Personal growth and its role in the professional development of novice clinicians

DEVELOPMENT OF THE NOVICE CLINICIAN 0

Clinical psychologists have been working to improve methods of training to prepare

novice clinicians for optimal performance since the first mental health services were provided in

1897 (Routh, 2000). While the field of applied psychology has progressed and now recognizes

the development of specific competencies as a preferred method of training (Fouad et al., 2009),

many questions remain as to what additional factors could be addressed in training that can

explain the large variance in clinical competence. Some have suggested that this variance is due

to “therapist factors” (Beutler et al., 2004; Goldfried, Greenberg, & Marmar, 1990; Hanna,

Bemak, & Chung, 1999; Hanna & Ottens, 1995; Kim, Wampold, & Bolt, 2006; Lambert, 1992;

Whiston & Sexton, 1993).

Mental health professionals have been interested in therapist personal factors as they

relate to effective training and clinical work (Buchanan, 2002; Ellis, 1991; Folkes-Skinner,

Elliott, & Wheeler, 2010; Grafanaki, 2010; Heppner & Roehlke, 1984; Hill, Sullivan, Knox, &

Schlosser, 2007; Ladany, 2007; Luke & Kiweewa, 2010; Orlinsky & Rønnestad, 2005;

Rabinowitz, Heppner, & Roehlke, 1986). Though client factors are most commonly investigated

relative to clinical outcomes, clinician personal factors have also been considered (Roos &

Werbart, 2013). From the perspective of clients, clinician personal factors such as being

unsympathetic, unsupportive, invalidating, hostile, indifferent or passive are often directly

relevant to clients’ decisions to drop out of therapy. Clinician openness to accommodating

client’s therapeutic needs, flexibility in use of treatment manuals, clinician personal experience

in therapy, and ability to provide emotional support (e.g., high emotional intelligence, openness

to negative feelings, genuineness) are predictive of lower dropout rates (Roos & Werbart, 2013).

Processes for evaluating novice clinicians’ success in training are longstanding and have

included consideration of the impact of therapist personal factors on development (Blank, 1964;

Lamb, Cochran, & Jackson, 1991; Lamb et al., 1987; Wilcoxon, Norem, & Magnuson, 2005);

however, personal factors that affect treatment are not currently being adequately addressed in

supervision (Ellis, 1991; Heppner & Roehlke, 1984; Rabinowitz, Heppner, & Roehlke, 1986).

Unaddressed personal factors have been shown to have a strong impact on a clinician’s

development, which has resulted in the need for remediation plans or student dismissal from

programs (Lamb et al., 1987; Lamb, Cochran, & Jackson, 1991). While recognition of one’s

limitations through ongoing self-awareness is an ethical imperative (APA, 2002a), some have

suggested that clinicians recognizing the potential to transcend their limitations and adapt aspects

of their personality are what lead to optimal professional development (Folkes-Skinner, Elliott, &

Wheeler, 2010; Trotter-Mathison, Koch, Sanger, & Skovholt, 2010). Novice clinicians, however,

may be unaware of the degree to which the self is used as a tool for the work they are embarking

upon, as the use of the self is unique to the profession of clinical psychology relative to other

professions (Falender & Shafranske, 2007, 2012b).

Considerations of the ways in which therapist personal factors impact client outcomes

have historically been a topic of discussion amongst prominent members of the field. There has

been longstanding support throughout decades of research literature to suggest that a therapist is

only capable of facilitating change for a client to the degree that they are engaged in their own

reflective process (Freud, 1910; Rogers, 1961; Warren, Morgan, Morris, & Morris, 2010).

Clinicians may find themselves unable to recognize a client’s needs or to facilitate client change

if they themselves have not endured the same level of growth (Benziman, Kannai, & Ahmad,

2012; Cain, 2007; Carter, 2003; Rogers, 1961; Warren, Morgan, Morris, & Morris, 2010). Folkes-

Skinner, Elliott, and Wheeler (2010) note “training is a potentially disturbing personal journey

that requires a deconstruction of the self in order to make space for the new therapist-self to

emerge” (p. 274).

The personal aspects of the therapist have thus far been considered as partially relevant to

training within select areas of the field. Multicultural counseling emphasizes the importance of

self-awareness (Lobb, 2012; Richardson & Molinaro, 1996; Suthakaran, 2011; Torres-Rivera,

Phan, Maddux, Wilbur, & Garett, 2001), psychodynamic psychotherapy discusses use of self

relative to transference and countertransference (Duthiers, 2005; Freud, 1910, 1937; Sandell et.

al., 2006; Szecsödy, 2003), the field of counseling psychology perceives therapist personal

factors as playing a significant role in treatment (Boysen, 2010; Ratts, 2009), third-wave

cognitive behavioral theories sparingly have investigated the impact of training on personal

development (Grepmair, Mitterlehner, Loew, & Nickel, 2007; Hayes et al., 2004; Lejuez, Hopko,

Levine, Gholkar, & Collins, 2006; Luoma & Vilardaga, 2013; Stafford-Brown & Pakenham,

2012; Varra, Hayes, Roget, & Fisher, 2008; Wei, Tsai, Lannin, Due, & Tucker, 2015), and more

recently Aponte (1992) developed a Person-of-the-Therapist (POTT) training model for masters

level students (Nino, Kissil, & Apolinar Claudio, 2015).

Education, as it exists today, does not necessarily promote growth. Learning that nurtures

and enriches human growth takes place when intelligent habits are formed that can be used in

present and future situations (Ralston, 2011). John Dewey, a pioneer in the education literature,

suggested in his 1916 Democracy and Education that teachers must encourage open-mindedness,

curiosity, and active and reflective thinking to facilitate student academic development and

prepare them to contribute to society (Dewey, 1916; Meadows, 2006). Teaching open-

mindedness discourages a narrow view of knowledge and allows for increased ability to problem

solve while considering a variety of worldviews (Dewey, 1916). Adapting to a continuously

changing environment, developing increasingly effective problem solving skills, an ability to

learn experientially, and adapt knowledge and behavior in accordance with what is learned, are

all processes which support personal and professional development (Ralston, 2011). These

processes can be taught in an educational environment in order to catalyze growth (Dewey,

1916). Clinical training programs may promote learning in these areas in order to support

students’ personal growth.

Explicit and formal opportunities to incorporate personal development in training and

supervision appear to be absent in clinical training programs despite the fact that novice

clinicians are told that they are responsible for understanding these highly personal processes

(Falender & Shafranske, 2012b). Many are now calling for additional research to fill this gap

given the apparent relevance of the personal growth of clinicians on clinician efficacy as a mental

health provider (Grafanki, 2010; Rønnestad & Ladany, 2006; Rønnestad & Skovholt, 2001;

Skovholt & Rønnestad, 2003; Truell, 2001). Eisler (2006) asserted that there is a need to study

more closely the mediating and moderating variables, including therapist factors that impact

therapeutic outcomes. Carol Falender, a leader in research on training and supervision stated,

“the field is moving toward a focus on personal factors, and there are an infinite range of

personal factors which are relevant to the therapeutic process” (personal communication,

October 1, 2014). Increased clarity around novice clinician’s personal development needs may

lead to more accurate ideas about how development of expertise in the field unfolds

(Csikszentmihalyi, 1990; Scardamalia & Bereiter, 1993; Winne, 1995).

Definitions

Key concepts referred to throughout this document are operationalized below. A

combination of the American Psychological Association Dictionary of Psychology (VandenBos

& APA, 2007) and recent literature were used as the main points of reference.

Personal factors. Personal factors are aspects of the person in both the intra- and

interpersonal realms of experience, which are not explicitly professional. These can include how

emotions are processed and experienced, schemas, worldview, life meaning or purpose, beliefs,

attitudes, assumptions, values, motivation, etc. (Falender & Shafranske, 2012b).

Personal development and personal growth. The literature has remained unclear as to

the distinction between personal development and personal growth (Donati & Watts, 2005; Irving

& Williams, 1999). Irving and Williams (1999) believe that development and growth are

different in that the process of growth is largely unpredictable, whereas development appears to

unfold along more predictable pathways.

The literature has defined personal development as both inter- and intrapersonal growth

that occurs through the improvement of personal factors including, but not limited to,

selfattunement and evaluation, genuineness, intimacy, positive regard, embracing one’s own

humanity, emotional awareness, management of countertransference, and balance of social

connectedness (Donati & Watts, 2005; J. Rosenberg, personal communication, November 15,

2012; Norcross, 2001).

The process(es) of personal development seem to produce and catalyze personal growth

(Irving & Williams, 1999). When personal factors are developed, Wilkins (1997) believes that

effectiveness in therapy increases. Therefore, for the purposes of this study, personal growth is

defined as a result of the development of any factors that make up an individual’s identity as a

human being. Personal growth will be referred to throughout this document as an outcome of any

efforts to develop personally.

Professional development. The literal definition of professional development is the

advancement of skills or expertise to succeed in a particular profession (Merriam-Webster Inc.,

2013). This dissertation draws from the competency-based approach to training (Fouad et al.,

2009). Thus, the professional development of the novice clinician is considered in terms of the

development of particular competencies determined to be pertinent to effective work in the field.

These include knowledge, skills, and attitudes obtained through graduate education, clinical

supervision, consultation, and other academic and professional activities.

Novice clinicians. The terms novice clinician, trainee, novice therapist, apprentice, and

early career psychologist are terms used interchangeably in literature, which often remain

undefined or unspecified. For the purposes of this dissertation, the term novice clinician is used

to identify any full time student enrolled in a doctoral psychology training program and receiving

ongoing clinical supervision.

Person of the therapist. Carl Rogers (1961) described the type of person he believed

would emerge from psychotherapy if the process were fully successful as, a “well-functioning

person” (p. 36). He discussed this person as embracing three continuous, ongoing processes that

include accepting and having awareness of one’s experiences, being capable of responding to

experiences genuinely or congruently, and accepting and having awareness that the self is always

in a constant state of change. Roger’s person-centered therapy (1961) aims to move clients in the

direction of becoming fully functioning persons. John Dewey (1916) mirrored Roger’s ideas

about growth being an endlessly evolving process.

Consistent with Roger’s opinion that therapists will benefit from experiencing the same

sort of change expected of their clients, this study uses Roger’s definition of the fully functioning

person to describe the person of the therapist despite its additional applicability to the client.

Since Carl Rogers has provided this universally known concept of what might constitute a person

who is maximally capable of experiencing therapeutic change, this definition is used to discuss

the ideal person of the therapist throughout this document. This is a person who is active and

thoughtful in their engagement in these three processes described by Rogers.

Statement of the Problem

Grafanaki (2010) unequivocally stated, “there is a need to study more closely the training

process and the factors that are relevant and meaningful to counselors-in-training (e.g.,

interpersonal skills development, coping strategies, self-reflection and awareness)” (p. 81). Yet,

few in the field of clinical psychology have investigated what factors about the clinical training

process are identified as personally meaningful to novice clinicians. Existing research is either

retrospective in nature, (Carlsson, Norberg, Schubert, & Sandell, 2011; Trotter-Mathison et al.,

2010), from senior clinicians’ perspectives (Rønnestad & Skovholt, 2001), or the focus of

attention is on learning processes for the purposes of development of competence (Folkes-

Skinner et al., 2010) as opposed to personal growth.

Many authors have identified this gap in the literature and urged additional research to

investigate, from the novice clinician’s perspective, the personal growth of novice clinicians and

its impact on their professional development (Auxier, Hughes, & Kline, 2003; Bennett, 1986;

Borders, 1989; Coleman, 2006; Ellis, 1991; Gibson, Dollarhide, & Moss, 2010; Grafanaki, 2010;

Hanna, Bemak, & Chung, 1999; Hill et al., 2007; Matthews, 2012; Rønnestad & Ladany, 2006;

Rønnestad & Skovholt, 2001, 2003; Taubner, Zimmermann, Kachele, Moller, & Sell, 2013;

Thaeriault & Gazzola, 2010; Trotter-Mathison et al., 2010; Truell, 2001).

A review of the existing literature suggests that personal growth and professional

development of novice clinicians may be complementary to one another, yet the ways in which

this might be true has yet to be investigated from a novice clinician perspective. As discussed,

many have called for the investigation of novice clinician personal growth and the impact on

professional development. In this study I investigated the interrelationship of personal and

professional growth of the person-of-the-therapist of novice clinicians by looking at first year

clinical psychology doctoral students’ perspectives of relevant personal factors and

developmental processes that emerge during clinical training and supervision.

Scope and Focus of the Proposed Study

This author used inductive qualitative content analysis to investigate a unique data set

comprised of 54 journal entries completed by first-year novice clinicians. These individuals

wrote about their phenomenological experiences during their first year of clinical training. This

writing was voluntary in nature and not a requirement of the training program. The author of this

study represents one of the three authors of the journal entries. The initial research question

under investigation is:

1. How do novice clinicians relate their personal growth to professional development or what

is the potential (bidirectional) relationship between novice clinician personal growth and

professional development?

Chapter 2: Literature Review

Personal growth and development of the novice clinician as a focus of clinical training is

largely absent and reflects a significant gap in formal clinical training at the doctoral level. Many

professionals have argued for and highlighted the value of focusing on this aspect of training

(Buchanan, 2002; Ellis, 1991; Folkes-Skinner et al., 2010; Grafanaki, 2010; Heppner & Roehlke,

1984; Hill et al., 2007; Ladany, 2007; Luke & Kiweewa, 2010; Orlinsky & Rønnestad, 2005;

Rabinowitz et al., 1986). Clinical training instead emphasizes the development of particular

competencies that appear to require, only in part, personal development of novice clinicians.

However, this is not an explicitly expressed goal of training (Fouad et al., 2009). This literature

review provides a full account of the inclusion of personal growth as a consideration for clinical

training as it is grounded in the development of various aspects of the field. The literature speaks

to the importance of personal growth to professional development.

The Field of Clinical Psychology: Applicability of Personal Development to Training

History. The relevancy of personal growth to clinical training has been subtly or

explicitly implied in various ways throughout the history of clinical psychology. Historically, the

field of clinical psychology has struggled to define its role in society with psychologists’

professional efforts and intentions varying greatly (Buchanan, 2002; Routh, 2000). Prior to

WWII, clinical psychology represented less than a tenth of the psychology field and the work

that psychologists would engage in during that time (Farreras, 2001). Over time, clinical

psychologists have evolved from professional roles of researcher and teacher, to a later role of a

direct service clinician; the idea of personal growth is most salient to this latter role (Abt, 1992).

Clinical service is now the most highly specialized area of the field; however, reaching

this point was a professional struggle. As the roles and responsibilities have evolved, the

question of how to best train individuals to provide clinical services has also remained a

longstanding, complicated issue.

At the earliest point in history when clinical psychology began to form beyond

psychoanalysis, the work of psychologists was limited to observation and diagnosis of children’s

sensory and learning disorders, and later intelligence testing for WWI (Abt, 1992; Farreras,

2001). The first psychological clinic opened in 1897, setting the trend for several others to open

across the country in subsequent decades (Farreras, 2001; Routh, 2000). At that time,

psychologists pursuing work in these clinics represented a small proportion of individuals

relative to the existing field of clinical psychology.

In 1918, Henry Goddard identified the absence of consensus in the field as to what

constituted a clinical psychologist; training programs had yet to possess any accreditation

standards or system for licensure (Routh, 2000). Clinical psychology was fighting an uphill

battle, as few training programs existed to prepare students for clinical work. Additionally, most

existing programs limited the postdoctoral activities of their graduates to non-clinical activities

(Abt, 1992). Research that moved to address clinical issues paralleled the gradual increase in

clinical training programs and establishment of psychological clinics. In 1947, the idea that

perception could be influenced by psychological factors was first introduced in the literature

(Farreras, 2001). This finding led to an increased awareness of the potential for intrapersonal

change through modification of external frames of reference, thus giving more credibility and

relevance to psychotherapy.

As the field gradually moved to distinguish itself from the work of psychologists as solely

academics and researchers, professionals contemplated what type of person could be a

successful psychotherapist, then referred to as a “mental examiner.” Thus, the concept of

identifying personal factors ideal for work in the field existed in conversations well before the

establishment of the first programs to emphasize clinical application (i.e., Vail practitionerscholar

training model; Buchanan, 2002). Between 1945 and 1962 several conferences were held in an

effort to establish guidelines for training. They identified several personal factors, which tended

to indicate poor candidates for clinical training, such as being overly concerned with helping

others, pronounced social prejudice, and those with overly rigid personalities. Despite the lack of

accreditation and formal standards, programs utilized a review process of students and

occasionally dismissed students on the basis of “personality deficiencies” (Blank, 1964).

In 1911, J. E. Wallace Wallin expressed his opinion that clinical training alone would be

insufficient to produce effective mental examiners. After touring the first psychological clinic, he

advocated for the establishment of additional clinics. He also stressed the importance of hiring

clinicians who were genial, friendly, sympathetic, versatile, resourceful, quick to praise, slow to

criticize, had unlimited patience, and were able to gain the confidence of others (as cited in

Farreras, 2001).

Clinical psychology is a relatively new field, and as such, is still developing standards for

effective treatment approaches as well as the training and supervision of novice clinicians.

Currently, psychology boards require therapists to meet educational requirements and gather a

specified number of hours of supervised professional clinical experience. However, there are not

current requirements for licensure that specify the development of competencies congruent with

effective practice (Rodolfa et al., 2014) and supervisors also do not consistently receive formal

training in the ways in which to train their supervisees (ASPPB, 2003; Falender & Shafranske,

2012b; Rings, Genuchi, Hall, Angelo, & Erickson Cornish, 2009).

The history of clinical training and supervision includes decades of challenges for

identifying the most appropriate and effective means for training psychologists (Routh, 2000).

Similarly, the training and supervision of novice clinicians in clinical psychology doctoral

programs has undergone several advances since their inception. The first training programs in

clinical psychology first emerged in 1946 as a result of a request for information by the Veteran’s

Administration about the process of training of psychologists. This began a search for identifying

the best methods for training clinical psychologists, which required clarification in the areas

necessary for professional development.

Prior to 1946, clinicians’ professional development was an undefined process, as there

was no official accreditation process for clinical training (Routh, 2000). However, in the last

three decades, clinicians have begun to explore more systematic ways of defining the process in

an effort to improve and unify clinical training and practice. Consistent with the medical field’s

training model, clinical psychology has looked towards the development of competencies during

training (Falender & Shafranske, 2012a; Kaslow et al., 2004).

Developments in clinical training have emphasized a competency-based approach to

supervision in order to develop objective standards from which to train and assess a novice

clinician’s readiness for practice (Falender & Shafranske, 2012a). Research over the past few

decades has been dedicated to exploring which competencies might be essential to a novice

clinician’s growth, in the interest of eventually outlining them as a standard of clinical training

(HSPEC, 2013; Rodolfa et al., 2014).

For the first time, in 1986, the NCSPP (National Council of Schools and Programs of

Professional Psychology) identified six core competencies which clinicians must develop

including relationships, assessment, intervention, research and evaluation, consultation and

education, and management of supervision skills (Callan, Peterson, & Stricker, 1986; Rodolfa et

al., 2014). A second significant shift involving a competency focus occurred; a workgroup of

professionals convened in 2002 in an effort to shift the field’s clinical training perspective to one

consistent with a “culture of competence” (Roberts, Borden, Christiansen, & Lopez, 2005;

Rodolfa et al., 2014). From this meeting, they produced the Competency Cube, which outlined

particular competencies. This task force continued to revise and encourage the exploration of

changes to these competencies, for the addition of new competencies deemed to be crucial to a

novice clinician’s development. For instance, competence in the area of diversity was later

included by the NCSPP (Rodolfa et al., 2014).

The Competency Cube was used by the Competency Benchmarks Workgroup to develop

an expanded training model (Fouad et al., 2009). It outlined 15 foundational and functional core

competencies across three progressive developmental levels or stages, each with sub-categories

and behavioral anchors for observing whether the competency has been mastered. Though some

have suggested alternative models, it appears many support this competency-based approach to

clinical supervision (Falender & Shafranske, 2012b).

Competencies are now thought of as a collection of skills, abilities, knowledge,

behaviors, attitudes, personal characteristics, motivations, and self-perceptions, which integrate

to form professional competence (Mentkowski & Associates, 2000). Thus, competence includes

habits, appropriate communication, use of skills, reasoning, emotions, values, and reflection to

improve clinical work (Epstein & Hundert, 2002).

Several competencies suggest a need for increased awareness of novice clinician’s

developmental experiences, and represent aspects of personal and professional development.

These include competencies such as Reflective Practice, which requires novice clinicians to

engage in intellectual curiosity and flexibility; Self-Assessment, which requires novice clinicians

to assess their strengths and weaknesses and make changes to improve practice; and Affective

Skills, which require novice clinicians to demonstrate affect tolerance and tolerate/understand

interpersonal conflict (Fouad et al., 2009). Such competencies are recommended because they

orient novice clinicians to behaviors that improve clinical work and protect the welfare of clients

throughout one’s professional practice (Falender & Shafranske, 2012a).

The Benchmarks model appears to be widely accepted, as it has since been utilized as a

foundation for further research in the area of identifying clinical competencies for training, as

well as in the development of a rating form for measuring readiness for clinical practice (Hatcher

Fouad, Grus Campbell, & McCutcheon, 2013; Rodolfa et al., 2014). Currently, the various

opinions regarding different competencies to be developed in clinical training differ in the

structure of the proposed models, but are mainly consistent with respect to the actual competency

areas defined (Rodolfa et al., 2014). However, the particular competencies essential to a

clinician’s professional development are not comprehensive and remain in their early stages of

development. For example, the importance of developing self-awareness as a competency is

recognized, but the extent to which this may be necessary as a foundation to personal

development has yet to be explored. Further, there do not currently exist any formal training

methods for novice clinicians to engage in reflection or personal growth, which may be

necessary to demonstrate such competencies.

Though the competency-based approach to supervision has been well-developed in

theory, there is no formal or required application of this model as of today. The intention in

applying the competency-based approach is to allow supervisors to ensure novice clinicians

consistently receive evidence-based training, and progress is measured through the observation

of their integration of particular competencies (Falender & Shafranske, 2012b; Snell & Frank,

2010).

Shifting to the use of these competencies marks a start to taking into consideration

individual differences in the ways novice clinicians learn and develop as therapists. It also allows

supervisors to meet novice clinicians where they are in their development, in order to best

address their training needs (Falender & Shafranske, 2007; Falender & Shafranske, 2012a; Fouad

et al., 2009; Sarnat, 2012; Watkins, 2012). However, novice clinician’s perspectives of their

experiences relative to their growth were absent in the development of the benchmarks. In order

to begin to identify individual novice clinician’s strengths and weaknesses, and to develop

responsive training opportunities, the investigation of novice clinician’s experiences becomes

imperative.

Ethics, laws, and guidelines. The field of clinical psychology has taken a stand with

respect to what and how they believe an ethically practicing psychologist should be and do. It has

been framed within the APA ethics code (APA, 2002a), and also within several documents

published by the APA outlining guidelines for professional practice (APA, 2000, 2002b, 2007,

2013). These documents emphasize addressing personal factors of the therapist as one element of

ensuring effective clinical practice.

The importance of a novice clinician’s personal factors relative to his or her work is

implied by the ethics codes for both professional psychologists and counselors by emphasizing

self-awareness (ACA, 2005; APA, 2002a). Psychologists are expected to utilize self-reflection to

remain aware of any personal problems that may prevent them from working competently (APA

Ethics Code, Standard 2.06). Additionally, section 1396.1 of California’s laws and regulations for

psychological practice recognize that sound interpersonal skills and psychologist’s personalities

impact their professional effectiveness. This law indicates that a psychologist, “shall not

knowingly undertake any activity in which temporary or more enduring personal problems in the

psychologist’s personality integration may result in inferior professional services or harm to a

patient or client” (Department of Consumer Affairs, 2012, p. 115). Some believe that clinicians

should be held to an even higher standard in which, “when personal values, beliefs and

perceptions are challenged, students are encouraged to re-evaluate and deepen their

understanding of themselves and others” (Marlowe, Appleton, Chinnery, & Van Stratum, 2015, p.

61).

The APA Ethics Code’s general principles emphasize specific values that psychologists

should strive to hold when engaging in clinical work (APA, 2002a). These values appear to set a

higher standard, moving beyond self-awareness to encouraging psychologists to be and do more

by encouraging the growth of their moral character to benefit the populations they serve.

Specifically, psychologists are guided to embody the values of beneficence and

nonmaleficence in their professional activities, as well as fidelity, responsibility, integrity, justice,

and respect for people’s rights and dignity. To implement these values, psychologists are asked to

develop: skills for conflict resolution to prevent harm, the ability to manage mental health,

acceptance of responsibility for one’s actions, interpersonal skills for developing trust, reasonable

judgment, consideration of personal boundaries in making professional commitments, and both

awareness and respect for cultural, individual, and role differences in the population. Though

these values are aspirational in nature, some have suggested psychologists should be held

accountable for them (E. Shafranske, personal communication, September 24, 2014).

The professional standard of ongoing self-awareness and the notion of personal growth are also

stressed throughout several of the guidelines for professional practice published by the APA for

working with various populations. The Guidelines on Multicultural Education, Training,

Research, Practice, and Organizational Change (APA, 2002b) urge psychologists to recognize

themselves as cultural beings whose attitudes and beliefs impact their perceptions and

interactions with others. This document notes that it is a normative tendency for individuals to

categorize others, and that implicit stereotypes are prevalent across even those who consciously

hold egalitarian beliefs. It advises the use of self-awareness of one’s attitudes and values, as well

as intentional effort and practice aimed at changing stereotypical or negative beliefs about others.

Authors of this document suggest activities for building trust and increasing tolerance of others,

such as increasing contact with diverse others, perspective taking, empathy, and intentional

avoidance of stereotyping others to see them as individuals. Thus, psychologists are encouraged

to seek higher levels of personal and professional self-awareness by actively seeking

growthpromoting activities in order to improve multicultural relationships in professional

practice.

The Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (APA, 2000),

Guidelines for Psychological Practice with Girls and Women (APA, 2007), and Guidelines for

Psychological Practice with Older Adults (2013) also indicate that self-awareness alone may be

insufficient. These guidelines respectively encourage psychologists to engage in ongoing

selfexploration and participation in activities that facilitate growth in the form of increased

sensitivity to issues of diversity. As an example, such activities may include gender sensitivity

and diversity training for work with girls and women.

