
==== Front
Res Psychother
RIPPPO
Research in Psychotherapy : Psychopathology, Process, and Outcome
2499-7552
2239-8031
PAGEPress Publications, Pavia, Italy

39221905
10.4081/ripppo.2024.799
Article
Shaping psychotherapy trainees’ potential: insights from training program directors
Messina Irene
Trimoldi Giovanna
Contributions. GT collected and analysed the data, wrote the first draft of the manuscript. IM supervised the research and wrote the manuscript. Department of Humanities and Social Sciences, Universitas Mercatorum, Rome, Italy
Department of Humanities and Social Sciences, Universitas Mercatorum, piazza Mattei 10, 00186, Rome, Italy. irene.messina@unimercatorum.it
Conflict of interest: the authors declare no potential conflict of interest.

Ethics approval and consent to participate: Informed consent was provided by participants.

Citation: Messina, I., & Trimoldi, G., (2024). Shaping psychotherapy trainees’ potential: insights from training program directors. Research in Psychotherapy: Psychopathology, Process and Outcome, 27(2), 799.

Publisher’s note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The role of the therapist has received growing attention in psychotherapy research, suggesting that training effectiveness may also depend on the person of the trainees, with relevant implications in terms of candidate selection or tailoring training to the person. In the present study, we focused on how and how much psychotherapy training can be effective in fostering trainees’ characteristics associated with successful therapists and contrast trainees’ characteristics that could represent limitations as therapists. The aim was to explore training program directors’ perspectives on individual trainees’ limitations and strengths, and on the effectiveness of training in shaping successful therapists. To this aim, we interviewed 14 training program directors with different psychotherapy approaches. Audio recordings of these semi-structured interviews were transcribed verbatim and analysed using NVivo software. According to our findings, transversally to different psychotherapy approaches, trainees’ self-awareness and the ability to embrace uncertainty were recognized as the main characteristics of good trainees. Four training elements were frequently mentioned by directors as effective in shaping trainees’ development: experiential learning, the use of paradigm that prioritizes self-awareness (instead of technique-focused approaches), the centrality of supervision and inter-vision, the trainer-trainee relationship. These insights highlight the importance of trainees’ self-awareness and the ability to embrace uncertainty as potential personal variables that may influence the effectiveness of future psychotherapists and suggest giving attention to experiential learning and training relationships as crucial elements of psychotherapists’ development during the training.

Key words

successful therapists
intervision
challenges
awareness
future of psychotherapy training
==== Body
pmcIntroduction

Research on influential and effective factors leading to a favourable psychotherapeutic outcome has identified, among other factors, therapist effects as important factors leading to therapy success (Johns et al., 2019; Wampold & Owen, 2021). There is growing evidence that therapists significantly differ in their effectiveness in terms of positive outcomes rates (Delgadillo et al., 2019; Nissen-Lie et al., 2016; Saxon & Barkham, 2012). Beyond technical competencies, the person of the therapist has received attention. Therapists’ relational styles – for example the ability to engage the patient in strong therapeutic alliances (Bordin 1979; Norcross & Lambert, 2018) and their empathy (Elliott et al., 2018) – have been proved to be significant predictors of good psychotherapy outcome. Furthermore, certain personality traits, such as warm and trusting interpersonal style facilitate the establishment of therapeutic alliances (Ackerman & Hilsenroth, 2003; Nissen-Lie et al., 2010). The findings concerning the person of the therapist, may also have important implications in the context of psychotherapy training. How and how much psychotherapy training can be related to and effective in fostering trainees’ characteristics associated with successful therapists and contrast trainees’ characteristics that could represent limitations as therapists? We can hypothesize that training effectiveness also depends on the person of the trainees, with relevant implications in terms of candidate selection or tailoring training to the person.

A recent study examining 90 psychotherapy training programs found that personal qualities such as empathy, self-awareness, and good mental health are the most frequently cited criteria for selecting trainees, followed by intellectual qualities like intelligence and theoretical interest (Orlinsky et al., 2023). Based on a self-report study (Messina et al., 2018), it appears that trainees frequently depict their interpersonal style in manners akin to those identified in effective psychotherapists, suggesting that there is also a self-selection process in psychotherapy trainees, based on personal attributes (and not only based on previous work or academic experiences). There is evidence that therapists’ own experiences in close personal relationships influence their relational approach with clients (Heinonen & Orlinsky, 2013), suggesting that the interpersonal style of psychotherapy trainees may shape their effectiveness as future therapists. However, we have little empirical evidence regarding trainees’ personal relationship style in determining whether they became effective therapists. Schöttke and colleagues (2017) showed that trainees who display positively assessed interpersonal behaviours achieve better psychotherapy results with their patients over a five-year period. Moreover, such effect remained controlling for relevant training variables, such as the amount of supervision. But the role of psychotherapy training in influencing such differences remains unexplored.

