Introduction
Until the last decade, the literature on the training and supervision of CBT therapists was sparse, with just a handful of empirical studies (e.g. Milne, Baker, Blackburn, James and Reichelt, Reference Milne, Baker, Blackburn, James and Reichelt1999; Williams, Moorey and Cobb, Reference Williams, Moorey and Cobb1991), and reviews on practitioner training only in adjacent (non-CBT) fields (e.g. Colquitt, LePine and Noe, Reference Colquitt, LePine and Noe2000). However, in the past decade, a growing literature has started to map the key components of CBT training and supervision, summarized in several recent publications (Beidas and Kendall, Reference Beidas and Kendall2010; Fairburn and Cooper, Reference Fairburn and Cooper2011; Milne, Reference Milne2009; Rakovshik and McManus, Reference Rakovshik and McManus2010).
One of the key components of effective CBT training and supervision is “active” or experiential techniques (Bennett-Levy, McManus, Westling and Fennell, Reference Bennett-Levy, McManus, Westling and Fennell2009a; Milne, Reference Milne2009; Rakovshik and McManus, Reference Rakovshik and McManus2010). Experiential techniques are thought to be particularly important in translating declarative knowledge (i.e. what to do) into procedural skills (i.e. how to do it) (Bennett-Levy, Reference Bennett-Levy2006).
In CBT, “experiential techniques” are usually in the form of role-plays of therapist/client interactions, brief self-experiential workshop exercises, or exploration of therapist cognitions, emotions or behaviours in supervision, where these appear to be interfering with the therapeutic process (Bennett-Levy et al., Reference Bennett-Levy, McManus, Westling and Fennell2009a; Milne, Leck and Choudhri, Reference Milne, Leck and Choudhri2009). Anything more than brief exploration of the “personal self” is not typically part of CBT training (Bennett-Levy and Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007).
In other forms of psychotherapy, exploration of the “personal self” through personal therapy is an intrinsic component of training (Macran and Shapiro, Reference Macran and Shapiro1998). A number of CBT writers have emphasized the importance of CBT self-practice (J. Beck, Reference Beck1995; Padesky, Reference Padesky and Salkovskis1996). For instance, Padesky (Reference Padesky and Salkovskis1996, p.288) remarked: “To fully understand the process of therapy, there is no substitute for using cognitive therapy methods on oneself.” However, none of three recent review papers on CBT training recommended practising CBT on one's own cognitions as a useful strategy (Beidas and Kendall, Reference Beidas and Kendall2010; Fairburn and Cooper, Reference Fairburn and Cooper2011; Rakovshik and McManus, Reference Rakovshik and McManus2010).
Bennett-Levy and colleagues (Bennett-Levy, Lee, Travers, Pohlman and Hamernik, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003; Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) formalized the concept of CBT self-practice into a structured CBT training paradigm, known as self-practice/self-reflection (SP/SR). The primary goal of SP/SR is to enhance therapist skills by experiencing CBT “from the inside”. Trainees practise therapy techniques on themselves (SP) either through use of a workbook or in “co-therapy” pairs. Then, through structured written reflections (SR), which are circulated anonymously to fellow course participants, they link personal experience to CBT theory and practice (Bennett-Levy, Thwaites, Chaddock and Davis, Reference Bennett-Levy, Thwaites, Chaddock, Davis, Stedmon and Dallos2009b). In this way, participants can experience and reflect on their own experience of CBT techniques, and compare and contrast it with that of their colleagues.
SP/SR differs from “usual” CBT training techniques in a number of important ways. First, the focus of SP/SR is on use of CBT on the “personal self” (e.g. anxieties, self-doubt, testing beliefs) consistently over a number of weeks (i.e. not just a one-off workshop exercise). Second, structured written reflections are a key part of the process. Third, SP/SR participants form a learning community in which the principal mode of learning is from each other's reflections rather than from an expert trainer. Fourth, the trainer's role is that of facilitator, rather than teacher. These key elements are listed in Table 1, and contrasted with “usual” training techniques.