The Guidelines and Principles for Accreditation of Programs in Professional Psychology

do not currently require programs to incorporate training and education goals that address the

importance of personal development, or guidelines for how to engage in such ongoing

selfreflection (APA, 2013). Additionally, according to section 1397.61 of the California

Department of Consumer Affairs (2012), psychologists are not eligible to seek continuing

education credit for activities meant to facilitate personal growth. The absence of encouragement

for personal growth in these two arenas speaks to a lack of concern as a field for producing and

maintaining practices for ongoing personal development in clinicians.

Managing personal factors that have the potential to impact work in clinical psychology

has been labeled an ethical imperative (Barnett, 2008; Youngson & Green, 2009). Youngson and

Green (2009) assert that self awareness must lead to ongoing self-development in order to

prevent doing harm to clients. Without doing so, clinicians are at higher risk of unintentionally

doing harm by projecting unresolved emotional difficulties, confusion and assumptions on to

their clients in the therapeutic encounter. This is particularly emphasized within multicultural and

psychodynamic training. These areas suggest that personal awareness and ongoing exploration

through self-evaluation and assessment are necessary for effective practice (Falender &

Shafranske, 2012b; Freud, 1910; Pope-Davis & Coleman, 1997; Sue & Sue, 2003). However, the

relevance of self-awareness and personal growth to clinical psychology is implied more broadly

by the research literature, ethics codes and principles, practice guidelines, and state laws and

regulations, and has yet to be fully embraced and embedded in actual clinical training practice.

The importance of self-awareness for effective practice, in particular, has gained

significant support in the literature (APA, 2002b; Eva & Regehr, 2008; Falender & Shafranske,

2012a; Falender & Shafranske, 2012b; Watkins, 2012). Many have supported the argument that

overall professional competence is dependent upon the clinician’s continuous self-reflection

(Johnson et al., 2014; O'Donovan, Halford, & Walters, 2011). Research suggests that novice

clinician’s professional development is dependent upon their engagement in self-reflection and

assessment, suggesting this is a behavior that should be reinforced from the start of training

(Falender & Shafranske, 2012b; J. Rosenberg, personal communication, October 10, 2012).

Discussion in the research literature of actual practices consistent with these views is very

limited in scope (Falender & Shafranske, 2012b; Grafanaki, 2010; Orlinsky & Rønnestad, 2005;

Rønnestad & Skovholt, 2001; Rønnestad & Ladany, 2006; Skovholt & Rønnestad, 2003; Truell,

2001).

Trainees with problems developing professional competence. Currently, there is little

agreement on the manner in which personal development can be facilitated or evaluated by

training programs. When attempting to address such a gap, other challenges are revealed. There

is also little agreement amongst training programs as to what challenges indicate a potential area

for growth versus an indication that the novice clinician may lack competency (Veilleux,

VanderVeen, January, Felice Reddy, & Klonoff, 2012).

Professional competencies such as one’s behaviors, attitudes, personal characteristics,

motivations, and self-perceptions, are likely influenced by life factors and one’s degree of

personal growth. Trainers often categorize competence problems, in part, in relation to their

origin as situational, developmental, or due to personality and interpersonal dynamics, all of

which include consideration of personal factors (Kaslow et al., 2007). Competency problems

may be exhibited when novice clinicians, or psychologists in general, lack self-awareness or do

not continue to change and grow (Bemak, Epp, & Keys, 1999; Wilcoxon et al., 2005). Novice

clinicians may exhibit social limitations, lack of sensitivity and respect, distrust or

defensiveness, lack of willingness or ability to accept feedback, limited skill and knowledge

base, limited motivation for learning, and/or an inadequate understanding of the therapeutic

process (Wilcoxon et al., 2005). These and other such difficulties may manifest as an inability to

control personal stress, psychological dysfunction, or emotional reactions that may affect

professional functioning (Lamb et al., 1987; Lamb et al., 1991).

Training programs must effectively teach and accurately evaluate competencies, while

remaining cognizant that they are fluid and contextual in nature (Epstein & Hundert, 2002;

Kaslow et al., 2007). Unfortunately, there is evidence in the literature to suggest that training

programs are inconsistent in addressing issues of professional competence due to the significant

time and energy it requires; complications related to the influence of culture; disagreement

regarding what issues represent problem areas; “gateslipping;” and trainers’ avoidance,

resentment, or lack of empathy for parties involved; fear of legal action or other outcomes; and

program culture and policies (Jacobs et al., 2011; Kaslow et al., 2007; Shen-Miller, Forrest, &

Burt, 2012; Veilleux et al., 2012). Failure to observe and intervene can be detrimental to a novice

clinician’s development and can model avoidance to the student body; students frequently report

being aware of a peer’s difficulties long before a faculty member may notice (Rosenberg,

Getzelman, Arcinue, & Oren, 2005; Veilleux et al., 2012).

Psychologists estimate that every year 4-10% of students will exhibit evidence of issue(s)

with professional competence (Veilleux et al., 2012). In the past, such novice clinicians may have

been misidentified as “impaired”. It has since been clarified that the use of this terminology has

legal implications, and is to be limited to use only in regards to novice clinicians who possess a

disability as per the Americans with Disabilities Act of 1990 and the ADA Amendments Act in

2008 (Falender, Collins, & Shafrankse, 2009; Kaslow et al., 2007). Alternatively, novice

clinicians with problems developing professional competence represent individuals failing to

meet training goals for many reasons other than disability. This discernment allowed for a more

acute understanding of the origin of such issues; however, there remains much ambiguity in our

understanding of the types of issues experienced by novice clinicians, the cause of these issues,

and the means by which they should be addressed (APA, 2002b; APA Board of Educational

Affairs, 2004; Kaslow et al., 2007).

The literature suggests that trainers misidentify problem areas in the cases where they are

complicated by culture or there is suspicion that such difficulties relate to personal factors

(Jacobs et al., 2011; Shen-Miller et al., 2012). It appears that novice clinician problematic

behavior can be mislabeled or missed entirely by training staff when the influence of cultural

factors on the novice clinician’s behavior is not adequately understood (Gizara & Forrest, 2004;

Miller, Forrest, & Elman, 2009; Shen-Miller et al., 2012; Vacha-Haase, Davenport, & Kerewsky,

2004).

It is necessary for trainers to maintain awareness, sensitivity, and the skills for working

with diverse others, including those they are training to become psychologists (Fouad et al.,

2009). Doing so reduces the possibility of inappropriately labeling culturally congruent behavior

as problematic behavior instead. It also has implications for addressing problems, as culturally

normative behavior may indicate a need for increased self-awareness, while problematic

behavior would warrant development of a remediation plan. Similarly, trainers may be reluctant

to address particular competence issues with novice clinicians when it is unclear if the issue

represents personal factors as opposed to deficiencies in knowledge or skill acquisition (Jacobs et

al., 2011). Consequently, novice clinicians may not receive assistance from their training

program to ameliorate the negative impact of an issue until it has reached the point of requiring

dismissal from the program.

Personal factors which lead to issues with professional competence range in severity.

Psychologists and those in training are just as vulnerable to periods of distress from life

difficulties as the general population, and specifically may be more susceptible to issues such as

vicarious trauma, compassion fatigue, and burnout (Elman & Forrest, 2007; Epstein & Hundert,

2002; Johnson, Elman, Barnett, Forrest, & Kaslow, 2013; Johnson et al., 2014; Norcross & Guy,

2007). Johnson and Barnett (2011) note that emotional depletion, disrupted personal

relationships, loneliness, anxiety, professional isolation and depression are potential difficulties

faced by those constantly caring for others. Clinical work has been known to leave therapists

susceptible to burnout due to prolonged exposure to emotional content (Canfield, 2005;

O'Donovan, Halford, & Walters, 2011; Weiss, 2004). Such issues tend to arise when personal life

factors are ignored (Adams, Boscarino, & Figley, 2006; Cheung & Chow, 2011; Cieslak et al.,

2013; Goode, 1960; Newell & Macneil, 2011; Stamm, 2010). Likewise, novice clinicians

frequently report high levels of stress and anxiety during their clinical work, not infrequently to

the level of temporarily meeting criteria for a psychological disorder (Dennhag & Ybrandt, 2013;

O’Donovan, Halford, & Walters, 2011; Orlinsky & Rønnestad, 2005; Rønnestad & Skovholt,

2003; Scott, Pachana, & Sofronoff, 2011; Stafford-Brown, 2010). These issues are likely to

contribute, in part, to why professional competence fluctuates and requires lifelong reflection and

growth (Johnson et al., 2013).

It is unfortunate to note that novice clinicians often fail to address difficulties that arise

from personal factors with their supervisors out of fear that they will be evaluated as

incompetent, or that doing so will result in repercussions that impact their educational or future

occupational opportunities (O'Donovan, Halford, & Walters, 2011). This issue is complicated by

the fact that there is little agreement as to what professional competencies represent areas of

potential growth or remediation, and which suggest an individual may be incompetent to practice

(Veilleux et al., 2012). Despite the highly personal nature of clinical work, novice clinicians may

consider interference of personal issues as unprofessional rather than as presenting an

opportunity for personal growth. Training programs also are likely to differ with respect to the

culture of the program and their receptiveness to personal disclosures (Punzi, 2015; Veilleux et

al., 2012).

The American Psychological Association (2013) has required all accredited training

programs to include procedures for addressing novice clinician competence problems. The

current standard is to encourage individual self-assessment and enact remediation action plans

when necessary, such as personal therapy, with little attention given to the development of

preventative measures (Falender & Shafranske, 2007; Johnson et al., 2014; Kaslow et al., 2007;

Lamb, Cochran, & Jackson, 1991). It has been proposed that limited insight due to insufficient

self-awareness may indicate an individual is incompetent to practice clinical work (Hays et al.,

2002). Thus, it is crucial that training programs develop cultures that value self-assessment, for

example by modeling willingness to explore personal factors that produce feelings of discomfort

(Kaslow et al., 2007).

Given the aforementioned problems with inaccurate individual self-assessment,

alternative methods that move away from individualistic and socially isolated self-assessment

must be explored (Johnson et al., 2013; Kaslow et al., 2007). Additionally, such alternative

approaches may better address problems with professional competence by recognizing the fluid

nature of these issues and considering culture and context in their assessment (Johnson et al.,

2014). Kaslow et al. (2007) suggest using a systems approach to identifying problems with

professional competence, by taking into consideration the influence of the academic and

professional organizations, life stressors, individual personalities, and coping styles. They also

recommend identifying psychological symptoms commonly reported by psychologists for the

purposes of implementing preventative measures.

Johnson et al. (2013) suggest that ensuring professional competence is a community,

rather than individual responsibility, as psychologists are interdependent and share a common

goal. Within a collaborative community of diverse individuals with strong, supportive, and

nurturing connections, novice clinicians and professionals may experience both personal and

professional transformations to improve clinical work. Colleagues can validate and monitor for

one another professional competence and overall emotional health and well-being (Johnson et

al., 2013). Such an approach supports novice clinician’s use of the psychological community to

facilitate personal growth in order to support their development and maintenance of professional

competencies.

Novice clinician’s engagement in personal growth may provide a preventative buffer to

developing subsequent issues related to professional competence. Training programs have the

power to encourage the use of the psychological community for accurate self-awareness and

support (Johnson et al., 2014). Novice clinicians can be encouraged to utilize peer and relational

mentoring, which have the potential for enhancing professional competencies and building

selfefficacy, compassion, emotional intelligence, and creating work-recreation balance (Johnson

et al., 2013).

Academic, Clinical, and Supervisory Support of Novice Clinician Personal Development

Several researchers have expressed that addressing personal development during clinical

training is imperative for professional development (Cain, 2007; Ellis, 1991; Folkes-Skinner,

Elliott, & Wheeler, 2010; Grafanaki, 2010; Heppner & Roehlke, 1984; Hill et al., 2007; Ladany,

2007; Luke & Kiweewa, 2010; Mathers, 2012; Orlinsky & Rønnestad, 2005; Rabinowitz,

Heppner, & Roehlke, 1986). However, the literature on personal growth in academia has

identified the inclusion of this aspect of training only in personal therapy, short-term personal

development groups (Ieva, Ohrt, Swank, & Young, 2009; Lennie, 2007; Luke & Kiweewa,

2010), and supervision (Batten & Santanello, 2009; Geller, Farber, & Schaffer, 2010; Norcross,

2005; Wiseman & Shefler, 2001).

General education. Education, generally speaking, appears to play a role in personal

development. Simply attending undergraduate courses has been demonstrated to have a

significant impact on student development of personal factors (Pascarella & Terenzini, 1991).

Measurable changes have been found with respect to self-esteem, responsibility, self-confidence,

openness to change, perseverance, tolerance for the differences of others, and the development of

attitudes and value systems that emphasize inner harmony, caring relationships, and

openmindedness (Graham & Cockriel, 1996; Jones, 1990; Pascarella & Terenzini, 1991). College

students’ retrospective reviews of their education tend to include endorsements of this growth

(Graham & Cockriel, 1996).

The value of achieving personal growth during one’s education appears, in some cases, to

be supported by universities through the offering of personal development courses

(FlemingHolland, 2000; Ware & Perry, 1987). Those who had aspired to engage in service work

in their future careers found the inclusion of personal development workshops in college to have

been both professionally and personally useful (Fleming-Holland, 2000). Further, student

involvement in service work during college appears to lead to greater insights into self,

improvement in interpersonal relationships, and self-acceptance (Puchkoff & Font-Padron,

1990).

The concept that personal factors are relevant to an individual’s professional development

has been embraced by the Chinese in their emphasis on holistic development of students. “All-

round development” can be achieved only if the social-emotional needs of students are met,

which is achieved through an education that embraces personal growth and development of the

self (Chan, 2001). This concept appears to be particularly relevant when it comes to the

education of health care providers. Researchers have suggested that physicians’ personal factors

can interfere with their work with respect to accurately diagnosing and treating illness (Novack,

Epstein, & Paulsen, 1999). Thus, they propose addressing personal factors during medical

students’ training to proactively manage this problem.

Novack, Epstein, and Paulsen (1999) recommend that physicians develop self-knowledge

so as to be able to create boundaries, seek support when skills or resources are limited, work

collaboratively, and to recognize when emotional well-being is compromised. It is also necessary

for physicians to adopt a lifelong commitment to personal growth, self-awareness, and wellbeing

to continuously engage in this level of learning. It seems that a tendency to engage in personal

development can result in not just personal growth, but to intrapersonal and interpersonal aspects

of intelligence. This includes adapting based on self-awareness and interpreting the internal

experiences of others. These skills are not achieved without explicit attention and effort toward

personal development (Chan, 2001).

Training in clinical psychology. Novice clinicians are training in clinical psychology all

over the world, and training standards vary from country to country. Personal development as a

focus for training is inconsistently addressed.

The British Psychology Society in the United Kingdom has requested accrediting bodies

to give increased attention to the ways in which courses include learning outcomes for personal

and professional development (Horner & Youngson, 2009). As such, some have gone as far as to

develop models for personal development. Youngson and Hughes (2009) delineated a process of

personal development to assist novice clinicians in managing personal challenges they are likely

to face during their training. They identify the process as nonlinear, beginning typically with a

“clue” that indicates there is a need for change (i.e., dissatisfaction with a partner,

countertransference with a client, etc.). The individual then enters a cycle of internal reflection,

understanding, evaluation of the impact of change, and a decision making process regarding

whether to change or ignore the clue to avoid change. Further, they outline several avenues for

personal development (e.g., reflection, meditation, writing, prayer, therapy, conversations with

others, supervision, personal development groups, social action, etc.), and barriers to personal

development (e.g., limited support, individual personality, insufficient self-awareness, limited

personal space or finances, cultural attitudes, etc.).

Trainers and supervisors in the United States are charged with the task of identifying

learning techniques and assessing competence in novice clinicians (Falender & Shafranske,

2012a). Contrary to the British Psychology Society, it is currently of less concern how novice

clinicians may themselves have experienced personal development during training or how this

can be cultivated. The American Psychological Association appears to place greater value on the

development of competence via structured gateway achievements (APA Benchmarks; Fouad et

al., 2009).

The link between personal growth and professional development within the field of

clinical psychology has been well established (Chan, 2001; Fleming-Holland, 2000; Horrocks &

Smaby, 2006; Leszcs, 2011; Novack et al., 1999; Ricks, 1993; Von Haenisch, 2011; Young,

Reysen, Eskridge, & Ohrt, 2013). Not only is there a relationship between the two, it appears the

work of a clinician can facilitate his or her own personal growth, just as willingness to grow and

change will catalyze change in others with whom the clinician relates (King & VanderVen, 1980;

Sandberg, Knestel, & Schade, 2013; Williams & Irving, 1996; Young Kaelber &

Schwartz, 2014).

A growing body of research literature suggests that clinicians’ commitment to personal

growth is significantly related to clinician efficacy (Anderson, Ogles, Pattersen, Lambert, &

Vermeersch, 2009; Bohart, Elliott, Greenberg, & Watson, 2002; Cain, 2007; Dunkle &

Friedlander, 1996; Falender & Shafranske, 2012b; Fauth & Williams, 2005; Folkes-Skinner et

al., 2010; Hill et al., 2007; Ladany, 2007; Najavits & Strupp, 1994; Nissen-Lie, Havik, Høglend,

Monsen, & Rønnestad, 2013; Orlinsky & Rønnestad, 2005; von der Lippe, Monsen, Rønnestad,

& Eilertsen, 2008). Studies that identify specifically how personal factors contribute to clinical

effectiveness are still scarce. However, emerging literature in this area has found that clinician

efficacy and treatment outcomes are not mediated by theoretical orientation, clinician level of

experience, personal qualifications, type of training, or client diagnosis, but rather by therapist

personal factors (Benish, Imel, & Wampold, 2008; Beutler et al., 2004; Blatt, Zuroff, Quilin, &

Pilkonis, 1996; Cain, 2007; Castonguay & Beutler, 2006; Duncan & Moynihan, 1994; Dunkle &

Friedlander, 1996; Goldfried et al., 1990; Hanna, Bemak, & Chung, 1999; Huppert et al., 2001;

Lambert, 1992; Lambert, Shapiro, & Bergin, 1986; Livesley, 2007; Mathers, 2012; Nissen-Lie et

al., 2013; Norcross, 2011; Sandell et al., 2007; Sexton & Whiston, 1994; Skovholt & Jennings,

2004; Strupp & Hadley, 1977; Wampold, 2007; Whiston & Sexton, 1993).

Many researchers have proffered suggestions regarding which specific therapist personal

factors may be relevant to clinical outcomes. For instance, it has been noted that clinical

competence may be dependent upon a therapist’s attentiveness, self-awareness, curiosity, and

ability to be present (Epstein & Hundert, 2002). Some have investigated this empirically

(Nissen-Lie et al., 2013) and found that empathy, responsiveness, the ability to be affirmative

(Bohart et al., 2002; Najavits & Strupp, 1994), interpersonal skills (Anderson et al., 2009), the

ability to maintain boundaries which prevent one from reacting when devalued by clients (von

der Lippe et al., 2008), and interpersonal functioning in one's’ personal life (Dunkle &

Friedlander, 1996; Hersoug, Høglend, Havik, von der Lippe, & Monsen, 2009) all play

significant roles in the effectiveness of treatment. In response to these findings, many have

asserted the need for additional research investigating therapist personal factors and how they

develop or evolve through training (Nissen-Lie et al., 2013; Rogers, 1956, 1961; Rosenzweig,

1936; Strupp, 1958; Taubner et al., 2013).

Therapist inter- and intrapersonal factors have been found to be responsible for therapist’s

ability to empathize, track emotions and nonverbal behavior, listen attentively, respond to

personal feelings that come up during session, and form a therapeutic relationship (Falender &

Shafranske, 2012b). In work with children, researchers have found that a clinician’s growth

towards actualization has a direct impact on their effectiveness (King & VanderVen, 1980).

Specifically, the ability to orient to the present, utilize interpersonal risk to build connections,

mature beyond dichotomous thinking, exhibit an openness to change, and develop problem

solving abilities all have the power to facilitate a child’s growth in treatment; the absence of such

traits can limit growth (King & VanderVen, 1980).

Clinician emotional intelligence, which involves both intrapersonal and interpersonal

skills, has been found to result in better treatment outcomes (Martin, Easton, Wilson, Takemoto,

& Sullivan, 2004; Reick & Callahan, 2013; Young Kaelber & Schwartz, 2014). Emotional

intelligence and empathy can be cultivated during training, and are necessary factors for being

able to communicate effectively, develop a therapeutic alliance, and detect and recognize affect

in clients (Young Kaelber & Schwartz, 2014). Additional personal factors such as the ability to

differentiate feelings within oneself and others, awareness of one’s emotional and behavioral

responses to stress, and self-awareness with respect to morals, values and beliefs, may suggest a

level of professional competence that results in safe and effective clinical work (Williams &

Irving, 1996.) To date, studies of this nature remain limited (Taubner et al., 2013).

While some have investigated various approaches to personal development within clinical

psychology training, there have been few who have explored the manner in which the current

graduate training may have an inherent effect on producing personal growth (Orlinsky &

Rønnestad, 2005; Pascual-Leone, Rodriguez-Rubio, & Metler, 2013). An extensive literature

search revealed two such studies. In one, novice clinicians identified developing personally as a

result of learning a particular approach to treatment (Sandberg et al., 2013). In turn, they found

that their development resulted in growth that became critical to the efficacy of their clinical

work. They described feeling personally challenged, resulting in a heightened sense of

competence, bravery, responsibility, purpose, love, caring, acceptance, empathy, compassion,

attitude of nonjudgment, comfort experiencing difficult emotions (e.g., vulnerability), and

improved interpersonal functioning (e.g., conflict management, expression of needs, increased

presence and intimacy). Additionally, they reported decreases in intrapersonal stress due to an

increased ability to manage work stress (Sandberg et al., 2013).

In a second study, novice clinicians were instructed to maintain journals outlining their

personal training experiences during a 13-week psychotherapy training course (Pascual-Leone et

al., 2013). The journals revealed that novice clinicians experienced awareness of having

developed both professionally and personally during the course. Professional development

occurred in the following areas: awareness of the therapeutic process and new things that emerge

in session, applying interventions, understanding client’s emotions and needs, facilitating

emerging affect and insight in session, exploring nonverbal cues, and using and managing

silences. Several areas of personal growth were also revealed: increased confidence, reduced

performance anxiety, clearer sense of self as a future therapist, increased openness to other

treatment approaches, awareness of one’s impact on the client, and increased ability to stay

present in the moment.

These two studies highlight the potential for training in clinical psychology to impact

novice clinicians on a personal level, which in turn may increase competency in their clinical

work. It remains that little research exists in the way of identifying what personal and

professional experiences result in growth that is beneficial to a novice clinician’s professional

training and development (Angus & Kagan, 2007; Aponte, Powell, Brooks, Lawless, & Johnson,

2009; Obegi, 2008; Orlinsky & Rønnestad, 2005).

Supervisory and training approaches. The aim of the training process of novice

clinicians is to develop ethical, knowledgeable, skillful, and self-reflective individuals who

possess the attitudes congruent with practices of mental health professionals (Fouad et al., 2009;

Ibarra et al., 2013; Rodolfa et al., 2005; Rubin et al., 2007). The efficacy of therapeutic work,

with each generation of novice clinicians, is dependent upon the efficacy of clinical training and

supervision. It is through supervision that future generations of therapists learn concepts and

integrate the values necessary for becoming effective professionals (Edwards, 2013; Falender &

Shafranske, 2012a; Watkins, 2011, 2012). Initial supervisory experiences provide a framework

for the novice clinician to understand the value of the use of self as a clinical tool (Falender &

Shafranske, 2007, 2012b; Froggett, Ramvi, & Davies, 2015). As such, this supervisory period is

a critical window during which habitual behaviors of a therapist are formed (Hill et al., 2007).

From the perspective of a competency-based approach to supervision, which has been

widely adopted by training programs across the United States, there are particular areas of

competency that are crucial to a clinician’s professional development. These competencies imply

a need for greater emphasis on personal growth of novice clinicians via self-awareness; however,

other potential aspects of personal growth are not considered (APA, 2002a; Eva & Regehr, 2008;

Falender & Shafranske, 2012a, 2012b; Watkins Jr., 2012). Further, there is a wealth of research

suggesting a need for clinicians to engage in personal development beyond self-awareness

throughout their careers. However, these ideas have not made a notable or consistent impact on

the manner in which clinical programs facilitate training.

Supervision is often the environment in which novice clinicians are meant to increase

self-awareness of relevant personal factors (Falender & Shafranske, 2004; Rosenfeld, 2008);

however, there are few programs in which actual procedures are in place to formally assist

students in learning to recognize when personal factors are relevant. Instead, training programs

and supervision remain focused on areas of skill development, knowledge acquisition, ethics,

professional behavior, stages of professional growth and professional identity development, with

little to no attention paid to the personal development of the novice clinician (Ibarra et al., 2013).

Ladany (2007) and Ricks (1993) point out that clinical training programs place emphasis on

teaching theory, intervention skills, and instilling relevant knowledge, but lack attending to

personal development. They stress the importance of going beyond teaching practical skills by

adding lessons in processes such as reflection and self-examination. Clinical training programs

must create growth-producing environments in which developmental processes that are being

taught are also being modeled (Blocher, 1987).

Personal growth can occur through experiential learning, which cannot be quantified.

Thus, it is simply assumed that it is occurring in ways that are beneficial to the novice clinician

(Williams & Irving, 1996). Alonso (2000) noted that it is imperative for supervisors to “listen

with a clinician’s ear and speak with a teacher’s mouth” (p. 55) in order to monitor and support

novice clinician’s inclusion of personal factors in their training. Novice clinicians must learn how

to navigate personal reactions to clinical work, ultimately synthesizing their identities as both an

individual and as a clinician (Leszcz, 2011).

The necessity for novice clinicians to engage in experiential learning by seeing real-world

clients results in an obligatory hierarchy of supervisor priorities; namely, that client welfare takes

precedence, followed by a supervisor monitoring the novice clinician’s development of

competencies for licensure (C. Falender, personal communication, September 17, 2014). Only

when these factors are sufficiently tended to can one address a novice clinician’s personal growth

relative to his or her success as a future psychologist. Yet, it is often the case that unmet needs for

personal development results in ineffective training of novice clinicians (Wilcoxon et al., 2005).