In addition to personal attributes, personal history may significantly impact trainees’ potential development as psychotherapists. Previous studies indicate that psychotherapists often report higher rates of adverse childhood experiences compared to professionals in other fields (Nikcević et al., 2007; Rønnestad & Skovholt, 2003) and negative family dynamics (Fussell & Bonney, 1990; Rønnestad & Skovholt, 2003). And we also know that personal experiences of trainees often serve as a motivation for pursuing psychotherapy training and are linked to negative childhood experiences (Messina et al., 2018). At the same time, it is recognized that by undergoing personal suffering and internal conflict, the therapist develops psychological awareness, enabling them to better understand and assist others (Barnett, 2007; Farber et al., 2005). Such developmental trajectories could be probably influenced by psychotherapy training, which may play a pivotal role in guiding trainees to leverage personal experiences to enhance therapeutic skills. And trainees may vary on the aptitude in utilizing psychotherapy training to enhance their awareness of how personal history shapes their current relational experiences as psychotherapists.

Due to the relevance of trainees’ personal background, in the SPRISTAD (Society for Psychotherapy Research Interest Section on Therapist Training and Development) study the collection of trainees’ self-reported limitations and strengths at the onset of their training has been included as a crucial element for comprehending the developmental trajectories of psychotherapy trainees (Messina et al., 2019; Orlinsky et al., 2015). Early results of this study documented that self-related attributes are the most frequently reported limitations at the beginning of the training (Schröder et al., 2022). Beside trainees’ point of view, we believe that the perspective of supervisors can provide valuable insights into identifying the typical strengths and limitations of psychotherapy trainees, for several reasons. Firstly, supervisors have a privileged vantage point for observing trainees’ progress, directly witnessing and discussing their efforts to overcome developmental challenges. Secondly, by observing numerous trainees, supervisors can make comparisons and intuitively assess the potential of each individual trainee. Thirdly, supervisors may have a broader perspective on the reinforcement of trainees’ strengths and the overcoming of limitations as integral aspects of the training and developmental process as a whole. In light of these considerations, in the present study we explored supervisor perspectives on training effectiveness, in association to individual trainees’ limitations and strengths. Given the explorative nature of the study and the novelty of the topic, a qualitative methodology was deemed appropriate to provide a nuanced understanding of the subject matter and foster the generation of new hypotheses.

Methods

Participants

Training program directors were selected through purposeful sampling, using a combination of convenience sampling and snowball sampling techniques based on referrals. We deliberately selected interviewees with long tenure of experience as supervisors. Moreover, in interviewees recruitment we considered both genders representation and the inclusion of different theoretical approaches, aiming to identify potential areas of convergence within their diverse perspectives. Recruitment of participants continued until repetition of themes occurred and no new information was evident (i.e. data saturation achieved). The final sample was composed by 14 training programs directors (9 males and 5 females), ranging from 35 to 40 years of professional experience and different theoretical perspectives: more specifically three from psychodynamic and psychoanalytic, one from the constructivist perspective, two from family and relational therapy approach, the others from CBT, Gestalt and bio-systemic approaches. Prior to conducting the interviews, informed consent forms were provided to participants. They were given detailed information about the study, including its purpose, confidentiality, and their rights as participants. Participants signed the consent forms, indicating their willingness to participate.

Data collection

A semi-structured interview guide was developed, containing open-ended questions (Table 1) designed to explore the participants’ experiences around the main trainees and trainers’ skills and challenges. Questions were framed to elicit rich and detailed responses. The interview guide was pilot tested with one of the participants to refine and clarify the questions. This ensured that the questions were clear and that they encouraged participants to share in-depth narratives about their experiences.

Interviews were conducted individually through an online setting, typically lasting 60-90 minutes. The researcher build rapport with participants to create a safe and open environment for sharing personal experiences. Open-ended questions from the interview guide were used as starting points, but the conversation was flexible to follow the natural flow of each participant’s narrative. Moreover, probing questions were employed to encourage participants to delve deeper into their experiences and offer detailed insights.

Data analysis

All interviews were audio-recorded with the consent of the participants. The audio recordings were later transcribed verbatim to preserve the nuances and richness of the narratives and imported into NVivo software (version 14; QSR International, 2024). Initial open coding was performed to tag relevant text segments.

These codes were then grouped into broader themes through axial coding using NVivo’s node hierarchy. Thematic analysis was used to identify recurring themes and patterns within the interview data (Fereday, 2006; Gioia et al., 2013). This involved coding segments of text and grouping them into themes related to challenges. Constant comparison was used to ensure data analysis rigour, where thematic saturation was achieved when no new themes emerged from the data analysis process (Hennink et al., 2017; Hennink & Kaiser, 2022; Hill et al., 2014). We finally identified and defined a set of 47 codes by means of a consensus-reaching procedure involving both authors of the present study (Hill et al., 2005) (Table 2).

