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 PSYCHOTHERAPISTS
Therapist 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 therapist
Beutler 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 PSYCHOTHERAPY
the 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, Stockholm
jan.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
Start
of training
End 2nd Yr.
End
of 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 training
2 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
Age
M (SD) (range)
Gender
Female
(%)
Basic academic
training
(%)
Experience of
working with
psychotherapy
a
M (SD) (range)
Personal
therapy
a
M (SD) (range)
Initial Cohort
b
,
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 89 1. 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
S
h
a
r
e

(
%
)

s
t
u
d
e
n
t
s
a) 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
After End End 2nd year Beginning
40
20
0
S
h
a
r
e

(
%
)

s
t
u
d
e
n
t
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 PUBLICATIONS
jan.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.