Professional competencies represent fixed criterion for establishing academic success; however,

becoming a psychologist requires an ongoing process of becoming that transcends fixed

competencies (Saito, 2005).

Currently, supervision practice has not yet fully acknowledged the importance of the

person-of-the-therapist in training, nor implemented training strategies to develop the person-

ofthe-therapist due to the already challenging tasks of uncovering the most effective means for

teaching conceptual knowledge, clinical skills and techniques, while being simultaneously

engaged in providing effective clinical supervision to novice clinicians (Falender & Shafranske,

2004; Rosenberg, 2006). As noted, the emphasis has been on client welfare and the means by

which to provide supervision; the welfare of the novice clinician especially as it is reflected by a

focus on the personal growth of the person of the therapist has been an oversight or met mostly

with neglect.

It has been suggested that clinical training requires deconstruction and emergence of a

new self (Folkes-Skinner et al., 2010). To take this journey, one must immerse their whole self in

a training program. Novice clinicians may do this through experiential learning or role-play.

Folkes-Skinner et al. (2010) suggest the practice of working with clients during training has a

hand in driving personal growth. Clinical work with clients inevitably involves exposure to

painful stories, which novice clinicians often compartmentalize resulting in diminished

emotional self-awareness (Warren et al., 2010). In order to work effectively, clinicians are

charged to accept, remain exposed to, and experience difficult feelings such as weakness,

helplessness, insecurity or frustration, rather than guarding against these experiences in session

(Kornfield, 1993; Warren et al., 2010).

In the past, personal development courses had in some cases been included in the

curriculum of clinical psychology students. Such courses aimed to achieve novice clinician

“personal adjustment,” including an understanding of self in relation to others, understanding of

one's’ psychosocial environment, improvement in personal behavior, self-awareness and self-

growth, and general understanding and control over psychological well-being (Borow, 1958;

Borow, Graver, & Haak, 1951). These courses used self-report and projective measures to

validate the positive effects of such courses on novice clinician personal growth. Results

included increases in insight, increased orientation toward psychological growth, persistence, an

increased desire to achieve, and even shifts in attitudes regarding sex, marriage, and family life

(Anderson, 1954; Borow, 1958; Heist, 1956; Krumboltz & Farquhar, 1957; Leino, 1956). Those

interested in the implementation of such personal development courses have found it difficult to

measure their effects objectively, largely resulting in the extinction of such courses (Borow,

1958).

Modern approaches have included few examples in which an emphasis on personal

development was found within group therapy courses and strength-based approaches to clinical

training (Ieva et al., 2009; McKenzie, Cossar, Fawns, & Murray, 2013; Meyers, van Woerkom,

de Reuver, Bakk, & Oberski, 2015; Wade & Jones, 2015). Experiential group therapy courses

may aim to facilitate novice clinician’s understanding of acceptance, self-disclosure, feelings of

vulnerability and hostility, empathy, self-growth, feedback, confrontation, insight regarding one’s

own strengths and weaknesses, and the development of skills (Ieva et al., 2009; Kline,

Falbaum, Pope, Hargraves, & Hundley, 1997; Shakoor, 2010; Yalom & Leszcz, 2005).

Participants in such courses have reported increased empathy for clients in group therapy, insight

regarding the importance of self-awareness, improvement in communication skills, and increased

confidence and motivation to enhance interpersonal relationships (Ieva et al., 2009).

Some have begun to explore more approaches for including personal growth in novice

clinician’s curriculum, for example, by implementing strength-based approaches to training

(Meyers et al., 2015). Meyers et al. (2015) found that a strength-based approach to training

improved novice clinician’s resilience, hope, self-efficacy, and overall inclination toward further

personal development. Others have suggested alternative approaches, such as values-based

training that would emphasize the particular values of the field (McKenzie et al., 2013).

Personal development groups and compulsory personal therapy are commonly found in

counseling programs, but not in clinical psychology programs (Galbraith & Hart, 2007; Kumari,

2011; Lennie, 2007; Moller & Rance, 2013; Payne, 1999; Robson & Robson, 2008; Young et al.,

2013). Personal development groups aim to assist novice clinicians in developing on a personal

level. They may include student self-disclosures, confrontations, and here-and-now processing of

group member thoughts and feelings (Yalom & Leszcz, 2005; Young et al., 2013). These groups

have been found to enhance novice clinicians’ perceived ability to reach their goals and their

abilities to express their thoughts, feelings, and desires, as well as increases in insight, catharsis,

empathy, and improved communication skills (Ieva et al., 2009; Myers & Sweeney, 2005; Ohrt,

2010; Young et al., 2013).

Until 2005, personal therapy was required by The British Association for Counseling and

Psychotherapy to seek accreditation as a counselor (Von Haenisch, 2011). Novice clinicians had

self-reported personal therapy to be “necessary” for the development of competence as a

counselor. They indicated having learned boundaries and developed core skills as a therapist,

such as empathy, congruence, non-judgmental attitude, use of intuition, ability to provide focus

and respect, and how to understand and build relationships (Von Haenisch, 2011). While

compulsory personal therapy is no longer required, counseling programs in the UK continue to

value personal growth work and consider it an essential aspect of training (Horner & Youngson,

2009; Moller, Alilovic, & Mundra, 2008; Simpson & Falkner, 2013; Williams & Irving, 1996).

Programs differ with respect to attitudes toward personal disclosures in supervision

(Veilleux et al., 2012). Novice clinicians have reported fears of addressing such challenges due to

concern over being evaluated as incompetent (O'Donovan, Halford, & Walters, 2011). These

fears result in novice clinicians not pursuing available avenues of support. In the absence of

formal efforts of training programs to prepare novice clinicians for these types of experiences,

nor to facilitate personal growth, novice clinicians are often left to navigate them on their own.

Clinical training programs have yet to explicitly declare a commitment to facilitating the

personal growth and development of novice clinicians, and one such result is that students have

different opinions regarding the necessity of personal development to their professional work

(King & VanderVen, 1980).

It is necessary for training programs to create a particular environment that is suitable for

personal growth to take place. Novice clinicians, and individuals in general, will not remain open

to growth if they perceive their environment as unsafe or marked by judgment (Robson &

Robson, 2008). To provide a learning environment that is supportive of personal growth, training

programs must explicitly embrace novice clinician’s exploration of personal factors by creating

safety and expressing acceptance (Williams & Irving, 1996).

Rogers (1956) initially described a particular therapeutic environment that would allow

for a personal development process to take place within the client. He urged clinicians to use

empathy and unconditional positive regard for the experiences of others (Rogers, 1956). He

observed that such an atmosphere resulted in clients becoming more integrated, personally

effective, healthy or well-functioning, self-confident and self-directing, open to experience,

accepting of others, less defensive, more mature, adaptive, creative, having higher stress

tolerance, and as possessing realistic views of self. Each of these qualities, it can be argued, may

offer the novice clinician an advantage in providing effective treatment to clients. The necessary

atmosphere for developing such qualities does not occur by chance, and thus must be decidedly

shaped by supervisors and training directors. Further, Williams and Irving (1996) urge training

programs to use risk assessment to ensure experiential learning has positive outcomes, and to

secure support systems for instances in which it may result in harm.

Training programs often do not talk explicitly with students about the manner in which

personal growth may benefit one’s training, or may be experienced as a result of training

(Blocher, 1987; Ladany, 2007). However, it is known that clinical training can have a significant

impact on the personal lives of novice clinicians (Hill et al., 2015). Novice clinicians face many

challenges throughout training such as self-criticism about competence, training-related anxiety,

difficult reactions to clients, and difficulty learning and applying skills (Hill et al., 2007;

PascualLeone et al., 2013). Most often they receive instructions to discuss such challenges in

supervision (Leszcz, 2011). However, when these challenges involve personal factors novice

clinicians may be unsure if they are appropriate supervision topics. Further, given that the

importance of engaging in personal growth is rarely highlighted, it is plausible that those

interested in clinical training programs may differ with respect to their receptiveness to growth

and development (Bhattacharya, Gupta, & Mehrotra, 2013; Blocher, 1987).

Youngson and Hughes (2009) have noted that differences in individual personality or

temperament have a large impact on an individual’s tendency to embark on a journey of personal

development. With this in mind, it seems also necessary to evaluate the ways in which training

programs consider applicants to doctoral programs in clinical psychology (Youngson & Green,

2009). Research has indicated that the current application requirements (i.e., Graduate Record

Examination scores, prior grade point average, etc.) have little utility in predicting an

individual’s orientation toward personal development (Smaby, Maddux, Richmond, Lepkowski,

& Packman, 2005).

Theoretical Orientations and Treatment: Where is Personal Growth Discussed?

Wilkins (2006) notes that, in the United States, training programs may address personal

development more or less dependent upon the theoretical orientation. Humanistic and

psychodynamic approaches appear to place more emphasis on personal factors than does

cognitive behavioral therapy, an orientation that is increasingly becoming the dominant approach

to treatment. Additionally, issues related the relevancy of personal factors to training are

discussed in the parallel fields of master’s level clinical programs and counseling psychology.

Psychodynamic influences on novice clinician personal growth and development.

Countertransference, according to Cartwright, Rhodes, King, and Shires (2015) is a therapists’

personal reaction to how a client relates in therapy, and psychoanalysis was arguably the pioneer

for considering the concept of person-of-the-therapist as relevant to clinical training. Threaded

throughout psychodynamic literature are discussions of using self-awareness to address

countertransference and transference issues (Duthiers, 2005; Freud, 1910, 1937; Sandell et al.,

2006). More recent psychodynamic research has found that therapist countertransference

responses have a significant impact on therapeutic outcomes in that they can either disrupt

therapeutic progress or improve therapeutic outcomes if well managed (Cartwright et al., 2015;

Hayes, Gelso, & Hummel, 2011; Safran & Muran, 2006).

Novice clinicians, in particular, are likely more vulnerable to experiencing

countertransference and yet they possess fewer skills for knowing how to manage these reactions

in therapy (Brody & Farber, 1996; Cartwright et al., 2015; Hill et al., 2007). Learning to manage

countertransference is a skill requiring personal development as it involves self-awareness and

self-management of personal factors (Cartwright et al., 2015). Szecsödy (2003) asserted that

competence in psychoanalysis might be achieved only when clinicians engage in personal growth

themselves. Monitoring countertransference reactions requires conscious awareness of emotions,

cognitions, physical sensations, and impulses that arise during the therapeutic encounter, all of

which require a certain level of emotional, cognitive, and behavioral maturity (Cartwright et al.,

2015).

Relative to managing countertransference, novice clinicians are urged to become aware of

their feelings and biases, maintain a character structure that is healthy and intact, gain awareness

of and control over anxiety experienced in the room, develop empathy for clients, and develop

the ability to use theory in the room (Falender & Shafranske, 2012b). They urge novice clinicians

to manage countertransference reactions, thus implying the importance of addressing both

personal and professional factors during education and training. One study was identified which

engaged in a pilot program to teach novice clinicians how to more effectively manage

countertransference reactions; the results were promising, though additional data is required

(Cartwright et al., 2015).

Despite psychodynamic literature’s implied support for personal development of novice

clinicians, very little research exists that provides direction on how to train novice clinicians to

incorporate this learning during their education (Orlinsky & Rønnestad, 2005). Many training

programs have required or strongly recommended personal therapy for their students, as personal

therapy is likely to contribute greatly to a novice clinician’s personal and professional

development. Specifically, a novice clinician’s capacity to relate to others and his or her overall

well-being are factors that are typically addressed in personal therapy; in turn, these factors may

be highly relevant to the development of professional competence (Orlinsky, 2013; Sandell et al.,

2006).

Psychodynamic literature appears to be narrow in scope in that it focuses predominantly

on personal therapy, self-reflection, and issues of transference and countertransference (Falender

& Shafranske, 2012b; Freud, 1910; Sandell et al., 2006).

Humanistic psychology and clinician personal factors. The field of clinical

psychology has parroted the medical model beginning with Freudian psychology. This position

in the healthcare industry remains stronger than ever today, and significantly directs the way in

which clinicians define and conceptualize client problems and the process of psychotherapy

(Elkins, 2009). The medical model prioritizes randomized clinical trials and the corresponding

establishment of evidenced based practice, while personal dimensions of therapy remain

undervalued (Baker, McFall, & Shoham; Elkins, 2009; Schneider & Längle, 2012; Wampold,

2007). The medical model remains the accepted method for establishing the name of clinical

psychology in the healthcare community, rather than emphasizing the unique and significant

inclusion of the personal dimensions of therapy as a means by which clinicians are effective at

their craft (Baker et al., 2009; Elkins, 2009; Wampold, 2007).

Humanistic psychology emerged more fully as a therapeutic approach during the 1950s

and 1960s (Elkins, 2009). Abraham Maslow, an early humanistic theorist, attempted to move

psychology away from the medical model by introducing a framework for personal growth, or as

he called it, self-actualization (Maslow, 1968). Maslow’s (1968) research defined measurable,

objective traits of healthy humans that he believed are characteristic of effective healers. Some of

the things identified by Maslow include having self-worth, being capable of experiencing love,

continuously growing in order to achieve one’s full potential, and feeling comfortable with and

seeking truth (Feist & Feist, 2009).

Humanistic theories differ from others in the way that they aim to understand a person as

a whole (Buhler, 1971). Abraham Maslow and Fritz Perls specifically highlighted the necessity

of the development of the person-of-the-therapist for providing effective therapy (Teegen, Frass,

& Honiger, 1979). Schneider and Längle (2012) determined openness to feedback from clients,

empathy, meaning making, and the development of a therapeutic alliance as foundational

qualities for novice clinicians. The integrative humanistic-existential model emphasizes

genuineness, personal involvement, understanding, and support as key aspects of a novice

clinician’s personal and professional development (Schneider & Krug, 2010).

Rogers (1961, 1969) also profoundly influenced the field of clinical psychology by

helping shift perspectives away from the medical model and toward an increased focus on the

development of the individual as a whole (Kirschenbaum & Jourdan, 2005). Rogers (1992)

emphasized experiential learning over knowledge acquisition. He believed it best for novice

clinicians to become self-learners by practicing self-reflection (Rogers, 1969). Roger’s training

model suggested a teacher should be capable of feeling and understanding the student’s

experience, similar to the way in which a clinician must understand their client in order to

facilitate development.

Humanistic psychotherapy aims to assist clients in achieving personal growth through the

liberation of interpersonal processes, so that they can best solve their own problems. This

approach is in contrast to the medical model’s aim to implement cures to psychopathology

(Elkins, 2009; O’Hara & O’Hara, 2012). The humanistic-existential approach is oriented toward

personal growth rather than alleviation of symptoms (Bracke & Bugental, 2002; Cain, 2002;

Cooper, 2007; Schneider & Krug, 2010).

Cooper (2007) argues that supervision from the perspective of a humanistic-existential

orientation parallels the clinician’s capacity to view the client as a whole being with respect and

capacity to relate to their experience and that good therapy is contingent upon a clinician’s skill

to collaboratively explore the client’s experience, his or her capacity to respect and value the

client, and the ability to genuinely relate with the client in the service of the client’s growth.

Using this lens, symptoms are viewed as the consequence of a client’s thoughtful or meaningful

attempts to adapt to life difficulties (Farber, 2012).

Training and supervision from a humanistic-existential orientation focuses on general

categories of development including reflective practice, multicultural themes and diversity,

knowledge acquisition, professionalism, interpersonal relationships, ethics and legal policies,

interdisciplinary systems, and knowledge of scientific methods of inquiry (Fouad et al., 2009;

Rodolfa et al., 2005; Rubin et al., 2007). Training and evaluation of novice clinicians is based in

categories to evaluate relative proficiency (Donovan & Ponce, 2009; Fouad et al., 2009).

Farber (2010) discusses a humanistic supervision model that emphasizes developing the

person-of-the-therapist by discussing how novice clinicians can promote client experiential

awareness while empathizing with the client through the clinician’s own self-awareness. Self-

awareness must be ongoing, and is achieved via the development of the person-of-the-therapist

by teaching and reinforcing reflective practice (Farber, 2010). This type of training has been a

core process of humanistic supervision for decades (Cain, 2002; May, 1983; Yalom, 1980).

Humanistic-existential supervision and corresponding training competencies are still in

development (Farber 2012; Rodolfa et al., 2005; Rubin et al., 2007). The field of clinical

psychology would benefit from the humanistic-existential orientation’s acceptance of the current

focus on evidenced-based practice, so as to empirically support the importance of addressing

clinician personal factors for effective practice (Farber, 2010).

A novice clinician must be willing to engage with their own experience by exposing

themselves to the full range of their emotions in the presence of others, also referred to as

empathy. Clinicians should reflect on their work with clients and identify the ways in which this

empathy is a mutual experience marked by reciprocal dynamics of the relationship and session

dialogue (Smyth & Cherry, 2005). This reciprocal and mutual experience between client and

clinician is referred to as a parallel process. The existence of this parallel process means that as a

client feels “stuck,” the clinician is likely to also experience being “stuck.” Therefore, a

clinician’s personal limitations with respect to their willingness and openness to their emotions,

has a direct and parallel impact on the client’s capacity to experience their emotions, and vice

versa. Often times clinicians talk of the client’s resistance or identify this being “stuck” as

indicative of client psychopathology, which may actually occur when the clinician is unable to

recognize that they themselves are having difficulty accessing emotion.

The humanistic model offers a unique emphasis on essential personal factors of the

novice clinician for effective practice, because it has emphasized these factors for clinicians and

clients alike (Farber, 2010). As the field continues to shift closer and closer to a strictly medical

model, it will be imperative for humanistic psychology to make a name for itself in the empirical

database to legitimize these findings (Hayes, 2012).

Multicultural influences on supervision and training: Self-awareness and knowledge

vs. wisdom. Novice clinician development of multicultural competence relies on teaching

knowledge, skills, and cultural awareness (Hanna, Bemak, & Chung, 1999; Sue & Sue, 2003).

The multicultural literature is replete with claims that self-knowledge is necessary for

understanding how one’s culture and overall worldview influences their thought processes and

behaviors as clinicians (Falender & Shafranske, 2007; Pope-Davis & Coleman, 1997; Sue & Sue,

2003). Self-awareness is highly encouraged, in addition to the development of knowledge and

skills, in order to achieve multicultural competence (Pope-Davis & Coleman, 1997; Sue & Sue,

2003).

The current emphasis on developing self-awareness as a skill may prompt increased

introspection and facilitate gains in personal functioning and development (Falender &

Shafranske, 2007) though some suggest that self-awareness is insufficient and that development

of interpersonal skills, coping strategies, self-reflection, and other personal factors require more

meaningful exploration (Crethar, Torres-Rivera, & Nash, 2008; Duran, Firehammer, & Gonzalez,

2008; Rønnestad & Ladany, 2006).

From a programmatic standpoint, multicultural training is the only area of clinical

psychology training that requires novice clinicians increase self-awareness by delving into their

personal lives to improve clinical competence; it may well be at the front end of a paradigm shift

that focuses on personal growth as one aspect of the professional development of novice

clinicians. However, the value of self-awareness with respect to overall development appears

absent in the training literature beyond this specific area of multicultural training.

By teaching knowledge, skills and awareness, as opposed to requiring engagement in

experiential learning opportunities, graduate programs prioritize intelligence and place less

emphasis on cultivating growth in other areas. In some cases, novice clinicians are encouraged to

engage in growth promoting opportunities such as developing personal relationships with

culturally diverse others; however, this is not a requirement to achieve competence (Coleman,

2006).

While intelligent clinicians demonstrate a breadth of knowledge, they may lack depth in

understanding or the ability to tolerate ambiguity without resorting to oversimplification (Hanna

et al., 1999). A focus on acquiring conceptual knowledge may be due to a cultural emphasis on

the importance of intelligence, which differs from other cultures where alternative factors such as

wisdom is highly valued (Hanna et al., 1999; Miller, 1976; Robinson, 1990). Phan, Rivera,

Volker, and Maddux (2009) suggest multicultural training is narrow in its emphasis on personal

factors, and have demonstrated that novice clinicians’ wisdom may account for up to 14%

variance in their multicultural competence. Thus, there is evidence to support a broader emphasis

on personal development in multicultural training, which can be achieved through the cultivation

of wisdom (Hanna et al., 1999).

Wisdom, defined as, “a particular set of cognitive and affective traits and understanding

necessary for living a life of well-being, fulfillment, effective coping, and insight into the nature

of self, others, environment, and interpersonal interactions” (p. 126) involves characteristics that

mirror those of highly effective counselors (Hanna et al., 1999; Hanna & Ottens, 1995). Such

characteristics include empathy, compassion, affective awareness, deautomatization, dialectical

reasoning, efficient coping skills, tolerance of ambiguity, perspicacity, recognition and efficient

solving of problems, metacognition, and deep insight regarding self and others. Others in the

field have stressed some of these characteristics (i.e., empathy), while others remain

underrepresented (Rogers, 1961).

Skills such as dialectical reasoning, or the ability to consider all sides of an issue, appear

highly valuable to the work of clinicians. Dialectical reasoning allows for a complex

understanding of dichotomous perspectives seen across cultures, such as individualism versus

collectivism. Wisdom potentiates movement away from dogmatic belief systems, such as those

that result in homophobia or racism. To develop wisdom, novice clinicians would need to go

beyond current academic standards to question their knowledge, reflect on process, and integrate

conflicting information in a way that results in a deeper understanding of the therapeutic process.

To adopt such skills, clinicians must be open to transcendence of self, which demands more than

mere self-awareness (Hanna et al., 1999; Torres-Rivera, Phan, Maddux, Wilbur, & Arredondo,

2006).

Others have emphasized the role of ‘practical wisdom’ relative to novice clinician

development. Punzi (2015) defined practical wisdom as the growth of the capacity to actively

listen, empathically relate to others, self-reflect, and accept constructive criticism. Punzi felt that

practical wisdom is developed in interaction with others, and that during training the

development of practical wisdom should receive equal emphasis to the gathering of theoretical

knowledge.

Punzi’s research (2015) found that novice clinicians believed practical wisdom develops

from personal experience through reflection and insight, a need to converse with other students,

acquired knowledge, and professional guidance. Novice clinicians emphasized the importance of

developing the person-of-the-therapist in addition to learning new theories or methods for

clinical work. They believed that the combination of personal and professional activities engaged

in throughout their training allowed for this process to take place, rather than highlighting one or

two activities as being solely responsible. Further, novice clinicians were unable to detangle

personal and professional development experiences, noting the two to be symbiotic. However,

the novice clinicians emphasized the importance of training programs’ explicit intent to provide

experiences for personal development; they felt that assuming personal development is taking

place would be insufficient. For example, increasing exposure to and emphasis on training

activities that highlight affective and relational aspects of clinical practice appear to lead to

personal and professional development.

The notion that personal characteristics of clinicians influence therapeutic outcomes more

so than the approach to treatment or the knowledge and skills of the treating therapist has been

well-established (Goldfried, Greenberg, & Marmar, 1990; Lambert, 1992; Whiston & Sexton,

1993). Helping novice clinicians develop wisdom may address an area of training that is

currently lacking (Hanna et al., 1999; Phan et al., 2009). While there is a trend towards personal

growth as reflected in multicultural standards, competencies and training, this focus remains

limited in scope and neglects the overall person-of-the-therapist. Likewise, while wisdom has

been shown to improve multicultural competency, this emphasis may also help promote the

overall personal growth of the novice clinician.

Third wave cognitive behavioral approaches and personal factors. The person-of-

thetherapist is a topic that has been largely absent from conversations regarding what produces

change in cognitive-behavioral therapy. However, with the rise of third-wave approaches to

treatment, the therapist is beginning to be considered relative to therapist clinical attitudes and

effectiveness. The protocol for training therapists in the various elements of Acceptance and

Commitment Therapy (ACT) has been identified as a method for supporting therapist

professional development and positive clinical outcomes.

The ACT concepts of defusion and acceptance significantly reduced stigmatizing

attitudes and burnout when they were taught to substance abuse counselors (Hayes et al., 2004).

Additionally, clinicians who attended an ACT workshop exhibited signs of significant attitude

shifts toward openness to the use of psychopharmacology and evidence-based treatments (Varra,

Hayes, Roget, & Fisher, 2008). Luoma and Vilardaga (2013) note that clinicians who are not

psychologically flexible (e.g., exhibiting openness) “are likely to model and reinforce the

opposite of what they are trying to shape in their clients” (pg. 2). Beyond shifts in attitude,

training in ACT appears to elicit positive change in novice clinicians including significantly

reducing stress, professional self-doubt, psychological distress and thought suppression, and

increasing self-efficacy, acceptance, action, mindfulness, valued living and strength of bond with

clients (Stafford-Brown & Pakenham, 2012).

Using particular interventions for the education of novice clinicians appears to benefit

client therapeutic outcomes and clinician self-efficacy. The clients of masters level student

clinicians who participated in nine weeks of mindfulness demonstrated significantly higher rates

of change than a control group on scales of somatization, obsessiveness, anxiety, anger/hostility,

phobic anxiety, and psychoticism (Grepmair, Mitterlehner, Loew, & Nickel, 2007). In another

study, novice clinicians who were taught psychological flexibility and mindfulness experienced

increased self-efficacy due to fewer barriers to good clinical work by personal factors, such as

anxiety or hindered attention (Wei et al., 2015). Wei et al. believe that mindfulness may have

allowed clinicians to remain present with their clients and fully attend to their client’s inner

experience. They also suggested that teaching psychological flexibility enabled clinicians to

accept distractions, which in turn allowed them to remain focused on helping the client.

The therapeutic alliance has been identified as the number one predictor of positive

clinical outcomes (Horvath & Symonds, 1991). Lejuez and colleagues (2006) indicate that in

behavioral therapy the client’s ability to reach their goals in treatment is largely dependent upon

the therapeutic alliance. For instance, Functional Analytic Psychotherapy (FAP) operates with the

therapeutic relationship as a primary vehicle of change (Kohlenberg & Tsai, 1995). The creation

of an intimate social relationship allows the therapist to respond to the client in ways that others

in the client’s life respond to them, allowing the client to shift behavior in treatment and

generalize these shifts to their everyday life. However, in order to establish such an intimate

relationship, the therapist must possess particular traits such as being caring, genuine, sensitive,

involving, and emotional (Kohlenberg & Tsai, 1987). It appears there is an emerging precedent

for cultivating clinician personal growth in widely utilized and highly effective therapeutic

interventions, particularly utilizing third wave cognitive-behavioral approaches.

