Utveckling under och efter en psykoterapeututbildning:

Forskning om professionsutveckling på olika stadier

Jan Carlsson

Kompetenscentrum för psykoterapi.

Institutionen för klinisk neurovetenskap, Karolinska Institutet.

Psykoterapienheten, Psykiatrin Södra, Stockholms läns landsting.

jan.karlsson@sll.se

Thirty years ago…

” […] the field of psychotherapy research now faces three

fundamental questions:

1. Is psychotherapy effective?

2. When and why is it effective?

Oh, yes

Work in

progress

?2. When and why is it effective?

3. How should psychotherapists be trained?

The latter two questions obiously presume that the first can be

answered affirmatively.”

Mahoney, M. J. (1980) Psychotherapy Processes: Current issues and future

directions. New York: Plenum Press.

?

We need to find answers to questions like:

What is an effective psychotherapist?

How can training improve the effectivness psychotherapists?

Can anyone become an effective psychotherapist ?

What is a psychotherapist?

EFFECTIVE PSYCHOTHERAPISTSTherapist contribution

� very little evidence

� observable traits (e.g. age, sex or ethnicity)

� only inconsistent evidence

� observable states (e.g. theoretical orientation or experience)

� modest effect on outcome

� Well-being and cultural belief (inferred states)

� somewhat stronger effect

� values, beliefs and attitudes of the therapistBeutler et al In M.J. Lambert (Ed.) (2004) Handbook of psychotherapy and behavior change.

The ideal therapist seems to be a warm and emphatic person with self-insight, a positive self-image and a capacity for self-critical reflection, who avoids complicated communications with patients, seldom contradicts the patient and is more interested in psychotherapy then medication (Luborsky, McLellan, Woody,

O’Brien & Aurebach, 1985; Lafferty, Beutler & Cargo, 1989; Van Wagoner, Hayes, Gelso & Diemer, 1991; Najavits & Strupp, 1994; Blatt, Sanislow, Zuroff & Pilkonis, 1996).

� four demonstrable effective general elements of the

therapeutic relationship: the alliance, cohesion, empathy,

and goal consensus.

� promising effective elements: Positive regard, congruence,

feedback, repairing alliance ruptures, self-disclosure,

EFFECTIVE PSYCHOTHERAPYthe therapeutic relationship

feedback, repairing alliance ruptures, self-disclosure,

management of counter transference, and relational

interpretations.Norcross, J. C. (Ed.) (2002). Psychotherapy relationships that work. Oxford: Oxford University Press.

� Conversely, therapists with a confrontational and rigid

psychotherapeutic style, whose perspective and

assumptions about the patient were dominating, tended to

be ineffective at best.

The functions of training

� Selection of trainees.

� Increase theoretical knowledge.

� Increase metodological knowledge.� Increase metodological knowledge.

� Develop characteristic/qualities.

� Socialisation.

� Control of qualifications and competence.

The effect of training and experience on outcome is not clear:

”Overall, these findings tend to cast doubt on the validity of the suggestion that specific training in psychotherapy, the suggestion that specific training in psychotherapy, even when unconfounded with general experience, may be related to therapeutic success or skill”

(Beutler et al p. 239) In M.J. Lambert (Ed.) (2004) Handbook of psychotherapy and behavior change (227-306). New York: John Wiley & Sons, Inc)

Maybe the focus have been wrong?

“the study of psychotherapies has been favoured over the study of psychotherapists – as if therapists, when properly trained, are more or less when properly trained, are more or less interchangeable”

(Orlinsky D. and Rönnestad H. M (2005) How psychotherapist develop. Washington DC: American Psychological

Association)

Problems in previous research

� To much focus on techiques/methods.

� To little focus on the individual therapist.

� Few longitudinal studies.

� Irreliable measures of training.� Irreliable measures of training.

� To little focus on the therapist professional

development.

� Training and experience have not been defined

clearly.

� To much focus on patient outcome.

What outcome?

� Client outcome.

� Supervisory relationship.

� Therapist conceptualization ability and knowledge.

� Therapist self-awareness.