Table 1. Differences between SP/SR and “usual” CBT training programs
SP/SR can have a range of potential benefits for CBT trainees both professionally and personally that apply both to novice and experienced practitioners (Bennett-Levy et al., Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003; Chaddock, Reference Chaddock2007; Davis, Reference Davis2008; Farrand, Perry and Linsley, Reference Farrand, Perry and Linsley2010; Haarhoff, Gibson and Flett, Reference Haarhoff, Gibson and Flett2011; Laireiter and Willutzki, Reference Laireiter and Willutzki2003). First, it can help trainees’ professional development by furthering their understanding of CBT, their CBT skills, and their belief in its value. In early research on SP/SR, Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001) found changes in the quality of the learning, changes in self-reported understanding and skills, and changes in therapist confidence. Later studies have reported similar findings (Farrand et al., Reference Farrand, Perry and Linsley2010; Haarhoff et al., Reference Haarhoff, Gibson and Flett2011).
Second, SP/SR may promote personal development (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Sanders and Bennett-Levy, Reference Sanders, Bennett-Levy, Mueller, Kennerley, McManus and Westbrook2010). For therapists working with clients with complex problems, awareness of one's own process may be particularly relevant when interpersonal factors feature significantly and on occasions disrupt the therapeutic process. In their landmark book, Cognitive Therapy of Personality Disorders (A. T. Beck, Freeman and Associates, Reference Beck, Freeman and Associates1990), the authors remarked on the importance of therapist self-awareness: “To manage the limits of the therapeutic relationship effectively, and to use their personal reactions in the process of treatment, cognitive therapists must first be sensitive observers of their own thoughts, feelings, and beliefs” (p.252); other CBT therapists have made similar points (Newman, Reference Newman2010; Safran and Muran, Reference Safran and Muran2000). Some data suggest that SP/SR may be a particularly effective training strategy for the development of therapist interpersonal skills (Bennett-Levy et al., Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003, Reference Bennett-Levy, McManus, Westling and Fennell2009a; Bennett-Levy and Thwaites, Reference Bennett-Levy, Thwaites, Gilbert and Leahy2007). Most of the early studies of SP/SR reported qualitative data; more recent studies have reported similar changes using quantitative measures (Chaddock, Reference Chaddock2007; Davis, Reference Davis2008).
Although SP/SR generally appears beneficial, the level of benefit varies between individuals (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001). At one extreme, there are trainees who report SP/SR to be life changing. At the other end of the scale, others are unable to engage with the process. Occasionally, CBT trainees may have a distressing emotional experience when engaging in SP/SR, emphasizing the need for safeguard strategies, including temporarily or permanently opting out (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001). Most CBT trainees lie somewhere in-between these extremes of experience and, generally, those who engage well with the process report greater benefit from SP/SR; also, importantly, their reflections tend to be richer (Bennett-Levy et al., Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003; Chaddock, Reference Chaddock2007). Therefore it is important to understand the parameters that effect engagement with SP/SR.
The purpose of the present study is to develop a testable model, which can predict trainees’ level of Engagement with SP/SR and their Experience of Benefit from the SP/SR process. Such a model can help trainers and researchers when designing future SP/SR programs. Grounded theory methodology has been used to analyse the data, since it was hypothesized that differences between the SP/SR and “usual” modes of training might result in different predictors of engagement and benefit (e.g. confidentiality and safety issues might be much more salient for SP/SR participants). Grounded theory not only provides a rigorous approach to the analysis of qualitative data, but also has the explicit goal of constructing theory that can be subject to further empirical testing.
Method
Participants
Participants were 46 CBT trainees/practitioners from four different training groups in which SP/SR was a core component. Two of the groups, TraineePsych1 (n = 7) and TraineePsych2 (n = 12), were postgraduate students on a clinical psychology program who undertook an introductory CBT course as part of their program. A third group were 8 experienced psychologists (ExpPsych), who answered an advertisement for experienced CBT therapists wishing to undertake a self-experiential training course in CBT. A more detailed description of these groups can be found in Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003). The fourth group were 19 mental health workers (MHWorkers) undertaking an introductory CBT course; the majority were mental health nurses and social workers.