Results

The good trainee

Before delving into the challenges within psychotherapy training, we have let the interviewees defined and agreed upon together with the interviewees what the essential characteristics of a good student to become a proficient psychotherapist are by asking what skills/characteristics distinguish a good trainee. Two main themes emerged regarding the qualities of good trainees: awareness and ability to embrace uncertainty.

Awareness

The concept of awareness has been universally acknowledged by psychotherapy trainers as an indispensable attribute of a good trainee and to then be a proficient psychotherapist. Various metaphors are employed by directors across diverse theoretical orientations, reflecting the nuanced and multifaceted nature of their respective approaches. The training process to develop self-awareness is defined as a gear that must always be kept free from dust and sand or a seismograph and a tool for self-recording (Trainer #4, Psychodynamic approach), like a craftsman shaping and reshaping the product (Trainer #2, Constructivist approach).

In order to establish a common understanding and interpretation of the term awareness, we sought definitions from each individual. Subsequently, we opted to present herein the elucidation that, in our judgement, most effectively encapsulates a shared conceptualization among all interviewees and that here refers to awareness with the term self-insight:

“a good self-insight. Intuition about oneself. Because working on the relationship is difficult, it’s not easy. At the beginning, all trainees have a very particular idea of psychotherapy that needs to be deconstructed. Some do it very quickly, some take two years, some three”. (Trainer #2, Constructivist approach)

“Students must implement a process of observation and change and start to see themselves from different angles”. (Trainers #1, Cognitivist approach)

“The task of building professional self-awareness is a challenge and it’s good to realize it early on.” (Trainer #3, Constructivist approach)

Table 1. Semi structured interview questions and prob questions.

Item	Question	Prob question	
Intro	Could you tell me about your main tasks as a supervisor?	What are your main duties as a supervisor?	
		Could you tell me about your relationship with your trainees?	
Abilities	What skills/characteristics distinguish a good trainee?	When meeting a new psychology student or trainee, how do you attempt to gauge from the first impression whether they possess the qualities to become a good student/psychologist? Can you provide any examples that come to mind?	
Trainee	How would you describe the process of development	Based on your experience, what are the typical limitations that a trainee might have?	
limits	for a psychotherapy trainee throughout their training? What makes a trainee a psychotherapist?	Which limitations are effectively overcome through training, and which ones are difficult to overcome through training?	
		What are the typical timelines for overcoming these limitations?	
		How does your approach contribute to alleviating difficulties? - but tends to promote your approach	
		What role does the training community play?	
		If you were an intern and came to me saying you believe you couldn’t overcome your weaknesses, what would I do?	
		What is he typical case that comes to mind where weaknesses are overcome is through consistent effort, targeted training, and receiving constructive feedback. The most difficult case that comes to mind where the limitations were not overcome? What could you have done?	
		What message do you convey to them regarding facing their limitations and difficulties as trainees?	
		Difference between therapist-patient contract and therapist-trainee contract.	
		Contradiction: one cannot observe oneself without guidance, at least initially.	
		How does the alliance contract contribute or not to overcoming trainees’ limits?	
Supervision limits	How have you changed as a supervisor since the beginning? How does it reflect your former self as a trainee with today’s trainees?	At the onset of your experience as a trainer, what improvements did you have to make to help trainees overcome their limitations? As a supervisor of yesterday and today, how have you changed?	
		What did you think of your teachers?	
		What are your concerns when taking on the role of supervisor?	
		As a supervisor who is also a therapist, you observe yourself in the relationship.	
		What questions do you ask yourself (awareness) regarding your work with the trainee?	
		What do you think makes you a good supervisor?	
Closure	What is the future of supervision and training in psychotherapy?	What additional steps could be taken to help trainees address the limitations we discussed?	

Table 2. Summary of codes and their descriptions.