� Therapist intrapersonal characteristics.� Therapist intrapersonal characteristics.

� Therapist skills.

� Therapist self evaluation ability.Rönnestad & Ladany (2006).

� Therapist professional identity.

� …and not forget to investigate the process of learning.

� The lay helper phase.

�Identifies the problem quickly, gives strong support, gives advice based on own experience.

� The beginning student phase.

�Challenged by learning new models of communcation, highly influenced by teachers/supervisors, strong anxiety about performance and suitability, a sense of helplessness. Role ambiguity.

� The advanced student phase.� The advanced student phase.

�Feels pressure to do things more perfect. Still external focus, but an increasing internal. Tension between belonging or not to the profession. Role conflict. Conflicts in supervision peaks.

� The novice professional phase.

�Seeks confirmation of training (mayby a period of disillusionment). Sense of freedom. Finding personal models of psychotherapy.

Becoming a Psychodynamic Psychotherapist

A study of the professional development during and

the first years after training

Jan Carlsson

The Department for Clinical Neuroscience,

Stockholm centre for psychiatric research and eduction,CPF Psychotherapy.

Karolinska Institutet, Stockholmjan.karlsson@sll.se

OBJECTIVES

This thesis aimed to explore psychotherapists’

professional development during training and professional development during training and

the first years after.

Participants Time Material Method of analyses

Paper I A random sample of

Swedish licensed

psychotherapists and a

Cross-validation

sample of therapist

within STOPPP†.

1995 Questionnaire

(ThId*)

Principal component

analysis, correlations,

cluster analysis.

Paper II Trainees during 1998-2006 Questionnaire Confidence intervals

Overview of the four component studies including participants, time,material and methods of analyses.

Paper II Trainees during

training and at follow-

up.

1998-2006 Questionnaire

(ThId)

Confidence intervals

for differences, t-test,

chi2, content

analysis, kappa

statistics.

Paper III Trainees during

training and at follow-

up.

1998-2006 Questionnaire

(ThId)

Paired samples t-

test, Cohen’s d,

Euclidean distance.

Paper IV Retrospective

interviews several

years after graduating.

2007/2008 Interviews Constant

comparative method.

* Therapeutic Identity† the Stockholm Outcome of Psychoanalysis and Psychotherapy Project

…a project on psychotherapists professional development

� Psychotherapy students (n=46) in an advanced psychodynamic psychotherapy training programme (1998-2003).

� ”Therapeutic Identity – a questionnaire on education, experience, style and attitude” (ThId) distributed during 8 years: at the start of training, after 2 years, at graduation, and at a

4 November, 2011

at the start of training, after 2 years, at graduation, and at a follow-up 3 to 5 years after.

� Interviews with all that answered at all four occasions.

� 21 students (46%) answered the questionnaire at four occasions.

� 18 agreed to participate in the intreview study.

Therapeutic Identity (ThId)- a questionnaire on education, experience, style and attitude

� Demographics and professional training.

� Professional experience.� Professional experience.

� Personal psychotherapy or training analyses.

� Theoretical orientation.

Therapeutic Identity (ThId)-a questionnaire on education, experience, style and attitude

� ”What do you think contibutes to long-term and stable therapeutic change?” – 33 items, 5-point likert-type scales ranging from 0 (does not help at all) to 4 (helps a lot).

� Adjustment

� Insight

� Kindness

� ”What are you like as a therapist?” – 31 items, 5-point likert-type scales ranging from 0 (do not agree at all) to 4 (agree very much).ranging from 0 (do not agree at all) to 4 (agree very much).

� Neutrality

� Supportiveness

� Self-doubt

� ”What are your general beliefs about the human mind and about psychotherapy?” – 16 items, continuous bipolar scales.

A five-step scale was derived from dividing the bipolar scale in five equal parts.

� Rationality/Irrationality

� Science/Art

� Optimism/Pessimism

Swedish national random sample 1995

Therapeutic profiles

Startof training End 2nd Yr.

