Learning As A Theater - A Smoke Screen

The five respondents’ reflections indicated that if the negotiations are characterized by conflict or surrender, subsequent processes risk having a theatrical character in order to divert or reduce the painful elements. The student's focus will then not be real knowledge development or personal development, but instead the assessments [29Muse K, McManus F. A systematic review of methods for assessing competence in cognitive-behavioural therapy. Clin Psychol Rev 2013; 33(3): 484-99.
[http://dx.doi.org/10.1016/j.cpr.2013.01.010] [PMID: 23454222]
, 37Blackburn IM, James IA, Milne DL, et al. The Revised Cognitive Therapy Scale (CTS-R): Psychometric properties. Behav Cogn Psychother 2001; 29: 431-46.
[http://dx.doi.org/10.1017/S1352465801004040]
] and how to cope with the education. Where theme A is about managing one’s own strong negative emotions, theme B is characterized by the lack of emotions or low-intensity abandonment.

Previous assessment research has noted that students generally learn what they perceive that they will be assessed on [28Jervelycke A, Larsson B, Norlander T. Attitudes to group assessments: Prospective psychotherapists’ experiences of being assessed by fellow students. Open J Med Psychol 2017; 6: 179-96.
[http://dx.doi.org/10.4236/ojmp.2017.63015]
, 29Muse K, McManus F. A systematic review of methods for assessing competence in cognitive-behavioural therapy. Clin Psychol Rev 2013; 33(3): 484-99.
[http://dx.doi.org/10.1016/j.cpr.2013.01.010] [PMID: 23454222]
, 39Black P, Harrison C, Lee C, Marshall B, Williams D. Assessment for learning: Putting it into practice 2003., 40Black P, Wiliams D. Inside the black box: Raising standards through classroom assessment. Phi Delta Kappan 2010; 92: 81-90.
[http://dx.doi.org/10.1177/003172171009200119]
] whereby the reflection process ends up in the dark [41Newman CF. Competency in conducting cognitive-behavioral therapy: Foundational, functional, and supervisory aspects. Psychotherapy (Chic) 2010; 47(1): 12-9.
[http://dx.doi.org/10.1037/a0018849] [PMID: 22401996]
] which may explain why theme B arises. It has also been discussed that the phenomenon may be due to anxiety which leads the student to select material that he/she believes suits the supervisor in order to protect him/her and thereby reduce the anxiety [28Jervelycke A, Larsson B, Norlander T. Attitudes to group assessments: Prospective psychotherapists’ experiences of being assessed by fellow students. Open J Med Psychol 2017; 6: 179-96.
[http://dx.doi.org/10.4236/ojmp.2017.63015]
, 42Coburn WJ. The vision in supervision: Transference-countertransference dynamics and disclosure in the supervision relationship. Bull Menninger Clin 1997; 61(4): 481-94.
[PMID: 9401152]
, 43Laura S, Steinberg PS. Learning within psychotherapy supervision. Smith Coll Stud Soc Work 2008; 78: 321-36.
[http://dx.doi.org/10.1080/00377310802114700]
]. In this study, the main reason why the theatrical situation arises seems to be that the negotiations in combination with the assessments do not create a sufficiently meaningful space for the student to be able to show what he/she needs help with.

4.4. Theme C. Learning As Post-Training Soreness - A Challenging Process

When learning to become a psychotherapist works well, it is still not an easy process according to our respondents. To borrow a respondent's expression, it can be likened to post training soreness. That is a kind of necessary pain for development to take place. The negotiation process must be characterized by, or at least result in an agreement on what should be the focus in order for learning to be challenging.

An experience-based model [9Turton W. Honing cognitive behaviour therapy skills through experiential learning. Ment Health Pract 2012; 10: 33-5.
[http://dx.doi.org/10.7748/mhp2012.07.15.10.33.c9199]
] fits well with the learning that theme C describes. When the student presents a genuine problem, the actual exposure process creates an opportunity for self-determination and self-reflection because the student can then come into contact with both personal and professional aspects of the presented issue. Bennett-Levy [12Bennett-Levy J. Therapist Skills: A cognitive model of their acquisition and refinement. Behav Cogn Psychother 2006; 34: 57-78.
[http://dx.doi.org/10.1017/S1352465805002420]
] describes the importance of focused attention for reflection to occur. Theme C, as shown by other research, indicates that it is difficult to practically distinguish between a personal-self and a psychotherapist-self [44Bennett-Levy J, Beedie A. The ups and downs of cognitive therapy training: What happens to trainees’ perception of their competence during a cognitive therapy training course? Behav Cogn Psychother 2007; 35: 61-75.
[http://dx.doi.org/10.1017/S1352465806003110]
]. These two “selfs” can be distin- guished and studied [17Bennett-Levy J. Experiencing CBT from the inside out: A self-practice/self-reflection workbook for therapists 2015., 45Haarhoff BA. The importance of identifying and understanding therapist schema in cognitive therapy training and supervision. N Z J Psychol 2006; 35: 126-31.] and these results indicate that self-reflection is important for the student therapist, and along with guidance from his/her therapist-self, the student is able to reflect on how the personal-self can influence the therapy.