Model for development of the person-of-the-therapist (POTT). Aponte and Carlsen

(2009) suggest that the self has become a relevant topic for development in the education of

therapists because of changes in society, thus prompting the need for changes in methods for

training and supervision. As the field has shifted to emphasize the role of culture in producing

therapeutic change, a focus on the person-of-the-therapist was imminent. By contrast, previously

therapy was considered an available method by which to assist individuals in moving toward

“normal” for purposes of social conformity. With the need to be aware of what the client brings

to therapy relative to facilitating change, the therapist must be increasingly aware of and able to

manage personal factors in particular ways.

The American Association for Marriage and Family Therapy will soon require marriage

and family therapy programs to instruct and evaluate competency in the area of the self of the

therapist (Aponte et al., 2009). As such, Harry Aponte’s Person-of-the-Therapist (POTT) model

has recently been applied to master student’s curriculum and as part of their clinical training.

Previously, this model had been developed for and applied exclusively to professional clinicians

who participated on their own accord (Aponte et al., 2009). For a full description of the POTT

model, the reader should refer to Aponte and colleagues’ (2009) “Training the Person of the

Therapist in an Academic Setting.”

The POTT model aims to facilitate a process in which the clinician seeks self-mastery for

meeting personal challenges as they relate to clinical work. The model has three main goals,

therapists must: (a) know their history and current personal psychological, cultural and spiritual

challenges; (b) be able to observe, have access to, and utilize good judgment about personal

emotions, memories, and behaviors in therapy; and (c) be able to actively and purposely manage

their self, including emotional, cultural, and spiritual factors, to both identify with and

differentiate from clients (Aponte et al., 2009).

To achieve the goals of the POTT model, novice clinicians must voluntarily enter a

process of personal growth for the purposes of improving clinical outcomes. This process is

taught within the graduate curriculum in three stages: (1) students familiarize themselves with

the concept of the person-of-the-therapist; (2) students engage in experiential work to identify

and understand their own “signature themes” (i.e., psychological, emotional, cultural, and

spiritual factors that may impact their own clinical work); and (3) students apply knowledge of

signature themes to clinical work via discussion and role-play.

Aponte and Carlsen (2009) distinguish between application of this model in training and

supervision. In training, the therapist participates in a process to develop awareness of personal

factors as they relate to their clinical work. In supervision, supervisors assist therapists in

becoming more effective with clients. It is of note that Aponte believes supervisors must also

have completed similar training in order to guide their supervisees appropriately. For a full

description of how the POTT model is implemented in supervision, the reader should refer to

“An Instrument for Person-Of-The-Therapist Supervision” by Harry Aponte and J. Carol Carlsen

(2009).

The application of the POTT model has been evaluated in one master’s level graduate

program (Nino et al., 2015). The researchers theorized that increased attention to the

development of the person-of-the-therapist would result in novice clinicians’ increased

understanding of their effects on relationships, awareness of shortcomings and vulnerabilities,

and ability to utilize this information to improve treatment outcomes.

Novice clinicians who were trained using the POTT model reported increased awareness

of personal strengths, values and limitations, which allowed them to conceptualize clients from

perspectives other than the clinician’s own worldview. They reported engaging in more

purposeful action and having less reactivity in session, resulting in increased confidence around

clinical decisions. Further, participants experienced greater acceptance for and tracking and

management of their own emotions in session, prompting them to take more responsibility for

their own internal reactions in session. They reported development of a clinical identity involving

trusting themselves as clinicians and a sense of preparedness for clinical work. Some reported an

increased sense of humanity and woundedness, allowing them to accept painful life struggles and

be more authentic in the clinical encounter. Finally, some observed an increase in meta-

awareness during client sessions, or the ability to observe themselves in the process of therapy,

further clarifying their role as clinicians.

Counseling psychology and novice counselor personal growth. The Council for

Accreditation of Counseling and Related Educational Programs (CACREP) is an accrediting

body that oversees counseling psychology programs by determining and enforcing standards for

education. CACREP urges educators and trainers to consider the capacity for personal and

professional development of applicants to their programs (CACREP, 2001; Smaby et al., 2005).

In this and other ways, the field of counseling psychology has partially embraced this notion of

personal factors being relevant to the education of those training to work in the mental health

field.

Personal development in the counseling psychology literature has been described as an

ability to achieve a greater understanding of self and to use this knowledge to understand social

interactions and effective counseling (Carkhuff & Berenson, 1967; Schaef, 1999). Carlozi,

Campell, and Ward (1982) asserted that the counselor’s personality is the most important factor

in effective counseling. Personal factors have been found to have a significant impact on whether

a novice counselor performs poorly or well (Wheeler, 2000).

Self-awareness has been noted as a critical developmental factor for novice counselors to

effectively know when and how to apply skills they’ve learned (Smaby et al., 2005). Clients

likewise identify counselor’s interpersonal skills as critical to a positive counseling experience

(Paulsen, Truscott, & Stuart, 1999).

The ACA Ethics Code (American Counseling Association, 2014) has been discussed as

providing a vague explanation of values that should be possessed by counselors. To clarify these

standards, Mintz and Bieschke (2009) proposed and later wrote an aspirational statement that

intends to articulate the values of training. Similar to APA Ethics Code, Principle E, they

recommended a requirement for counselors to evaluate their personal values and learn to work

effectively with a diverse population of clients (APA, 2002a, Ethics Code, Principle E; Bieschke

& Mintz, 2012). To do so, they recommend counselors reflect on their attitudes, beliefs, opinions,

feelings, and personal history to identify aspects of self that might interfere with their ability to

effectively provide services to a clientele different from themselves (Bieschke & Mintz, 2012).

Formal evaluation measures have been developed to measure novice counselors’ personal

and professional areas of growth that are thought to produce a more integrative, well-rounded

counselor (The Counseling Skills Personal Development Rating Form, CSPD-RF; Wilbur, 1991).

However, such tools have yet to be widely utilized by training programs (Youngson & Green,

2009).

Winterowd, Adams, Miville, and Mintz (2009) recommended strategies for making these

expectations known to the training class as well as a part of the training curriculum. They believe

that novice counselors may develop to become more personally and professionally competent

providers if programs explicitly discussed these issues with the students and if these processes

were modeled by supervisors and professors. Furthermore, they proposed that students could be

evaluated on these measures throughout their training.

Focus and Purpose of the Current Study

In order to begin integrating personal development processes so they are a known and

embraced aspect of clinical training, it is first necessary to investigate ways in which various

elements of clinical training may already produce personal growth. Thus far, senior clinicians

have retrospectively reflected on the ways in which their professional work prompted

experiences of personal development, and also the ways in which efforts towards personal

growth improved their clinical work (Carlsson et al., 2011; Hughes et al., 2009; Rønnestad &

Skovholt, 2001; Trotter-Mathison et al., 2010). Few have investigated the potential impact of the

training process itself on the novice clinician’s personal development (Orlinsky & Rønnestad,

2005; Pascual-Leone et al., 2013). Further, little is known about novice clinicians’ perspectives

of these developmental experiences.

A strong link between personal and professional development is evident in the literature

(Chan, 2001; Fleming-Holland, 2000; Horrocks & Smaby, 2006; Leszcs, 2011; Novack et al.,

1999; Ricks, 1993; Von Haenisch, 2011; Young et al., 2013) and while many stress the

importance of implementing personal development programs in clinical training, few are utilized

today (Hemanth & Fisher, 2015; Youngson & Green, 2009). The creation and implementation of

such programs requires that educators first gain a clear understanding of the types of

developmental experiences that appear organically during the supervision and training years.

Currently, there are only two known studies investigating the phenomenological perspectives of

clinical psychology doctoral students relative to their personal and professional development.

The current study sought to further clarify this area of research by analyzing the lived

experiences of novice clinicians during supervision and clinical training. Specifically, this

researcher was interested in the bidirectional relationship between personal and professional

development that occurred naturally during novice clinicians’ training.

It is believed that by delineating the processes by which novice clinicians experience

personal development during training, educators can gain awareness of how personal

development is already taking place and its influence on professional development. Additionally,

to begin to understand how and where training programs should incorporate growth-promoting

activities that would improve professional development, more needs to be known of what

specific personal and professional experiences facilitate the kind of growth that benefits clinical

work (Orlinsky & Rønnestad, 2005; Pascual-Leone et al., 2013; Rønnestad & Skovholt, 2003).

Summary of Literature

The field of clinical psychology has been active in efforts to refine clinical training and

supervision since its inception in the late 1800s (Farreras, 2001; Routh, 2000). The relatively

recent establishment of the competency benchmarks marks a significant milestone relative to

these advancements (Fouad et al., 2009). It is likely we will see the field continue to advance its

training efforts to improve the competency of psychologists entering the workforce.

Psychologists, along with other mental health practitioners, have often reflected on their training

and work life and have described the importance of devoting more attention to developing

personal factors in novice clinicians to support success in the field (Rønnestad & Skovholt,

2001). Such practices, however, are scant (Ellis, 1991; Heppner & Roehlke, 1984; Rabinowitz et

al., 1986).

As part of the move to competency based clinical training and supervision, self- reflection

and personal awareness have been elevated in importance. Yet, despite the fact that

psychodynamic, humanistic, cognitive-behavioral and multicultural perspectives each believe,

that the person-of-the-therapist is an important training focus to achieve effective clinical

practice (Freud, 1910, 1937; Hayes et al., 2004; Maslow, 1968), the focus on the overall personal

growth of the novice clinician during training and supervision remains largely absent. It is in the

parallel fields of counseling psychology and marriage and family therapy, that there have been a

few more explicit efforts to address personal factors in training (Aponte & Carlsen, 2009;

Norcross, 2002; Young, 2001). However, the clinical psychology field has all but neglected

attention to personal factors while supervising and training novice clinicians (Eisler, 2006).

To address these gaps, this dissertation explored the lived experiences of novice clinicians

that organically arose during clinical training and supervision in the first year of doctoral

training; efforts were devoted to understanding the areas of supervision and training that

promoted the personal growth and development of these clinicians (Auxier et al., 2003; Gibson et

al., 2010; Hanna et al., 1999; Hill et al., 2007; Rønnestad & Ladany, 2006; Skovholt &

Rønnestad, 2003; Taubner et al., 2013; Thaeriault & Gazzola, 2010; Trotter-Mathison et al.,

2010). While there have been a small number of educators reviewing the experiences of novice

clinicians at the masters level in both counseling and marriage and family therapy programs, no

such studies were found to have been completed with doctoral students (Aponte & Carlsen,

2009; Gibbons, Cochran, Spurgeon, & Diambra, 2013). An exploration of the aspects of

supervision and training that promote personal growth will likely invite other training programs

to address this currently overlooked area of research.

Chapter 3: Research Methodology

The research methodology used for this qualitative archival study is presented here.

Included are discussion of the rationale for study design, archival data description, procedures for

data collection, participant descriptions, researcher bias, research approach, limitations and

contributions to the field.

Many are inviting empirical investigation of the areas of personal growth and

development of novice clinicians due to increased awareness of the impact of clinical training

(Grafanaki, 2010; Truell, 2001; Rønnestad & Skovholt, 2001; Rønnestad & Ladany, 2006;

Skovholt & Rønnestad, 2003). Though there exists over 50 years of research in supervision, this

author has found that existing literature is narrow in scope focusing only on the areas of ethics,

professional behavior, knowledge and skill acquisition, professional identity development, and

stages of growth. Empirical explorations of personal growth and development of the novice

clinician are lacking, as current literature is retrospective and narrow in focus (Carlsson et al.,

2011; Folkes-Skinner et al., 2010; Lutz & Spell Izizarry, 2009; Rønnestad & Skovholt, 2001;

Trotter-Mathison et al., 2010; Tryssenaar & Perkins, 2001).

The focus and purpose of this dissertation is to unveil aspects or elements of personal

growth that unfold during clinical training, as they influence professional development. Data for

this study was drawn from novice clinicians’ documented observations and experiences of their

own personal growth throughout a first year practicum. Devoting time to this area of research is

intended to hone aspects of clinical training for the purposes of enhancing novice clinician

education. Results of this study have the potential to illuminate processes by which developing

personal factors of the novice clinician are cultivated during professional development.

Research Design

An inductive, qualitative content analysis of a preexisting data set was used for the

current study, as the research question was exploratory in nature (Elo & Kyngäs, 2008).

Interpretative phenomenological analysis (IPA), a type of content analysis, was implemented in

the discovery of themes and analysis. The purpose of utilizing such an approach was to be able to

understand a situation without imposing preexisting theory or themes on the phenomena being

studied. Interpretative phenomenological analysis in particular aims to gather explicit and

implicit themes for a thorough understanding of data depicting subjective experiences of the

participants (Smith, Flowers, & Larkin, 2009).

A qualitative methodological approach is thought to have potential for adequately

capturing the full and complex nature of a topic, such as novice clinician development (Morrow,

2007). Further, a qualitative approach granted the researchers access to processes in addition to

relevant content, and may aid in future theory development regarding novice clinician personal

growth (Morrow, 2007). However, conventional content analysis is limited in that initial findings

may only contribute to the establishment of an overall concept or model; thus, additional

research will be required to round out a theory (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005).

This approach was appropriate for the following study design given that currently no existing

theory and minimal literature exists to describe this phenomenon with this population (Hsieh &

Shannon, 2005). Through the use of open coding, this researcher allowed themes (i.e., categories)

to emerge from the data (i.e., inductive category development; Mayring, 2000).

The present study proposed to investigate personal and professional development in order

to understand their bidirectional relationship. This researcher coded the data for content (i.e.,

descriptive codes; Saldaña, 2009) and processes (i.e., process codes; Saldaña, 2009) of personal

and professional development and examined ways in which they are depicted as influencing one

another. Some have asserted that it is highly unlikely to determine causality utilizing a qualitative

approach (Stake, 1995); rather, that qualitative data can more accurately be examined with

respect to chronology. Thus, potential relationships between content and process codes identified

in this data set are explored in relation to one another with respect to their chronology rather than

inferring cause and effect via their narrative.

Participants and Researchers

Autoethnography as a method. The current study utilizes a unique methodological

approach in that the three researchers of the current study are also the participants. Such an

approach is supported in the autoethnographic research literature as well as historically in the

field, providing precedence for this type of research design. Many prominent investigators have

included themselves as contributors to their data, as in the case of Jung analyzing his own dreams

and Wundt’s use of introspection (Selby, 2003). The theories on which the field of clinical

psychology is built have largely been developed with the use of theorists’ personal experiences as

their data (Selby, 2003).

Autoethnography is a methodological approach to research that aims to chronicle and

examine subjective experiences for the purposes of clarifying an overall cultural experience

(Ellis, Adams, & Bochner, 2011). This approach is introspective in nature and is often used to

understand phenomena that are difficult to observe, thus shedding light on aspects of the human

experience that are infrequently uncovered via other approaches (Stanley, 2015; Wambura

Ngunjiri, Hernandez, & Chang, 2010). Autoethnography positions the researcher as an object of

inquiry and includes investigation of self-awareness, introspection, and internal experiences such

as thoughts and emotions (Crawford, 1996). Berry and Patti (2015) expressed that

autoethnographic data, “open(s) up possibilities for broadening a sense of connection, while

deepening appreciation for the ultimate uniqueness and complexity of any life as lived and

narrated” (p. 267).

Autoethnography as a method of inquiry for investigation of novice clinicians’

experiences is warranted, given that so much of a clinician’s development cannot be observed

objectively (Stanley, 2015). Stanley (2015) suggests that trainers and supervisors may

misperceive novice clinician’s development when viewing it through an alternative empirical

lens. This author believes that having utilized an autoethnographic approach to research for the

current study allowed for the best understanding of the phenomenological experience of a novice

clinician’s clinical development.

Researchers. This author is a clinical psychology doctoral student and is also one of the

three participants of the current study. Likewise, each of the three participants were also

responsible for coding the collected data. An auditor for the study, a clinical psychologist,

oversaw the processes of data collection, coding and analysis. Multiple (3) coders were used in

this study to create a variety of perspectives from which to understand the data. This approach

aimed to minimize bias while sufficiently capturing the full complexity of the data (Hill,

Thompson, & Williams, 1997). Included below are descriptions of relevant personal information

written by each of the coders and the auditor, presented here to clarify and make transparent

potential areas of bias.

Coder 1. The first researcher and author, Coder 1, is a 28 year-old, white, female clinical

psychology doctoral student. She was born and raised in an upper-middle class family in the

south western part of the United States. Coder 1 was raised in a Christian family, and self

identifies as spiritual and non-religious. Coder 1 generally conceptualizes and treats clients from

an existential-humanistic approach; including the use of cognitive behavioral techniques,

acceptance, and mindfulness. More specifically, she believes that therapeutic change often

emerges from a strong therapeutic alliance, relying on the therapist's’ level of attunement and

ability to meet the client where they are while challenging them to become more. In order to do

this, the therapist must be willing to reflect upon her own process and be willing and open to

continuously grow.

Coder 2. The second researcher and author, Coder 2, is a 28-year-old, white, married,

female clinical psychology doctoral student. She was born and raised in an upper-middle class

family in the midwestern part of the United States. Coder 2 was raised in a Catholic family and

self-identifies as a non-practicing Christian. Coder 2 generally conceptualizes and treats clients

from a humanistic perspective; including acceptance-based cognitive-behavioral techniques.

More specifically, she believes that client’s gradually experience healing in therapy as their

selfawareness increases, and is contingent upon their willingness to embrace such awareness

without denying or distorting the truth of who they are and their experiences in the world. The

therapist’s role in producing such a shift is that of a metaphorical mirror, in that the therapist

experiences the client as they present in therapy and reflects back to them what is observed. This

coder believes this process of reflection must take place without judgment of what is observed or

experienced. Further, the therapist must be active in their use of empathy in order to both fully

recognize all aspects of the client’s difficulties, and to validate the client’s experience as one that

is or could potentially be experienced by all humans. Thus, an additional element of treatment

deemed necessary by coder 2 is that the therapist themselves must maintain congruence so as not

to collude with the client’s denial or distortion, and to model healthy psychological processes.

The elements of reflection, nonjudgment, empathy, and congruence are believed to be reliant

upon the therapist’s commitment to their own personal development. Accurate reflection, for

example, can be influenced by the therapist’s personal biases and overall life experiences. Thus,

ongoing self-awareness and congruence on the part of the therapist precludes the use of accurate

reflections in therapy. Further, non judgment and empathy are both effortful processes that may

require the therapist to confront their personal biases, thoughts, behaviors, and overall sense of

self as it has been shaped by their own unique experiences.

Coder 3. Coder 3, a researcher and author, is a 31-year-old, multiracial, male clinical

psychology doctoral student. He was born and raised in a upper-middle class family in the

western part of the United States. Coder 3 was raised in a Catholic family, and considers himself

as spiritual with affiliations to Buddhism and the Catholic church. Coder 3 generally

conceptualizes and treats clients, from an existential approach; including acceptance-based

cognitive-behavioral techniques, person-centered therapy, and purpose-centered therapy. More

specifically, he believes that the growth and recovery of an individual stems from focusing on

purpose-driven personal goals, increased awareness of human limitation and inevitable death,

and forging meaning within the context of the lived human experience the individual has

encountered up until that point in their life, while enacting a willingness to embrace and

overcome the challenges presented to shift towards personal growth and self-actualization.

Auditor. The auditor of the study, who is also the dissertation chair and the licensed

clinical supervisor of the participants/researchers, is a European-American, Jewish single female.

She has a doctoral degree in psychology and is senior level /master clinician and lecturer /

professor of psychology. She teaches applied psychotherapy courses and uses an integrative

theoretical approach combining principles from four theoretical positions as part of the clinical

training provided to six novice clinicians. First, she uses psychodynamic as a theoretical

foundation, understanding that one’s past history affects and contributes to present day

functioning. Second, she finds that first through third wave cognitive-behavioral theories help

individuals move out of the strictures of the past and help them change their perspective and

ability to function in the present. Third, she maintains an overall positive view of the self,

emphasizes self-responsibility, and uses the “here and now” of therapeutic sessions, elements

which are drawn from a humanistic/existential perspective. Fourth, all of this is ground in an

understanding of how the brain functions, information drawn from neuroscience, and more

specifically, interpersonal neurobiology. Finally, her work is informed by systems, developmental

and strength-based approaches. Her teaching approach highlights the use of psychotherapy

process. She greatly enjoys mentoring the individuals she has the opportunity to teach and has a

strong belief in personal growth, ideas threaded throughout humanistic / existential and

neuroscience literature. Accordingly, she supports the exploration and use of research on personal

and professional development, and believes that such emphases contribute to the overall

professional development of clinicians.

Participants

The pool of potential participants included six first year doctoral students. The final

participants who consented to take part in the study included one man (identified as Multiracial)

and two women (both identified as White). Their mean age at the time of data collection was 29

(SD = 1.73). All participants completed the first year of their doctoral program at a major

Southern California private university that is accredited by the American Psychological

Association. All participants completed their master’s degrees in psychology prior to beginning

their doctoral training, and all were placed at one of two community counseling centers for their

first year practicum during the time that the data used in this study was created. None of the

participants had clinical experience prior to beginning their doctorate training, and none had

committed to using a particular theoretical orientation in treatment at the time of data creation.

All participants regularly attended the same supervision group and received clinical training

under the direction of a licensed psychologist for the duration of one academic year, whom also

served as the auditor for the current study. This licensed psychologist is a White female with 28

years of experience in training and supervising novice clinicians. Clinical training and

supervision totaled 140 hours for the year and included activities such as case conferences,

didactic supervision, and bi-annual daylong seminars. The approach to supervision was one

which involved frequent review of audio and visual recording of sessions, teaching aspects of

clinical practice guided by session tape review and student report of session, and supportive

encouragement of students to challenge themselves toward personal and professional growth as it

pertained to clinical work.

At the time the data was created, one 7-hour educational training seminar within the first

two weeks of the doctoral program first year was required of the students (i.e., participants).

Content included: 15 basic assumptions for conducting psychotherapy; six listening skills

discussed by Allen Ivey (Ivey, Normington, Miller, Morrill, & Haase, 1968); nine elements that

enhance attunement to the client (J. Rosenberg, personal communication, November 14, 2012);

description of the shifting between content and process in psychotherapy; introduction of

concepts of neuroception and neuroceptive challenges grounded in interpersonal neurobiology (J.

Rosenberg, personal communication, November 14, 2012), discussion of therapeutic concepts of

safety, window of tolerance, body sensations as emotions, affect tolerance and regulation of eight

emotions and concepts of connection and congruence. Additionally, students attended two hours

of weekly case conference as a group of six, during which one student presented a case including

video of taped sessions. Finally, one hour of weekly dyadic training was required throughout the

full duration of the first academic year with the aforementioned licensed psychologist as

supervisor.

Procedure

Sampling procedures. In accordance with the recommended guidelines for this type of

qualitative research study, purposive sampling was used to gather 53 total journal entries. This

archived set of pooled journal entries is likely to contain sufficient data, as they represented

variant viewpoints across a total of 53 entries. Purposive sampling allowed the researcher to

focus on particular aspects of the targeted population, which are likely to best answer the specific

research questions (Merriam, 2014). A maximum variation approach to sampling was utilized to

identify diverse experiences across participants who range in age, gender, clinical experience,

and cultural background. A maximum variation approach to sampling is one that, “documents

diverse variations and identifies important common patterns” (Miles & Huberman, 1994, p. 28).

The goal of using these approaches was to produce results that may represent common patterns

or themes seen in a variety of doctoral students (Merriam, 2014). This approach was also chosen

to ensure the relative strength of identified patterns or themes by considering both common and

uncommon student experiences.

Potential participants were contacted for inclusion in the study based on their status as

first-year doctoral students in a clinical psychology program. Additionally, for convenience, only

those who completed supervision under the direction of a single supervisor were chosen for

participation. Participant involvement was not determined based on gender, age, years of clinical

experience, or cultural background. This inclusion/exclusion criterion allowed the researchers to

identify processes that are not dependent on gender, age, cultural background, supervisory style

or orientation, clinical experience, or education level.

This cross-case sample aimed to maximize conceptual understanding of the results, which

can then be utilized to identify themes to be investigated or compared to future studies

investigating similar content. Such study designs are essential for laying the groundwork for

eventual development of novel training approaches that include potentially imperative training in

personal development (Miles & Huberman, 1994). The procedures and materials used in the

procurement of research data was approved through the university’s Institutional Review Board

(IRB) prior to the accessing of subject archival data (see Appendix A for copy of IRB approval

letter).

Critical Incidents

Critical incidents are events, activities, or situations that can be systematically described,

observed, or retrospectively elicited, and through which individual performance can be

categorized and better understood (Flanagan, 1954). Critical incidents were defined by Flanagan

(1954) so as to provide clinicians with a systematic way of decoding complex conflicts,

processes, or values. These are discussed here as they are a concept closely resembling the types

of data investigated in this study (Fraser & Hunt, 2011).

The Critical Incident Technique developed by Heppner and Roehlke (1984) has been

utilized by Ellis (2006) and others in research. Ellis (2006) requested that participants describe

critical incidents that occur within the supervision process and that result in changes in

effectiveness as a clinician. Using this technique, a researcher might ask a participant to describe

a critical incident from a supervisory session and then expand on this to include when it took

place and what made this particular event a critical incident (Ellis, 2006; Heppner & Roehlke,

1984). Further, the use of this technique has previously been found to be helpful for not only

exploring current processes, but also for developing methods of change via problem solving

(Fraser & Hunt, 2011). The Critical Incident Technique is relevant to the current study in that it is

often used as a method by which others can understand and describe the meaning they associate

with significant events in their life (Fraser & Hunt, 2011; Kain, 2004).