The four groups differed in their levels of experience of CBT, their backgrounds, ages and professional experience (See Table 2 for full details). They also differed in the extent to which they had voluntarily enrolled in the courses. The ExpPsych group had explicitly decided that they wished to undertake a self-experiential CBT course. TraineePsych1 and 2 were doing a CBT module as part of their clinical psychology training. TraineePsych1 had not anticipated the SP/SR component which was newly introduced, while TraineePsych2 knew this component was part of the course. The MHWorkers were doing the CBT course at the behest of their health authority employers. The majority (>50%) were mental health nurses working on inpatient wards; others included psychologists and occupational therapists. Some appeared rather more motivated to participate than others, both in the program and with the SP/SR homework. Whereas for TraineePsych1 and 2, SP/SR was a compulsory course requirement in their clinical psychology program, ExpPsych or MHWorkers were not subject to any sanctions if they did not do the SP/SR homework.
Table 2. Participant characteristics, course structure and requirements, study data and outcomes
*Missing data; 1 gender. Of those who gave professions, 7 nurses, 6 social workers, 1 clinical psychologist
Courses
The 4 SP/SR courses differed along various dimensions including:
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• Their length and structure
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• Their purpose e.g. basic skills training vs. advanced self-experiential
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• Homework that was required or could be expected
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• The extent to which SP/SR was a central component
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• The outcomes
These differences are summarized in Table 2 and previous papers (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003).
Data
Questionnaires were used to gather basic demographic information. Full details of data collection methods for TraineePsych1, TraineePsych2 and ExpPsych groups can be found in Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003); here they are summarized in Table 2. Qualitative data were of four types: written reflections of course participants, transcribed post-course group and individual interviews, post-course questionnaires, and trainer observations. Written reflections of SP/SR experiences were regularly e-mailed to the first author (course trainer) during the TraineePsych1, TraineePsych2 and ExpPsych courses, and circulated anonymously to other course participants. Following TraineePsych1 and ExpPsych courses, a group interview was held at which reflections were recorded and transcribed. For the TraineePsych2 course, all participants were interviewed individually. All interviews were also recorded and transcribed. Data for MHWorkers consisted of a course feedback questionnaire, plus the pooled observations of two trainers during the course. It should be noted that the data for MHWorkers group were less comprehensive than for the other groups.
Data analysis
The data were subject to rigorous grounded theory analysis, as part of a larger research project identifying the impact of personal experiential work on CBT trainees. Analytic techniques are fully described in Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003).
In brief, the “constant comparison method” (Glaser and Strauss, Reference Glaser and Strauss1967; Strauss and Corbin, Reference Strauss and Corbin1990) was used to compare participant with participant and training course with training course in order to ascertain why one participant or set of participants derive considerable benefit from SP/SR while others do not do so to the same degree. The principal focus was on differences, not similarities. NUD*IST computer software (Richards and Richards, Reference Richards and Richards1991) was used to categorize participant data.
The principal author undertook analysis of the data to ensure a detailed knowledge of the differences between different training courses, and their participants. This type of analysis explicitly acknowledges the highly contextual nature of cognitive therapy training (or any training), the large variety of variables that can impact on the engagement of individuals and groups in the SP/SR process, and the provisional nature of the resultant model.
Member checking, a key grounded theory technique, was used as the prime method to establish credibility of the data (Glaser and Strauss, Reference Glaser and Strauss1967; Strauss and Corbin, Reference Strauss and Corbin1990) and to guard against any possible analytic bias by the first author. Three strategies were adopted:
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1. A preliminary version of the model was presented at a follow-up meeting for research participants in TraineePsych1 and 2 and ExpPsych groups. Subsequently, the model was amended slightly in the light of feedback.