4.5. Theme D. Learning As Reflections – Searching the Intrinsic Meaning

The occurrence or absence of meaningful reflections in order to gain a greater understanding of the therapeutic processes is included as an intrinsic factor in themes A to C. Theme D further illustrates the significance of the five respondents’ reflections as a meaning-making process which in accordance to Rogers [46Rodgers CR. Attending to student voice: The impact of descriptive feedback on learning and teaching. Curric Inq 2006; 36: 209-37.
[http://dx.doi.org/10.1111/j.1467-873X.2006.00353.x]
] moves a student from one experience to the next. Thus Theme D constitutes the hub that the other themes revolve around. It may be through reflections in interaction with others and through self-reflections that most students eventually can move on and act as self-determining therapists. These observations seem to be in line with recent research [17Bennett-Levy J. Experiencing CBT from the inside out: A self-practice/self-reflection workbook for therapists 2015.-23Fernández-Álvarez H, Castañeiras C, Wyss G. Commentary on three articles on self-practice/self-reflection in Cognitive-Behavioural Therapy. Aust Psychol 2015; 50: 335-9.
[http://dx.doi.org/10.1111/ap.12156]
] and the following definition by Korthagen: “Reflection is the instrument by which experiences are translated into dynamic knowledge” [47Korthagen FAJ. Linking practice and theory: The pedagogy of realistic teacher education 2001.
[http://dx.doi.org/10.4324/9781410600523]
].

A quantitative study [28Jervelycke A, Larsson B, Norlander T. Attitudes to group assessments: Prospective psychotherapists’ experiences of being assessed by fellow students. Open J Med Psychol 2017; 6: 179-96.
[http://dx.doi.org/10.4236/ojmp.2017.63015]
] dedicated to examine the prospective psychotherapists' attitudes to group assessments with participants from two Swedish educational institutions (Gothenburg University and Evidens University College) showed that a majority of two-thirds of the participants had a very positive opinion of group assessments while one third were negative or skeptical. The analysis showed that decisive for how to adhere to group assessments was whether the students considered themselves as fairly evaluated by their student colleagues within the group and whether the supervisor should make the assessments. The students who were positive [28Jervelycke A, Larsson B, Norlander T. Attitudes to group assessments: Prospective psychotherapists’ experiences of being assessed by fellow students. Open J Med Psychol 2017; 6: 179-96.
[http://dx.doi.org/10.4236/ojmp.2017.63015]
] estimated that the reflections became more extensive when not only the supervisor but also the student colleagues participated, and that it was instructive to take part of each other's strengths and mistakes. Those who were negative or skeptical feared that the relations between the students affected the discussions but they still hoped and longed for something else which could lead to a freer and deeper evaluation. These results relate to what has been elaborated in themes A to C and which also emphasizes the need for reflections highlighted in theme D.

CONCLUSION

This explorative study consisted only of five respondents, which means that conclusions must be tentative. However, the study provided a basis for preliminary hypotheses for future investigations: that is, reflections are helpful for managing the challenges described in the four themes. Research questions on what would be useful to investigate in future studies may be about how constructive reflections can be implemented at an early stage of the psychotherapy education, how the students' experience of security can be strengthened, how assessments may be designed in a new way so that they also serve as exciting learning opportunities, how students integrate professional and private aspects, and how the education of supervisors can be designed in the light of all the challenges that occur within the psychotherapy programs.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study procedure was reviewed and approved by the Ethical Research Committee at Evidens University College.

HUMAN AND ANIMAL RIGHTS

The study followed the ethical standards of the World Medical Association's Declaration of Helsinki concerning Ethical Principles of Medical Research Involving Human Subjects and in accordance with the Swedish rules on ethics.

CONSENT FOR PUBLICATION

Written informed consent was obtained prior to data collection.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

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