Name	Frequency	Description	
Awareness	68	Trainee/therapist’s ability to feel and see why and how they feel and see, producing a differentiation of the self from others	
Comfort with uncertainty	48	Trainee/therapist’s ability to listen without patterns, prejudices, and personal defences, willingness to observe oneself and to know oneself, to stay in doubt, to undergo change, and to know the unknown	
Self-analysis	46	Trainee/therapist’s ability to introspect and analyse their own defences, mechanisms, and history	
Trainee-supervisor relationship	42	Definitions, characteristics, and dynamics of the relationship between trainee and supervisor	
Training limits	41	Limits and difficulties that trainees encounter during the training process	
Experiential factor	30	Practical and hands-on nature of psychotherapy training	
Our school	25	Declaring, showing, and promoting the uniqueness of the school compared to others for: work on awareness, experiential factor, specific practices	
Supervisor egocentrism	23	Supervisor/director’s tendency to respond to questions incongruently by recounting their own qualities and professional achievements	
Patient-therapist relationship	21	Definitions, characteristics, and dynamics of the relationship between patient and therapist	
School training procedures	18	Structuring, methods, and timelines related to the didactics and training of the school	
Interview techniques	17	Specific techniques of each approach for psychotherapeutic interview with the patient	
Change	14	Trainee’s capacity for personal transformation and change during and following self-analysis	
Institutions	14	Bureaucratization of the psychotherapy training process and its requirements	
Supervision and teaching	14	Practical and bureaucratic implications of supervision and teaching	
Supervisor perspective	13	How the supervisor/director sees their own past training and that of today’s trainees	
Supervisor model	12	Educational principle according to which the supervisor does not teach a model of reference techniques but rather guides the trainee to self-awareness and self-knowledge	
Peer supervision	11	Support for supervision in class carried out by former trainees. Also defined as: group, co-training	
The good psychotherapist	10	Characteristics of the good psychotherapist	
Psychotherapist evaluation	10	Modes of evaluation of trainee progress	
Affection	9	Feeling of affection from supervisors/directors towards trainees	
From knowing to knowing how	9	Shift of educator/supervisor/director from a focus on theoretical knowledge to one on experiential practical knowledge during the training process	
Trust	9	Attitude of trust from the supervisor towards the trainee as if they were a patient	
Best quotes	9	Special reflections and descriptions and through the use of metaphors in psychotherapy	
Reimbursement	8	Need for economic compensation or free or discounted rates that do justice and gratify the specialization and internship in psychotherapy	
Listening	7	Trainee/therapist’s ability to listen to others and oneself	
Procedure improvements	7	Desirable changes in the psychotherapy training process	
The approach	6	Referring to the advantages and perspective of one’s own psychotherapeutic approach	
Lack of listening	6	Inconsistent responses from the interviewee compared to the interviewer’s questions	
Training contract	5	Training contract entered between psychotherapy school and trainee	
Sectorial diatribe	5	Debates and disagreements ongoing about the differences between different psychotherapy approaches and between medical and psychological professionals regarding training	
Do no harm to the patient		Trainee/therapist’s ability to not harm the patient	
Solving one’s own psyche		Trainee’s tendency or need to begin training to resolve their own personal issues	
What does being a psychotherapist mean?	4	Definition and vision of the psychotherapeutic process	
Feedback	4	Trainees’ feedback and opinion on the quality of training within the school	
Integration of models	4	Practice, experience, or need to integrate psychotherapy approaches	
Professional vs. personal	4	Difference between personal and professional trainee growth	
Spoiled immature trainees	3	Description of trainees recognized as more immature than in the past	
From trainee to professional	3	Elements determining the transition from being a trainee to being a professional	
Judgment	3	Feeling of the former trainee-supervisor of being constantly judged as right or wrong by teacher trainers. Fear or apprehension of the former trainee/supervisor of being judged negatively by teachers	
Internal resources	3	Trainee’s ability to respond to changes and difficult times	
Director’s role	3	Director’s duties	
Saving the other	3	Trainee/therapist’s tendency to want to solve the patient’s problem	
Need for psychotherapy	2	Increased demand from patients for professional psychotherapeutic help	
Burnout	2	Stress condition manifested during the development and career of the psychotherapist	
Supervision yesterday vs. today	1	Characteristics distinguishing between supervision yesterday and today	
Plasticity	1	Trainee therapist’s ability to modify and change	
Self vs. other	1	Trainee/therapist’s ability to differentiate their own experience from that of the patient	

Related to self-insights, awareness was described also in terms of self-focused attention during the therapy session and in reaction to the interpersonal dynamics with the patient. The focus on awareness within psychotherapy training extends beyond the individual therapist’s self-awareness to encompass the very fabric of the therapeutic relationship. Trainees are encouraged to cultivate acute awareness of the intricate dynamics manifesting within the therapeutic interaction, fostering a nuanced comprehension of the client’s verbal and non-verbal cues. This heightened level of awareness empowers therapists to forge a deeper connection with their clients, augmenting their ability to attune to subtle shifts in affect, communication patterns, and relational dynamics:

“Willingness to suspend judgment and look at people with fresh eyes, not as they were taught in university. Above all, the willingness to question oneself because if one cannot learn from their mistakes, they can never aspire to become a wise person”. (Trainer #9, Family therapy/Systemic approach)

“The key is: how willing are you to put yourself into it, understand how you function, and then work in interaction with the other person” (Trainer #2, Constructivist approach)

Interestingly, despite the consistency among trainers with different theoretical orientations, more than one of them asserted the distinctiveness of their training, based on awareness acquisition, as a unique characteristic compared to other schools.