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2. Once written up, an extended written report was sent to five “member checkers” in TraineePsych1 and 2 and ExpPsych. They rated the following questions on a 5-point scale (ranging from “Not at all well” to “Very well”, “Not at all” to “Very much”) and provided comments: How well was your own experience of SP/SR represented in the report? How well was your group's experience represented in the report? To what extent did the interpretation of the data in the report “ring true” for you? All three questions received ratings of 4 or 5 from all respondents, and the qualitative comments indicated that members saw the data, and its interpretation, as representing their experience well. No member checkers were available from the MHWorkers group; accordingly, their data are less well validated.
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3. Member checking by the second author (NL), an experienced CBT therapist and researcher, who had experienced SP/SR from a combination of unique perspectives: first as an “insider” as a group participant in the ExpPsych group; later as the first author's Ph.D. thesis supervisor. Thus, she was in a unique insider/outsider position to evaluate the credibility of the resulting analysis.
Results
A model of the factors that influence participants’ experience of SP/SR was developed from the grounded theory analysis (see Figure 1). The “fulcrum” of the model is engagement with SP/SR and Experience of Benefit. We have termed these “outcome factors”. Our data suggested that engagement is central to the Experience of Benefit. These factors appeared to mutually influence one another, such that the more motivated a trainee is, the more benefit s/he experiences; and the more benefit s/he experiences, the more s/he is engaged. This is illustrated by a comment of Martina (ExpPsych) who noted:
What helped me further engage [were] . . . the small “light bulbs” that lit up across the sessions for me.
The other five elements – Course Structure and Requirements, Expectation of Benefit, Feeling of Safety with the Process, Available Personal Resources, and Group Process - are “influencing factors” that impact on the two outcomes. All elements are described below and illustrated with exemplar quotes from interviews or textual data. We start with the two outcome factors.
Figure 1. Factors influencing Engagement and Experience of Benefit from SP/SR
Outcome factors
Engagement with SP/SR. Participant responses indicated Engagement with SP/SR had both quantitative and qualitative aspects. Quantitatively, Engagement with SP/SR requires that a certain amount of time be devoted to SP/SR. It seems that there are no shortcuts; one cannot “skim” SP/SR in the same way that one can skim a book chapter. Qualitatively, our experience was that SP/SR requires the participant to reflect at some “depth” if the experience is to be maximally effective. Depth of reflection is indicated by some of the following qualities: the participant fully experiences CBT techniques “from the inside”; recognizes and reflects on the emotional content of the experience, and on the cognitive model; draws out implications of personal experience for clinical practice and cognitive theory; and recognizes both the commonality and idiosyncrasy of personal experience.
When engagement is lost, benefit is lost. In his interview, Francis (TraineePsych2) noted that during a period of personal stress:
I sort of lost the contact with the SP/SRs for a few weeks. I typed out a few lines and that was it basically. Once I started to get back into it in the end, I found those other qualities, and the feeling that you've done a good bit of work, and it's something new that's integrated information that's relevant to your area.
Experience of Benefit
Participants undertaking SP/SR reported a “deeper sense of knowing” of cognitive therapy practices, which found expression in enhanced understandings of CBT, enhanced skills and therapist self-concept (e.g. self-confidence and belief in CBT). We also found that benefit may also be experienced on a personal level through greater self-awareness and, sometimes, through direct personal change (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001). The types of benefit described by participants are reported in full detail in Bennett-Levy et al. (Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001, Reference Bennett-Levy, Lee, Travers, Pohlman and Hamernik2003).
Influencing factors
Course Structure and Requirements refers to the specifications of the training course; for instance, goals, structure, length, components of training and forms of assessment. Expectation of Benefit refers to positive or negative trainee expectations of SP/SR prior to starting the course. Feelings of Safety with the Process indicate the extent to which agreements and structures are put in place, which enable participants to feel safe to self-explore, self-reflect and share their reflections with others. Available Personal Resources indicate the amount of time and energy that participants are able to give to SP/SR in their present life circumstances. Group Process refers to the impact of group participation, cohesiveness and feedback on group members’ engagement.