Critical incidents have frequently been used within the context of clinical training and

supervision literature measuring relationships, competence, autonomy, personal issues, and

emotional awareness (Ellis, 1991). They have been used often to describe several types of

therapeutic impacts, as well as experiential learning (Kivlighan, Multon, & Brossart, 1996;

Smith-Adcock, Shin, & Pereira, 2015). Specifically, many have used them to describe novice

clinician development (Furr & Carroll, 2003; Howard, Inman, & Altman, 2006; Smith-Adcock et

al., 2015).

Supervisors appear to identify critical incidents in clinical training often related to

relationship issues, whereas novice clinicians often recognize critical incidents related more to

competence, purpose, autonomy, and direction (Ellis, 2006; Fine & Fenell, 1985). There appears

to be value in using critical incidents in the context of supervision for reducing novice clinician

anxiety and increasing perception of safety for openly processing difficult topics that lead to

development or growth (Nelson, Oliver, & Capps, 2006; Sommer et al., 2009). It has been long

recognized by authors in the field that there is a need to better understand the thoughts, feelings

and behaviors of novice clinicians at different developmental stages of professional development

(Borders, 1989; Holloway, 1987; Stoltenberg, 1981). Critical incidents are of value to this calling

as they can be utilized to depict shifts in development relative to attitudes and/or beliefs that

inform novice clinician clinical work (Arrendondo et al., 1996; Delsignore et al., 2010). They

have also been used to recognize ethical issues in supervision, such as looking at the concepts of

benefiting others and doing no harm to clients (Goodyear, Crego, & Johnston 1992; Kitchener,

1984).

Critical incidents and the current study. Critical incidents have been implemented for

purposes of analysis in qualitative research across the field (Angelides, 2001; Cormier, 1988;

Delsignore et al., 2010; Furr & Carroll, 2003; Leong & Kim, 1991; Mwaba & Pedersen, 1990;

Skovholt & McCarthy, 1988). Data collected for this study mirror those described by others who

have implemented the Critical Incidents Technique (Heppner & Roehlke, 1984). Participants in

this study wrote about “critical moments” in their training, recognized via visceral reactions,

cognitive shifts, or significant turning points. Of note were instances in which one experienced

increased self-reflection and/or insight and self-awareness, changes in efficacy as a clinician,

personal growth, and increased self-efficacy and self-agency. For the purposes of this study,

critical moments often also resulted in a personal or professional challenge and an implied

invitation to be or do more using what was learned. Examples of these types of experiences

include when past experiences are clarified while engaging in a professional activity, or a

budding personal issue is discussed in supervision prompting the novice clinician to face that

issue. Learning can take place at any point in time, whether it is while directly involved in a

professional activity or afterwards upon reflection of said activity. Learning that takes place

becomes new knowledge available for more effectively handling future situations, whether

professional or personal in nature.

Using a critical moment approach, six (three who participated in the current study) novice

clinicians used writing to process situations, events, or experiences in which they felt inspired to

be or do more in their personal or professional lives. This writing took place over the course of

seven months during the second semester of the first doctoral year, and occurred at a frequency

of approximately two entries per month. Each entry varies in length; however, they are on

average one double spaced page.

Data Collection and Management

This study utilized an archival data set that was phenomenological in that it was a

selfreport of the actual lived experiences of the participants (Moustakas, 1994). During the first

year of clinical training and through experiences in supervision, six doctoral students attending a

private university in Southern California noted experiencing significant personal changes. These

students voluntarily conversed with one another about these experiences and were inspired by the

consistency with which these personal changes appeared to relate to professional development.

These conversations provided a platform from which these students began spontaneously and

voluntarily documenting these critical moments as they related to personal or professional

development. This process began shortly after the end of the fall semester and continued

throughout the student’s spring semester. The documentation of these experiences was completed

prior to the development of the current study, and was not in any way developed with the

intention of being used in a research study. Given that the collection of these entries for data was

retrospective in nature, the data set is considered to be archival.

The journal entries (hereafter referred to as ‘journal entries’ and/or ‘data entries’) making

up this data set reflect naturalistic experiences of each writer and participant. In other words, the

journal entries were not written in such a way that they could be influenced by the development

or parameters of the current study. Of consideration are the current author’s interests that

influenced participation in the creation of journal entries in this topic area. This interest likely

reflects a bias this author has with respect to personal and professional development of novice

clinicians. The decision to design the current study is a result of this bias.

The collection and de-identification of all data entries is discussed here. A third party

assistant, who is a master’s student at Pepperdine University Graduate School of Education and

Psychology, was selected as a volunteer to assist with this process. Volunteers were recruited by

the dissertation chair who announced the opportunity in a first-year doctoral class. Selection

criterion for the volunteer included someone who was unfamiliar with both the current author

and the study’s potential participants. The volunteer chosen to assist indicated her interest in

helping had to do with gaining additional experience with research. She signed a confidentiality

agreement addressing proper handling of the data (see Appendix C for a copy of the

confidentiality agreement).

The chosen volunteer consulted with the current author for instructions that were used to

initiate the study recruitment and consent processes. The current author provided the volunteer

with a recruitment script to send to all potential participants via email (see Appendix D). The

volunteer then handled recruitment and informed consent procedures without assistance from the

current author so as to maintain anonymity of those who did or did not chose to participate. As

part of this data collection procedure, all potential participants were asked to also complete a

demographic form providing personal information to be included in the study (Appendix H).

Information collected from demographic forms was provided earlier in this chapter and is

included so as to transparently illustrate potential areas of bias. This information was not utilized

in any way during the data analysis process.

All students who were known to have created journal entries were contacted for

participation in the current study, of which there were a total of six students. All potential

participants were provided an informed consent document, on which they were able to read

information about the quality and time commitment for participation, confidential storage and

handling of data, potential risks and benefits of participating, and to whom questions could be

directed (see Appendix B). Three of the six both provided consent and were able to provide

copies of their journal entries. Two students gave consent to participate but were unable to locate

their journal entries, and one did not respond to outreach efforts. Thus, the final data set included

data from three participants for a total of 54 stories. One story was found to be incomplete;

therefore, the final data set included 53 complete stories.

After recruitment and informed consent procedures were complete, the study volunteer

followed a set protocol, developed and provided by the current author, to de-identify all journal

entries (see Appendix E). After de-identification was complete, this volunteer copied all journal

entries to a password protected flash drive provided by this author, and submitted the flash drive

to the dissertation chair. Per the de-identification protocol, this volunteer then erased all traces of

data from her personal computer.

This study’s dissertation chair collected the flash drive containing the data set and created

four copies. The dissertation chair sent one copy of each data set to each of the three coders for

the study, and kept one copy for purposes of auditing. All data sets were stored in locked drawers

at each of the coder’s and the dissertation chair’s offices during the data coding and analysis

phases of the study. All signed informed consent documents were stored by the dissertation chair

in a separate locked drawer in her office so as to keep the data separated from the informed

consent documents to further protect participant confidentiality. Data collected for this study will

be maintained for a duration of five years before it is destroyed.

Coding and Data Analysis

Data analysis was completed in a three-step process of open coding, categorizing, and

abstraction (Creswell, 2009; Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). Additionally, the

reliability of data analysis was monitored and evaluated throughout the coding process. The

coders for this study consisted of three doctoral level psychology graduate students. The

dissertation chair served as an auditor. Each coder read and coded every journal entry and

participated in multiple conference calls for establishing consensual agreement prior to the start

of the coding process (Consensual Agreement; Hill et al., 1997).

Consensual agreement. A procedure developed by Clara Hill referred to as Consensual

Agreement was utilized to establish reliability of the final codes identified across coders. This

approach aims to reduce researcher bias and maximize information derived from the data by

utilizing multiple perspectives to highlight “the truth” of a complex data set (Hill et al., 1997;

Marshall & Rossman, 1989). Hill et al. (1997) recommend using a team of coders of three to five

people, and one to two auditors, in order to access a variety of perspectives, avoid biases of any

individual person, and to highlight the intricacies of the data. This approach was selected as an

alternative to the establishment of interrater reliability, because the qualitative nature of the data

makes it difficult to establish levels of agreement on specific verbiage for codes. Hill et al.

(1997) note that attempts to establish interrater reliability with qualitative data can result in a

constriction of the clinical judgment and wisdom of the coders, and results that may be

unnecessarily and unfortunately narrowed in complexity. This process is delineated in the

description of the various steps of data analysis described below.

Coding procedures. The start of the coding process began with discussion amongst the

coders and auditor regarding the basic approach to open coding. This conversation was

comparable to Hill et al. (1997) approach of establishing domains so as to establish a conceptual

framework for working with large amounts of data (Miles & Huberman, 1994). In this

conversation, the coders and auditor agreed to initially approach coding by looking for

descriptions of strategies (i.e., an approach aimed at producing a particular result), relationships

or interactions (i.e., something takes place between two or more people or events that results in a

change), and consequences (i.e., a particular approach has an impact on the outcome). These

particular descriptions were selected amongst a variety of types of codes that could be identified

in a qualitative database with the particular research question in mind (Taylor & Gibbs, 2010).

It was noted that codes may be indicative of content discussed in the data, defined as

descriptive codes, or processes illustrated in the data, defined as process codes. A descriptive

code summarizes the primary topic of a portion of the data, whether a single sentence or a series

of sentences. A process code, by comparison, is a word or phrase that captures action. A third

type of code was thought to be relevant to the current study, which are simultaneous codes

(Saldaña, 2009). These represent situations in which codes overlap due to two or more codes

appearing in a single data piece (i.e., single sentence or grouping of sentences). Thus, descriptive,

process, and simultaneous codes were all explored by considering strategies, relationships or

interactions, and consequences during the open coding process.

Finally, a discussion of the units of coding aimed to clarify if individual words, sentences,

or groups of sentences were to be considered for a single code. Given that the researcher was

interested in obtaining the maximum amount of nuanced information as possible from the data

set, coders were asked to investigate every line of the data and ensure that all potential codes

were captured. This represents more of a “splitting” approach to coding in contrast to a

“lumping” approach (Saldaña, 2009). Splitting allows the coder to split the data into small,

codable moments, and requires careful scrutiny of each line of data. In contrast, lumping would

be used if the aim was to capture more of the overall essence of the data set. The current

researcher suggested these guidelines to the coders and auditor as it was believed that these

would best focus the open coding process on the types of information delineated in the journal

entries that might best answer the research question.

Next, five journal entries were randomly selected using computer software that generates

random numbers of a given data set (Urbaniak & Plous, 2013), which the coders independently

coded manually (i.e., paper and pencil) using the above guidelines. Two conference calls lasting

a total of five hours were then held with all coders and auditor present to discuss each coder’s

findings. Codes were compared and contrasted for similarities and differences in each coder’s

interpretation of the same information units (i.e., same content or processes identified within a

data entry). This marked the second point in time when coders and auditor came together to

continue establishing consensual agreement, during which the approach to coding was further

clarified for the members of the research team. Each code that had been identified was discussed

in detail relative to clarifying the thought process behind identifying and establishing a code as

relevant to the current study. These five data entries were then collectively recoded based on the

clarified coding guidelines. A list of codes identified during this process and their definitions are

provided in Appendix I for review. The process of open coding began following this step.

Open coding. Open coding began with each of the three coders independently reading

through each data entry and manually coding per the predetermined protocol. It is recommended

that this process be completed independently by each coder so as to reduce groupthink (Hill et

al., 1997). The intention of this phase of data analysis is to capture first impressions (Saldaña,

2009). Each coder created an electronic record of codes identified in this step by listing all codes

and the line numbers on which they were identified on an excel spreadsheet. These spreadsheets

were provided to the primary researcher for review. The primary researcher created a spreadsheet

for comparison of codes established by each coder, by lining up codes identified on the same

page numbers side-by-side.

This author (the primary researcher) completed a second reading of each data entry to

systematically look at each code established on the same set of line numbers, and identified

consistencies in codes identified across coders as well as discrepancies in codes. This process

involved an in-depth reading of the data entries to ensure that discrepancies were understood in

the context of the actual writing within the data rather than relying on the chosen verbiage

assigned to each identified code. It is recommended by Hill et al. (1997) that during the coding

process, the researcher stay close to the actual data for as long as possible during the data

analysis process so as to best represent what is actually being communicated by the participants.

During this process, codes were identified as being consistent if they occurred across the same

line numbers and were described with similar verbiage by multiple coders. If this was not the

case, a discrepancy was noted. There were times in which a process code and a descriptive code

were identified by different coders. In these cases, both codes were maintained to create a

simultaneous code representing a process and description of the details of that process (e.g.,

selfawareness that a countertransference reaction took place as process and specific

countertransference reaction as description). As a result of this second reading, this author

created a single set of codes that were identified as consistent, and made note of discrepancies so

that these could be further explored.

Of a total of 347 identified codes across the full data set of 53 data entries, 42 codes were

found to be discrepant (12%). A conference call was scheduled between the primary researcher

and auditor to discuss these discrepancies and agree upon appropriate codes. The auditor and

primary researcher did this by, again, systematically going through the data set and reviewing

each entry that contained a discrepant code. This call required approximately three hours of

discussion, during which eight patterns of discrepancies were identified. The auditor and primary

researcher discussed each discrepancy and decided together whether to dismiss, add, or collapse

each of these codes. A full description of the specific types of discrepancies and decisions made

relative to how these manifested in the final set of codes is provided in Appendix F.

The auditor of this study identified a seemingly significant finding during the

aforementioned conference call in which a pattern was noted that in many instances, rich

descriptions of a process code was missing. In other words, each of the coders most consistently

identified process codes but were less consistent in identifying descriptive codes within those

process codes, which would result in a simultaneous code. Given this finding, the primary

researcher conducted one additional full read-through of the data entries to ensure that these

descriptions were captured. Thus, during this read-through, several process codes were

transformed into simultaneous codes when descriptive codes were collapsed within them to

better capture missing detail.

Categorization. Categorization of codes, the second phase, involved comparing and

contrasting codes both within and across journal entries to identify common themes. This process

of categorization began with reviewing the codes within each data entry and identifying themes.

Common themes were identified, and data entries that illustrated these themes were listed to gain

perspective of the commonality of the theme across the data set. The process of identifying

themes was discovery oriented, and did not involve imposing preconceived ideas on the data so

as to ensure that the themes emerged from the data itself (Mahrer, 1988). This approach to data

analysis follows that of an interpretative phenomenological analysis (IPA) in that it aims to

understand the subjective experience of individuals through their writing (Larkin, Watts, &

Clifton, 2006; Smith & Osborn, 2008). Participants in this study created each data entry without

research prompts or other external direction; therefore, data are viewed as representative of the

issues and topics that the writer found to be valuable to their developmental experience. In order

for the researcher to get in touch with the participant’s personal and subjective experiences

illustrated in their writing, individual cases were viewed one-by-one, and themes developed based

on what appeared to be both the explicit and implicit content of the participant’s experience

(Smith et al, 2009).

As themes emerged, each data entry was reviewed for similar themes so as to capture the

full number of data entries illustrating the emerging themes. As discussed previously, it is

recommended that during the data analysis process, one continue to return to the actual data in

order to ensure codes and categories are accurately representative of the original data (Hill et al.,

1997). In order to avoid misrepresentative of the data, the actual journal entries were often

reviewed in conjunction with their codes to gain a clear concept of the theme being

communicated by the data.

After all data entries had been reviewed and all themes written down, the data entries

listed as having contained the theme were each individually reviewed again to ensure that the

theme was represented in the data in a way that was consistent with the identified theme. During

this process, summary descriptions were written for each data entry for ease of comparing the

individual data entry to the overall theme (Hill et al., 1997). This step was taken to further ensure

accuracy of themes for a complex and thorough data set (Appendix J: Summary descriptions of

themes). Finally, these themes were named in congruence with the processes in the data that they

represent, and became the initial set of categories for data analysis.

A crucial observation of the data was noted during this phase of the data analysis process.

Initially, this writer attempted to look at common themes that emerged across data entries with

respect to the chronology of the codes identified during open coding. The intent of doing this was

to answer the original research question by identifying processes illustrative of relationships

between personal and professional development factors. It became evident that this was not

possible due to the manner in which the data entries were written. Given that the stories (i.e., data

entries) were written on the writer’s own volition without consideration of a research prompt, it

was found that each story was written with unique chronology relative to the writer’s experience.

These patterns appeared to follow the writer’s stream of consciousness rather than depicting the

chronology of the writer’s experience of external or internal events or learning. Therefore, the

chronology of the codes for each data entry was not representative of the chronology of the

writer’s experiences. As a result, it was noted that the original research question could not be

answered with the provided data in the way it was originally written. A new, similar research

question was then discussed with the auditor of this study and decided upon prior to the start of

the next phase of data analysis. The research question was reformulated in such a way that was

believed could best capture the information desired by the researcher, taking into consideration

the formulation of available data. This new research question is as follows: What aspects or

elements of personal growth influence professional development?

Abstraction. The final phase of data analysis involved an abstraction process during

which categories were further condensed into clusters of main ideas, each represented by the

multiple categories identified during the categorization phase. In order to do this, the researcher

considered how the themes identified during categorization related to one another with respect to

what they were communicating. From this, main categories were created as overarching ideas

communicated by the relationships of the themes. Each category contained several subcategories,

which were the themes from which the categories were identified. Both the categories and sub-

categories were named in congruence with their content.

Auditing of this step took place by phone between this researcher and the auditor of the

study. Three phone calls were held totaling approximately nine hours of time spent reviewing the

sub-categories and categories with respect to their fidelity, and accuracy and clarity in the way

they were named. The auditor provided assistance and checking of the researcher’s work by

reviewing each descriptive summary of a data entry that was found to be representative of each

sub-category, to check fidelity of the sub-category (see Appendix J). Names of sub-categories

were edited to maximize clarity and accuracy. Additionally, sub-categories were merged with

others at times when significant overlap was identified. Similarly, the overarching categories

were reviewed and found to be accurate in the way they represented the sub-categories; however,

they were also renamed to maximize clarity and accuracy. Each category was then assigned a

description in addition to a name to assist the reader with deciphering what each category was

communicating about the results of the data analysis.

Validity. The codes that emerged from the data analysis process were checked for validity

in several ways as discussed by Creswell (2009) and Hsieh and Shannon (2005). Similar or

relevant existing literature was reviewed and is included in the discussion session of this

document, in order to triangulate various sources of data and to identify evidence for the

existence of a given result. Additionally, member checking, or presenting the themes to the

original authors of the journal entries, was used to determine whether they view the results as

accurate. The dissertation chair acted as an auditor for the data by reviewing the codes

established by each of the three coders. As was delineated in the description of the process of

data analysis, the auditor engaged the primary researcher over the course of several conference

calls to explore incongruencies in the codes relative to those identified by the different coders.

Researcher bias and discrepant data is included in this document in a transparent manner.

Results of the aforementioned processes are discussed in the results sections of this study.

Additionally, rich descriptions and relevant quotations are provided to convey the findings.

Reliability. Reliability in qualitative data is concerned with the data generating

understanding, which is the overall purpose of a qualitative study, in contrast to quantitative

research where reliability is concerned with the data’s ability to explain the generalized value of

the results (Golafshani, 2003; Stenbacka, 2001). It is argued by Stenbacka (2001) that this makes

the concept of reliability irrelevant in qualitative research. Further, Lincoln, and Guba (1985) and

Stenbacka (2001) agree that reliability in a qualitative research study is inferred through the

establishment of validity, because validity cannot be established with reliability (Golafshani,

2003). However, others (Patton, 2002) believes that one can illustrate the reliability of data with

respect to the quality of the study in order to communicate to the reader that the results have

worth (Golafshani, 2003).

The quality of a qualitative study can be inferred if the results can be determined to be

credible, neutral or confirmable, consistent or dependable, and applicable or transferable

(Lincoln & Guba, 1985). Credibility can be ascertained from the study’s design having used

well-documented methods for inquiry. Neutrality has to do with bias, which is inherent in

qualitative research. The neutrality of the results is maximized in the current study with the use

of participant, coder, and auditor transparency of personal factors that may contribute to bias, and

with the use of multiple coders and auditor for analyzing the data. The use of consensual

agreement (Hill et al., 1997) was also used for ensuring that the codes established during the

open coding process were reliably identified. The current results are expected to be consistent or

dependable given the large number of data used in the current study; however, future studies may

benefit from recruitment of a larger number of participants to ensure dependability across a

larger variety of perspectives. Within the current study, consistency and dependability of the

findings can be ascertained through the transparent delineation of each step of data analysis and

documentation of the researcher’s decision making in each of these steps. Finally, applicability or

transferability of results has to do with the ability of the results to contribute to the development

of a theory. As discussed earlier, the use of a content analysis in this study aims to investigate

data without imposing preexisting theory so as to allow for emergence of results that can

eventually contribute to a new theory. However, additional studies will be required to continue to

expand upon the concepts identified by this study’s results in order to round out a more holistic

theory (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). In other words, it is hoped that this

study’s results will contribute to a pool of studies that can come together to create such a theory.

Human Subjects/Ethical Considerations

The confidentiality of participants in this study and the adherence to ethical standards of

research are discussed in this section. A voluntary external reviewer was utilized to de-identify

all data entries prior to the coders or auditor receiving the data. This data preparation process is

outlined in full in the section entitled, “Data Collection.” Formal instructions for handling of the

data were provided to the external reviewer to ensure that data was handled properly and in an

ethical and confidential manner. This author and all coders for the study completed an IRB

certification course and Health Insurance Portability & Accountability Act of 1996 (HIPAA)

course prior to gaining access to the data to ensure all involved adhered to ethical standards and

handling confidential health information in participant research (see Appendix G).

Participant Benefits of Participation

It is feasible to believe that participants may have gathered insights via a self-reflection

process inherent in the creation of the data. Many new experiences and/or patterns may have

emerged as a result, including an increase in self-awareness, increased use of critical reflection of

one’s work, experiential learning, and increased emotional awareness (Cornish & Cantor, 2008;

Ghaye, 2007; Lauterbach & Hentz, 2005; O’Connell & Dyment, 2011; Thorpe, 2004).

Selfreflection may have led to increased awareness of past or present development and growth,

therefore creating new opportunities for development that may not have existed if the data

creation process had not taken place (DeStefano, Overington, & Bradley, 2014). Participation in

the current study was not incentivized. It is the belief of this author that the results of this study

have the potential to contribute to greater insights about training in clinical psychology, which

may increase awareness of particular areas of growth relevant to professional development.

Limitations

The current study’s methodological design appears to have several limitations. First,

having used a small and homogeneous sample supervised and trained by a single supervisor

presents some challenges for generalizing results, as does the use of purposive sampling. In

order to better generalize results, future studies should investigate the experiences of novice

clinicians from a greater variety of theoretical orientations, supervision groups, and clinical

training programs. Additionally, self-selection for participation in the current study may indicate

bias in the data emanating from participant inherent interest in the topic area.

The current study relied on self-report, which may be interpreted with caution given the

limited capacity of individuals to self-assess accurately (Dunning, Heath, & Suls, 2004). What is

more, a social desirability response bias should be taken into consideration as having influenced

the writing of the journal entries. A social desirability response bias suggests that the content of

the journal entries may over represent perceivably desirable characteristics and processes, while

those perceived as undesirable may be under represented (Zerbe & Paulhus, 1987).

Despite the chosen approach to data analysis appearing to be the most appropriate for the

type of study presented here, it remains inherently limited. Even with the use of three separate

coders and auditor, the coders may have been unable to fully and accurately develop an

understanding of each journal entry’s context, thus misrepresenting the quantity and/or quality of

categories represented by the data (Hsieh & Shannon, 2005). Learning to code qualitative data is

a process that requires ongoing experience for sharpening accuracy; thus, the coders for this

study having not had prior experience with coding is likely to have resulted in the development

of codes that may not have fully captured all information inherent in the data (Saldaña, 2009).

Factors such as coder past experience, bias, culture and diversity of backgrounds are likely to

have also played a role in filtering each coder’s method of coding the data relative to how

another person may have coded the same data. Future research may benefit from the addition of

supplemental or other sources of data, such as supervisor observations of novice clinician

growth, therapeutic outcomes, or more objective measures of novice clinician development over

time. Such additional sources of information are likely to strengthen the results of the current

research.

Finally, an additional source of bias is considered a limitation in this methodological

approach. As previously discussed, there is a precedent for analyzing data developed by the

researcher themselves (see: Autoethnography as method). However, this approach is likely to be

vulnerable to bias during the coding process in that coders may perceive data they have written in

a way that would be different than a coder who is not as familiar with the context of the data

(Adler & Adler, 1987). Further, all qualitative coding includes bias given that determining codes

is always a judgment call, which is subject to interpretation and influenced by an individual’s

culture. This researcher is interested in conducting future studies that may eliminate this

particular bias by utilizing a similar study design to collect data from future generations of

firstyear doctoral students in clinical psychology.

Chapter 4: Results

Through the analysis process, 14 themes were identified as emerging from the data.

These themes represented what appear to be important aspects or elements of personal growth,

which are discussed in the data as influencing professional development in some meaningful

way. The 14 themes were reviewed for similarities and further categorized into six main ideas or

categories. The final results consist of these six overarching categories, each with two to three

sub-categories that total the 14 themes identified from the data. This author, under the guidance

of the study auditor, developed the category and subcategory titles and definitions. Titles and

definitions are intended to communicate the content of each category and subcategory. These

results are presented in Table 1 and represented pictorially in Figure 1, and are discussed below.

Included in this section are narratives of the data so that the reader can gain a deeper

understanding of the themes being presented.

Hindering Beliefs and Experiences

Definition: Awareness, Introspection about, and in-session experiences involving

personal challenges or issues that hinder clinical effectiveness.

The first overarching theme illustrates the different ways in which novice clinicians

became cognizant of problems with their clinical effectiveness. Across much of the data

participants noted having become aware of a problem with their clinical work, marked by a

personal challenge or issue, which was seen as an impediment to client’s progress in treatment.

The data suggests that through three processes of self-awareness, self-reflection, and in-session

experiences, novice clinicians became cognizant of these challenges and issues. Note that for the

purposes of this study, self-awareness was considered to be a process of becoming aware of

aspects of the self in the present, whereas self-reflection involved thinking about aspects of the

past that were/are relevant to how aspects of the self came to be. This theme was identified as

being present in 32 of the 53 total data entries, suggesting that it is a typical pattern in the data

(Hill et al., 2015). Overlap in the data indicates that in many instances, one of these processes

was used in conjunction with another to gain awareness of the hindrances to clinical

effectiveness.