“Many schools operate this way because for trainees, it’s fantastic: tell me what to do, and I’ll do it. And so, they find themselves in trouble, of course, right afterward. What we do instead is, ‘I can’t tell you how to do it’”. (Trainer #2, Constructivist approach)

“To be psychotherapists, one thing is to adopt techniques, and there are basic requirements set by the Ministry of Education, Universities and Research (MIUR) to determine if the therapist is effective with patients. However, we then ask for additional awareness to become Jungian analysts. So, there is an additional year of integrative training.” (Trainer #7, Transactional Analysis approach)

“Awareness is crucial. I, of course, refer to it as the distinguishing element of the approach I use and believe in.[..] It’s not just about technical skills, at least not for the type of approach we propose. It operates at a human level—essential, sensitive, empathetic, in short.” (Trainer #5, Gestalt approach)

“I have some knowledge of other approaches, and I cannot assume the right to speak about things in which I lack expertise. The self as a measure of the relationship is scarcely employed in a non-psychodynamic model. Some times, even within the psychodynamic model, it is underutilized. However, in this school, it is an aspect that we consider very important, fundamental.” (Trainer #4, Psychodynamic approach)

Embracing uncertainty

According to supervisors, trainees (and psychotherapists) must possess a foundational capability to navigate and maintain a sense of ease within the domain of uncertainty. Throughout the therapeutic process, clients frequently present intricate and nuanced challenges, underscoring the therapist’s imperative capacity to endure ambiguity. This indispensable skill entails the therapist’s readiness to acknowledge that not all facets of a client’s experience can be neatly compartmentalised or readily comprehended. Therapists must adeptly navigate uncharted territories, recognizing that personal growth and transformative change often emerge from the exploration of uncertain terrain. This proficiency necessitates a nuanced equilibrium, wherein the therapist provides a secure and supportive environment for the client while concurrently acknowledging the intrinsic unpredictability inherent in the therapeutic journey.

“There are many people who have boxed all of this up [personal problems]. So, reopening these boxes or drawers can be very difficult. However, we cannot help but do it because in our relationship with others, all of this comes to the surface. And if we don’t know it, it gets acted out. And this can be very serious because we project something of ourselves onto others. This is the first thing we learn not to do.” (Director#7, Transactional Analysis approach)

“There is not a template. Those who work with psychotherapy models operate with protocols and standardized structures that anyone can apply, making it quite straightforward: if you are good at applying these protocols, you are a good psychotherapist […] That’s not what we do. Instead, we focus on the relationship. (Director #2, Constructivist approach)

Moreover, the capacity of trainees to embrace uncertainty transcends the confines of the therapeutic relationship itself. Within a broader context, societal and cultural shifts, coupled with the evolving landscape of scientific understanding, contribute to the perpetual evolution of the mental health domain. Therapists must continually adapt to these dynamic forces, showcasing resilience and an openness to novel perspectives. This adaptability ensures their sustained efficacy in assisting clients in confronting the uncertainties intrinsic to their individual life experiences. Ultimately, the indispensable aptitude for navigating uncertainty empowers trainees as much as psychotherapists to cultivate an environment wherein clients can explore, reflect, and undergo personal growth amidst life’s inherent unpredictability.

Heading towards a novel paradigm in training

With regard to the role of psychotherapy training in in fostering trainees’ characteristics associated with successful therapists, the interviews focused on directors’ description of the process of development for a psychotherapy trainee throughout their training. The result was a comprehensive vision for psychotherapeutic education that embraces awareness, interpersonal dynamics, experiential learning, and collaborative reflection as integral components for the holistic development of psychotherapeutic practitioners. More in details, four foundational pillars emerged from training program directors’ interviews: a) greater experiential learning; b) the shift from technical rigidity to self-awareness; c) the cultivation of trust and affection in relation to trainees; d) the shift from supervision to “intervision”.

Greater experiential learning

Throughout the conducted interviews, trainers consistently underscored the imperative for a paradigm shift in the pedagogical approach employed, that should be based on a more practical training.

Directors are advocating for an increased focus on practical, hands-on training experiences rather than theoretical or abstract approaches. The emphasis on “experiential” suggests a desire for learning through direct involvement and real-life application, emphasizing the importance of practical skills and knowledge. An interviewer illustrates with an example:

"Upon their arrival, for the initial weekend, we, the instructors, engage in discussions exclusively. Following that, we promptly delve into exercises for 2 hours. Personally, I would extend the exercise duration to 4 hours, thereby broadening the experiential dimension." (Director #4 - Psychodynamic approach)

The director expresses a personal sentiment, indicating a strong belief or conviction: the focus is on enhancing the experiential aspect, emphasizing learning through direct, hands-on involvement rather than theoretical concepts. Once more the desire is to reduce reliance on theoretical knowledge, possibly implying a preference for practical, real-world application.