To provide an immediate illustration, many of the elements are well summarized in a reflection from Martina (ExpPsych) [variables in brackets]:
I was able to engage with the project [Engagement with SP/SR] because I had free choice of what it was to be [Feeling of Safety with the Process]. What helped me further engage was the therapist [Feeling of Safety with the Process] and group relationship [Group Process], the accountability of having to report to someone [Course Structure and Requirements] and the small “light bulbs” that lit up across the sessions for me [Experience of Benefit].
Course Structure and Requirements
Course Structure and Requirements refer to the institutional context and specifications of the training course: for instance, the goals, structure, length of course, components of training, and forms of assessment. It also encompasses whether SP/SR was a stand-alone course (as in ExpPsych), or part of a more general CBT training program, as in the other three groups. Contextual differences between the four courses included: the learning tasks, the amount of homework required, the trainer's leverage (e.g. to expect homework), the professional background of participants, their previous training, their motivation, and their level of accountability (see Table 2).
For instance, the degree of motivation for participation in the training courses, and the SP/SR component, varied considerably across groups. At one end of the scale, the ExpPsych group attended an introductory session, after which they specifically signed up to be part of an experiential SP/SR group. However, there could be no sanction if they didn't complete their reflections for the week (in the event there was 81% compliance). The two TraineePsych groups were in an intermediate position; they were studying CBT as part of their program. SP/SR was a course requirement. For most, this was a positive. At the other end of the scale, the MHWorkers group were required to attend the CBT course by their health authority; most had little or no psychology training; the course was much shorter; and SP/SR was suggested homework, rather than a requirement.
Many of the TraineePsych and ExpPsych participants noted that “having to” do SP/SR as a course requirement facilitated their engagement - for instance, Jane (ExpPsych) noted the value of “the accountability of having to report to someone”. Although the specific SP/SR compliance rate of the MHWorkers group is not known, some participants reported doing no homework, and most did less than one hour's homework per fortnight. It seems likely that engagement with written reflections were for the most part cursory or non-existent.
Expectation of Benefit
Many course participants reacted to the idea of SP/SR, when first introduced, with some degree of concern, anxiety, or resistance. Others positively welcome the idea. At one extreme, Anne (TraineePsych1) recalled her reaction at the start of the first SP/SR group:
When I first read that thing about having a reflection assignment, I thought, “Oh god! How stupid!” (laughter). I was really appalled. (laughter). . . It was like, when I'd bumped into people who were doing the course, I'd say, “did you read the thing . . . it's scary isn't it”.
Other participants like Jeff (TraineePsych2) already had positive expectations:
I have always been of the opinion that experiential work is valuable (even if uncomfortable at times!) so was quite prepared to be open-minded and give it a go.
Feeling of Safety with the Process
As already indicated, SP/SR can initially be perceived as threatening, depending on participant and context. Responses indicate that the perception of threat came from two sources:
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(i) Fear that SP/SR may lead to loss of control and personal distress, or, at an extreme, loss of sanity
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(ii) Fear of exposure to other participants.
One of the most often expressed fears about SP/SR was that it might get out of control; at an extreme, it might drive people crazy. Some participants acknowledged that they normally used avoidance as a coping style, and that in the context of a busy degree course, they were not willing to let down the barriers. For example, Helen (TraineePsych1) expressed her concern about
not wanting to delve too deeply because you don't have somebody there to pick up the pieces if something happens.
There was quite a degree of variation in the extent to which participants had concerns about public communication of SP/SR experiences. Some participants had few concerns, and felt that they could adjust their level of exposure in role-plays, “co-therapy” or email communications, while for others this was a far greater issue, particularly with “co-therapy” situations. For instance, Michael (ExpPsych) made the link between fear of exposure and Engagement with SP/SR explicit when he wrote:
I felt somewhat engaged in the project, but not completely. One of the things that stopped me was my apprehension about disclosure of a problem to a peer. Initially it didn't worry me, but when I discovered the intensity of the emotional reaction to it, which completely surprised me, I was more reticent to disclose too much.