Self-awareness of how present beliefs, behavior patterns, and degree of emotional

attunement hinders clinical effectiveness. Self-awareness was depicted as an important

component of the process for becoming aware of a personal challenge or issue that hinders

clinical effectiveness. Participants described self-awareness of their present thoughts or beliefs

systems, patterns of behaving and engaging with others, and own emotional attunement to either

the self or the client relative to how these elements hindered clinical effectiveness. It became

apparent through the data that novice clinicians bring with them particular ways of interacting

with themselves, others, and the world, and that these approaches are not left at the door upon

entering the therapy room. Self-awareness appears to be a critical activity for being cognizant of

when these challenges or issues are at play. This theme appeared in the data 17 times. The

following transcript is an example of a participant expressing self-awareness of the way that

emotional attunement to self is a personal challenge, which has the potential to hinder his or her

effectiveness in helping clients with the same issue.

Vulnerability is a tough feeling to experience. I have found that I avoid vulnerability

quite a lot in my life. This is something I do so naturally now that I did not realize the

extent to which I was avoiding. As I began to learn more about this feeling and challenge

my clients to move toward vulnerability, I began to look more critically into my

mechanisms of avoidance.

In another example the participant recognizes that their beliefs about themselves hinders their

ability to use silence in session to help the client.

I still struggle with silences, and I know exactly why. There is so much that can be

misinterpreted during a silence, about what another person is thinking or feeling. When

people are quiet in my presence, I tend to think more negative things than positive things

are likely going through their mind. I especially had trouble in therapy with silences,

because I always filled the silence with the idea that I was incompetent as a therapist, and

that the client was perceiving me in that way.

In session experience led to awareness of personal challenges or issues that were

hindering clinical effectiveness. At times it seemed that the participants were unaware of a

personal challenge or issue until it was illuminated through a therapeutic encounter. This took

place in the form of projection of personal challenges or issues on to the client, misinterpreting a

client’s reaction to an intervention, failing to thoroughly and appropriately inquire about a

client’s experience, and failure to recognize the client’s emotional experience. When participants

described becoming aware of these or other personal challenges or issues for the first time

insession, they expressed recognizing this to be a hindrance to clinical effectiveness. This theme

was identified in the data 11 times. The following is a participant narrative describing a clinical

encounter that was seen as harmful to the client due to a personal issue that appeared as a result

of the session content.

[Personal story regarding family history of alcoholism]. One client in particular, who no

longer drinks in excess, was telling the story of their sexual assault while intoxicated that

occurred a decade ago…In my blind confidence, I failed to recognize the anger that my

tone of voice was laced with while speaking to them for 50 minutes about an event that

was shaming to them. In doing so, I disregarded their shame and other feelings in

response to being raped, and I didn’t help them, but rather induced additional shame by

communicating through my tone that I was angry with them. The disappointment that

ensued when I became aware of this a week later while transcribing the tape was

overwhelming.

Self-reflection for the purpose of understanding the personal challenges or issues

hindering actual in-session clinical effectiveness. The activity of self-reflection was found to

be the most common method for identifying personal challenges or issues that were, or could act

as hindrances to clinical effectiveness. This theme was identified in the data as appearing 22

times, nearly half of the total data set. Participants discussed memories of the past relative to

salient experiences, lessons learned from others, or a personal habit or pattern of doing things.

Several examples of this were depicted in the data, including difficulties with empathy, love,

trust, telling the truth, making decisions, vulnerability, and the interaction of cultural norms with

those of being a therapist. In the following narrative, the participant uses self-reflection to

consider how past experiences contribute to current hesitancy or discomfort with confronting

clients in session.

When my supervisor first told me and my classmates that confrontation was the most

sincere form of empathy, I was so astonished by it that I refused to even try and wrap my

head around it. Then when I sat in a room with a client, I noted immediately feeling a

need to smother the client with normalizing, comforting, seemingly compassionate and

empathic statements. This resulted in a habit I still linger with, of trying to be friendly

with clients rather than being a therapist. I thought, ‘how can I be considered an authority

in a situation where I know nothing?’ And this was the story of my life. I was told all my

life that I didn’t know how to do things, didn’t understand, couldn’t understand… and

what’s more, anytime I tried to do things they were met with reactions of laughter,

disappointment, or confusion by my parents.

Uncertainty

Definition: Self-doubt & uncertainty impact clinical effectiveness.

Uncertainty was found to be a common theme depicted in the data. Discussion of

uncertainty was discussed in 17 total data entries, making this category variant in its

commonality. It seems that novice clinicians are moderately concerned with their level of

certainty in their professional abilities. The participants described experiencing frequent and

significant self-doubt, which is discussed as a hindrance to professional development. Two

subcategories describe different processes that are related, as both are concerned with issues of

uncertainty. However, they differ with respect to whether this uncertainty became a hindrance to

professional development, or a catalyst.

Self-doubt regarding personal experience, knowledge application, and client evoked

behavior. Issues related to self-doubt appeared in 9 data entries, and it was in the context of this

self-doubt that they described difficulties with professional development. Participants appeared

to struggle with feeling confident entering the therapy room, applying knowledge they learned in

supervision, interpreting client reactions as unrelated to the therapist’s clinical skills, or generally

envisioning themselves as competent clinicians. At times, this self-doubt was related to the

novice clinician’s past, making the pattern somewhat clearer with respect to its origin. At other

times, issues of self-doubt appeared to be somewhat inherent to the experience of seeing clients.

Thought it took me a while, I finally learned how to sit in a room with a client. Before

this, I was so nervous and so stressed over what I might do or forget to do, that I wasn’t

at all present.

In the following narrative, the participant describes a personal history of self-doubt that

continued into doctoral training.

…my history of thoughts that I couldn’t have an effect on the workforce didn’t just go

away because it was time. I continued forward, sweating, scared, wanting to run away,

with the voices in my head telling me I could never be a psychologist. I became even

more aware of this when my professor suggested an exercise in which we envision

ourselves graduating and then working as a psychologist…I closed my eyes, saw myself

graduating, and then nothing.

Recognizing uncertainty, not knowing, and making mistakes is part of the growth

process. In contrast to the category above, 10 instances of uncertainty that represent this theme

were discussed as helping, rather than hindering professional development. In these instances,

participants described a process of coming to terms with their current level of competence as a

budding clinician. Awareness of the self as a student who requires ongoing learning and

experience was met with acceptance and followed by meaningful progress toward professional

development. Development was understood to be a process involving alternating episodes of

confidence and uncertainty. As one participant put it: “My experiences as a novice clinician have

ranged from feeling like I am totally drowning and failing to feeling capable and effective.”

Another participant spoke explicitly about coming to a new understanding of what it means to

learn, recognizing this to be a process that involves many ups and downs.

Doctorate programs are absolutely not easy, and ‘failing’ time and time again is

extremely discouraging when you aren’t used to it. This is the first time I actually learned

about learning. The process of taking in new information, letting it sit with you while you

identify how it is either in sync with or out of sync with information that you already

possess, while you learn what it is like to apply it, and fumbled your way through it.. all

of this is a process…Learning is integration, and integration takes time. The process of

learning how to be a therapist is nothing like I anticipated, because this integration is

constantly taking place. It’s exhausting and really exciting.

In another example a participant discussed entering a doctoral program as a reflection of their

accomplishments, only to have this notion challenged.

The opportunity to place ourselves into a position of vulnerability and accept that

although we have reached a point in our lives where we have become accepted for our

accomplishments, does not state, in any way, shape, or form, that we have overcome all

the challenges an individual can face. Yet this is how graduate students think. I’m now a

doctoral student, which means I have my shit together. It means you have some of your

shit together. The rest is an opportunity to seek out your own personal growth and

development, and it can be seen as an adventure.

Emotional Presence

Definition: Risk taking grounded in emotional presence supports clinical effectiveness.

A prominent finding was one involving the relevancy of the novice clinician’s emotional

presence, which appeared in 31 of 53 data entries, suggesting this a typical pattern. This theme

was one in which participants described experiencing significant difficulties in their personal

lives with the act of sitting with an unpleasant emotion, which in turn impacted their clinical

effectiveness. Several specific unpleasant emotions were named throughout the data, which may

serve as a hint that different novice clinicians may experience difficulty with different types of

emotions than others. Two sub-categories below depict two separate processes that appear

important relative to emotional presence, one involving ‘being’ and the other involving ‘doing.’

Staying present in one's own experience, especially unpleasant feelings, was a new

and enhanced ability within the self that positively impacted clinical effectiveness. The first

sub-category reflects the ‘being’ process, and appears in 17 data entries. This illustrates the

participant’s cognizance of simply noting the impact of their emotional presence on personal

growth, and in turn, clinical efficacy. A process of learning how to be with the self is depicted in

these data entries, and specifically how to be with an emotion. This is described as an intentional

effort, in that participants appear highly aware of their difficulty allowing an unpleasant emotion

to be experienced, and describe making explicit choices to allow this to happen for the benefit of

personal growth and professional development. In one circumstance, the explicitness of the

participant’s awareness of this kind of challenge was influenced by the content of supervision

involving discussion of the value of emotional presence. Participants note, in some cases, the

impact of not allowing an emotion to become a part of their emotional repertoire. This is depicted

clearly in the following narrative:

One day in supervision, my supervisor challenged me on naming a particular feeling, I

skirted around it so much so that they said something along the lines of ‘I wonder if this

is a feeling you often avoid.’ … they were correct. The feeling was anger and I avoid this

feeling more than any other. The reasons… [description of memories from past]…I

would never admit to feeling angry about anything. Instead I would use words like sad,

irritated, or annoyed. By avoiding or denying this feeling, I was just closing myself off to

experiences that could help inform my life choices and decision making. As soon as I

actively started feeling anger when it was present, I was able to understand it more and

use it to my advantage.

Sitting with unpleasant emotions is described as uncomfortable, foreign, and even in some cases

confusing as to how one might do this. In the following narrative, the participant describes trying

to cognitively understand an emotional experience they are having related to their past, and how

initially failing to label this same emotion for their client leads to experiencing it personally and

gaining clarity of what it is. Gaining personal experience with how one recognizes emotional

experiences within the self leads to clarity around how to assist clients with discovering and

understanding their own emotions.

When I learned about how a client would respond when I asked what they were feeling, I

understood it conceptually, and I thought at the time that was sufficient. It wasn’t until I

experienced this myself that I understand the impact of that knowledge in terms of how I

can use it to help my clients gauge where they are at in their…growth. Throughout the

spring semester of my first year, I struggled with my own personal issue…I spent… days

reflecting and journaling as a means of making sense of… pain and many thoughts… was

able to conceptually understand it… wasn’t until one day reflecting on a session with a

client with similar feelings… that I made the connection. It came in a second… all of the

many thoughts… I reflected on daily, could be summed up in one sentence… I feel

shame.

Risk taking or making use of the experience that you just stayed present to. The

second sub-category highlights the “doing” process. This was marked by a pattern in which

participants described taking a risk in their personal or professional lives relative to their own

level of comfort with a particular unpleasant feeling. This was done in an effort to challenge the

self and grow beyond their comfort zone. They used words like “bravery” to describe what it

took to allow themselves to acknowledge, accept, and express unpleasant emotions in personal

and professional capacities. The difficulties participants described related to sitting with

unpleasant emotions occurred in several different scenarios, including in interpersonal

interactions, asking questions or participating in discussions in class and supervision, working

with clients in session, understanding knowledge, applying an intervention, challenging their

own self-concept, discussing a clinical challenge in supervision, accepting a difficult situation,

etc. This pattern appeared in 23 data entries. Participants described becoming aware of the

hindrances of not recognizing emotions in themselves or their clients, and using this knowledge

to challenge themselves to experience emotional presence for the benefit of the client.

I have discouraged clients from experiencing their emotions in subtle and obvious ways

in therapy, and continue to do so as if it were a reflex response to the presence of affect.

Most recently… I relayed pity to my client for their situation rather than expressing

empathy, which has a negative impact on their concept of themselves as efficacious in

being able to experience and tolerate affect. It also communicates to them that I cannot

tolerate affect, and thus, it should not be brought into the room, limiting what the person

can tell me…. In my personal life I have done this…I thought I was being

empathic…However being empathic is to acknowledge the difficult situation the client is

experiencing, recognize it aloud, and sit with the client in their discomfort of

experiencing it to demonstrate that it is tolerable, acceptable, and a normal response to

what they are going through. What is more…the client then recognizes their own ability

to deal with unpleasant affect because they see that you have faith in their emotional

strength.

It was consistently noted that learning and challenging the self to sit with one’s own emotional

experience has a positive impact on clinical effectiveness. Participants describe increased

capability of recognizing their reactions to the client in the moment, being better able to

empathize with client’s expressed experiences, and improved ability to guide the client toward

change in an effective way. Some of these outcomes are found in the following narrative:

… I have found myself being much more in tune with myself and my surroundings. I

always felt that I had an intuitive nature, but now I really do. I have been able to hone my

awareness and pick up on the subtleties of my bodily sensations. This has enabled me to

become actively aware of my feelings, which has informed me in much greater details of

my own decision making and choices… in others, the information has led me to a greater

understanding and ultimately better decision making. Furthermore, I am more attuned to

others’ facial expressions, word choice, body position and movements, and voice

inflections and tone. This has proven quite eye-opening in the sense that I am cued into

anothers’ moment to moment experience when I look for these changes. I have found

myself better able to adjust to changing moods and feelings both with clients and with

my interpersonal relationships.

Cognitive Shifts

Definition: Cognitive shifts catalyzed by continued introspection, peer processing, and

supervisory/peer feedback led to greater clinical effectiveness.

A theme emerged that centered on participant cognitions related to themselves, their

clinical work, and their role as graduate students. Participants described both a shifting in their

pattern of thinking or belief system, and experiencing validation for existing thought processes.

What is more, they described their perceived effectiveness as a clinician and student as hinging

on these types of experiences. This theme appears to suggest that novice clinicians feel they must

undergo personal challenges and experience validation in the midst of these changes, in order to

experience themselves as effective clinicians and students. The two sub-categories that emerged

from this theme are described below. This pattern appeared in 31 data entries.

Cognitive shifts and openness to applying new perspective enhanced clinical

effectiveness. A surprisingly common finding was observed in the data in which participants

explicitly noted a shift in their cognitions. This finding was found to be represented by the data in

27 different data entries, making this sub-category only one of two sub-categories identified from

the data that describes a “typical” pattern (Hill et al., 2015). Participants described how their

beliefs about themselves and the world shifted in ways that resulted in experiencing increased

openness to understanding and applying new techniques in session, speaking up in class, and

sharing challenges in supervision.

[Personal growth leading to increased sense of bravery]…Being brave is a motto I now

live by. This shift in attitude is what allowed me to be excited to go into the room on the

first day with a client and to try new techniques with a client. The therapist is just as

vulnerable as the client and by allowing myself to be vulnerable in the room has given

me great strength.

The commonality of this concept in the participant’s writing suggests that an open mind

contributes to novice clinician’s perceptions of their competence during professional

development. One participant spoke about having to shift away from an aspect of their

selfconcept that had been solidified in their past, because it was incongruent to effective clinical

work. Doing so involved the use of other processes as well, including self-awareness of the

selfconcept, self-reflection regarding where this stemmed from, and critical reflection regarding

the applicability of this self-concept to clinical work.

When I was a kid my parents used to call me the ‘problem solver.’ Conflict would arise in

my family and I would point out the obvious flaws in logic and solve the problem.

Looking back I don’t think I was so much uncomfortable with the conflict as I was

uncomfortable with my parent’s obvious discomfort with conflict…Except being a

therapist doesn’t mean problem solving, and using problem solving isn’t effective.

In other instances, self-awareness was central to the participant’s ability to face a

cognitive shift to benefit their professional development. One participant described a challenging

situation in which their personal and professional lives overlapped during a class presentation.

This person shared a unique ethical dilemma in which they gradually became aware during a

colleague’s presentation that the case example being presented was about a personal friend. The

participant recalls having been “frozen” by “shock” and an increasing feeling of “nervousness”

in not knowing how to handle it. A cognitive shift was experienced when they discussed it with

their supervisor and gained perspective about the opportunity that they had missed for not only

their own development, but also that of others in the class.

When I got lost in the excitement of it all I forgot…by putting ourselves into a vulnerable

position for the sake of presenting a learning experience, then, and only then, can we

share the experience with others so they could learn from our mistakes. After all, we’re

all human, and we all make mistakes. Why shouldn’t we learn from that? What I should

have done all along was…

In this instance, the participant actually develops a new concept of what it means to learn and

how to approach learning opportunities differently in the future to maximize their own and

others’ benefit. Cognitive shifts around the concept of learning in general were particularly

common. Here, a participant recognizes the cognitive shift that transforms the way they approach

their education.

When I was going through my undergraduate and master’s studies there was this insipid

need to excel in my schoolwork…learning for purely extrinsic purposes, and it served

little purpose…but what happens when all the motivation for a grade is removed? True

education begins. We learn, because it will help our clients. We learn, because it will help

someone’s life. We learn, because we want to learn.

Peer confrontation/challenging a perspective, and peer validation, promoted

perseverance/persistence, personal growth and clinical effectiveness. Participants often

described experiencing these cognitive shifts in the company of others. A variant theme appeared

in the data in 11 entries, describing meaningful interactions with peers and/or supervisors. In

these interactions, participants described experiencing confrontations or challenges by others to

view a situation differently, normalizing or validating a difficult experience, peer/supervisor

modeling something being learned, and peers offering support that allowed the participant to

embrace necessary changes and growth that ultimately led to further professional development.

These experiences appeared essential to participants’ overall development in that they described

having felt perplexed or uncertain about something related to their professional development until

they were able to utilize these resources. In an example in which a participant describes learning

and challenging themselves to stay present with their emotional experience, also a significant

theme, they note that they could not have done so without the support of their peers and

supervisor.

Experiencing feelings is a huge part of well-being. Being able to experience,

acknowledge, accept and express feelings leads to true emotional strength. This concept

seems easy to understand, yet in practice it is much more difficult than expected. The

reason it is so difficult for me is because I have spent most of my 26 years building up

strategic defenses in order to avoid feelings…As I began doing this [allowing self to be

present with emotions], I felt many more feelings much more intensely than before,

simply because I was allowing myself to. This was overwhelming for me at first but I

kept at it with the encouragement from my supervisor and colleagues and I have now

found myself to be much more in tune with my own process and moment to moment

experience, which has in turn allowed me to make better decisions…

Peers and supervisors were used as resources throughout the data to assist with both personal

growth and professional development.

…when I would start to feel down [re: perceived competence as a clinician] I would

remind myself of this, think about where I was a month ago, and seek out a listening ear

in one of my colleagues. This has really helped in keeping me afloat during the phases of

development.

Table 1

Categories, Sub-categories, and Representativeness of Categories to the Sample (RCM)

Category RCM Sub-categories RCM

Hindering Beliefs 32 Self-awareness of how present beliefs, behavior and patterns, and 17

Experiences degree of emotional attunement hinders clinical effectiveness

In session experience led to awareness of personal challenges or 11

issues that were hindering clinical effectiveness

Self-reflection for the purpose of understanding the personal 22

challenges or issues hindering actual in-session clinical effectiveness Uncertainty 17

Self-doubt re: personal experience, knowledge application, and client 9

evoked behavior

Recognizing uncertainty, not knowing, and making mistakes is part 10

of the growth process

Emotional Presence 31 Staying present in one's own experience, especially unpleasant feelings, 17

was a new and enhanced ability within the self that positively

impacted clinical effectiveness

Risk taking or making use of the experience that you just stayed 23

present to

Cognitive Shifts 31 Cognitive shifts and openness to applying new perspective enhanced 27

clinical effectiveness

Peer confrontation/challenging a perspective, and peer validation, 11

promoted perseverance/persistence, personal growth and clinical

effectiveness

Experiential Learning 35 Growing awareness of clinical effectiveness after application of 8

knowledge and skills in therapy

Applying knowledge to client/in session, assessing effectiveness, 7

gaining insight, and then applying to self

How the application of supervision knowledge to the self lead to 31

profound positive personal and professional changes and growth

Intent 28 Expressed intent to teach client something that was gleaned from 12

personal growth experience

Expressed intent to shift approach and/or try new things in therapy 17

based on personal experiential learning

*Note. Representativeness to the sample determined based on Clara Hill’s approach (Hill et al., 2015): Categories

containing all or all but one case are considered “general,” categories containing more than half of the cases are

considered “typical,” and categories containing half or less than half of cases are considered “variant.”

Experiential Learning

Definition: Experiential learning influences personal growth and clinical effectiveness.

Several examples of experiential learning were depicted in the data, appearing 35 times

making this the most significant, “typical” finding (Hill et al., 2015). The types of experiential

learning that participants described appeared to fall under one of three patterns, illustrated by the

three sub-categories. Across these data entries, conceptual knowledge of information or skills

learned during the participant’s doctoral education was described as insufficient to truly grasp the

material. Experiential learning allowed participants to experience what they had learned as

authentically true or effective in the applicability of it to their clinical work. There was a

symbiotic pattern depicted that marked the steps of experiencing knowledge or skills as true,

effective and applicable, involving both personal growth and professional development. This

symbiotic relationship between the personal growth and professional development is broken

down into three commonly identified steps by the three sub-categories, in order to best illustrate

all that took place for these participants involving experiential learning.

Growing awareness of clinical effectiveness after application of knowledge and skills

in therapy. Participants noted 8 times in the data set (variant pattern or theme) having gained

insights and a deeper understanding of knowledge and skills taught during supervision, via the

application of these in session with clients. Participants made note of not having had a solid

grasp on the same knowledge or skills prior to application. Trying out knowledge or skills in

session despite having a weak understanding helped to strengthen participant’s understanding of

the information conceptually, as well as experientially in that the therapist experienced it as

clinically effective. Participants were then able to generalize this experiential understanding of

knowledge and skills by knowing how to better apply this learning in future sessions. An

example of this is depicted in the following narrative in which the participant describes learning

the value of recognizing and responding to sensory acuity in session.

There are times when we start to recognize minute details during sessions that at the time

seem irrelevant or unknown. In fact, there are times we respond or react and upon further

review we can’t figure out why we did that in the first place…[in session] I seemed to

stop mid-sentence and ask about a paper that was sitting off to the side in the client’s

portfolio…It turned out to be a deep, rich, and sensitive piece of material that the client

had been resisting and avoiding sharing in session because they did not know how to best

present it…this unknown acuity prompted the opportunity…By attending to these

sensory acuities, we allow ourselves the opportunity to dig deeper into the content of the

conversation, and allow it to shift towards process. Although the “safe room” with a

therapist is often implied, it is by creating that safe space that we allow ourselves the

opportunity to dig deeper into our clients challenges, and in doing so we can present

opportunities to overcome these challenges.

Another participant better understood the therapeutic process as a whole via engagement with

clients. This person was able to use a useful metaphor that they had learned to experientially

grasp how to approach therapy, after having applied it to work with a client.

The most valuable asset I learned as a developing clinician is that everything we do, both

inside and outside of the room is a dance…My first major experience with this was with

a client who could not stop telling stories about people around them…We have to adapt

to our clients because regardless of how much time we spend preparing for a session, it is

inevitable that more will be brought into the room… Simultaneously, we have to adjust

for those changes within the context of our treatment planning. We have to adapt, we

have to prepare, but even in that preparation we must remember to remain flexible.

Applying knowledge to client/in session, assessing effectiveness, gaining insight, and

then applying to self. At times, participants described taking the above process a step further.

They noted having applied knowledge or skills to session, found it to be effective at an

experiential level, and then applied that same knowledge or skills to themselves for purposes of

personal growth. This pattern was also variant, appearing seven times throughout the data. In

these instances, it appears participants were so moved by their experiential learning that they

believed what they were doing with their clients could benefit them in a personal way.

One thing I have learned through supervision is a concept…curiosity. I am not one to ask

a lot of questions or inquire too deeply about things. However, this has changed…being

curious, in a kind way, is almost always received well and responded to enthusiastically.

By reframing the delivery of curiosity in my mind, I have found that I am much more

likely to ask questions and I have found that I have many more questions about things

than I had even realized. This has had the biggest impact with my clients, as I am more at

ease asking them direct questions or making confrontations, but I have also noticed that

by using this approach in my daily life, I am able to acquire much more detail about even

my closest friends’ experiences, which has been satisfying to both me and them.

Other times, applying knowledge and skills in session prompted the participant to react in some

way that stimulated self-reflection, leading to a deeper awareness of self and of an opportunity

for personal and professional development.

I found the concept of using metaphors in the room very interesting, and difficult to grasp

at first, but once I started understanding how it worked in the room with my clients I was

able to identify my metaphorical voice…I had a client who told me that the person

doubted their perception of depth which impacted their driving…This client kept their

whole life on the surface, never diving into the experience of their emotions, never

allowing themselves any depth…I began to see this with respect to my self-doubt as a

person, and of course as a clinician. I often found myself questioning clients in the room,

but then questioning my own questioning of them. I would recount in detail an

interaction with a client with my colleagues and supervisors in order to figure out if my

own perception of the client’s presentation was accurate…And I realized after a long

time that I could tie this back to how I was raised…So in the room, I doubted my

perception of things…I had to learn to trust myself.

How the application of supervision knowledge to the self lead to profound positive

personal and professional changes and growth. This sub-category represents a “typical”

pattern in the data, as it appeared in 31 of the total data entries (Hill et al., 2015). This pattern

was one in which participant’s described having thought to use knowledge learned in supervision

to manage a personal challenge or issue. It appeared that this tendency to utilize professional

knowledge for the self in a personal way, was done so on the participant’s own volition. This was

shared by all of the participants, as each of them expressed explicit intent to use the knowledge

they were gathering in a personal way. Two of the three participants made note of the importance

of doing so to their clinical work: “My focus on applying my knowledge to my personal life has

impacted me in ways I could not have imagined,” and “it was apparent within a week that if I

couldn’t figure out how to do this on my own, there was no way I was going to teach it to a

client.”

Heading down this road of Clinical Psychology was a personal journey, an adventure of

personal growth. I realized that all of the techniques I was learning to apply towards my

clients issues were techniques I had to apply to myself first. I had to experience the

change, before I could instill change.