The unanimous sentiment among interviewees highlighted the inherent value of immersive, experiential learning in fostering a comprehensive understanding of psychotherapeutic dynamics. This shift in orientation recognizes the significance of firsthand, lived experiences in cultivating the requisite skills and insights essential for effective therapeutic practice.

The shift involves not only theoretical knowledge but also a critical examination of one’s own subjective experience. Additionally, the statement advocates for changing the perspective from a mere obligation to know to a more profound aspiration to understand. The focus is on fostering a deeper and more meaningful engagement with the learning process, encouraging curiosity and a genuine desire for comprehension over a mere accumulation of knowledge.

“Before, they were much stricter about teaching and how things are done. Now, we don’t teach so much about how things are done. Instead, we guide the trainees to understand how things are done. Back then, they threw techniques at us and told us what to do; we had to do them. Today, there’s more focus on awareness and the relational aspect.” (Director #7 Transactional Analysis approach)

“Greater attention to the diversity of the learning experience, not just theory but also questioning one’s own subjective experience. Then, an idea that diminishes the concept of having to know and increases the desire to understand." (Director #9 - Family Therapy approach)

From rigidity to self-awareness

The discerned need for this transformative shift reflects a collective acknowledgment of the evolving landscape within psychotherapeutic education, wherein the emphasis on technical rigidity gives way to a more holistic approach that prioritizes the development of the trainee on both a professional and interpersonal level. Some psychotherapy trainers also clearly claim to have created or devised a unique training model for the development of awareness:

“In the educational program, I have built a section every year dedicated to self-observation.” (Supervisor and Director #8, Client-centered therapy)

“Well, if they had made a mistake in a technique, I would have clearly said, "You need to relearn this technique. You need to look at why you don’t know it." Now, I say, "Let’s see what went well or what you could change or improve. There is no perfect technique, but there is always something that can be improved." (Director #7 - Transactional approach)

Or they envision emphasizing their program on the use of new awareness tools that need to be enhanced for the self-observation of the trainees themselves, rather than basing the course on learning techniques.

“Perhaps there is room for improvement in this area here to make the internal check-ups that people do on their experiences more precise. I also think of more precise self-observational questionnaires to make individuals pay attention to the essential aspects of the training they are undergoing. This way, we can make self-observation more structured.” (Director #9 - Family therapy approach)

This deliberate emphasis on awareness equips therapists with a profound understanding of their own reactions, biases, and emotional responses, fostering an elevated sensitivity to the intricate nuances embedded within their clients’ experiences. The integration of awareness techniques can furnish therapists with invaluable instruments to adeptly navigate the intricacies inherent in the therapeutic relationship, enabling them to respond with heightened empathy and insight.

Trainer-trainee relationship

Trainers expressed feelings of affection and trust toward their trainees. The interviewees were consequently invited to expound upon their individual experiences as trainees and detail their trajectories in training. This introspection highlights a discernible disparity between the training methodologies employed in the past and the dynamic landscape of present-day approaches.

“It was very different many years ago, quite distinct in its approach, and the relationship between trainers and trainees was also very different. There was much less familiarity and much less equality; there was more distance between trainers and trainees. Today, that distance just isn’t there. There is a lot of openness of mind and heart between the parties. Back then, my difficulty was... I felt quite judged by my teachers, at times very judged, not nurtured, and without the desire to be nurtured, to be taught and helped to improve on certain things. Instead, I felt a lot of judgment, something that we simply don’t do anymore. But back then, this distance between the faculty and the trainees translated into a form of judgment” (Director #11, Gestalt approach)

“It is a relationship of respect, trust, and attention is also one of affection and warmth, but above all, it is characterized by respect, attention, and esteem.” (Director #1, Cognitivist approach)

And, directors also engaged in introspection regarding the transformation they have undergone in their roles as psychotherapy trainers:

"I have become more optimistic. That is, initially, I was more rigid, so I saw fewer resources, fewer potentials in the therapeutic relationship that came from external sources." (Director #10, Gestalt approach)

They suggest that a fundamental and unavoidable aspect of training will involve a dual observation, referring to a two-fold perspective likely involving both the trainer and the trainee. Additionally, the mention of meta-reflection implies a higher-order reflection or contemplation about the ongoing situation. The statement emphasizes the necessity of this dual observation and meta-reflection, suggesting that it will always be a crucial and irreplaceable element in the practice of supervision. In fact, in the past, their attention was primarily directed towards assessing someone’s knowledge. However, at present, they have redirected their focus towards understanding how an individual approaches therapeutic action. There is now a heightened awareness and attentiveness to the trainee’s underlying emotional state and their capacity to comprehend and engage with this aspect. This shift suggests a deeper consideration of the emotional and relational aspects in the therapeutic process.