Available Personal Resources
Another important element in the experience of SP/SR was the amount of available personal resource or energy that participants felt they had at their disposal. Participants noted that SP/SR was quite a different form of training from other experiences of learning CBT, making different, more emotional demands on personal resources. For instance, Richard (TraineePsych1) wrote:
I suspect that the ability to distance yourself from your emotions and focus on something that is “cerebral” is a necessary skill for students. Yet SP/SR did not allow this. My personal life became the domain of my learning processes, and so was no longer able to be distanced.
Mostly, SP/SR was experienced as an interesting, exciting and engaging form of learning. However, if participants were experienced high levels of concurrent stress and/or lack of social support, SP/SR could be experienced as exhausting, draining and time-consuming. For instance, Colette (TraineePsych2) wrote:
It was a particularly bad time in my life to be going through this process, and I did not identify any supports as being available for me (at the personal intimate level that I would have needed) . . . I stopped participating actively in SP/SR . . . my non-compliance was a self-preserving strategy.
Group Process
Participation and cohesiveness of the training groups, and the opportunity to discuss or read about the experiences of others, played an important role in enhancing group members’ engagement with SP/SR. Referring to the reflections digest, the weekly e-mail summary of the group's experience, Tom (TraineePsych2) wrote:
I especially enjoyed reading how the other students responded to each of the exercises. I was fortunate to be able to complete the subject with a wonderful group of people who I felt comfortable in discussing the various issues with.
Martina (ExpPsych) noted that another value of group reflections was the “different levels of distance” that it allowed:
I really liked the coming back to reflect in the group after the pairs work - I felt this allowed a variety/different levels of distance from the material to process the issue.
The Group Process, when working effectively, was therefore able to increase engagement, and deepen the SP/SR experience of participants, by offering alternative perspectives and allowing the reflection process to operate at different depths.
Discussion
The purpose of this paper has been to develop an empirically-derived model of Engagement and Experience of Benefit from SP/SR, which may be of value to trainers thinking of running SP/SR programs, and which can be formally tested. Central to the model is Engagement with SP/SR and Experience of Benefit that appear to have a reciprocal and repeating relationship throughout an SP/SR program. A minority of participants had difficulty engaging with the process. Without Engagement, they experienced few benefits from SP/SR, which in turn diminished their engagement further. However, the majority engaged well with SP/SR; some had major “aha” experiences on a personal or professional level; others reported a “deeper sense of knowing” CBT and increased understanding and skills (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001), which in turn further enhanced engagement. A similar mutually reinforcing relationship between engagement and outcomes has long been noted in psychotherapy research (DeRubeis et al., Reference DeRubeis, Evans, Hollon, Garvey, Grove and Tuason1990; Greenberg, Reference Greenberg1991; Westra and Dozois, Reference Westra and Dozois2006).
It was hypothesized that the factors predicting Engagement and Benefit in SP/SR programs might differ from “usual” CBT training programs in several important respects, due to differences in focus (prolonged self-practice of CBT), output (structured written reflections), participant relationships (learning community) and trainer role (background group facilitator). Five factors influencing outcome were identified from the data: Course Structure and Requirements, Expectation of Benefit, Feeling of Safety with the Process, Available Personal Resources, and Group Process. Two of these factors - Course Structure and Requirements, and Expectation of Benefit - are typically those that have been found to influence outcomes from skills training programs (Beidas and Kendall, Reference Beidas and Kendall2010; Colquitt et al., Reference Colquitt, LePine and Noe2000). However, the other three factors – Feeling of Safety with the Process, Available Personal Resources, and Group Process – look to be specifically related to the personal experiential nature of SP/SR. Although one-off self-experiential exercises sometimes feature in CBT workshops, and clear boundary setting is important in CBT supervision, issues to do with confidentiality, safety and personal resource are almost certainly more salient in the SP/SR learning community context than in “usual” forms of CBT training.