Endof training

After Interviews

Questionnaries: Studies II and III Study IV

Timeline of distributed questionnaires and interviews

1

0 yrs 3 yrs 3, 4 or 5 yrs

after training2 yrs 4, 5 or 6 yrs

after training

1998

1999

2000

2000

2001

2002

2001

2002

2003

2006 2007/2008

Figure 1. Timeline of distributed questionnaires in Studies I and II, and interviews in

Study IV.

Characteristics of the initial student cohort,and the participants in study II, III and IV

AgeM (SD) (range)

GenderFemale

(%)

Basic academic

training(%)

Experience of

working with

psychotherapya

M (SD) (range)

Personal

therapya

M (SD) (range)

Initial Cohortb,

n=46

45.3 (4.6) yrs.

(34-55) yrs.

78.3 MD 14

Psychologist 49

Social Worker 14

Other 23

9.2 (4.1) yrs.

(2-18) yrs.

6.4 (2.3) yrs.

(2-12) yrs.

Studies II and

III Answered at

all 4 occasions,

n=21

45.8 (4.9) yrs.

(34-55) yrs.

71.4 MD 19

Psychologist 43

Social Worker 14

Other 24

10.2 (4.3) yrs.

(2-18) yrs.

6.3 (2.4) yrs.

(2 – 11) yrs.

Study IV

Interviewed,

n=18

45.2 (5.0) yrs.

(34-55) yrs.

72.2 MD 22

Psychologist 44

Social Worker 0

Other 33

10.3 (4.1) yrs.

(4-18) yrs.

6.5 (2.4) yrs.

(2 – 11) yrs.

a Based on answers from the questionnaire, and thus for the initial cohort only from those who answered in the beginning of training (n=35).

b Two students were excluded from the study because of discontinuation of training. This reduced the number of the initial cohort to 46.

What has been most influential on the professional development?

Therapists in the whole world n=4923

Influential factor % high

1. Experience in therapy with patients 891. Experience in therapy with patients 89

2. Getting formal supervision 80

3. Getting personal therapy, analysis 77

4. Experience in personal life outside of therapy 66

5. Having informal case discussions with colleagues 63

6. Taking courses or seminars 61

7. Reading specialist literature or journals 55

Orlinsky, Botermans & Rönnestad (2001). Towards an empirically grounded model of psychotherapy training: Four thousand therapists rate influences on their development. Australian Psychologist, 36(2), 1–10.

100

80

60

40

Sha

re (%

) stu

dent

sa) Experience in therapy

with patients

b) Getting formal

supervision

c) Getting personal therapy,

analysis

d) Reading specialist

literature or journals

e) Experience in personal

life outside of therapy

(2)

(3)

1

4 November, 2011

AfterEndEnd 2nd yearBeginning

40

20

0

Sha

re (%

) stu

dent

s

literature or journals

f) Taking courses or

seminars

g) Having informal case

discussions with

colleagues

h) Institutional work

conditions

4

n=21 n=21 n=21 n=21

Figure 1. What has been most influential on the professional development? - The eight most chosen influences and

the proportions (%) of students (n=21). The numbers indicates the four significant differences: (1) –43% CI95%: -16 to –

70%; (2) 24% CI90%: 4 to 44%; (3) –24% CI90%: 8 to 44% and (4) 19% CI95%: 8 to 30%.

The development of therapeutic attitudes during and after psychotherapy training.

(Carlsson, J., Norberg, J., Schubert, J. & Sandell, R. (in press) European Journal of Psychotherapy & Counselling (September, 2011)

Aim

4 November, 2011

To explore how the attitudes and values of

psychotherapy students develop during and after an

advanced psychodynamic training programme, by using

the therapeutic attitudes scales (TASC-2).

Aim

Searching for recognition:The professional development of psychodynamic psychotherapists during training and the first few

years after it.Carlsson, J., Norberg, J., Sandell, R. & Schubert J. (2011). Psychotherapy Research 21, 141-153.

4 November, 2011

To explore the development of the professional self

during training and the first few years after, as described

by the therapists in an open format

The Interview

� Retrospective interviews 4-6 yrs after training

� Two parts:�A) open-ended covering the professional development during

training, after training, thoughts about the therapists’ own therapy, and thoughts about becoming licensed with special focus on not having to be in supervision anymore. Lasted 45 minutes.