The data reflects instances in which participants felt inspired by or connected to the information

being taught in supervision, in such a way that they were curious about its application to their

personal lives. Using this knowledge in a personal way was described as beneficial to the

participant’s clinical work in that having an experiential understanding of the information made

the participant feel better equipped to apply it in session. Other types of benefits to professional

development were noted as well, such as speaking up more in class or supervision and bringing

challenges to supervision more openly. A participant discussed using this approach to challenge

their self-doubt regarding their competence as a clinician, which opened them up to feel more

confident in their clinical work:

…taught the concept of updating your self story to one that is positive, by recognizing all

the evidence to the contrary…I realized that this was my answer to understanding myself

as a competent therapist. I had received my masters, earned good grades, I was not

struggling in my doctoral program, I was helping my client’s make progress…I had to

take all this information and internalize it to create a new self-story that I was

competent…and that created this competence/confidence loop that allowed me to become

more confident, and then more competent.

Participants commonly described gaining greater self-awareness or a deeper sense of self after

thinking through the application of knowledge from supervision to their personal lives. The

following narrative illustrates this pattern and makes note of an intent to apply the knowledge

from supervision to clinical work, because it was understood on a “personal level:”

After learning about how children adapt…by internalizing feelings that they are “bad”

when their parents are fighting…I realized how accurately our childhood patterns follow

us into adulthood. It made me wonder what I learned about love…what I now recognize

as love in others…I ended up recognizing my parents’ passive behavior as love…became

interested in those who were disinterested in me…resulted in a pattern of

relationships…It’s interesting to take some of the theories we’ve learned, and apply it to

our own lives to provide explanations for some things. It also makes patterns like this

more clear, so we can understand and recognize them when they continue to happen, in

order to reverse them. This is a lesson I’ve been able to take into therapy and use with my

clients, because I understand it on a very personal level.

In this final example, the participant notes a behavioral shift in their personal life and a desire to

better understand it. Despite describing some hesitancy (e.g., “gathered up the courage…”), the

participant wrote that they brought the personal challenge to their supervisor to gain clarity. The

supervisor provided a prompt regarding knowledge previously acquired in supervision to assist

the participant in applying this knowledge to their personal situation. An interesting aspect of this

narrative is the implied level of comfort and understanding the writer has with their supervisor to

discuss such a personal issue. Doing so appears, from the narrative, to have been beneficial to the

participant in that they were able to develop self-awareness that had not been present before.

I experienced a situation where I drank in excess four days in a row immediately after the

semester ending. While drinking in and of itself is nothing out of the ordinary, the

quantity and time frame was enough to provide some concern and insight…I had no idea

why I was doing it…It took me a full week before I gathered up the courage to discuss it

with my supervisor, because I recognized it was something I should address…When I

brought it up, the first response was: Time and timing?...What had happened, what

changed, and why were those four days different from the rest?...It was about loss. All of

my peers had left town, the semester had ended, all our assignments were turned in…

Intent

Definition: Expressed intent to teach concept or shift approach in treatment based on

personal growth experience.

The sixth and final category that emerged from the data is one involving a theme of

intent. Participants noted often that their experiences of personal and professional growth

prompted a desire to apply salient information, knowledge, or skills again with their clients,

taking their learning a step further. This pattern appeared as a “typical” pattern in the data, having

emerged through 28 different data entries, or just over half (Hill et al., 2015). It was in this

category that the impact of several different aspects or elements of personal growth were

illuminated as having transformed from a personal experience, centered on the self, to one of

wanting to be and do more in the world for the benefit of others at large. Two sub-categories

exist which highlight subtle differences between the ways in which this pattern showed up in the

data.

Expressed intent to teach client something that was gleaned from personal growth

experience. In this first sub-category, the actual content or experience of personal growth is

thought by participants to be relevant to the client, and there is a desire to bring that specific

content into session. This sub-category represents a variant pattern appearing in the data 12

times. This pattern appears to reflect, at times, the aftermath of a profound personal growth

experience in which knowledge or skills taught in supervision had been applied to the self, and

through this experiential understanding participants gained a deeper understanding and profound

respect for the utility of the knowledge or skills. This profound respect and clarity of

understanding of its application combined to prompt the participant to share this knowledge

beyond themselves, mostly, in session with clients. The following narrative illustrates a concept

taught in supervision related to “bravery,” the profound impact of applying it in a personal way,

and a sense of feeling challenged to apply it to session.

Bravery is…The most exciting part was not that I opened the doors to my career for the

first time, but that I opened my eyes to my life…I gained an awareness of my true self,

and that…allowed me to finally discover who I am…in the first few months of my

doctorate program I learned that bravery allows for awareness of truth, and that truth is

all we need to become the best versions of ourselves. Now the challenge is to teach that

to my clients.

A second narrative is provided that depicts a participant’s journey of transforming their ability to

experience and manage sorrow after applying a supervision concept to a personal life experience.

What is noteworthy here is the expression of gratitude, which implies that the application of the

knowledge to self had a profound impact that inspired a sense of “urgency” to share the

knowledge beyond oneself.

I learned the concept of ‘riding the wave’…I had not yet experienced this on my own

until…[family member’s accident described]…initially I stuck with my usual, keep to the

grind and send them positive thoughts…finally broke down and the tears came. And they

didn’t come easily. I remember making a decision that I was fighting them, that I

wouldn’t fight anymore…I’m so grateful for the knowledge I received that allowed me to

‘ride the wave,’ and I feel a sense of urgency now to teach it to others.

Expressed intent to shift approach and/or try new things in therapy based on

personal experiential learning. In the second sub-category, a personal growth experience

inspires the participant to generally try new things in session and/or use a treatment approach that

may be somewhat different to what they had been doing initially. This pattern is similar to the

one described above; however, the material being brought to session is not necessarily the same

knowledge or skills that were applied to the self that had prompted a personal growth experience.

Here, a variety of personal experiences were seen as leading to a general awareness of a need to

approach session in a more clinically effective way, and/or greater professional development.

This participant reflects on their application of a concept taught in supervision to their personal

life, and how the growth they experienced manifests in supervision and with clients:

“[Application of bravery as concept to personal life]…bravery has become a motto for me…I

remind myself frequently to “be brave” in regards to sharing a mistake in supervision, attempting

a new technique with a client…” The relevancy of the novice clinician’s culture is depicted in the

next narrative. The participant experiences a difficult time applying techniques in session due to

incongruence with their personal values. The participant reflects having to make changes in order

to adapt and improve their clinical work.

Because of my upbringing…it was incredibly challenging for me to interject comments

during the therapeutic process…this is an essential tool we must have…so how does one

adjust for this? You acculturate to the therapist culture…it was simply a matter of

insight…so I made the change. I took baby steps…within two weeks I was able to have

dialogues, not monologues, and the panorama of the therapeutic environment completely

shifted for me.

In the final example, this participant describes a more subtle but profound shift in session that

was prompted by their identification with the client’s experience. This identification lead to

selfreflection as a means of gaining deeper understanding of both the personal experience, and in

parallel, the emotions the client may be experiencing. The deeper understanding of the client’s

potential emotional experience leads the participant to have a better understanding of how to

help.

As I watched tapes of clients who I was told in supervision were extremely disconnected

from their experiences, I felt myself identifying with them…[expressed understanding

and empathy for client’s experience] there is no concept of self…I believe the first step…

sitting with them in their experience of hopelessness…The therapist must endure their

own helpless feelings to sit with this client.

Summary of Findings

The above six categories represent the main findings of this research study. In response to

the research question it appears that several processes are taking place during a first year novice

clinician’s training, which promote personal and professional growth. These processes include:

Self-awareness, self-reflection, and in-session incidents of hindering beliefs and experiences,

uncertainty, emotional presence, cognitive shifts, experiential learning, and intent to be and do

more are all aspects or elements of personal growth that influence professional development. Of

these, experiential learning appeared to be the most commonly discussed method of achieving

personal and professional growth. The application of knowledge gained in supervision to

professional work and ones’ personal life was the most frequently discussed method for

achieving such growth. Though the above categories and subcategories are discussed separately,

it appears from the data that there is much overlap between them. It is noted that participants

nearly always spoke of experiences of personal and professional growth as having been produced

by a combination of two or more of the above discussed processes. Future studies may

investigate the ways in which these processes work together to produce experiences of growth.

Figure 1. Results in the form of categories and subcategories

Chapter 5: Discussion

This study utilized qualitative methods for investigation of personal growth in the context

of novice clinician professional development. Few studies were found to exist which investigated

the personal growth experiences of novice clinicians from the perspective of the student as their

development unfolded, as much of the existing literature appears to be retrospective in nature as

told by senior clinicians (Carlsson et al., 2011; Rønnestad & Skovholt, 2001; Trotter-Mathison et

al., 2010). In a recent and related study investigating clinical psychology student’s perceptions of

the development of ‘practical wisdom’ (Punzi, 2015), participants shared their experience that

professional development in this area emerged from personal experiences. They expressed their

belief:

…that there are no definite boundaries between their professional and their personal

development. The development of practical wisdom was connected to both learning

experiences and to personal insights, and the participants thus sensed that their personal

characteristics could not be distinguished from their developing practical wisdom. (p.

352)

Punzi (2015) demonstrated that there is a precedent for considering the personal growth

experiences of novice clinicians as highly relevant to their professional development. In the

current study, results appear to parallel those of the aforementioned research in that the results

support consideration of the importance of personal growth for novice clinician professional

development.

The original research question was reformulated due to methodological challenges with

the formatting of the data, as was previously discussed. The revised research question, what

aspects or elements of personal growth influence professional development, was answered by the

results of this study. The following text includes a discussion of the findings in the context of

existing, relevant literature. Also included is a discussion of the implications for training and

considerations for future research.

Hindering Beliefs and Experiences

Beliefs and experiences that were identified as hindering clinical effectiveness were noted

throughout the data relative to how the participants became aware of and addressed these issues.

As discussed, at times participants were aware of potential hindrances prior to them having any

impact on an actual client and sometimes it appeared through the therapeutic process. Often self-

awareness was used as a method of remaining cognizant of these issues throughout training. Self-

reflection was also frequently used to gain a deeper understanding of the personal mechanisms

behind hindrances to clinical effectiveness. Through in-session experiences and the use of self-

awareness and self-reflection, the participants described engaging in personal development work

that contributed to the enhancement of their clinical skills or overall professional development.

Self-awareness and self-reflection are discussed in the literature as being skills that must

be tended to in order to develop competence in the field (De Stefano et al., 2014; Fouad et al.,

2009; Hatcher & Lassiter, 2007). These skills become especially important as methods of

protecting against and improving upon hindering events in clinical work related to either

countertransference issues, or issues with multicultural competence (Cartwright, Rhodes, King,

& Shires, 2015; Hayes et al., 2011; Johnson, 2014). Novice clinicians in particular may be more

susceptible to difficulties managing countertransference relative to senior clinicians (Brody &

Farber, 1996; Hill et al., 2007). Johnson (2014) discusses the value of in-session experiences as

well as interactions with a multicultural community of colleagues and supervisors for

recognizing and improving upon issues related to multicultural competence. Though there is a

wealth of literature in these two areas, fewer studies were identified that address novice clinician

reactions as hindrances to clinical effectiveness more broadly.

It is thought that experiencing difficulties with clinical effectiveness due to personal

reactions as a novice clinician is common and to be expected (Froggett et al., 2015; Mazzetti,

2012; Pica, 1998; Skovholt & Rønnestad, 2003; Williams, Judge, Hill, & Hoffman, 1997).

Williams, Judge, Hill, and Hoffman (1997) investigated this from the perspective of novice

clinicians, clients and supervisors collectively, and found that novice clinicians experience a

variety of feelings and reactions, personal concerns, and identification of “shared” concerns

between the client and novice clinician. Examples include novice clinicians feeling anxious or

uncomfortable, empathy, frustration, distraction, concerns about therapeutic skills or

performance, reactions to difficult clients or difficult session content, and experience of shared

personal or interpersonal stressors between the clinician and client. Another study cited

clinician’s experiences of anger and even aggression toward clients (Froggett et al., 2015). These

reactions and concerns appear to mirror those of the participants in the current study in many

ways. However, this author was primarily interested not in the content of the reactions or

concerns experienced by novice clinicians, but in how these types of experiences are managed

personally so as to have an influence on professional development.

The existing literature is consistent with the current study in that it supports and even is

described as expecting or requiring novice clinician’s use of self-awareness as a method of

managing reactions that can act as hindrances to clinical effectiveness (De Stefano et al., 2014;

Fouad et al., 2009; Froggett et al., 2015; Gardner, 2015; Hill & Lent, 2006; Nissen-Lie et al.,

2015; Williams et al., 1997). Self-awareness around these issues involves developing a deeper

sense of one’s internal processes, beliefs and perceptions, personal values, biases or judgments,

and ways in which personal histories influence clinical work (Bransford, 2011; De Stefano et al.,

2014; Lam, Wong, & Fong Leung, 2007; Marlowe et al., 2015). The value of self-awareness as a

clinical tool appears to be contingent upon the novice clinician’s openness to inspecting aspects

of self, which was seen in the current study’s results as a highly personal activity. The degree to

which training programs discuss and normalize introspection as a foundational skill for clinical

work is likely to influence novice clinicians’ accountability in addressing when personal factors

impact professional work.

Trainers and supervisors have in various ways tried to instill in novice clinicians the habit

of using intentional self-awareness, or “conscious observation” of personal reactions (Cartwright

et al., 2015, p. 150) as an instrument for understanding the impact of the self in their clinical

work (Froggett et al., 2015; Hemanth & Fisher, 2015). In some cases, increased self-awareness

has led to personal development including shifts in one’s relationship to internal experiences

(i.e., thoughts, feelings), self-care, and improvements in ability to cope with difficult experiences

(Hemanth & Fisher, 2015; Marlowe et al., 2015). The capacity to be aware of difficulties in

clinical practice may in fact be a prerequisite to decisive action around improving professional

skills, such as the capacity to self-correct mistakes made in clinical work (De Stefano et al.,

2014; Marlowe et al., 2015).

Ideally, novice and senior clinicians alike would have the capacity and forethought to

become aware of all personal challenges that may lead to hindrances to their clinical

effectiveness; however, it was at times the case that these challenges were not known until they

were highlighted through a clinical encounter. There is a scarcity of research highlighting this

pattern more generally than through the more specific study of countertransference reactions.

One study was found that spoke to the importance of in-session experiences for improving

clinical effectiveness, a finding implied as significant in the current study. Researchers

investigated the content of novice clinician self-reflective experiences and found that clients

played a strong role in guiding sessions in a clinically helpful direction when clinicians used their

observations of client verbal and nonverbal reactions as sources of feedback (De Stefano et al.,

2014). Novice clinicians spoke of learning via their in-session experiences that they could not

preemptively determine the pace of the client’s progress, and the collaborative nature of the

process became more highly valued with these experiences. In-session experiences also allowed

novice clinicians to develop their ability to monitor technical skills effectively so as to selfcorrect

deficits in clinical effectiveness. The use of metacognition and introspection while insession is

also likely to be a skill that develops over time, allowing clinicians to improve in this area as they

gain experience and advance professionally.

Self-reflection also has much support in the literature as a means of developing a deeper

understanding of personal reactions in sessions that act as challenges or barriers to clinical

effectiveness, and is seen as crucial to ongoing learning and development (De Stefano et al.,

2014; Gale & Schroder, 2014; Gale, Schroder, & Gilbert, 2015; Harvey & Jenkins, 2014;

Mazzetti, 2012; Nissen-Lie et al., 2015; Punzi, 2015; Stahl et al., 2009). Results of the current

study mirror the importance of self-reflection for professional development. Self-reflection is

identified as a method by which professional knowledge is acquired or recognized as missing

from one’s clinical repertoire, and is seen as essential to professional development (De Stefano et

al., 2014; Hatcher & Lassiter, 2007; Schon, 1983). Results of this study highlight the ways in

which this can occur due to gaps in knowledge acquisition, but also through personal blind spots

that can only be addressed by reflecting on the novice clinicians’ personal past experiences.

Trainers and supervisors suggest novice clinicians think critically about their personal histories

relative to how these impact clinical work, and even re-evaluate understanding of themselves and

others when personal beliefs or values are challenged (Marlowe et al., 2015).

Self-reflection can and is approached both formally and informally, and in private and

shared ways by novice clinicians (Gale et al., 2015). Investigations of what specifically novice

clinicians reflect on relevant to their professional development found that reflection on internal

processes is particularly common, including affective and emotional processes (De Stefano et al.,

2014). Novice clinicians have also previously noted self-reflection relative to aspects of how

personal culture intersects with aspects of one’s developing professional identity (Marlowe et al.,

2015). Difficulties engaging in self-reflection have been seen as a barrier to learning generally,

and development of clinical effectiveness more specifically (Boud, Keogh, & Walker, 1985;

Marlowe et al., 2015). The literature suggests that hindrances to effective clinical work paired

with self-reflection, repeated over time, is the path by which novice clinicians improve in their

management of these reactions (Mazzetti, 2012; Punzi, 2015).

Uncertainty

Specific types of personal reactions commonly experienced by many or even potentially

most novice clinicians during their professional development, and experienced by the

participants in the current study, are those marked by professional self-doubt (De Stefano et al.,

2014; Gale et al., 2015). In some cases, self-doubt was demonstrated in the current study to be a

personal reaction that became a hindrance to clinical effectiveness. Novice clinicians have

documented instances of becoming self-critical after a personal or client negative reaction

insession or having thoughts that their peers or colleagues were more competent than they are

(De Stefano et al., 2014; Gale et al., 2015). This self-doubt arose even in the face of contradictory

evidence, such as client feedback about positive change (De Stefano et al., 2014). It appears to

persist throughout training even with ongoing experiential learning (De Stefano et al., 2014).

It is unclear as to how self-doubt may remit over time; however, there is evidence to

suggest that the presence of self-doubt has benefits for clinical effectiveness (De Stefano et al.,

2014). Participants in the current study and other studies describe initially wanting to perform

perfectly, and even recognizing having done so in their school work prior to clinical training, but

coming to terms with perfectionism as unrealistic in their work now (Punzi, 2015). Redefining

what perfect means in the field assisted participants in developing healthy professional habits,

such as holding and considering multiple perspectives at once instead of assuming the existence

of one correct perspective (Punzi, 2015). Teaching clients to remain emotionally and cognitively

present to ambiguity and uncertainty is often an important aspect of clinical work, as it reflects

the reality of the world we live in. When working with complex and ambiguous life challenges, it

is unrealistic and inauthentic for clinicians to assume an all-knowing posture. Clinicians are

likely to experience personal growth by learning to accept uncertainty as part of the work, and as

a truth of the world.

The experience of anxiety and self-doubt is a normalized experience in the literature for

novice clinicians (De Stefano et al., 2014; Mazzetti, 2012; Pica, 1998; Skovholt & Rønnestad,

2003). Acknowledging self-doubt and uncertainty appears to be a vital aspect of managing it, and

it is recommended that novice clinicians use self-awareness and seeking support as methods of

mitigating any harmful effects it may have on clinical work (Froggett et al., 2015). Some have

recommended novice clinicians secure support from a mentor to assist with redefining the novice

clinician’s self-concept in order to manage relentless self-doubt and balance it the demands of a

training program (Gardner, 2015). Novice clinicians are likely to benefit from supervisors and

professors who are able to model self-doubt as a common aspect of clinical work as opposed to

implying an all-knowing stance. Students who witness senior clinicians who embody professional

self-doubt and model how to use it constructively may be in a better position to channel self-

doubt in their own clinical work.

Self-doubt or uncertainty is depicted in the literature and in the current study as both a

hindrance and catalyst for growth (De Stefano et al., 2014; Punzi, 2015). Worries regarding

selfdoubt were identified by Punzi (2015) as a resource in that participants learned to be more

patient with themselves and their clients, and to tolerate uncertainty. Retrospective accounts by

senior clinicians include awareness of the learning that took place as a result of past mistakes in

clinical work, and the way they catalyzed professional development (Mazzetti, 2012). For

example, Mazzetti (2012) speaks of having learned how to work well with a particular diagnostic

presentation as a result of having made significant mistakes with similar past clients.

Nissen-Lie, Havik et al. (2013) and Nissen-Lie, Rønnestad et al. (2015) found that

professional self-doubt, conceptualized as healthy self-criticism and the ability to be open,

sensitive, reflective and accountable for therapeutic challenges, had a positive impact on

patientrated working alliance and interpersonal distress during treatment. It has been suggested

that self-doubt protects against blind-spots that can arise as a result of perceived competence, as

novice clinicians are then more conscious of what they are doing and of the complex and

ambiguous nature of clinical work (Rønnestad & Skovholt, 2013; Macdonald & Mellor-Clark,

2014). Professional self-confidence appears to influence clinical effectiveness in negative ways

leading to reluctance to admit mistakes, misattribution or distortion of client behavior, and

oversimplification of the therapeutic process (Mazzetti, 2012; Rønnestad & Skovholt, 2013).

Nissen-Lie et al. (2015) found that novice clinician self-doubt coupled with a capacity to

critically evaluate clinical work is a promising combination. The self-doubt of individuals who

lacked this capacity did not produce the same positive effects on clinical work (Nissen-Lie et al.,

2015). Novice clinicians are urged to approach learning with acceptance of mistakes that if

approached with frankness, honesty and humility, can be powerful opportunities to learn

(Mazzetti, 2012).

Emotional Presence

In some cases, uncertainties around clinical effectiveness have been found to prompt

improvements in novice clinicians’ capacity to regulate difficult emotions (Skovholt &

Rønnestad, 2003). The current study found that learning to be present with the self relative to

difficult feelings was a personal growth experience that became highly valuable to experiencing

the self as clinically effective. The topic of exploring how novice clinicians’ emotional presence

impacts clinical effectiveness is largely unexplored in the literature; however, few studies were

found that support the value of this as a personal growth experience for novice clinicians.

It is not unusual for novice clinicians to report a flooding of emotional experiences

related to, and as an aspect of, starting clinical training (De Stefano et al., 2014). Social work

students reported awareness of feelings or noticing bodily sensations (e.g., sweating, muscle

tension, breathlessness) in session, and how these things assisted them in identifying particularly

stressful aspects of their clinical work (Marlowe et al., 2015). These students ability to notice or

become aware of these sensations within their bodies increased with clinical experience over the

course of a practicum year. Clinical psychology students who took part in a mindfulness

selfpractice group throughout one year of clinical work also described noticing bodily sensations

and feelings through an increased ability to be present with clients in session (Hemanth & Fisher,

2015; Rimes & Wingrove, 2011). This presence allowed novice clinicians to be more self-aware,

express more immediate empathy to clients, and use better self-awareness of feelings and bodily

sensations for information about what was happening during the therapeutic process. Other

support in the literature exists for clinician emotional presence as a skill for improving clinical

effectiveness. Clinician emotional presence in emotion-focused treatment approaches was

identified as essential to positive clinical outcomes (Furrow, Edwards, Choi, & Bradley, 2012).

Hemanth and Fisher (2015) note a paucity in clinical training procedures around teaching

intrapersonal skills for novice clinicians to use in-session self-awareness, empathy, affect

tolerance, and to manage focused attention (Fulton, 2005; Gockel, 2010; Nutt-Williams, 2008).

The relevancy of clinicians recognizing, understanding, and using affect in treatment is not

explicitly addressed as an aspect of the work when considering how to develop competency. For

example, empathy is often taught at cognitive and behavioral levels, with emotional awareness of

empathy unaddressed (Sargeant, 2014; Yakeley, Hale, Johnston, Kirtchuk, & Schoenberg, 2014).

Johnson (2004) notes that the clinician’s own emotional self-awareness is a critical prerequisite

to accessing empathy. More objective approaches by the clinician appear to be favored for

addressing the client’s emotional experience and shielding from the clinician’s emotional

experience or reaction. Clinicians may experience embarrassment or denial at having had

emotional reactions to clinical work, as these may be viewed as interfering with the work rather

than adding to it (Sargeant, 2014; Yakeley et al., 2014). Sargeant (2014) warn against the impact

of this professional attitude as supporting clinician alexithymia in approaching clinical work.

Though clinicians often teach their clients to remain present and open to their emotional

experiences, the opposite attitude is often conveyed to individuals in the workplace, including

professional clinicians. Access to emotional experiences leads to greater cognitive clarity and

deepening levels of self-awareness, which are important processes for monitoring clinical

effectiveness. Thus, awareness and discussion of emotional reactions to clinical work should be

supported as a professional activity.

Novice clinicians appear to often interpret their personal emotional experiences as

hindrances to clinical effectiveness, so ignoring or suppressing them becomes a method of

avoidance frequently used. De Stefano et al. (2014) stress the importance of teaching novice

clinicians to remain present to difficult emotional experiences, as suppressing or distracting from

them appears to become a hindrance to clinical effectiveness. In distracting or suppressing

emotional experiences, the novice clinician fails to identify the value of using these experiences

as information or resources in their clinical work (De Stefano et al., 2014). It was the experience

of the participants in the current study, along with other studies discussed here, that allowing

oneself to remain present with emotional experiences during clinical work contributed to

enhanced effectiveness rather than hindering professional development. Participants in the

current study discussed having to make an explicit choice to allow their emotions to remain

present in their bodies, and echoed the challenge of doing so noted here by others.

Some have suggested ways in which the teaching of these skills can be addressed, such as

introducing affect management strategies as part of clinical training (De Stefano et al., 2014).

Marlowe et al. (2015) found that students’ attention skills played a critical role in their ability to

notice bodily sensations and feelings during sessions, and suggested activities such as

mindfulness as useful for building this skill. Similarly, Mahoney (2003) recommends teaching

relaxation and centering techniques. Implementation of a mindfulness group during a graduate

training program in clinical psychology assisted novice clinicians in building self-awareness,

ability to shift attention, and cultivation of attitudes of acceptance (Hemanth & Fisher, 2015).

Development of these skills lead to novice clinicians self-reported changes in their ability to

recognize and cope with their thoughts, feelings and bodily sensations during clinical work. It

was noted that novice clinicians expressed discomfort around their engagement in mindfulness

work due to the involvement of sitting with personally challenging thoughts, feelings, bodily

sensations and/or personal insights (Hemanth & Fisher, 2015). Others described how increased

presence with self resulted in new awareness of highly difficult personal challenges that

participants sensed they would not have come in psychological contact with had they not chosen

clinical psychology as a profession (Froggett et al., 2015). Novice clinician insights around their

discomfort with staying present to their experience are valuable in the development of empathy

around client’s likely discomforts with the same things in therapy.