It is almost axiomatic in educational research that Course Structure and Requirements will influence students’ level of engagement. For instance, student outcomes are associated with perceptions of how work will be assessed, degree of choice over content and method of learning, perceived demands, and interest in content of the subject (Ramsden, Reference Ramsden, Marton, Hounsell and Entwistle1984). In the present context, Engagement with SP/SR was related to the length of courses, the learning tasks, the amount of homework required, the trainer's leverage (e.g. to expect homework), the professional background of participants, their previous training, their motivation, and their level of accountability. The MHWorkers’ relative lack of engagement may have been related to a number of these factors e.g. their lack of CBT background, the shorter SP/SR course, and trainers’ lack of leverage to have them do homework.
The model identifies Expectation of Benefit as another element that needs to be addressed before participants will engage adequately with SP/SR. Pre-course briefings have always framed the potential value of SP/SR in terms of its potential impact on CBT competency. To date, we have probably underestimated the emotional commitment that is involved in SP/SR, resulting in dropouts from some programs (e.g. Davis, Reference Davis2008). It is recommended that in future trainers emphasize the emotional demands of SP/SR, and suggest that participants postpone their involvement if they do not have sufficient available personal resources (see below).
Creating a feeling of safety with the process has also always been part of the SP/SR protocol. It is a core requirement for any course involving SP/SR; in its absence, it is likely that engagement would be stalled from the outset. The notion of creating a safe environment for personal exploration in group settings is an important element of training in some of the more experiential psychotherapies e.g. group psychotherapy (Anderson, Reference Anderson2001; Feiner, Reference Feiner1998; Lasky and Riva, Reference Lasky and Riva2006; Osborn, Daninhirsch and Page, Reference Osborn, Daninhirsch and Page2003; Payne, Reference Payne2001). However, a crucial difference between SP/SR and group therapy for trainee therapists is that SP/SR boundaries are more contained.
SP/SR participants identified two kinds of safety concerns: fear of losing control, distress and possibly insanity; and fear of exposure to other participants. Responses indicated that these concerns were best addressed by two strategies: participants having control of the process, and having adequate safeguards and support. As emphasized by trainers who use experiential exercises in other settings (Burns, Reference Burns1996), choice and negotiation are key to participants’ sense of control. Participants need to be clear that it is their decision at what level they engage with SP/SR; that they have choice whether or not to use a particular technique; choice over the material or project for self-practice; choice not to use self-material for role-plays; choice of what reflections are publicly reported; and choice to work with a partner or not work with a partner. Fear of exposure was addressed by making the key distinction between reflection on content and reflection on process, and by making clear confidentiality agreements between partners and groups. Participants also need to have devised a safeguard strategy in the event of distress, and to feel comfortable with all these arrangements before SP/SR should proceed (Bennett-Levy et al., Reference Bennett-Levy, Turner, Beaty, Smith, Paterson and Farmer2001; Sanders and Bennett-Levy, Reference Sanders, Bennett-Levy, Mueller, Kennerley, McManus and Westbrook2010).
Group Process was another factor identified as facilitating engagement with SP/SR. The SP/SR cohort forms a learning community where participants learn from one another's reflections (Farrand et al., Reference Farrand, Perry and Linsley2010). Reading or hearing about other group members’ experiences enables participants to normalize their experience and/or compare and contrast it with others. Some group members also suggested that sharing reflections enhanced group bonds, which, in turn, enabled them to feel safer about sharing. Recent SP/SR research using online blogging supports this conclusion (Farrand et al., Reference Farrand, Perry and Linsley2010; Haarhoff and Farrand, Reference Haarhoff, Farrand, Dryden and Branch2012). On the other hand, one adverse factor we have found on some SP/SR courses is that doing programs with workplace colleagues can inhibit engagement. This may have been a significant factor in the MHWorkers’ relative lack of engagement.