4 November, 2011

minutes.

�B) participants were asked to reflect on their development as described in the questionnaire and on the possible reasons for changes or lack of changes. Lasted about 45 minutes.

In all, the interview was about 90 minutes long.

� 18 agreed to participate in the interview study (3 drop-outs)

� Verbatim transcription

Analysis

� Constant comparative method.

� Coding of meaning units.

� Merging codes to categories.

4 November, 2011

� Clustering of categories.

� Core category.

� All codes and categories indexed by time reference

(beginning, during and after training).

� Theoretical memos.

Validation - trustworthiness

� Meetings to discuss preconceptions.

� Coding and categorization made by the first two authors.

� Weekly meetings to discuss and challenge the emerging results.

4 November, 2011

emerging results.

� Presentations in internal research seminars and at international psychotherapy research conferences.

� Two independent researchers read early versions of the report.

� Member checking.

� The entire research process took about 2 years.

Beginning During

Attachment to the preformed professional

self(n=18)

Finding one’s own style(n=18)

Searching for improvement

(n=18)

Wanted to become a

better clinician

(n=17)

Being confirmed

(n=17)

Continuing development

(n=16)

After

Wanted to be part of the

psychoterapeutic

community

(n=16)

Being questioned

(n=18)

Searching for recognition

Gaining confidence

(n=16)

General Conclusions

� Preformed professional self.

�attachment to the preformed professional self

� The supervisory relationship.

� Compliance.

� Towards an eclectic therapeutic profile.

Limitations

� The selected sample of participants.

� The small group of participants.

� The lack of external variables.

Implications for future research

� Compare different training contexts and explore whether different cultures of training stimulate different patterns of development.

� The development of psychotherapeutic attitudes also needs to be investigated at earlier stages of training. It would be of interest to see whether students at the level of basic training follow the same kind of development.

� Future studies should also include external variables (i.e. measure of skill or competencies, other aspects of therapeutic attitudes).

� Repeated interviews every semester. The study might also explore the � Repeated interviews every semester. The study might also explore the concepts of “attachment to the preformed professional self” and “searching for recognition” and how they influence learning in different training settings.

� Explore teachers’ understanding of what they believe to be facilitating or obstructing learning and what they believe are relevant learning goal. Specifically, it seems to be important to explore how teaching staff cope with the students’ previous experiences and preformed professional selves.

� Lastly, studies of how pedagogical theories can be integrated with the training of psychotherapists are needed.

Implications for training

� Be aware of the pre-formed professional self, and use it as a

starting point for the individual student’s learning goals.

� Be aware of the students’ need for recognition.

� Be aware of the risk of power struggles and the possible role

conflict for the student.conflict for the student.

� Include regular time-outs in the training to discuss its aims and

what is going on in the process, including the relationships

between the student and the teachers and supervisors.

� Continuously explore and negotiate the supervisory alliance.

� Transform findings from the present studies to training

programmes by creating ongoing learning and assessment

strategies.

LIST OF PUBLICATIONSjan.karlsson@sll.se

1. Sandell, R., Carlsson, J., Schubert, J., Broberg, J., Lazar, A., & Grant, J. (2004). Therapist attitudes and patient outcomes: I. Development and validation of the therapeutic attitude scales (TASC-2). Psychotherapy Research, 14, 469–484.

2. Carlsson, J. & Schubert, J. (2009). Professional values and their development among trainees in psychoanalytic psychotherapy. European development among trainees in psychoanalytic psychotherapy. European Journal of Psychotherapy & Counselling 11, 267–286.

3. Carlsson, J., Norberg, J., Schubert J., & Sandell, R. (In press). The development of therapeutic attitudes during and after psychotherapy training. European Journal of Psychotherapy & Counselling (September, 2011). Epub ahead of print.

4. Carlsson, J., Norberg, J., Sandell, R. & Schubert J. (2011). Searching for recognition: The professional development of psychodynamic psychotherapists during training and the first few years after it. Psychotherapy Research 21, 141-153.