"Perhaps, in the past, I was more focused on what we can define as the ‘mistake’ in the way of conducting. So, in terms of personal change, this has allowed me to be less demanding towards the trainee. What I used to do before was to say, ‘Is it possible that this person can’t do it?' and so I have loosened some rigidities." (Trainer #3, Constructivist approach)

“The concept we have of supervision is supervision of the therapist, not the patient. Therefore, what interests us is the information the therapist reflects on regarding what has happened to them, the difficulties they have encountered, and their self-observation or emotional fluctuations and disturbances.” (Director #3 - Constructivist approach)

From supervision to intervision

Trainers agreed on the importance of intervision (additionally to more traditional supervision), characterized as a collective endeavour where peers contribute diverse perspectives, share insights, and engage in a mutually beneficial exchange of experiences. The recognition of intervision as an enriching element in the training regimen underscores the communal and collaborative ethos that is deemed essential in cultivating a supportive and intellectually vibrant learning environment.

“We also propose the concept of intervision, which is no longer traditional supervision but becomes an opportunity for continuous mutual exchange and assistance." (Trainer#6 – Client-Centered approach)

In this process, trainers empathized the importance of intermediate teachers or former trainees, intermediate specialist, or co-trainer:

“The co-trainer is typically a trainee who has completed the school for 4 years and re-enrolls for an entire cycle, serving as a bridge between the teacher, all teachers, and the class. They follow the class. They are naturally much younger than the teachers, especially younger instructors, and mediate the situation, providing updates on the dynamics of the class.” (Director #2, Constructivist approach)

"The figure of the Co-trainer is important for us; we introduced it from the very beginning, since the school started. It was necessary to truly support the trainees because it is not a teacher they see much. They see me four times a year, and I am the one they see the most compared to a teacher they see once. The Co-trainer is present at every single lesson, providing a reference figure much closer to them. So, for us, it is an important choice." (Director#1, Cognitivist approach)

The role of peer supervision is also designed to enhance well-being within the training process. This entails creating an environment where trainees can feel supported, understood, and encouraged in their educational journey. Peer supervision aims to foster a climate of collaboration and sharing, contributing to the development of strong relationships among trainees and addressing any challenges or difficulties in the educational path. Additionally, it provides an opportunity to explore and manage stress or tensions associated with training, ultimately promoting a more positive and supportive context for personal and professional growth.

Discussion

The present study explored psychotherapy trainers’ perspectives on trainees’ strengths, limitations, and the effectiveness of training in cultivating characteristics associated with successful therapists. Given the explorative nature of the study and the novelty of the topic, we used a qualitative methodology based on semi-structured interviews, followed by Nvivo thematic analysis. Our findings shed light on the qualities of good trainees and on the pivotal role of psychotherapy training in nurturing characteristics linked to successful therapists, as consistently highlighted by supervisors across varying theoretical approaches.

Self-awareness emerged as a key quality of the trainee. This result was not surprising due to importance attributed to the therapist’s self-awareness in psychotherapy literature (Knapp et al., 2017; Nutt, 2008; Williams et al., 2008). Among a variety of nuanced meanings attributed to the therapists’ self-awareness, in the literature it has been viewed either as global knowledge concerning the self (cognitive understanding) or a more temporary condition of focusing on the self (physiological and affective reactions) (Pieterse et al., 2013; Williams et al., 2003).

Both aspects of self-awareness emerged from supervisors’ interviews. They often referred to trainees’ awareness in terms of self-insight on their personal issues (e.g. awareness of personal limitation and strengths), but also in terms of the ability of self-focused attention in the psychotherapy process (e.g. paying attention to their emotional reactions in the here and now of the session). The importance of self-awareness has been previously mentioned in psychotherapy training studies. For instance, there is preliminary evidence that trainees’ self-awareness increases over time in training, together with an enhanced self-reflective attitude and awareness their strengths and limitations (Hill et al., 2015; Lohani & Sharma, 2023; Hiebler-Ragger et al., 2021). The second key aspect emerged as a feature of good trainee is the capacity to embrace uncertainty. Uncertainty touches psychotherapists’ deepest selves and presses upon psychotherapists not to simply retreat into the comfort of certainty but to open to that which is other in themselves (as well as in their patients in future practice) (Norcross, 2009). In their study qualitative on 100 psychotherapists development, Rønnestad and Skovholt (2003), mentioned uncertainty in terms of awareness of complexity, considered as a precondition for maintaining constructive professional development. And, in another qualitative study senior therapists recognize the importance of developing a capacity to tolerate and make meaning of uncertainty in their clinical work, reaching a condition in which therapists’ experiences of self-doubt and uncertainty remain in an ongoing dialectic (Roeske, 2014). But, to the best of our knowledge, the tolerance of uncertainty has been not previously tested in psychotherapy training research. Thus, self-awareness and uncertainty tolerance are potential elements to consider in the evaluation of trainees’ potentiality to become good psychotherapists but research evidence in this field are still scarce.