The fifth element that impacted significantly on trainees’ Engagement with SP/SR was the amount of personal resources or energy available to them. SP/SR is personally demanding in a different way from “usual” training. It makes emotional demands that trainees can experience as exhausting and draining if facing concurrent stressors from external factors (e.g. relationship difficulties, bereavements, work, and other hassles). A few participants also identified lack of social support as a barrier to full engagement with SP/SR. Social support has been shown to exert a buffering effect on stress (Lin, Woelfel and Light, Reference Lin, Woelfel and Light1987), and may have affected participants’ engagement both by affecting the amount of stress experienced, and by increasing concerns about wellbeing in the event of adverse consequences from self-exploration. In summary, future research still needs to ascertain more precisely the personal and environmental factors that determine emotional engagement, and the reasons for “dropouts” from SP/SR progams.
In several respects, there are limitations to the study. It would have been preferable to have had the same quality of data from the MHWorker group that we gained from the other three groups. However, due to institutional restrictions this was not possible. Accordingly, we had to rely on session feedback sheets and trainer observations.
The interpretation of the qualitative study data was also primarily dependent on the lead author's analysis. To guard against bias, the second author and five member checkers reviewed and commented on the analysis. However, as with all formative qualitative studies, the data interpretation and model should be regarded as preliminary, awaiting further verification. The model now requires testing with different types of trainee in different settings, preferably using quantitative measures.
The model itself requires refinement. Within the model, there are two “hidden presences” that were pervasive across most categories but were not directly addressed by the data: the course leader and the course participants. Of necessity, the course leader's style and actions impact strongly on Course Structure and Requirements, Expectation of Benefit, Feeling of Safety with the Process and Group Process (Fennell, Reference Fennell, Mueller, Kennerley, McManus and Westbrook2010; Henry, Schacht, Strupp, Butler and Binder, Reference Henry, Schacht, Strupp, Butler and Binder1993). As indicated in Table 1, the necessary qualities for the course facilitator role appear to be different from the “usual” CBT trainer role, exemplified by the fact that one SP/SR program for highly experienced CBT therapists was successfully facilitated by a postgraduate clinical psychology student (Davis, Reference Davis2008). However, as all courses in the present study were facilitated by the same group leader, the data do not allow analysis of the leader's contribution. Since the leader's role is clearly important in therapy training (Fennell, Reference Fennell, Mueller, Kennerley, McManus and Westbrook2010; Henry, Strupp, Butler, Schacht and Binder, Reference Henry, Strupp, Butler, Schacht and Binder1993), future research should examine which of the key competencies and qualities are required for effective SP/SR facilitation.
Course participants’ life experiences and personality structure are also likely to impact on Feelings of Safety with the Process, Expectation of Benefit, Availability of Personal Resources, Group Process, and Engagement with SP/SR (Colquitt et al., Reference Colquitt, LePine and Noe2000). However, the present study does not allow us to draw conclusions about the relevance of course participants’ personality style as these data were not collected. Delineation of their impact requires further research, which will be helpful in determining who benefits and who has difficulty with SP/SR programs.
Development of the model, and the five influencing factors, enables specific recommendations to enhance engagement and benefit from SP/SR to be tested for each of the five categories. Our provisional recommendations, derived from our own research and that of others over the past decade, are listed in Table 3.
Table 3. The five influencing factors: recommendations to enhance Engagement with SP/SR and Experience of Benefit
In summary, we have developed a model to be tested by researchers and practitioners, which provides guidance about the best ways to set up and develop SP/SR programs in order to create the conditions in which trainees can gain maximum benefit. The factors identified within the model are thought to mediate the trainee's experience of SP/SR. Highly engaged trainees appear to gain much benefit from SP/SR. However, if there are difficulties with any one of the influencing factors (e.g. Course Structure and Requirements, or Feeling of Safety with the Process), it may significantly affect outcomes. We expect the model to be further developed over the next years as new courses provide new data, adding variability and finer-grained distinctions to the present findings.
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