Froggett et al. (2015) stress the importance of understanding and acknowledging the role

of emotions in relationship-based work. They were prompted by this interest to design a course

for understanding the use of self in clinical work, which aimed to increase awareness of the

novice clinician’s psychological self in relation to the work. Awareness of the self as present in

all aspects of the clinical work was stressed as a means of beginning to understand how

awareness of personal experiences could be used as a resource for understanding aspects of the

work. Novice clinicians were urged to remain aware of both conscious and unconscious

processes taking place within themselves during sessions, so that their critical awareness and

more reflexive emotional awareness could work together to enhance clinical effectiveness.

Gale et al. (2015) alternatively found that by encouraging novice clinicians’ self-practice

of Compassion Focused Therapy, novice clinicians experienced an enhanced ability to remain

present and cope with difficult emotions during clinical work. They described using grounding

techniques to intentionally settle into the present moment prior to starting sessions. Being able to

remain present to and observe these difficult emotions was identified as highly important to

clinical effectiveness. Similar to the findings of the current study, novice clinicians described the

value of being aware of and present to their own difficult emotions as a precursor to staying

present with clients’ difficult emotions in session, modeling for their clients how to not avoid

these experiences (Gale et al., 2015).

Normalization and validation by others of the difficult nature of the process was noted as

useful for increasing novice clinician openness to the process of learning to stay present with

their experiences (Hemanth & Fisher, 2015). Having a supervisor who can act as a container for

the exploration of difficult emotional experiences was found to be helpful to novice clinicians for

learning how to experience difficult emotions, in order to help their clients with this (Froggett et

al., 2015). This implies the importance for supervisors and trainers to engage in their own

emotional work as well. Though supervision must remain separate from the experience of

personal therapy, novice clinicians’ emotions set the stage for opportunities to teach and learn

lessons that are vital to clinical effectiveness and overall professional development (De Stefano

et al., 2014).

The current study identified particular ways in which novice clinicians use their exposure

to difficult emotions through the challenge of staying present with themselves, for the purposes

of clinical work and professional advancement. A comprehensive literature review found no

other studies that speak to this intention or habit of clinicians. Future research may explore how

novice clinicians use the growth experience of learning to stay present with themselves in their

clinical work. Training and supervision procedures are likely to benefit from a deeper

understanding of how these types of experiences are channeled, and can be improved upon, in

their impact on clinical effectiveness.

Cognitive Shifts

There was a subtle, but profound aspect of personal growth found to influence

professional development identified by the current study’s results involving a shift in the way

novice clinicians perceive themselves, others or the world. A review of the literature found that

no studies exist to date that highlights these shifts in the way they were identified in this study.

This particular gap in the literature appears to represent a core aspect of personal growth

influencing professional development. Cognitive shifts were found to commonly be a point at

which novice clinician’s professional development hinged from ineffectiveness to effectiveness

through the engine of personal growth.

It is curious that the topic of profound personal cognitive changes remains largely absent

from the literature base given the value of this process to professional development as perceived

by the participants of this study. Related literature on the ethical and legal aspects of this may

suggest that this gap exists due to strong controversy in the field over particular issues around

changes in novice clinicians’ values and/or belief systems for the purposes of professional

development (Paprocki, 2014). It is well known by any cognitive behavioral therapist that change

and growth is often contingent upon an individual’s willingness and ability to adapt their

perspective. However, this is not a concept that has been discussed in the literature as an aspect

of learning and growth in a professional context.

The current study reflects only instances in which participants reflected on cognitive

shifts that were self-initiating and permitted by the person experiencing them; however, a

culturally diverse student body is likely to vary with respect to openness to particular shifts in

their beliefs or values. The variety of beliefs and values that novice clinicians bring with them to

their clinical training are likely to have a significant impact on their professional development

given the ethical beliefs and values of the field. Some have suggested the field develop

statements around the core values or dispositions central to clinical work to utilize for

transparency and clarity of expectations during the application process for clinical training

programs (Winterowd et al., 2009). These core values of the field would communicate the

importance of openness to a variety of worldviews and perspectives, rather than rigid adherence

to one particular perspective. These findings indicate that novice clinicians would benefit from

learning to tolerate the possibility of multiple perspectives, even if those perspectives differ from

one’s personal values or preferences.

A full discussion of this important controversy is beyond the scope of this dissertation.

Rather, it is noted here that participant openness to these cognitive shifts allowed for what they

perceived as highly valuable positive advances in their professional development. Trainers and

supervisors may wish to speak to novice clinicians about the particular attitudes and values of the

field in an effort to cultivate openness to new ideas that may involve significant shifts in one’s

personal belief system, for the benefit of clinical effectiveness. It has also been suggested that

cognitive shifts be viewed as existing on a continuum rather than as fixed points of change

versus no change, by distinguishing between discomfort with a new concept or clinical

presentation, or incompetence with this professional challenge due to one’s personal beliefs or

values (Paprocki, 2014).

Discomfort during the development process may be seen as a normal reaction to learning

new experiences and information, and if novice clinicians are open to integrating these new

things by remaining with that discomfort, these can present as significant opportunities for

development via cognitive shifts. The literature supports the possibility of holding one’s beliefs

and values while creating an openness to differing perspectives for the purposes of clinical

effectiveness, as an alternative to abandoning a value or personal belief system altogether

(Paprocki, 2014). Paprocki (2014) noted specifically the role of novice clinician “willingness” or

“openness” to new ideas or change as central to positive professional development. Winterowd et

al. (2014) echoed this as a more general criterion that may be applied during selection of

applicants for clinical training, as willingness, flexibility and openness appear to be crucial

personal qualities that influence advancement in the field. This speaks to the potential value of

attending to novice clinician personal factors as early as during the applicant selection process

for doctoral programs.

A smaller, but seemingly significant aspect of cognitive shifts that appeared in the current

study is noted. Metacognitive awareness has been discussed in the literature as an important

aspect of becoming aware of the processes taking place within oneself, and being able to

recognize the value of that process in such a way as to be able to apply it to work with others

(Rimes & Wingrove, 2011). Results of the current study suggest that novice clinicians did benefit

from learning about learning, as it allowed them to use their understanding to facilitate learning

in themselves and others, including their clients. For example, the explicit awareness that

learning involves approaching situations that are anxiety provoking, or involve risk to how the

novice may be perceived by peers or supervisors, may create an opening for novice clinicians to

approach their development in a vulnerable way so as to maximize professional growth.

Rønnestad & Skovholt (2003) in their model of therapist development note a shift that

takes place when novice clinicians move from focus on external resources (e.g., supervisors,

treatment manuals) for becoming an effective clinician, to focus on internal resources such as

personal development, parallel processes, transference or countertransference issues, etc. This

shift may occur as novice clinicians internalize the valuable perspectives and opinions of others

such as peers or supervisors (De Stefano et al., 2014). The role of supervisor, and more

commonly noted peer support for professional development was an important theme identified

by the current study. This is a finding that is paralleled by existing research on novice clinician

perspectives of their professional development (De Stefano et al., 2014; Gale & Schroder, 2014;

Gale et al., 2015; Marlowe et al., 2015; Punzi, 2015; Stahl et al., 2009).

Peer and supervisor support became crucial during times that novice clinicians described

clinical challenges that lead to feeling “stuck” or needed guidance (De Stefano et al., 2014).

Seeking support normalized the learning experience, increased openness to using clinical

techniques, allowed novice clinicians to view their experience from another perspective, and

inspired application and reflection of new perspectives on clinical work (Gale & Schroder, 2014;

Punzi, 2015). Supervisors sharing clinical examples or personal successes and failures, as well as

offering constructive criticism was noted as highly useful (Punzi, 2015). The act of sharing or

seeking support from others facilitated development of strong bonds between peers, and

promoted a sense of safety around sharing clinical challenges with peers and supervisors

(Bennett-Levy & Lee, 2014; Gale & Schroder, 2014; Marlowe et al., 2015).

The use of peers for informal processing of clinical challenges has been around since

Freud’s practice of an “inner circle” (Gosskurth, 1991). Parker, Kram, and Hall (2014) felt that,

“learning through relationships is a foundation for career growth, and it must be a lifetime

pursuit” (p. 122). Peers offer cognitive and emotional support, heighten self-awareness, develop

critical and relational skills, motivate to rise up in the face of challenges, and inspire to develop

ongoing supportive relationships (Parker, Kram & Hall, 2014). These findings were reflected by

the results of the current study. It appears that if novice clinicians are provided with the

opportunity to regularly connect with their peers, their professional work will benefit.

Parker et al. (2014) recommend certain key conditions for cultivating in novice clinicians

the use of peer support. They stress the importance of a foundational environment where pursuit

of peer support is valued and nurtured by the training program, trust and support among

classmates is established through respect and authentic disclosure, and peers are matched at

similar developmental levels (Parker et al., 2014). Novice clinicians are likely to benefit from

peer support when it involves the posing of questions that stimulate reflection rather than giving

advice (Parker et al., 2014). Benefits to professional development of using peers as support

include developing skills of active listening, appropriate self-disclosure, empathy, self-

awareness, social skills, and metaawareness of the benefits of peer support that inspires

continued use of this resource (Parker et al., 2014).

Experiential Learning

It is widely agreed in the literature and reflected in the results of the current study that

experience in therapy with clients is the one of the most influential resources for professional

development (De Stefano et al., 2014; Farber, 1983; Freeman & Hayes, 2002; Gale & Schroder,

2014; Gale et al., 2015; Goldfried, 2001; Orlinksky, Botermans, & Rønnestad, 2001; Punzi,

2015; Skovholt & McCarthy, 1988; Skovholt & Rønnestad, 1992; Stahl et al., 2009). Novice

clinicians agree that conceptual knowledge is simply insufficient, and that learning does not take

place until knowledge is applied and struggled with in the therapy room (Hemanth & Fisher,

2015; Punzi, 2015). Stahl et al. (2009) found that through clinical experience, novice clinicians

learned to pay attention to personal reactions to clients and use them for conceptualization and

treatment, how to be flexible with treatment due to awareness that change takes time and therapy

is a process that requires constant revision, and that doing therapy is complex, emotional, and at

times scary. Providing clinical services can be just as much an art as a science. Novice clinicians

receive the science piece in their classrooms, textbooks, and supervision. They must enter the

therapy room to recognize it as an art, and approach it this way so as to maximize effectiveness.

Novice clinicians have described being impacted by clients and clinical work through

changes in personality, sense of self, increased self-esteem and self-confidence, increase in

psychological mindedness and introspection, and a greater appreciation for and understanding of

the therapeutic process and relationship (Farber, 1983; Myers, 2002). Greater understanding of

aspects of self via clinical work leads to significant professional development in that novice

clinicians experience increased awareness of personal limitations and reactions, empathy for

clients via normalizing or identifying with clients’ experiences, and ability to see self as “good

enough” (p. 380) clinicians to help clients in therapy (Stahl et al., 2009).

Clinical experiences prompted novice clinicians to inquire further about conceptual

knowledge and seek out additional resources for learning in a search to add depth to their

knowledge base (Punzi, 2015). Additionally, increasingly broad clinical experiences appear to be

paramount for bridging the gap between theory and practice (Punzi, 2015). Existing literature on

experiential learning supports ongoing clinical experience as a main factor in the development of

expertise, as ongoing experience leads to acquisition of a breadth and depth of knowledge

necessary to become clinically effective (Stahl et al., 2009).

Though not identified in the current study, supervision appears to be an opportunity for

experiential learning as well. Senior clinicians have reflected on experiential learning of

clinically relevant concepts to find that conceptual knowledge is superficial, and to know

something is to experience is personally (Gardner, 2015). Gardner (2015) offers the example of

the significant difference between knowing about empathy, and experiencing it. Gardner stresses

the influence of this in her supervisory work, in that when she is able to create experiences in

supervision for her supervisees that mimic the concept being taught, she is most effective in

helping them to enhance their clinical effectiveness. Thus, Gardner urges “the process we want

our students to use with their patients is one we must also offer them” (p. 417).

Researchers have discussed few instances of novice clinicians’ self-application of

knowledge or learning that was gained during client interactions (Farber, 1983; Freeman &

Hayes, 2002; Kahn & Fromm, 2001; Orlinksy, Rønnestad, & Willutzki, 2004; Stahl et al., 2009).

Novice clinicians have noted experiencing increased self-awareness, greater psychological

mindedness, and a more self-assured attitude and self-concept from their clinical encounters

(Farber, 1983; Froggett et al., 2015; Myers, 2002; Kaslow, 1996; Stahl et al., 2009). The concept

of applying knowledge to the self as part of training appears relatively new, but seems highly

intuitive. To embrace this, clinicians need to see themselves as vulnerable to the experiences of

emotional and cognitive distress in the same way clients are. If clinicians can tolerate knowing

that as human beings we are always growing, changing, and requiring a permissive attitude for

these changes to take place, we can be more open to applying change techniques to ourselves in

ways that allow for personal growth to benefit both our personal and professional lives.

The ‘use of self’ in clinical work is supported in the literature as relevant to clinical

effectiveness (Froggett et al., 2015; Gale & Schroder, 2014). However, there are few instances in

the research where the results of self-application have been investigated. Froggett et al. (2015)

found that novice clinicians might, through clinical work, develop an awareness of a need to

grow personally in the ways that they ask their clients to grow. In their investigation of clinicians’

use of self in clinical work, a participant discussed a need to acknowledge vulnerability within

her before she could see it in her client to effectively empathize. In this case, personal growth via

self-application becomes a prerequisite to effectively helping clients with that growth. Failure to

engage in this form of personal development could result in invalidation or misattunement with

clients.

Some studies exist that outline the experiences of clinicians’ self-application of

mindfulness as a specific example of applying knowledge to the self. Positive effects on both

personal growth and professional development have been noted, such as increased presence and

attentiveness with clients, ability to sit with silence and cope with self-doubt, compassion for

clients, and self-awareness of and ability to sit with emotions in session (Christopher & Maris,

2010; Hemanth & Fisher, 2015; McCollum & Gehart, 2010). It is commonly understood that

active listening and empathy are critical elements of clinical work, both of which are greatly

enhanced by ones’ ability to remain present.

Gale et al. (2015) measured clinician reactions to self-application of Compassion Focused

Therapy and found that clinicians experienced a variety of benefits to personal growth and

professional development. Participants described increased self-awareness, consolidation of

learning, greater empathy for their clients, flexibility and clarity in use of the techniques with

clients, increased confidence for applying the techniques, and greater compassion toward self and

others. They found that they were more compassionate toward clients generally, as well as

specifically with respect to the difficulty of using the techniques, the problems clients might run

into, and cognizance of the pressure clinicians sometimes put on clients to make changes.

Afterwards, clinicians advocated for self-application of the clinical skills, as it was perceived as a

powerful and important experience.

Cognitive behavioral therapists have urged clinicians to apply clinical tools to their self

personally to fully understand the process of therapy and enhance professional development

(Beck, 2011; Gale & Schroder, 2014; Padesky, 1996). Bennett-Levy et al. (2001) was the first

study to investigate the effects of self-application of cognitive behavioral material. They found

that self-application increased clinician empathy for the client and enhanced skills and

understanding of the therapeutic process and material. Clinicians feel better equipped to apply

material in session after self-application of material due to a deeper understanding of the impact

it is likely to have on clients. Clinicians described examples of this, such as being able to use

metaphors in session to explain material to clients, that they could create based on their personal

experience with the material. Increased empathy for clients, in particular, involved fewer

assumptions made about the client, better care and thought in the application of material in

session, improved ability to assist clients in predicting difficulties that may arise with the

material, and a better appreciation for the challenges clients may face during self-disclosure and

exposure (Bennett-Levy & Lee, 2014; Haarhoff, Gibson, & Flett, 2011). Clinicians noted

experiencing themselves a desire to distract or avoid difficult personal challenges that arose

through self-application, which helped them to understand this in their clients (Bennett-Levy

Lee, Travers, Poholman, & Hamernik, 2003).

By applying material taught in supervision or classes, it appears that clinicians may

experience a better appreciation for the value of the material in facilitating change (Bennett-Levy

et al., 2003; Hemanth & Fisher, 2015; Rimes & Wingrove, 2011). Clinicians also report

experiencing increased confidence in their clinical skills, which in turn impacted their perception

of competence (Bennett-Levy et al., 2001, 2003).

Haarhoff et al. (2011) and Bennett-Levy et al. (2003) found that through self-application

clinicians developed an increased capacity for observing internal thoughts, emotions, and

physiological and behavioral triggers, as well as self-acceptance and psychological growth.

Others have noted ways in which self-application impacts personal growth, referring to these

experiences as life changing (Fraser & Wilson, 2011). Bennett-Levy et al. (2001) noted a positive

impact of self-application of material on clinicians’ self-concept. In later studies they also noted

that clinicians relationship skills improved (Bennett-Levy et al., 2003). It appears that self-

application of clinical material results in the personal growth of clinicians. As demonstrated by

the current study and others discussed here, personal growth appears to influence professional

development in many useful ways. Thus, teaching or guiding self-application of knowledge and

clinical material may be a method by which training programs can cultivate greater professional

development in their students.

Intent

There is a gap in the literature in the area of measuring clinician intent to apply new

learning to future clinical situations. Marlowe et al. (2015) defined this as “praxis,” or a clinician

developing the “aspiration and creative incentive to improve practice and make changes

previously reflected upon” (p. 62). In other words, having experienced new learning the clinician

becomes specific and intentional in applying it. This was a theme that emerged in the current

study that appears not to have been investigated by many others to date. Praxis in this context

appears to represent a level of motivation to work harder and smarter, which is perpetuated by an

enthusiasm about having experienced profound growth. In this way, personal growth that benefits

professional development is highly valuable, as it has the residual effect of inspiring more

engagement with the work.

A review of the literature discussed in this section suggests that experiential learning may

result in clinicians being more likely to apply their learning in the future. In the current study,

participants described how personal growth via self-application of knowledge or material often

inspired a desire to use their new, deeper understanding of the material to their work with clients.

While many note that self-application of material leads to a better understanding of the material

and greater capability for applying it, only two studies were found that illustrated an increase in

clinician motivation to apply it in future work (Hemanth & Fisher, 2015; Marlowe et al., 2015).

Additional research would be required to further understand the processes involved in motivating

clinicians to use techniques in session, and if this motivation is influenced by personal growth as

it appears to be in the current study.

The six processes identified by the results of this study are discussed individually here;

however, they appear to overlap significantly and work in conjunction with one another to

produce changes. Beginning with self-awareness and self-reflection, they appear to build on one

another to produce increasing levels of growth. Clinical training has implemented conversations

mainly around the areas of self-awareness and self-reflection, but is inconsistent in the use of

strategies for activating the additional five processes in students. Introspection provides a good

entry point for facilitating personal growth as it relates to professional development; however,

training programs can deepen these experiences and further growth by teaching the successive

use of uncertainty, emotional presence, cognitive shifts, experiential learning and intent in their

practice. Once exposure to each of these processes is achieved, clinicians are likely to benefit

from career-long, repeated intentional exposure to them as various professional challenges arise.

Implications and Future Directions

Interviews with those aspiring to become clinicians found that those thinking of entering

the field often times bring with them a desire to do so for development of the self (Hill et al.,

2013). Given the findings of the current study that elements of personal growth do influence

professional development, selection of students for clinical training may benefit from

consideration of applicants who are motivated for personal growth. Novice clinicians should

enter the field prepared for academic and non-academic challenges, as both are required for

professional development (Silvester, 2011). Future clinicians who are open to their own personal

growth would embody openness to development that can be taught to clients in an authentic way.

Processing personal reactions with supervisors is identified in the literature as an

important step to improving clinical effectiveness (Gale et al., 2015; Marlowe et al., 2015).

Supervisors can explicitly invite students to engage in this type of processing by modeling it and

explicitly discussing it as an important aspect of training. It is recommended that supervisors

offer activities such as journaling and explicitly asking novice clinicians to reflect on what they

learned from clients to facilitate self-reflection (De Stefano et al., 2014; Stahl et al., 2009). Stahl

et al. (2009) suggest that explicitly asking novice clinicians about their personal reactions may

reduce risk of burn out and compassion fatigue, as novice clinicians would be prompted to

process the types of experiences that often lead to these professional challenges. Some

recommend the importance of doing this in particular when it appears that novice clinicians may

be struggling with some of the more ambiguous, complex, or personal aspects of training (Punzi,

2015). Novice clinicians from other studies who reflected on the value of personal growth during

their training urge supervisors to “be more courageous, deliver constructive criticism and

suggestions, and demand active reflection from the students” (Punzi, 2015, p. 357).

Supervisors may assist novice clinicians with personal growth experiences beyond

selfreflection. For example, they may assist novice clinicians in clarifying different feeling states

as they arise in relation to clinical work (De Stefano et al., 2014; Marlowe et al., 2015). Doing so

would assist novice clinicians in processing personal reactions and achieving greater levels of

personal growth, while also modeling how to guide clients in doing the same, thus contributing

to professional development as well. Supervisors can develop procedures for making

selfapplication of knowledge and material a central part of clinical training (Gale & Schroder,

2014).

Issues have arisen in studies similar to the present one in which participants felt they were

unable to discuss personal or clinical challenges with their supervisors due to a perception that

one must present as competent. Novice clinicians may also hesitate to talk with supervisors about

challenges due to fear of judgment or punitive action for holding beliefs or values incongruent

with their supervisor or the field (Paprocki, 2014). Researchers have recommended that

supervisors and trainers create an atmosphere of safety and support that is permissive of, and

explicitly urges novice clinician’s engagement in self-reflection around clinical challenges

(Punzi, 2015; Wilson, Davies, & Weatherhead, 2015). When supervisors create an atmosphere in

which this is the norm and it is understood that learning is a process during which mistakes will

be made, novice clinicians are less defensive and more open to processing challenges.

Supervisors can achieve this by communicating tolerance for mistakes and not knowing, as well

as modeling how to embrace the complex and ambiguous nature of the various aspects of clinical

work (Nissen-Lie et al., 2015).

Finally, additional research is required to move toward the development of a theory that

may support implementation of personal growth as an aspect of clinical training. Froggett et al.

(2015), along with several others, urge further studies on the use of self in clinical work to

contribute to this literature base. Additional research may benefit from the use of formal

instruments to measure personal growth and professional development, as the current study

relied on participant self-report. A revision of the current study might benefit from the use of a

research prompt that would guide participants’ writing in particular ways, so as to gather more

specified information about novice clinician experiences. Additionally, the sample of participants

used in the current study is smaller than was intended. The inclusion of a larger sample of novice

clinicians would present a wider range of experiences that might change, add to, or strengthen

the current results. Inclusion of novice clinicians from a variety of age groups might also clarify

the true origin of participants’ experiences of growth, as the participants of the current study were

at an age when personal growth is typical.

Personal Reflections

Qualitative research often involves the limitation and benefit of including the researcher’s

experience in the way the data is collected and results perceived. As a researcher and participant

of the current study, I bring to these results a more vivid memory of personal growth during my

clinical training than could ever be depicted in writing. With this memory I also carry

recollections of the many additional factors that played a role in my professional development

that were not depicted in the data, such as the use of textbooks, class lectures, and consultation

with professors. These resources and experiences were necessary aspects of my professional

development that were strengthened by my personal growth.

In considering some of the results of the current study, I am struck by the complexity of

processes that may be unintentionally oversimplified by the nature of the data. For example, as I

recall my self-reflection at this time I realize that it involved journaling, talking to others,

reading, keeping lists, pondering and feeling confused for long periods of time, searching for

relevant literature to help clarify, initiating conversations with old friends and family to find out

more about my past, and experiencing an ever changing notion of who I am as a person that

constantly required ongoing self-reflection to understand each layer that was uncovered by these

activities.

Another personal reflection that I believe to be highly significant to this study’s research

question involves the interaction of all processes identified in the results presented in this

document. The journal entries that made up the data of this study were written without

consideration for the chronology of events, which made it impossible to identify any patterns that

may have illuminated a learning process around personal growth. However, having personally

read each journal entry numerous times, I developed the sense that a chronology more-or-less

exists. This chronology would read: Developing self-awareness, in-session experiences of

hindrances to clinical effectiveness, self-reflection regarding personal reactions in session,

paralyzing self-doubt, uncertainty in practice, learning to be emotionally present to self,

challenging self to take risks, beginning to shift in beliefs, perceptions, morals, values, etc.,

processing changes and gaining clarity in conversations with peers and supervisors, using

experiences in and out of session to deepen knowledge, and finally, developing an inspired intent

to share what was learned with others.

A review of a number of articles that explored novice clinician’s self-reported experiences

during professional development appear to support the above theorized chronology; however,

this process is not explicitly defined in these studies either (De Stefano et al., 2014; Gale et al.,

2015; Punzi, 2015). Thus, additional research would be needed to clarify if this chronology exists

in actuality. Additionally, it seems important to note that the theorized chronology of elements

that influence personal growth appear to work, not in a linear manner, but rather building on each

as the novice clinician progresses in their professional development.

The above-cited studies also reflect this. So, self-awareness is learned and then carried through

each of the additional elements, adding to the value of each so that in the end the novice uses all

elements in conjunction with one another as aspects of personal growth that maximize

professional development.

The notion that personal growth influences professional development in a cumulative

manner is congruent with my personal experience as a developing clinician. I wrote some of the

journal entries that were included in the data of this study as a first-year doctoral student. I recall

reflecting on the profound breadth and depth of my personal growth at the time, but in retrospect

I could have never known the true enormity of it then like I can see it now. The personal growth

and professional development continued beyond my first year, but there is something to be said

about the concentrated amount that was experienced during that specific time. This anecdotal

reflection speaks to the value of having used first-year doctoral students as a sample in the

current study, and calls into question how personal growth is experienced differently as training

progresses.

It is the hope of this author that more studies of this nature will be developed so as to

build a literature base around the personal growth of novice clinicians. The field of clinical

psychology is unlike many others in the relevancy of personal factors to clinician professional

development. It is the opinion of this researcher that procedures for supporting and cultivating

personal growth in novice clinicians would be a valuable addition to clinical training programs.

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