A second issue is how psychotherapy training can foster trainees’ characteristics associated with successful therapists. For example, a previous study reported that even if trainees’ level of in-session self-awareness was generally predictive of more interpersonal involvement and more clients’ perceptions of the therapeutic alliance, increasing efforts to manage self-awareness in trainees was related to decreased involvement and lower volunteer client ratings of the therapeutic alliance (Fauth & Williams, 2005). Four pillars for the improvement of current psychotherapy training emerged from the present study. First, the attention for the development of relational skills is reflected by the importance attributed to experiential learning (contrasted to theoretical learning), moving from a rigid, technique-focused approach to a more open paradigm that prioritizes awareness. With this regard, we observe a convergence between the large empirical evidence in support of the importance of relational factors as predictor of psychotherapy outcome (Norcross, 2002) and the perspective of experienced trainers. In the context of psychotherapy training, the attention for the relational factors is also recognized in the case of trainer-trainees relationship. Trust and affection should constitute the basis for a safe and nourishing learning context, suitable for the development of relational skills. This is in line with the recognition of the importance of supervisory alliance (Ladany et al., 1999; Ramos-Sánchez et al., 2002; Watkins, 2014), supervisor responsiveness (Silva & Sousa, 2022) and attachment to supervisor (Mammen, 2020) for trainees’ development. Finally, school directors reported the relevance of intervision, additional to supervision, as an instrument for therapists’ development. Despite the role of intervision is less investigated compared to the traditional supervision, there is consistent evidence on its potential usefulness to contribute to personal and professional identity development through reflective practice (Staempfli & Fairtlough, 2019) but also as an instrument to protect help-professional wellbeing and prevent professional burnout (Jorissen et al., 2024; Schumann et al., 2020).

Curiously, we observed a gap between trainers’ perceptions of their training program in comparison to the others and the actual differences between training programs. Indeed, most of trainers reported the issues of awareness and uncertainty as distinctive aspect of their training model, whereas such elements have been transversally mentioned by trainers of different theoretical approaches. This phenomenon highlights a common cognitive bias where individuals view their own methods as unique or superior, often due to a heightened sense of familiarity and investment in their approach (Dunning, 2011). This gap can reflect a more general tendency, typical of psychotherapy training institutions in the Italian context, which tends in providing distinctive definitions of their theoretical approaches, whereas in other countries is more common to identify the training with internationally recognised school of thought (Maffei et al., 2015). Anyway, this perception can obscure the reality that many training programs share common challenges and elements, whereas recognizing commonalities can be an important starting point for the research on psychotherapy trainings effectiveness.

While providing valuable insights, the qualitative nature of the present study is subject to several limitations that should be considered when interpreting the findings. First, as with all qualitative research, the potential for researcher bias is present. The data collection and analysis were influenced by the researchers’ perspectives, which may have shaped the interpretation of the results. Efforts were made to mitigate the influence of researchers’ perspective, including the use of Nvivo software, reflexivity and triangulation, and using a consensus-reaching procedure to avoid single researcher bias, but the absence of independent rater evaluations remains a limitation of the present study. Further research addressing these limitations could enhance the robustness and applicability of the conclusions drawn from this study. Moreover, future quantitative research could focus on testing the hypotheses generated from these interviews with larger and more diverse international samples to assess the generalizability of the findings across broader populations and different contexts.

Conclusions

Delving through the perspectives of experiences trainers we can provide early hypothesis of self-awareness and uncertainty tolerance as potential predictors of psychotherapy trainees’ development. We can also outline possible directions for training programs that effectively influence the development of such skills in trainees’, including the emphasis on experiential learning and on self-awareness (instead on theoretical knowledge) and on the relational experiences in the context of the training (trainer-trainee relationship and intervision). Finally, we observed a gap between trainers’ perceptions of the specificity of their training programs and the current similarities observed in their view of how psychotherapy training should work. Due to the explorative nature of the study, such consideration should be considered as very preliminary but useful for the construction of hypotheses of future studies on psychotherapists’ development and their determinants.

Availability of data and materials

The data reported in this manuscript have been presented only in this study and will be made available under reasonable request.
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